Reasons for failure to construct the colonic J-pouch. What can be done to improve the size of the neorectal reservoir should it occur?

PURPOSE: The aim of this study was to determine first, the reasons for failure to construct a neorectal reservoir after anterior resection and coloanal anastomosis for rectal adenocarcinoma and the rate at which it occurred and second, to determine whether the adoption of a new "coloplasty" pouch-anal anastomosis improved this failure rate. METHODS: From the colorectal cancer database of a single institution, a single surgeon's patients who underwent resection and coloanal anastomosis from March 1990 to June 1999 were identified. After thorough chart review those patients who underwent straight coloanal anastomosis, J-pouch-anal anastomosis, and coloplasty pouch-anal anastomosis could be identified. In each case of straight coloanal anastomosis, the cause of the failure to create a neorectal reservoir was sought. The study group was further subdivided into those who had their operation either before or after the introduction of the coloplasty pouch-anal anastomosis. RESULTS: Of 107 patients who fitted the criteria for study, 66 (61.7 percent) had a J-pouch-anal anastomosis, and 13 (12.1 percent) had a coloplasty pouch-anal anastomosis. Twenty-eight patients had a straight coloanal anastomosis when a neorectal reservoir could not be constructed, an overall failure rate of 26.2 percent for the total period of study. Seven reasons were identified for this failure, of which there were a total of 31 episodes. These reasons were 1) technical (narrow pelvis, bulky anal sphincters or need for mucosectomy, diverticulosis, insufficient colon length or pregnancy) and 2) nontechnical (complex surgery or distant metastases present). Failure to construct a neorectal reservoir for the period of study before the introduction of coloplasty pouch-anal anastomosis occurred in 27 of 88 (30.7 percent) patients. This was reduced to 1 of 19 (5.3 percent) patients in the later period of study, a significant improvement (P = 0.022). CONCLUSIONS: Seven factors have been identified which may result in the failure to construct a neorectal reservoir after rectal resection and coloanal anastomosis. This may occur in a sizable minority of patients. The introduction of coloplasty pouch-anal anastomosis has resulted in a significant improvement in this failure rate.

Factors affecting local recurrence of colonic adenocarcinoma.

PURPOSE: The aim of this retrospective study was to determine which aspects of tumor morphology and histology influenced the incidence of local recurrence after curative resection of colonic adenocarcinoma. METHODS: Patients who had a curative resection for a primary colonic adenocarcinoma between 1980 and 1993 (inclusive) were identified from the colorectal cancer database in the Department of Colorectal Surgery. The charts of patients diagnosed with a local recurrence were then reviewed and their findings at operation and histologic assessment analyzed. Patients were followed up for at least five years or until death. RESULTS: Over the period of study, 1,031 patients had a curative resection for colonic adenocarcinoma. Local recurrences were detected in 32 patients (3.1 percent). The gender distribution of patients with local recurrence was 18 males (56.3 percent) and 14 females (43.7 percent) with a mean age of 63.4 years. The median time to local recurrence was 13 (range, 2-71) months. The distribution of primary tumors that recurred locally favored the cecum (n = 9; 28.1 percent) and sigmoid colon (n = 14; 43.7 percent) over other locations; these were, however, the most common sites of primary lesions. Less common sites included the ascending colon (n = 0; 0 percent), hepatic flexure (n = 2; 6.3 percent), transverse colon (n = 1; 3.1 percent), splenic flexure (n = 3; 9.4 percent), and descending colon (n = 3; 9.4 percent). Of the total number of tumors, 101 were found to be adherent to at least 1 other intra-abdominal viscus, and 12 (11.9 percent) recurred locally. Other factors associated with local recurrence were tumor perforation and fistulation. Overall, 30 tumors (2.9 percent) were perforated, and 6 (20 percent) recurred locally. Four tumors (0.4 percent) were fistulating; of these, 2 (50 percent) recurred locally. Advanced tumor stage was also associated with an increased rate of local recurrence (Stage I, 0 percent; Stage II, 2.05 percent; Stage III, 7.0 percent; and Stage IV, 6.1 percent). Similarly, tumor differentiation was related to local recurrence, with no instances in well-differentiated tumors, 2.8 percent in moderately differentiated tumors, and 6.8 percent in poorly differentiated tumors. CONCLUSIONS: The location of the primary tumor is not a factor in producing local recurrence. Fixity to another viscus, perforation or fistulation, advanced stage of disease, and differentiation of tumor appear to increase the chances of recurrence of curatively resected colonic carcinoma. Although the recurrence rate is higher in these groups than for tumors overall, definitive oncologic surgery prevents recurrence in the majority of cases. No colonic tumor that was T1 or T2 (N0, N1, or N2) or that was well differentiated recurred locally.

Factors affecting survival after palliative resection of colorectal carcinoma.

OBJECTIVE: To determine the factors affecting survival following palliative large bowel resection for colorectal adenocarcinoma. PATIENTS AND METHOD: From the Colorectal Cancer Database of a single institution patients who had a palliative resection of a colorectal cancer from 1980 to 1993 inclusive were identified. Survival curves were constructed using the Kaplan-Meier method. Criteria studied were sex, age at operation, site of tumour, T, N and M status, tumour differentiation, involvement of tumour margins, tumour fixity and the presence or absence of peritoneal, liver or distant metastases. Multivariate analysis of factors was conducted using Cox proportional hazards analysis. RESULTS: Three hundred and seventy-seven patients (232 men, 145 women, median age 64 years) fitted the above criteria. Operative mortality was 5.6%. Crude 6 month survival rate was 71.1% and median survival 10.5 months. Significant factors affecting survival on univariate analysis were - Age (<75 vs. >75 years) (P=0.019); T status (T1/T2 vs. T3/T4) (P=0.039); nodal status (N0 vs. N1/N2) (P=0.0059); distant metastases (P=0.039) or liver metastases (P=0.0058); tumour differentiation (poor vs. moderate/well differentiated) (P < 0.001); involved tumour margins (P < 0.001). Multivariate analysis found the following factors significant: age (P=0.02), liver metastases (P=0.05), distant metastases (P=0.044), T status (P=0.042), nodal status (P=0.0063), tumour differentiation (P < 0.001) and involvement of tumour margins (P < 0.001). CONCLUSIONS: The data suggest that palliative resection of advanced colorectal carcinoma should be considered carefully in patients with advanced age, where distant metastases are present and in cases when primary tumours can not be completely resected. For the remaining patients, palliative resection may be accomplished with acceptable operative mortality and postoperative survival.