Full text of DOI:10.1007/s00053-000-0004-5

coloproctology
© Urban & Vogel 2000
Functional Results in Patients with Coloanal
Pouch after Low Anterior Resection of the
Rectum
1
Marco Sailer, Eike Sebastian Debus, Karl-Hermann Fuchs, Arnulf Thiede
Abstract:
Functional results after low anterior resection of the rectum and straight end-to-end
coloanal anastomosis are often poor. Patients are frequently troubled by the so called
„anterior resection syndrome“ which comprises fecal incontinence, urge, frequency
and fragmentation.To investigate the potential functional benefit of a coloanal pouch
reconstruction we conducted a prospective study.
Some 42 patients (23 men;median age 65 years [30 to 85]) underwent low anterior
resection of the rectum followed by coloanal J-pouch reconstruction. Pouch size was
5 to 7 cm, a temporary stoma was fashioned in 32 patients. Indications for the operation
were: 1. rectal cancer n = 38,2. recurrent adenoma n = 2, 3. recto-vaginal fistula n = 1
and 4. severe non-specific proctitis n = 1.
We observed 5 anastomotic leakages of which 2 patients required reoperation. A
pelvic abscess was encountered in 3 patients as well as 1 pelvic hematoma. Micturition
was impaired in 4 patients. To date 35 patients have completed 12 months follow-up
after reversal of the ileostomy. Patients were seen at 3-monthly intervals. Mean stool
frequency/day was 3.9 after 3 and 2.2 after 12 months.After 3 months 24 patients (69%)
reported complete continence which increased to 86% at 1 year. Nine patients (26%)
complained of urge defecation initially, which decreased to 9% after 1 year.
Fragmentation was observed in 40% and 20% at 3 and 12 months, respectively.
In conclusion, our initial experience with colonic J-pouch reconstruction shows
good functional results.
.
.
Key Words: Coloanal J-pouch Rectal cancer Functional results
1
Chirurgische Klinik und Poliklinik (Direktor: Prof. Dr. A. Thiede) der Universität
Würzburg, Germany.
Annahme des Manuskripts: 17. 1. 2000
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Sailer M, et al. Functional Results with Coloanal Pouch
Funktionelle Ergebnisse bei Patienten mit tiefer anteriorer
Rektumresektion
Zusammenfassung:
Die funktionellen Resultate nach tiefer anteriorer Rektumresektion sind häufig un-
befriedigend. Die betroffenen Patienten klagen über ein mehr oder weniger ausge-
prägtes Syndrom, das eine Vielzahl von Symptomen, wie Inkontinenz, imperativen
Stuhldrang, Stuhlfragmentation, erhöhte Frequenz u. a., beinhalten kann. Ziel dieser
prospektiven Untersuchung war die Evaluierung des koloanalen J-Pouches als Re-
konstruktionsmethode nach Rektumresektion.
Bei 42 Patienten (23 männlich, 19 weiblich, Durchschnittsalter 65 [30 bis 85] Jahre)
wurden das Rektum tief anterior reseziert und ein koloanaler J-Pouch angelegt. Die
Pouch-Größe betrug 5 bis 7 cm, ein temporäres Ileostoma wurde bei 32 Patienten ange-
legt. Die Indikationen zur Operation waren: 1. Rektumkarzinom n = 38, 2. rezidi-
vierende Adenome n = 2, 3. rektovaginale Fistel n = 1 und 4. schwere nicht spezifische
Proktitis n = 1.
