Management of acute malignant large-bowel obstruction with self-expanding metal stent.

BACKGROUND: Colorectal stents are being used for palliation and as a "bridge to surgery" in obstructing colorectal carcinoma. The purpose of this study was to review our experience with self-expanding metal stents (SEMS) as the initial interventional approach in the management of acute malignant large bowel obstruction. METHODS: Between February 2002 and May 2006, 67 patients underwent the insertion of a SEMS for an obstructing malignant lesion of the left-sided colon or rectum. RESULTS: In 55 patients, the stents were placed for palliation, whereas in 12 they were placed as a bridge to surgery. Stent placement was technically successful in 92.5% (n = 62), with a clinical success rate of 88% (n = 59). Two perforations that occurred during stent placement we retreated by an emergency Hartmann operation. In intention-to-treat by stent, the peri-interventional mortality was 6% (4/67). Stent migration was reported in 3 cases (5%), and stent obstruction occurred in 8 cases (13.5%). Of the nine patients with stents successfully placed as a bridge to surgery, all underwent elective single-stage operations with no death or anastomotic complication. CONCLUSIONS: Stent insertion provided an effective outcome in patients with malignant colonic obstruction as a palliative and preoperative therapy.

Causes and outcomes of pouch excision after restorative proctocolectomy.

BACKGROUND: Pouch failure occurs in up to 10 per cent of patients after ileal pouch-anal anastomosis (IPAA). The aims of this study were to determine the reasons for pouch excision and to evaluate the outcome of the perineal wound after pouch excision. METHODS: Between 1984 and 2002, 91 patients with severe ileal pouch dysfunction were treated. This was a retrospective analysis of data collected prospectively from 24 patients who underwent pouch excision. RESULTS: Patients were grouped according to the final histological diagnosis. Fourteen patients with Crohn's disease developed extensive fistulous disease and/or recurrent abscesses, of whom six had a persistent perineal sinus after pouch excision. Five patients had familial adenomatous polyposis, in three of whom desmoid tumours were the cause of failure. Three patients had chronic ulcerative colitis and developed recurrent pelvic sepsis. Finally, two patients with multiple colorectal adenocarcinoma developed recurrent cancer (one) or sepsis (one). CONCLUSION: Sepsis was the principal reason for pouch excision and was usually associated with recrudescent Crohn's disease in the pouch. Perineal wound healing was problematic after pouch excision for Crohn's disease.

[Multivisceral resections of extracolorectal lesions in familial adenomatous polyposis]. / Exérèses multiviscérales dans les polyposes familiales adénomateuses. A propos de neuf observations.

AIMS: 1/ To report our experience with multivisceral resections in familial adenomatous polyposis (FAP) for extracolorectal lesions in a cohort of nine patients. 2/ Discuss the long term results of an agressive surgery. PATIENTS AND METHODS: Nine patients (7 males and 2 females) were operated at the University Hospital of Nimes (N=4) and Nantes (N=5). The median age at the first operation was 29 years (range 18-43). A genetic study was performed in six patients and confirmed the mutation on APC gene (exon 11, 13 and 15). All the patients were operated through a classic laparotomy. RESULTS: All patients have underwent a mean of three operations (range 2-5). Eight patients have had initially a total colectomy and 4 underwent subsequent proctectomy. Seven patients had pancreaticoduodenectomy for extensive duodenal adenomas and/or carcinoma. Three had one or multiple small bowel resections for development of carcinoma and one had partial gastric resection for large adenovillous tumor. The median follow up was 25 years (range 15-37) since the first operation. Three patients were died: one of gastric cancer with hepatic metastases, one of peritoneal carcinosis after ileal resection and one of astrocytoma. CONCLUSION: With regard to these nine observations, the authors underline the possibility of multivisceral resection in FAP. Despite a major digestive mutilation, it permits a long survival with acceptable quality of life. The prognosis depends on the aggressiveness of the duodenal or jejunoileal lesions more than of the colorectal tumors if found at the first resection.

Salvage reoperation for complications after ileal pouch-anal anastomosis.

