Long-term functional outcome after low anterior resection

OBJECTIVE: The purpose of this study was to compare long-term functional results of two methods of reconstruction after anterior rectal resection for cancer: low colorectal anastomosis and colonic J-pouch-anal anastomosis. SUMMARY BACKGROUND DATA: After anterior resection for mid or low rectal cancer, the decision to perform low colorectal or coloanal anastomosis is made intraoperatively, depending on the distance of the tumor from the anal verge. Functional results of these operations are considered to be similar one to two years after surgery. No study to date has compared long-term functional results after rectal excision followed by either low colorectal anastomosis or colonic J-pouch-anal anastomosis. METHODS: From 1987 to 1992, 173 patients underwent anterior resection for cancer located between 2 to 12 cm from the anal verge. All patients alive without recurrence were contacted by telephone interview for assessment of functional results. There were 47 patients with colonic J-pouch-anal anastomosis and 34 patients with low colorectal anastomosis. Minimum follow-up was three years for all patients (mean, 5 years). RESULTS: The two groups were well matched for gender, age, histologic stage, and use of adjuvant therapies. Patients with colonic J-pouch-anal anastomosis displayed significantly better function in terms of frequency of defecation (1.57±1vs. 2.79±1;P=0.001) and presence of irregular transit or stool clustering (30vs. 71 percent;P=0.003). Patients who underwent colonic J-pouch-anal anastomosis were significantly less likely to require constipating agents (4vs. 21 percent;P=0.03) or need to follow a estricted diet (14vs. 41 percent;P=0.01). Results concerning the need to defecate again within one hour and disruption of social or professional life as a consequence of surgery showed a tendency in favor of colonic J-pouch-anal anastomosis. CONCLUSION: Colonic J-pouch-anal anastomosis offers superior long-term function compared with low colorectal anastomosis after radical treatment of rectal cancer. Preservation of a short rectal segment followed by a straight colorectal anastomosis does not offer any clinical advantage over colonic J-pouch-anal anastomosis.Poster presentation at the Digestive Disease Week and the meeting of the American Gastroenterological Association, Washington, D.C., May 11 to 14, 1997.     

Preoperative Radiotherapy Improves Outcome in Recurrent Rectal Cancer

PURPOSE When local recurrent rectal cancer is diagnosed without signs of metastases, a potentially curative resection can be performed. This study was designed to compare the results of preoperative radiotherapy followed by surgery with surgery only.METHODS Between 1985 and 2003, 117 patients with recurrent rectal cancer were prospectively entered in our database. Ninety-two patients were suitable for resection with curative intent. Preoperative radiation with a median dosage of 50 Gy was performed in 59 patients; 33 patients did not receive preoperative radiotherapy. The median age of the patients was respectively 66 and 62 years.RESULTS The median follow-up of patients alive for the total group was 16 (range, 4–156) months. Tumor characteristics were comparable between the two groups. Complete resections were performed in 64 percent of the patients who received preoperative radiation and 45 percent of the nonirradiated patients. A complete response after radiotherapy was found in 10 percent of the preoperative irradiated patients (n = 6). There were no differences in morbidity and reintervention rate between the two groups. Local control after preoperative radiotherapy was statistically significantly higher after three and five years (P = 0.036). Overall survival and metastases-free survival were not different in both groups. Complete response to preoperative radiotherapy was predictive for an improved survival.CONCLUSIONS Preoperative radiotherapy for recurrent rectal cancer results in a higher number of complete resections and an improved local control compared with patients treated without radiotherapy. Preoperative radiotherapy should be standard treatment for patients with recurrent rectal cancer.     

Evaluation of preoperative and postoperative radiotherapy on long-term functional results of straight coloanal anastomosis

PURPOSE: Preoperative radiotherapy for rectal cancer avoids radiation to the reconstructed rectum and may circumvent the detrimental effects on bowel function associated with postoperative radiotherapy. We compared the long-term functional results of patients who received preoperative radiotherapy, postoperative radiotherapy, or no radiotherapy in conjunction with low anterior resection and coloanal anastomosis to assess the impact of pelvic radiation on anorectal function. METHODS: One hundred nine patients treated by low anterior resection and straight coloanal anastomosis for rectal cancer between 1986 and 1997 were assessed with a standardized questionnaire at two to eight years after resection. All radiotherapy was given to a total dose of 4,500 to 5,400 cGy with conventional doses and techniques. Most patients received concurrent 5-fluorouracil–based chemotherapy. RESULTS: There were 39 patients in the preoperative radiotherapy group, 11 patients in the postoperative radiotherapy group, and 59 patients in the no radiotherapy group. The postoperative radiotherapy group reported a significantly greater number of bowel movements per 24-hour period (P < 0.01) and significantly more episodes of clustered bowel movements (P < 0.02) than either the preoperative radiotherapy group or the no radiotherapy group. No significant difference in anal continence or satisfaction with bowel function was found among the three groups. CONCLUSION: In this study of straight (nonreservoir) coloanal anastomoses, postoperative pelvic radiotherapy had significant adverse effects on anorectal function, with higher rates of clustering and frequency of defecation than with preoperative radiotherapy. No differences in continence rates were demonstrated, perhaps because of the sample size of the compared groups. We attribute the adverse effects of postoperative radiotherapy to irradiation of the neorectum, which is spared when treatment is given preoperatively. The deleterious effects of adjuvant radiation on long-term anorectal function can be reduced by preoperative treatment.     