Postoperativ beobachteten wir fünf Anastomoseninsuffizienzen, die bei zwei Pa-
tienten revidiert werden mußten. Bei drei Patienten kam es zu Abszedierung im klei-
nen Becken, in einem Fall zu einem pelvinen Hämatom. Blasenentleerungsstörungen
traten bei vier Patienten auf. Bei 35 Patienten konnte eine komplette zwölfmonatige
Nachbeobachtung nach Ileostomarückverlagerung durchgeführt werden, wobei alle
Patienten vierteljährlich evaluiert wurden. Die durchschnittliche Stuhlfrequenz/Tag
betrug 3,9 nach drei und 2,2 nach zwölf Monaten. Nach drei Monaten berichteten 24
Patienten (69%) über eine vollständige Kontinenz, was nach einem Jahr auf 86% ge-
stiegen war. Initial klagten neun Patienten (26%) über einen imperativen Stuhldrang,
nach einem Jahr waren es lediglich 9%. Stuhlfragmentation beobachteten wir in 40%
der Fälle nach drei Monaten und 20% nach zwölf Monaten.
Zusammenfassend zeigten sich mit der Pouch-Rekonstruktion nach tiefer ante-
riorer Rektumresektion gute funktionelle Ergebnisse.
.
.
Schlüsselwörter: Koloanaler J-Pouch Rektumkarzinom Funktionelles Resultat
Sphincter saving procedures have become the standard
often interferes with the daily life of the patients
resulting in a reduction of their quality of life. The
incidence of early postoperative functional disorders is
reported to be as high as 80 to 87% [3].
treatment in the surgical approach of cancers situated in
the lower and middle third of the rectum. However,
functional results following low anterior resection with
straight coloanal reconstruction have been dis-
appointing.The so called „anterior resection syndrome“
comprises a variety of symptoms, e. g. fecal incontinence,
increased stool frequency, stool fragmentation („stooling
sessions“), urgency to defecate, perianal skin irritation,
and the requirement of specific medication (loperamide
etc.). Depending on the severity of the complaints, this
To compensate for the loss of the rectal reservoir
Lazorthes et al. [19] as well as Parc et al. [25] introduced
the J-coloanal pouch in 1986. Meanwhile, randomized
trials have shown its functional superiority especially
within the first months after surgery [8, 24, 26]. In order
to investigate postoperative function of the J-pouch
30
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Sailer M, et al. Functional Results with Coloanal Pouch
Results
n
%
There were no technical problems related to pouch
construction. Early postoperative complications were
encountered in 40% and are listed in Table 1. One
patient died of myocardial infarction leading to a
mortality of 2%.
Anastomotic leakage
Pelvic abscess
Pelvic hematoma
Urinary retention (> 7 days)
Cardiopulmonary
Mortality*
5
3
1
4
3
1
12
7
2
10
7
2
Mean stool frequency/day was 3.9 after 3 and 2.2
after 12 months, respectively (Figure 1).After 3 months,
24 patients (69%) reported complete continence which
gradually increased to 86% at 1 year (Figure 2). Five
patients (12%), of which 3 had received adjuvant
treatment, continued to complain of partial incontinence
to flatus and occasionally to liquid stool after 1 year of
follow-up. One female patient was deemed completely
incontinent after thorough evaluation (clinical exami-
nation, anal endosonography, anorectal manometry,
defecography), so that her ileostomy was never reversed.
26% of the patients (n = 9) complained of urgency
initially, which decreased to 9% 1 year after surgery
(Figure 3). Stool fragmentation was observed in 40%
and 20% at 3 and 12 months, respectively. While 12
patients used bulking agents regularly, only 1 patient
required the regular use of enemas to assist evacuation.
Total
17
40
*due to myocardial infarction.
Table 1. Postoperative complications.
following low anterior resection of the rectum, we
conducted a prospective study.
Patients and Method
Fourty-two patients (23 men, 19 women; median age 65
[30 to 85] years) underwent low anterior resection of the
rectum with total mesorectal excision followed by
coloanal J-pouch reconstruction. The reservoir was
fashioned with a stapling device (GIA 90®, Autosuture,
Tönisvorst) resulting in a 5 to 7 cm pouch size. The
pouch-anal anastomosis was performed using either a
circular stapler (CEEA®, Autosuture, Tönisvorst) (n =
34) or a transanal hand-suture (n = 8) with an
absorbable, monofilament thread (4/0 Maxon®, Braun-
Dexon, Spangenberg). A temporary ileostomy was
fashioned in 32 patients which was reversed after a
median of 86 (41 to 152) days.