BACKGROUND: Surgical revision may be possible in patients with a poor outcome following ileal pouch-anal anastomosis (IPAA), using either a transanal approach or a combined abdominoperineal approach with pouch revision and reanastomosis. METHODS: Sixty-four patients underwent revisional surgery. The indication for salvage was sepsis in 47 patients, mechanical dysfunction in ten, isolated complications of the residual glandular epithelial cuff in three and previous intraoperative difficulties in four patients. RESULTS: A transanal approach was used in 19 patients and a combined abdominoperineal procedure in 45. Six of the latter had pouch enlargement and 25 received a new pouch. During a mean(s.d.) follow-up of 30(25) months, three patients required pouch excision because of Crohn's disease. Two patients had poor continence after abdominoperineal surgery. At last follow-up 60 (94 per cent) of 64 patients had a functional pouch. Half of the patients experienced some degree of daytime and night-time incontinence, but it was frequent in only 15 per cent. Of 58 patients analysed, 27 of 40 who had an abdominoperineal procedure and 13 of 18 who had transanal surgery rated their satisfaction with the outcome as good to excellent. CONCLUSION: Surgical revision after failure of IPAA was possible in most patients, yielding an acceptable level of bowel function in two-thirds of patients.

Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection.

BACKGROUND: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

Sutured perineal omentoplasty after abdominoperineal resection for adenocarcinoma of the lower rectum.

PURPOSE: This study was designed to describe and evaluate the efficacy of sutured perineal omentoplasty on perineal wound healing after abdominoperineal resection for adenocarcinoma of the lower rectum. METHODS: Charts of patients who underwent abdominoperineal resection for adenocarcinoma of the rectum from June 1995 to December 2001 were reviewed for mortality, morbidity, and perineal healing. Abdominoperineal resection was accomplished according to Miles combined with total mesorectal excision. The omentum was pediculized on the left gastroepiploic artery and tightly sewn to the subcutaneous fatty tissue. The perineal skin was then closed primarily. RESULTS: A total of 104 patients were included in the study. The mean age at surgery was 65 (range, 13-91) years. The distance of the tumor from the anal sphincters was 0.45 +/- 0.9 mm (range, 0-50). During the study period, 92 patients (88 percent) had sutured perineal omentoplasty. The rate of primary perineal wound healing was 80 percent. Postoperative perineal wound complications consisted of perineal abscess in seven patients. Six of these patients had a sutured perineal omentoplasty (6 percent). Only four patients required a surgical drainage. Minor perineal suppuration occurred in four patients (4 percent), whereas partial perineal wound dehiscence occurred in eight patients (8 percent). All wounds healed completely at three months. Intestinal obstruction occurred in three patients (3 percent). No complication of the pedicled omentoplasty was observed. CONCLUSIONS: This study demonstrated that sutured perineal omentoplasty is possible in the majority of patients after abdominoperineal resection for adenocarcinoma of the lower rectum with excellent primary perineal wound healing.

Ultralow anterior resection with intersphincteric dissection--what is the limit of safe sphincter preservation?

INTRODUCTION: In the treatment of low rectal cancer, the possibility of sphincter preserving surgery is increased by partial sphincteric resection which may allow an oncologically safe resection margin in some patients who would traditionally have been treated by abdominoperineal resection. The aim of this study is to evaluate the morbidity, mortality and the oncological and functional results of intersphincteric resection to determine whether the technique may be considered a safe means of sphincter preservation. METHODS: Between May 1992 and December 1999, 26 patients (mean age 55 years, range 28-82) with adenocarcinoma of the rectum had partial sphincteric resection by an abdominal approach with a colonic J-pouch anal anastomosis. The mean distance between the tumour and the anal verge 4.25 (range 3.1-5.25) cm. Four tumours were T1, 14 T2 (3 N+), 7 T3 (3 N+), and 1 T4 (N+). Neoadjuvant radiotherapy was used in 10 patients. The distal resection margin was positive in one patient who then proceeded to safe abdominoperineal resection (APR). In the remaining patient the mean distal resection margin on the fixed specimen was 1.6 (range 0.3-3.5) cm. RESULTS: There were no deaths. Morbidity was 30% with an anastomotic leak rate of 11%. At mean follow-up of 39 (range 11-93) months the local recurrence rate was 3.4%. Functional results were evaluated in 25 patients at mean follow-up of 27 (8-66) months: 65% had 0-2 bowel motions per 24 h, 31% had 3-5 and 4% between 6 and 9. Nine patients (36%) had nocturnal defecation. Continence was normal in 50% with 23% reporting incontinence to gas and 27% reporting minor episodes of incontinence. None had major incontinence and 85% considered their outcome satisfactory. CONCLUSION: This study supports the current literature indicating that partial sphincteric resection is an oncologically and functionally safe alternative to abdominoperineal resection for some selected low rectal tumours.