Influence of preoperative high-dose radiotherapy on postoperative outcome and colonic anastomotic healing

PURPOSE: Surgical treatment of rectal cancer is followed by local recurrence in up to 30 percent of cases. Recently, preoperative low-dose radiotherapy has been shown to improve both local recurrence rate and overall survival. Down-staging of locally advanced tumors, however, requires preoperative doses of at least 50 to 60 Gy. Most experimental studies investigating the effect of preoperative radiotherapy have made use of a single dose or a limited number of fractionated doses. Moreover, in most studies, both limbs of the anastomosis were irradiated, in contrast to clinical practice, in which one limb of the anastomosis consists of nonirradiated bowel. We studied the effect of a fractionated, clinically relevant scheme of high-dose preoperative radiotherapy on colonic anastomotic healing in the rat. METHODS: Male Wistar rats randomly received 0, 40, 60, or 80 Gy of preoperative radiotherapy on one limb of the anastomosis only. Radiotherapy doses were validated with implanted dosimeters; before the start of radiotherapy, the cecum was fixed outside the radiation field. A clinically used fractionation scheme of 2 Gy per day, 5 days per week for 4 to 8 weeks was used. The day after radiotherapy completion, a side-to-side colorectal anastomosis was performed. Rats were killed 10 days after surgery. The following parameters were determined: presence of abscess or peritonitis, anastomotic complications (stenosis, leak, or dehiscence), intestinal obstruction, anastomotic bursting pressure, and anastomotic hydroxyproline content. RESULTS: No significant differences were found in peritonitis rate, anastomotic complications, anastomotic bursting pressure, or hydroxyproline content. Irradiated animals gained weight more slowly than the control group. CONCLUSION: In this rat model, preoperative high-dose radiotherapy using a clinically relevant fractionation scheme does not affect outcome or anastomotic healing when only one limb of the anastomosis is irradiated.     

Techniques for restoring bowel continuity and function after rectal cancer surgery

INTRODUCTION The most important priority in the surgical management of mid and distal rectal cancers is adequate oncologic clearance. It is generally accepted that this is achievable by total mesorectal excision, although in Japan extended pelvic lymphade…     

Stapled colonic J-pouch-anal anastomosis without a diverting colostomy for rectal carcinoma

PURPOSE: Colonic J-pouch reconstruction is designed to improve functional outcome of coloanal anastomosis. Most surgeons use a diverting colostomy to avoid severe pelvic sepsis caused by anastomotic breakdown. METHODS: We report the outcome of 30 consecutive patients with colonic J-pouch-anal anastomosis without a diverting colostomy performed between November 1992 and October 1993. All patients had carcinoma of the lower two-thirds of the rectum. Patients were seen every three months. Functional results were compared with those of 21 rectal cancer patients with straight coloanal anastomosis who underwent surgery in the same period and 20 normal patients. RESULTS: There were two anastomotic leakages and one postoperative death. After one year, patients with pouch anastomosis had significantly less frequency of defecation and rectal urgency compared with those with straight anastomosis (P <0.01); 48 percent of patients with straight anastomosis had more than five bowel movements per day, whereas all patients with pouch anastomosis had five or less bowel movements per day. Manometric studies showed maximum tolerable volume was significantly higher in patients with pouch anastomosis (81 vs. 152 ml;P <0.01). CONCLUSIONS: Stapled colonic J-pouch-anal anastomosis without a diverting colostomy is a reliable procedure that provides good, long-term functional results.Supported by National Science Council, Taiwan, Research Grant NSC 83-0412-B182-021.Read at the meeting of the International Society of University Colon and Rectal Surgeons, Singapore, Singapore, July 2 to 6, 1994.     