Discussion
The surgical approach to tumors situated in the middle
and lower rectum has changed considerably in the past
decade. Several authors were able to demonstrate that,
from an oncologic point of view, a resection margin of
2 cm distal to the tumor is sufficient to achieve local
control [1, 16, 27, 30]. As rectal cancers tend to spread
laterally rather than distally, total mesorectal resection
as propagated by Heald et al. [9] is of paramount
importance in the surgical treatment of cancers
situated in the middle and lower third. Therefore,
many rectal malignancies that used to be approached
by abdominoperineal resection in previous years are
nowadays treated using a sphincter preserving
technique. However, preservation of the sphincter
complex cannot be automatically equated with
preservation of anorectal continence. The loss of the
rectal reservoir, intraoperative manipulation of the
sphincter apparatus (e. g. by the use of stapling
devices) and injury to the complex neuromuscular
integrity of the anorectal structures can lead to
substantial functional dysfunctions.
Indications for the operation were: 1. rectal cancer
n = 38, 2. recurrent adenoma with severe dysplasia n =
2, 3. rectovaginal fistula following radiation of a
gynecologic tumur n = 1, and 4. severe non-specific
proctitis refractory to conservative treatment n = 1.
Seven patients (17%) received postoperative radio-/
chemotherapy due to advanced disease.
Thirty-five patients completed 12 months of follow-
up after the operation or after the reversal of the
ileostomy, respectively. Patients were seen at 3-monthly
intervals, and the results recorded using a thorough
history and a standardized anorectal function scoring
system [13].
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Sailer M, et al. Functional Results with Coloanal Pouch
While it is well known that postoperative radiation
has a negative effect on functional outcome [6, 11, 22],
recent data from Sweden indicate that this is also the
case if radiotherapy is applied preoperatively [5]. In fact,
3 of our 5 partially incontinent patients had undergone
adjuvant therapy.
Evidently, there is a strong correlation between the
extent of rectal excision and functional changes.
Karanjia et al. [14] as well as Lewis et al. [21] found, that
patients with a rectal remnant of at least 4 cm fare much
better compared with individuals in whom a total
resection at or near to the dentate line had been
performed. Severity and duration of symptoms after low
anterior resection vary widely in the literature and seem
to depend on the population studied, the height of the
anastomosis, the time interval between operation and
follow-up examination, the observer bias and the criteria
used to define symptoms. Continence may be altered in
6 [28] to 87% [29] , defecatory urgency is reported
ranging from 8 [17] to 87% [29] and increased bowel
movements (> 3/day) in up to 75% [29] in these patients.
Figure 1. Mean stool frequency per day.
Figure 2. Anorectal continence.
Figure 3. Urgency to defaecate.
While there is general agreement that functional
disorders diminish with time, a considerable proportion
of patients continue to experience changes of their
bowel habits. Ortiz et al. [23] found an altered continence
in 52% of patients 1 year after surgery compared to 8%
in age-matched controls.
In an attempt to improve functional outcome
following rectal resection, Lazothes et al. [19] and Parc
et al. [25] have described the incorporation of
a colonic double loop reservoir anastomosed directly
to the anal canal. Although some investigators could
not demonstrate any substantial functional benefit [6],
several trials were able to show better results of the J-
pouch with regard to early postoperative anorectal
physiology and function compared with straight
coloanal anastomosis (Table 2). According to a recent
report, this functional superiority is sustained even
after a follow-up period of 2 years [18]. In the largest
prospective trial so far, Hallböök et al. [8] found a
mean stool frequency of 1.6/day in the pouch group
compared to 3.6/day in the straight coloanal group 1
year after the operation. Incontinence and urgency
were also significantly reduced in pouch patients.
patients with a large J-pouch [15]. In a large series by
Berger et al. [4], reporting on the functional outcome
of 162 patients with a coloanal pouch, an increase over
time was noted with regard to defecatory problems.