Oncologic results following abdominoperineal resection for adenocarcinoma of the low rectum.

PURPOSE: The role of abdominoperineal resection for rectal cancer has changed because of advances in sphincter-preserving surgery. Our aim was to evaluate the results of this operation in the five-year period following introduction of the concept of total mesorectal excision METHODS: Data on all patients undergoing abdominoperineal resection for very low rectal cancer between 1992 and 1997 were collected prospectively. All patients had had total mesorectal excision. Curative resection was defined as absence of macroscopic disease after resection and local recurrence as any infiltration or tumor identified in the pelvis, alone or combined with distant disease. Survival and local recurrence rates were calculated using the Kaplan-Meier method and log-rank analysis. RESULTS: Of 165 abdominoperineal resections performed, 106 were for primary adenocarcinoma of the rectum. The male:female ratio was 50:56, with a median age of 65 (range, 33-85) years. There was one postoperative death. Twenty-seven patients received short-course preoperative radiotherapy (25 Gy over 1 week), whereas 22 had a longer course, with concomitant chemotherapy in 2. Postoperative chemotherapy was administered in 29, postoperative radiotherapy in 4, and combined therapy in 8. After curative resection (n = 91), survival at five years was 76 percent and differed significantly by stage. Recurrence at any site was 7 percent (3/34) for Stage I, 27 percent (6/26) for Stage II, and 53 percent (16/31) for Stage III. Nine patients presented with local recurrence, with an overall rate at five years of 10 percent. Isolated locale recurrence was observed in only 5 percent of patients CONCLUSIONS: After abdominoperineal resection and total mesorectal excision, good rates of local control may be achieved provided surgical technique is meticulous.

Treatment of postoperative peritonitis of small-bowel origin with continuous enteral nutrition and succus entericus reinfusion.

HYPOTHESIS: Proximal intestinal stomas established by the exteriorization of leaking anastomosis in the presence of peritonitis can be used to reinfuse succus entericus and provide adequate enteral nutrition. DESIGN: Retrospective analysis of prospectively gathered data from a cohort of consecutive patients admitted between January 1993 and December 1999 for postoperative peritonitis requiring laparotomy and the construction of one or more small-bowel stomas. SETTING: Tertiary referral center with a surgical intensive care unit experienced in the treatment of intra-abdominal sepsis and succus entericus reinfusion. PATIENTS: Twenty-one consecutive patients with postoperative peritonitis originating from a jejunal or ileal leak. We excluded patients with established enterocutaneous fistulae, abscesses amenable to percutaneous drainage or other conservative treatments, and postoperative peritonitis caused by ileocolic or ileorectal anastomosis. INTERVENTIONS: Early laparotomy with exteriorization of small-bowel leak(s), and continuous enteral nutrition (CEN) and succus entericus reinfusion (SER) via the distal portion of the stoma until gastrointestinal continuity was restored. MAIN OUTCOME MEASURES: Feasibility of CEN and SER with temporary, diverting small-bowel stomas and their associated postoperative morbidity and mortality rates. RESULTS: One patient died, and 14 experienced complications. For technical reasons, CEN and SER were discontinued early on in 7 patients. The mean duration of CEN and SER was 58 days and 61 days, respectively. Enteral feedings allowed the suppression of central venous access after a median of 28 days, with 82 days as a median time to restoration of intestinal continuity. CONCLUSIONS: Although the exteriorization of small-bowel leaks with CEN and SER is generally feasible and effective in the treatment of critically ill patients with peritonitis secondary to small-bowel leaks, it is associated with significant morbidity and mortality, in part relating to patients' underlying diseases.

Results of reoperations in colorectal anastomotic strictures.