Quality of life after proctocolectomy with ileoanal anastomosis for patients with ulcerative colitis

Ulcerative colitis, a chronic inflammatory disease of the rectal and colonic mucosa, affects approximately 250,000 to 500,000 people in the United States, with 30% to 40% of patients requiring some form of surgical intervention during the course of their disease. The predominant reason for total proctocolectomy is for symptoms refractory to currently available medical therapy. Less common reasons are dysplasia or cancer. The goal of colectomy is to prevent recurrence of systemic inflammatory disease. Consequently, surgery with total proctocolectomy and creation of an ileal J-pouch-anal anastomosis has become the procedure of choice for many patients without other therapeutic options. Health-related quality of life (QOL) in patients with severe ulcerative colitis is so poor that, after ileal J-pouch-anal anastomosis, QOL is considered to improve in most clinical studies (8 studies, improved QOL; 1 study, no change; 1 study, QOL worse than general population). However, QOL and bowel function after such surgery cannot be considered "normal" in all patients, because a substantial number still have problems with urgency, leakage, nocturnal soiling, sexual dysfunction, and pouchitis, and some require conversion to a permanent ileostomy after ileal J-pouch-anal anastomosis failure. Thus, despite the availability of ileal J-pouch-anal anastomosis, surgery does not always restore all aspects of QOL to normal.     

Colonic J-Pouch-Anal Anastomosis for Rectal Cancer: A Prospective, Randomized Study Comparing Handsewn vs. Stapled Anastomosis

PURPOSE Colonic J-pouch-anal anastomosis performed after complete proctectomy and total mesorectal excision for adenocarcinoma of the rectum can be handsewn or stapled. Stapling the coloanal anastomosis is believed to shorten operating time and reduce morbidity, but there are no randomized trials comparing the techniques.METHODS Between January 1999 and May 2001, all patients with rectal adenocarcinoma requiring total mesorectal excision were randomized intraoperatively to handsewn or stapled anastomosis. Mortality, intraoperative, and postoperative findings and functional results at 3, 6, and 12 months were analyzed.RESULTS Thirty-seven patients (12 females; mean age, 60 ± 10 years) were randomized (stapled group: n = 20; handsewn group: n = 17). The two groups were comparable for age, gender, distance between the tumor and the levator ani, tumor volume, and use of preoperative radiotherapy (3 in each group). Morbidity did not differ between stapled group (3/20) and handsewn group (4/17; P > 0.05). Mean ± standard deviation operative time was shorter in stapled group (261 ± 40 minutes) than in handsewn group (314 ± 46 minutes; P = 0.0008), and median distance between the anastomosis and the anal verge was shorter in handsewn group (19 ± 9 mm) than in stapled group (27 ± 8 mm; P = 0.01). Three patients of handsewn group and none of stapled group developed an anastomotic stricture requiring a single digital dilation (not significant). Number of stools per 24 hours, urgency, incidence of fragmented stools, degree of continence, requirement for protective pad, and/or need to take medication at 3, 6, and 12 months were similar in both groups.CONCLUSIONS Stapled coloanal anastomosis is significantly faster than handsewn CAA and has similar functional results. It should be the preferred technique when it is feasible.Reprints are not available.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, June 3 to 8, 2002, and at the meeting of the European Association of Coloproctology, Erlangen, Germany, September 12 to 14, 2002.     

Misconceptions about the colonic J-pouch

INTRODUCTION: Since 1986 when the colonic J-pouch-anal anastomosis was first described, it has gained increasing acceptance as the operation of choice for low rectal cancer surgery. However, there still exist several misconceptions about its use, namely anastomotic complications, alterations in anorectal physiology, and functional outcome. METHODS: All relevant articles derived from MEDLINE databases from 1986 to the present were reviewed. Emphasis was placed on reviewing the features that are claimed to make the colonic J-pouch-anal anastomosis superior to a straight anastomosis. RESULTS AND CONCLUSIONS: The colonic J-pouch has a role in ultra-low rectal cancer surgery, with an apparent reduction in the incidence of anastomotic leaks and reduced bowel frequency. Continence is unchanged and defecatory difficulties can be reduced by constructing a small pouch (< or =5 cm).     

Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse

Purpose This study examines whether preoperative anal manometry and pudendal nerve terminal motor latency predict functional outcome after perineal proctectomy for rectal prolapse. Methods All adult patients treated by perineal proctectomy for rectal prolapse from 1995 to 2004 were identified (N = 106). Forty-five patients underwent anal manometry and pudendal nerve terminal motor latency testing before proctectomy and they form the basis for this study. Results Perineal proctectomy with levatoroplasty (anterior 88.9 percent; posterior 75.6 percent) was performed in all patients, with a mean resection length of 10.4 cm. Four patients (8.9 percent) developed recurrent prolapse during a 44-month mean follow-up. Preoperative resting and maximal squeeze pressures were 34.2 ± 18.3 and 60.4 ± 30.5 mmHg, respectively. Pudendal nerve terminal motor latency testing was prolonged or undetectable in 55.6 percent of patients. Grade 2 or 3 fecal incontinence was reported by 77.8 percent of patients before surgery, and one-third had obstructed defecation. The overall prevalence of incontinence (77.8 vs. 35.6 percent, P < 0.0001) and constipation (33.3 vs. 6.7 percent, P = 0.003) decreased significantly after proctectomy. Patients with preoperative squeeze pressures >60 mmHg (n = 19) had improved postoperative fecal continence relative to those with lower pressures (incontinence rate, 10 vs. 54 percent; P = 0.004), despite having similar degrees of preoperative incontinence. Abnormalities of pudendal nerve function and mean resting pressures were not predictive of postoperative incontinence. Conclusions Perineal proctectomy provides relief from rectal prolapse, with good intermediate term results. Preoperative anal manometry can predict fecal continence rates after proctectomy, because patients with maximal squeeze pressures >60 mmHg have significantly improved outcomes. Supported exclusively using institutional funding. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Colonic J-pouch function in rectal cancer patients

PURPOSE: The colonic J-pouch technique of reconstruction optimizes functional outcome after proctectomy with coloanal anastomosis. However, the impact of adjuvant chemoradiation therapy on pouch function in rectal cancer patients has not been investigated. METHODS: From January 1994 to December 1999, 74 patients with midrectal or low rectal tumors (less than 10 cm from the anal verge) underwent a proctectomy with coloanal anastomosis with colonic J-pouch reconstruction. Chemoradiation was offered in patients with Stage II and III disease. Radiation therapy was administered using a four-field technique including the anal canal, for a total dose of 50.4 Gy (1.8 Gy/fraction/day). Fifteen patients (20 percent) died with metastatic disease, five (6.8 percent) died of other causes without evidence of recurrence, and five (6.8 percent) were lost to follow-up. In addition, two patients had local recurrence (2.7 percent) at the time of follow-up. Forty-five of 47 eligible patients (96 percent) responded to a questionnaire designed to evaluate specifically the degree of continence and pouch evacuation. RESULTS: The mean age of patients was 68.9 (range, 42–88) years and the mean duration of follow-up was 28.8 (range, 1–69) months. There were 28 patients in the surgery alone group and 17 patients who received either preoperative (13) or postoperative (4) adjuvant chemoradiation therapy. Patients in the surgery alone group had a significantly better degree of continence (mean ± standard deviation continence score: 18.1 ± 2.9vs. 13.3 ± 4.1,P<0.001) and were less likely to experience evacuatory problems (mean ± standard deviation evacuation score: 21.3 ± 3.7vs. 16.4 ± 3.5,P<0.001). Use of a pad was more frequent in the chemoradiation therapy than in the surgery alone group (53vs. 18 percent,P=0.02). The incidence after functional disorders was also more frequent in the irradiated group of patients: incontinence to gas (76vs. 43 percent,P=0.03), to liquid stool (64vs. 25 percent,P=0.01), and to solid stool (47vs. 11 percent,P=0.01). Moreover, irradiated patients reported more frequent pouch-related specific problems, such as clustering (82vs. 32 percent,P=0.001), and sensation of incomplete evacuation (82vs. 32 percent,P=0.001). Finally, regression analysis demonstrated that radiation-induced sphincter dysfunction was progressive over time. CONCLUSIONS: Both preoperative and postoperative chemoradiation therapy adversely affects continence and evacuation in patients with colonic J-pouch. Because radiation-induced damage to the normal tissues is known to be cumulative over time, long-term progressive dysfunction of the anal sphincter and neorectum are causes of concern. Consideration should be given to excluding the anal canal from the field of irradiation in patients with Stage II and III rectal cancer, whenever a sphincter-preserving procedure is planned.P. Gervaz is a recipient of the James Ewing Young Investigator Award for clinical research by the Society of Surgical Oncology. Supported in part by the Caporella Family     

Defecation mechanisms after anterior resection with J-pouch-anal and side-to-end anastomosis in dogs

