Ileocecal reservoir reconstruction after total mesorectal excision: functional results of the long-term follow-up.

BACKGROUND: The aim of this study is to obtain functional results of the long-term follow-up after TME and ileocecal interposition as rectal replacement. METHODS: The study included patients operated on between March 1993 and August 1997 who received an ileocecal interposition as rectal replacement. Follow-up was carried out 3 and 5 years postoperatively. For statistical analysis, the paired t-test, rank test (Wilcoxon), and chi-square or Fisher's exact test were applied; level of significance, P<0.05. RESULTS: Forty-four patients were included in the studies. Of these, five were not available and four patients could not be evaluated (dementia 1, radiation proctitis 1, fistula 1, pouchitis 1). Seventeen patients died during the observation period; 12 died of the disease. Recurrence of the disorder occurred in 2 of 35 patients (5.7%); 26 and 18 patients, 3 and 5 years postoperatively, respectively remained in the study. At 5 years, 78% of the patients were continent; mean stool frequency was 2.5+/-1.6 per day. CONCLUSIONS: Functional results and subjective assessment of ileocecal interposition were constant at 3 and 5 years postoperatively. If construction of a colonic J-pouch is not possible due to lack of colonic length, especially after prior colonic resections, the ileocecal interpositional reservoir may offer an alternative to rectal replacement.

Transanal endoscopic microsurgical excision of rectal tumors: indications and results.

Transanal endoscopic microsurgery (TEM) allows local excision of rectal tumors located 4 to 18 cm above the anal verge. The technique is not yet generally established because of the necessary special instrumentation and tools, the unusual technical aspects of the approach, and the stringent patient selection criteria. The aim of this prospective, descriptive study was to analyze the currently accepted indications for TEM and to evaluate the use of this procedure for treating rectal cancer. Over a 4-year period 50 patients aged 31 to 86 years (mean 64 years) underwent TEM for treatment of rectal tumors located 12 cm above the anal verge (range 4-18 cm). The local complication rate was 4%. Altogether, 76% of lesions were benign, and 24% were T1 and T2 tumors. Of 12 cancer cases, 4 required reoperation by total mesorectal resection; the other 8 are currently under follow-up management. Over the follow-up period of 30.6 months (range 11-54 months) the recurrence rate of T1 tumors was 8.3%. TEM is a minimally invasive surgical technique that may benefit a small, specific population of patients with rectal tumors. Compared with conventional transanal resection, TEM provides superior exposure of tumors higher up in the rectum (i.e., up to 18 cm from the anal verge). The greater precision of resection combined with low morbidity (10%, relative to that of anterior resection) and short duration of hospitalization (5.5 days) make this technique a reliable and in some cases more effective surgical approach than laparotomy and low anterior resection.

Ileocecal segment transposition does not alter whole gut transit in humans.

OBJECTIVES: We have recently described a reservoir for rectal replacement after total mesorectal excision for rectal carcinoma. The ileocecal segment with its intact extrinsic nerve and blood supply is placed between the ascending colon and the anal canal. This reconstruction has been shown to provide good defecation quality and anorectal function. Whether gastric emptying and small as well as large bowel transit are affected by this transposition remains unclear. Our aim was to quantify whole gut transit in such patients and compare it with that of a matched group of controls. METHODS: Gastric emptying rates and small intestinal and colonic transit times were assessed scintigraphically in 12 patients aged 46 to 87 years with ileocecal reservoir reconstruction after total mesorectal excision and compared to a sex-matched group of asymptomatic healthy volunteers of similar age. Gastric emptying rates and small intestinal and colonic transit times were calculated as described previously. Data were compared using Wilcoxon's signed rank test for gastric emptying rates and small bowel transit or by analysis of variance for colonic transit; p < 0.05 was considered significant. RESULTS: Gastric time for half of the meal (T50) was 161 +/- 16 minutes for patients and 201 +/- 22 for the controls. Small bowel transit time was 150 +/- 15 minutes for patients and 177 +/- 22 for the controls. Geometric center at 6 hours was 1.53 +/- 0.13 for patients and 1.27 +/- 0.16 for the controls. Geometric center at 24 hours was 2.96 +/- 0.23 for patients and 2.57 +/- 0.25 for the controls. Data are mean +/- SEM. SUMMARY: Gastric emptying rates and small bowel transit and colonic transit times (expressed as geometric center at 6 and 24 hours) were similar in patients with ileocecal reservoir reconstruction and in a sex- and age-matched group of healthy controls. We conclude that the transposition of an ileocecal segment with intact extrinsic neurovascular supply between the sigmoid colon and the anal canal does not alter whole gut transit, not even in any of the presumably key regions.

The ileocecal reservoir for rectal replacement in complicated radiation proctitis.

BACKGROUND/AIMS: Total rectal resection is the radical treatment method for radiation proctitis complications. Park's straight colo-anal reconstruction to replace the rectum often impairs anal continence, increases stool frequency, and causes imperative urgency. We developed and assessed a colo-anal reconstruction (ileocecal reservoir) after resection of radiation-damaged rectum. METHODS: An ileocecal segment was isolated on its lymphovascular pedicel, rotated counterclockwise, and reanastomosed at the dentate line. This provided a neorectal segment with intact intrinsic and extrinsic nerve and lymphovascular supply. We evaluated the safety, defecation quality, and anorectal function of this neorectum in two radiation-injured patients when compared with 15 patients after total mesorectal excision without radiation damage. RESULTS: No perioperative morbidity related to this technique was observed. Neorectal patients showed good defecation quality with maximal tolerable volumes, compliances, and anal manometry comparable with patients without radiation injury. CONCLUSIONS: This rectal replacement technique permits good defecation quality and excellent anorectal function.

Ileocecal reservoir reconstruction with physiologic function after total mesorectal cancer excision.

BACKGROUND/AIMS: After proctectomy for low rectal cancer and straight coloanal reconstruction, the main causes for increased daily stool frequency, urgency, and incontinence are the limited capacity and distensibility of the anastomosed colic segment in the pelvis. The authors postulated that a pedunculated (preserving the nerve) ileocecal interpositional graft (cecum-reservoir) placed between the sigmoid colon and the anal canal would greatly reduce these inconveniences. METHODS: The authors evaluated the safety, defecation quality, and anorectal physiology of such a neorectum in 20 consecutive patients with rectal carcinoma between 5 and 10 cm above the anal verge who underwent total mesorectal excision. RESULTS: No perioperative morbidity related to the technique and no mortality was observed in these 20 patients. Six months after the operation, 16 patients showed excellent and 4 patients good defecation quality, with maximal tolerable volumes, compliance, and mean colonic transit times comparable to age- and gender-matched healthy volunteers. In addition, anal resting pressure was decreased, squeeze pressure was maintained, and the rectoanal inhibitory reflex remained positive in 80%. CONCLUSIONS: The cecum-reservoir as a neorectum, using an intact neurovascular colonic segment, is a safe technique, providing excellent defecation quality. It enables a nearly normal physiologic anorectal function, which is already seen 6 months postoperatively.