PURPOSE: The incidence of colorectal anastomotic strictures varies from 3 to 30 percent. Most of these anastomotic strictures are simple narrowings shorter than 1 cm that can be successfully treated by dilation or endoscopic alternatives. However, up to 28 percent of patients will require surgical correction. This can be technically difficult, with the possibility of a permanent colostomy. This study reports the outcomes after operative treatment of severe strictures of colorectal anastomoses. METHODS: From August 1992 to October 1996, 27 patients were referred for surgical treatment of severe rectal anastomotic strictures. The reasons for the initial surgery were as follows: rectal cancer (13), diverticular disease (7), Hirschsprung's disease (2), rectal endometriosis (2), uterine carcinoma with rectal invasion (1), ruptured abdominal aortic aneurysm with rectosigmoid necrosis (1), and rectovaginal fistula (1). There were 15 (56 percent) stapled anastomoses, and 21 (78 percent) patients had developed a postoperative leak. RESULTS: The median time between initial surgery and diagnosis of the stenosis was 7.2 (range, 1-24) months and between the last operation and referral was 15.1 (range, 1-44) months. Stenosis was located at a mean distance of 9.5 (range, 4-15) cm from the anal verge. Eleven patients (41 percent) had been unsuccessfully dilated before referral. Surgical correction of the stenosis required 7 colorectal anastomoses for upper rectal anastomotic strictures and 20 coloanal anastomoses for middle and lower rectal strictures (19 Soave's procedures and 1 colon J-pouch-anal anastomosis). Intestinal continuity was restored in all cases. After a mean follow-up of 28.7 +/- 14 months, no recurrences were detected and functional results were satisfactory. CONCLUSIONS: Resection of the stenosis and construction of a new colorectal anastomosis can be performed successfully for upper rectal anastomotic stricture. For a stenosis located in the middle and lower rectum, Soave's procedure offers a good alternative, with satisfactory long-term functional results. Whichever technique is used, a permanent colostomy should rarely be required.

Intravenous chemotherapy, early debulking surgery, and consolidation intraperitoneal chemotherapy in advanced ovarian carcinoma.

OBJECTIVE: The efficacy of a cisplatin-anthracycline combination, early debulking surgery, and intraperitoneal chemotherapy has been demonstrated through separate studies. We evaluated a multimodal treatment strategy integrating these therapeutic options. METHODS: Women with stage III or IV ovarian carcinoma received six cycles of cisplatin/epirubicin alternating with leucovorin and 5-fluorouracil. Patients with a residual disease (RD) measuring more than 2 cm after the initial laparotomy underwent an early debulking surgery after the first three cycles of chemotherapy. A second-look laparotomy (SLL) was performed after six cycles of intravenous chemotherapy. Intraperitoneal chemotherapy with cisplatin, VP16, and mitoxantrone was then administered in patients with no or RD < 2 cm after SLL. RESULTS: A total of 87 patients were included. After initial laparotomy, 11 patients (12%) had no macroscopic residual disease, 38 (44%) had a RD < or =2 cm, and 38 (44%) had a RD > 2 cm. After early debulking surgery, an additional 18 patients (21%) had a RD < 2 cm. Seventy-five patients were evaluable for response to intravenous chemotherapy: the overall response rate was 80%, and 30 patients achieved a pathological complete response (40%). Eight percent of the patients had stable disease and 12% had a progression. Sixty-eight patients received intraperitoneal chemotherapy after second-look laparotomy. With a 72-month median follow-up, median overall survival and progression-free survival were, respectively, 37 and 19 months. Five-year survival was 41%. CONCLUSION: The prognosis of patients with advanced ovarian carcinoma may be improved by a sequential treatment strategy including intravenous chemotherapy, early debulking surgery, and intraperitoneal chemotherapy.

Primary adenosquamous carcinoma of the rectum. Report of 4 cases and review of the literature.

OBJECTIVE: To review the experience of two referral centres in the management of an infrequent condition: primary adenosquamous carcinoma of the rectum, a rare disease. MATERIALS AND METHODS: Four cases of primary adenosquamous carcinomas of the rectum are reported with a review of the literature. No preoperative diagnosis of adenosquamous carcinoma was established. All tumours were located in the rectum. Two patients presented with liver metastasis. No preoperative therapies were indicated. All patients underwent surgery. RESULTS: Patients underwent anterior resections (n=2), recto-sigmoid resection (n=1) and abdomino-perineal excision (n=1). All resected specimens had positive lymph nodes and metastatic liver disease was confirmed in the two cases. No adjuvant therapy was carried out after surgery and patients died within 8 months after surgical treatment. CONCLUSIONS: Adenosquamous carcinoma of the rectum is a rare and aggressive tumour characterized by coexisting of malignant glandular and squamous components. Presentation is usually at an advanced stage. The tumour is aggressive and metastatic disease at the time of diagnosis is common. Surgery is the treatment of choice. Adjuvant therapy is difficult to evaluate prospectively due to the rarity of the condition. Survival is less than 50% than that for adenocarcinoma.