While 85% of the patients had spontaneous
evacuation 1 month after surgery, this declined
On the other hand, some authors have described
considerable evacuation difficulties in up to 70% of
32
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Sailer M, et al. Functional Results with Coloanal Pouch
Author
n
Months
postop.
Continence
Stools
> 3/dayå
Urge
Fragmen-
tation
Enema
Anti-
diarrhoe
I
II
III
IV
Lazorthes et al. [19]
Gross et al. [7]
Joo et al. [12]
P 20
S 42
7
7
60
43
20
24
20
26
0
7
40*
67*
10
24
0
19
10
19
–
–
P 10
S 11
5
5
90
18
–
–
–
64
–
18
–
–
–
–
–
–
–
–
–
–
P 44
S 39
6
6
2.0a*
5.3a*
4.7b*
6.5b*
7*
41*
–
–
–
–
–
–
Randomized studies
Hallböök et al. [8]
P 43
S 50
2
2
1.5c*
7.0c*
–
–
21*
70*
–
–
–
–
7*
42
Lazorthes et al. [18]
P 18
S 19
3
3
–
–
–
–
–
–
6
26
11*
63*
22*
63*
–
–
6
0
–
–
a
Tabelle 2. Functional results comparing coloanal J-pouch recons-
stool; IV: complete incontinence. Jorge and Wexner-score ranging
b
truction (P) with straight coloanal anastomosis (S) in the early
from 0 [normal continence] to 20 [complete incontinence]; mean
c
postoperative course (3 to 7 months). Values are given as percent.
(Continence I: normal continence; II:incontinence to gas; III: liquid
bowel movements/day; Millner-score ranging from 0 (normal
continence) to 18 [complete incontinence]; *p < 0.05.)
to 75% after 1 year. Furthermore, 21% suffered
from fragmented bowel movements. Progressive
deterioration of stool evacuation was also seen in
the randomized trial conducted by Hallböök et al. [8].
inconveniences. Furthermore, complete rectal resection
is of great importance, as a rectal stump exceeding 3 to
4 cm seems to also interfere with proper pouch
evacuation. Using a small reservoir of 5 to 7 cm we
observed only 1 patient who required enemas to assist
evacuation.
It was soon hypothesized that pouch size and/or the
part of the colon used for pouch construction (sigmoid
versus descending colon) are the major contributing
factors to poor pouch function [10]. A variety of sizes
ranging from 6 [7] to 12 cm [19] have been proposed.
Although a recent mathematic model by Banerjee et
al. [2] predicted an ideal limb length for pouch
construction of 8 to 10 cm, this was not confirmed in a
randomized trial conducted by Hida et al. [10] who
demonstrated that a 5-cm pouch conferred adequate
reservoir function without compromising evacuation as
opposed to a 10-cm pouch design. Lazorthes et al. [20]
performed a similar study randomizing 47 patients to
either 6 cm or 10 cm pouches. They did not find any
statistical difference with regard to defecation
frequency, urgency, and fecal continence between the 2
groups. However, at 2 years 40% of patients with a
large reservoir compared with 10% of patients in the
small-pouch group required laxatives and/or enemas to
assist bowel evacuation. The authors concluded that a
small pouch is preferred to avoid evacuation
In conclusion, our initial experience with colonic J-
pouch reconstruction shows good functional results. A
small pouch size of 5 to 7 cm adequately restores
anorectal function without compromising evacuation.
Pouch construction is usually easy to perform
and does not lead to an increased rate of perioper-ative
complications.Whether this leads to a better quality of
life needs to be investigated in a randomized trial which
is currently being conducted at our institution.
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