Results of coloanal anastomosis for rectal cancer.

It is now accepted that, in the absence of direct invasion of the anal sphincter, cancers of the middle and lower rectum can be successfully treated with sphincter-preserving surgery. Conservation of the sphincter mechanism should never compromise the oncologic outcome of surgery and the method of neorectum construction must provide acceptable function for patients. This review describes the results of coloanal anastomosis following rectal excision. The oncological and functional results of both straight coloanal and colonic-J-pouch anal anastomosis are presented in detail. The authors discuss recent evidence supporting the functional superiority of colonic-J-pouch reconstruction after rectal excision.

Management of postoperative peritonitis after anterior resection: experience from a referral intensive care unit.

PURPOSE: Anastomotic leakage is the main cause of death after anterior resection. If it causes a single abscess, it may be successfully cured by percutaneous drainage, but in case of extensive peritoneal infection (multiple abscesses and generalized peritonitis), it is associated with a 40 to 60 percent mortality. This study aimed at evaluating aggressive, one-stage surgical management in such cases. METHODS: All patients referred to our surgical intensive care unit during the past ten years with generalized, multilocular, intra-abdominal sepsis after anterior resection were reviewed. There were 32 patients, with a mean age of 65 years, among which 15 (47 percent) were referred from other institutions. The mean Acute Physiology and Chronic Health Evaluation II score on admission was 18. All patients underwent a laparotomy with complete peritoneal exploration, intraoperative lavage, fecal diversion, capillary drainage of the pelvis excluding the rectal stump or the leaking anastomosis from the peritoneal cavity, and primary closure of the abdomen. A Hartmann's operation was done in 22 cases, and conservation of the anastomosis with proximal colostomy was done in 10 cases. The choice was based on the size of the leak, the viability of the colon, and the site of the anastomosis. RESULTS: Four patients died (12 percent), and five patients (16 percent) had recurrent sepsis. When the anastomosis had been conserved, restoration of continuity was achieved in all cases. After Hartmann's operation 8 patients of 19 survivors kept a permanent stoma; 7 had undergone a low anterior resection. CONCLUSIONS: Extensive intra-abdominal infection after anterior resection may be efficiently controlled by a surgical approach combining peritoneal debridement, fecal diversion, and capillary drainage of the pelvis. Intestinal continuity may be restored after diversion stoma or Hartmann's procedure after high anterior resection. This is not the case after a Hartmann's operation after a low colorectal anastomosis, and this procedure should be avoided whenever possible.

Rectal excision and colonic pouch-anal anastomosis for rectal cancer: oncologic results at five years.

PURPOSE: Preservation of the anal sphincter is now accepted as a primary aim in surgical treatment of rectal cancer. The use of colonic J-pouch-anal anastomosis after complete rectal excision is one method that permits retention of continence without compromising oncologic principles. This study aimed to assess carcinologic results of rectal excision followed by colonic J-pouch anal anastomosis, with particular reference to rate of locoregional recurrence. METHOD: From 1984 to 1990 complete rectal excision and colonic pouch-anal anastomosis were performed in 167 patients for cancer of the middle or low rectum. A total of 154 patients were followed for this study for a minimum of five years, with evaluation of the frequency of locoregional recurrence. RESULTS: Sixty-five patients died during the period of surveillance, giving a five-year survival rate of 68.8 percent. Twenty patients (13 percent) presented with locoregional recurrence at an average of 31 months after surgery. In 11 cases (7 percent) the local recurrence was not associated with metastatic disease, and six of these patients underwent further curative surgery. CONCLUSIONS: These results confirm that coloanal anastomosis after complete rectal excision is a valuable option in the surgical treatment of rectal cancer and is accompanied by a frequency of isolated locoregional recurrence of less than 7 percent, of which half underwent surgical resection with curative intent.

Results of salvage abdominoperineal resection for anal cancer after radiotherapy.

PURPOSE: Nonsurgical treatment of anal cancer by radiotherapy alone or combined with chemotherapy is the standard therapy for epidermoid carcinoma of the anal canal. Surgery is only recommended for treatment failures. Very few studies have been devoted to the outcome of this salvage surgery. The aim of this study is to evaluate these results. METHODS: A retrospective review from 1986 to 1995 revealed 21 patients with residual or recurrent anal canal carcinoma after initial radiotherapy, operated on by abdominoperineal resection. Patients were reviewed as to age, gender, initial treatment, any symptoms of recurrence, duration until recurrence, any diagnosis imaging, treatment, and outcome. RESULTS: None of these 21 patients had known lymph node involvement or metastases at radiotherapy or at salvage abdominoperineal resection. Eleven patients had residual disease (positive biopsy less than 6 months after the end of radiotherapy) and 10 had tumor recurrence (more than 6 months after cessation of treatment). Recurrence occurred at a mean of 15 (range, 9-41) months after radiotherapy. All 21 patients underwent an abdominoperineal resection. Pathologic examination of the 21 specimens showed complete excision in all cases except one and lymph node metastases in two cases. There was no perioperative mortality. The mean follow-up after surgery was 40 months; no patients were lost to follow-up. Of the 21 patients, 10 died and 11 lived, of whom 9 are disease free. The overall survival rate at three years after salvage abdominoperineal resection was 58 percent. The overall survival rate for patients with residual disease (vs. recurrence) at three years was 72 percent (vs. 29 percent) and at five years was 60 percent (vs. 0 percent; P = 0.06). CONCLUSIONS: Salvage abdominoperineal resection for anal cancer can be expected to yield a number of survivors from residual disease, but the low rate of survival after abdominoperineal resection for recurrent disease suggests the need for additional postoperative treatment if salvage abdominoperineal resection is performed.

Use of a jejunal pouch with ileal interposition in salvage surgery after restorative proctocolectomy.

PURPOSE: A novel technique is described for pouch reconstruction after failed restorative proctocolectomy and pouch excision. METHODS: Surgery was undertaken in two patients who had undergone restorative proctocolectomy with subsequent excision of the ileal J-pouch after necrosis. At revisional surgery it was technically impossible to form a pouch using the terminal ileum because of mesenteric shortening. A new 18-cm J-pouch was formed with a jejunal segment. After selective division of axial vessels, adequate length was obtained to allow formation of a jejunal-pouch-anal anastomosis. The small bowel distal to the pouch was interposed between the proximal jejunum and J-pouch and a defunctioning stoma was made. RESULTS: The postoperative course was uneventful in both cases. The functional results at 3 and 12 months after stoma closure were good, with five to seven bowel movements per day and complete continence. CONCLUSION: Shortening of the terminal ileal mesentery may preclude the formation of an ileal pouch in patients undergoing salvage surgery after failed restorative proctocolectomy. This novel technique of jejunal J-pouch formation and small-bowel interposition has value as an alternative to definitive ileostomy or Kock's pouch in such patients.

Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch-anal anastomosis.

BACKGROUND: Anal sphincter function is increasingly preserved following rectal excision for cancer and provides a better quality of life for patients than does a permanent colostomy. However, anastomotic complications may cause considerable morbidity and mortality. This retrospective study examined the incidence of anastomotic complications following two forms of reconstruction after resection for mid-rectal cancer: colonic pouch-anal anastomosis (CPAA) and low colorectal anastomosis (LCRA). METHODS: Some 258 consecutive patients with mid-rectal cancers between 6 and 11 cm from the anal verge underwent proctectomy with mesorectal excision and either CPAA or LCRA. The incidence of clinical and radiological leaks was determined in these patients who were considered in three groups: LCRA (defunctioning stoma), LCRA (no defunctioning stoma) and CPAA (all defunctioned). RESULTS: In the LCRA group without a defunctioning stoma, a clinical leak occurred in 17.0 per cent, compared with two of 30 in the LCRA group with a defunctioning stoma. In the CPAA group a clinical leak occurred in 4.9 per cent of patients, which was not significantly different from the rate in those with a defunctioned LCRA. Patients with a non-defunctioned LCRA were more likely to suffer a clinical anastomotic leak (P=0.01), peritonitis (P=0.001) and require unscheduled reoperation (P=0.006) than those with a defunctioned LCRA and/or CPAA. CONCLUSION: The use of a protective defunctioning stoma is advocated in conjunction with LCRAs.