Background Colonic J-pouch-anal anastomosis or colonic side-to-end anastomosis is the reconstruction of choice after low anterior resection. However, the mechanisms of defecation after both reconstruction forms are still speculative. Methods Low anterior rectal resections were performed in 12 dogs with six colonic J-pouch-anal (pouch) and six coloanal side-to-end (SE) reconstructions. Four months postoperative stool frequency, intestinal transit time, and neorectal compliance were determined by radiography and barostat. Defecation mechanisms were evaluated radiographically during expulsion of artificial stool. Results One dog with pouch reconstruction could not be evaluated due to an anastomotic leak, while the others had uncomplicated course. Spontaneous stool frequency was significantly increased with both reconstruction methods (control 2.0±0.9, pouch 2.7±1.2, SE 3.3±0.9 day; p<0.05). Intestinal transit time was significantly higher with pouch reconstruction due to storage of stool in the pouch and the descending colon compared to SE (control 760±82, pouch 592±97, SE 550±87 min; p<0.05). Compliance and functional capacity were higher in pouch than in side-to-end reconstructions (pouch 5.0±0.7 ml/mmHg, 124±23 ml; SE 2.7±0.3 ml/mmHg, 92±24 ml; p<0.05). During defecation, there were no contractions of the pouch detectable. Conclusions The colonic J-pouch reconstruction results in better functional outcome than side-to-end coloanal anastomosis. Our results show that pouch evacuation is passive and independent from pouch motility. The functional principle of the colonic J-pouch is not its reservoir function but a delay of colonic motility.     

Familial adenomatous polyposis

PURPOSE: Virtually all untreated patients with familial adenomatous polyposis develop colorectal carcinoma. Thus, prophylactic colectomy is indicated. Detractors of ileal pouch-anal anastomosis prefer ileorectal anastomosis for teenagers because of the potential negative impact of ileal pouch-anal anastomosis on quality of life. The aim of this study was to assess the effects on quality of life of ileal pouch-anal anastomosis in teenagers with familial adenomatous polyposis. METHODS: Between 1981 and 1998, 48 teenagers underwent ileal pouch-anal anastomosis for familial adenomatous polyposis. One patient had proctectomy and ileal pouch-anal anastomosis after previous ileorectal anastomosis. A temporary diverting loop ileostomy was established in 42 patients (87.5 percent). One patient had colonic carcinoma diagnosed preoperatively. Two other patients were found to have unsuspected rectal cancer at surgery. Mean follow-up (± standard deviation) in 43 patients was 80.5±42 months. RESULTS: There was no immediate postoperative mortality. Postoperative complications included pelvic sepsis (3 patients; 1 requiring reoperation) and bleeding (1 patient; no surgery required). One patient died of metastatic colonic carcinoma. Ten patients required reoperation, seven had bowel obstruction, one had portal hypertension, and two required an ileostomy. The mean (± standard deviation) daytime and nighttime stool frequency was 4±1.5 and 1±1, respectively. One patient reported daytime and nighttime incontinence, and two patients reported nighttime incontinence only. No patient experienced impotence or retrograde ejaculation. Social, sexual, sport, housework, recreation, family, travel, and work activities were improved or unchanged in 82.5, 87, 80, 90, 80, 92.5, 77.5, and 89 percent of patients, respectively. Three male patients fathered children, and three female patients had a total of six children after normal pregnancies and deliveries. CONCLUSION: The impact of ileal pouch-anal anastomosis on quality of life was favorable in the majority of teenagers. The risk of rectal cancer should be the major consideration before proposing an operation to teenagers with familial adenomatous polyposis.Poster presentation at The American Society of Colon and Rectal Surgeons' 100th Anniversary and Tripartite Meeting, Washington, D.C., May 1 to 6, 1999.     

Colonic Surgery in Patients With Juvenile Polyposis Syndrome: A Case Series

PURPOSE Juvenile polyposis syndrome is characterized by multiple hamartomatous polyps in the large intestine. When indicated, the surgical choices in symptomatic juvenile polyposis syndrome patients are colectomy with ileorectal anastomosis or proctocolectomy with pouch. The aim of this study was to evaluate the long-term outcomes of the surgical options in juvenile polyposis syndrome patients who present with symptomatic colonic polyps.METHODS The charts of all juvenile polyposis syndrome patients who had had at least one colonic operation since 1953 in our institution were reviewed. The following data were abstracted: demographics, the number and site of the polyps, symptoms, the intervals and types of the colonic operation, follow-up, and the patients current status.RESULTS There were 13 patients (6 males) with a median age of 10 years (range, 1–50 years) at the time of diagnosis. Patients had colonic (n = 13), rectal (n = 12), and gastric (n = 6) polyps. Rectal bleeding (n = 11) was the most common presenting symptom. Three patients underwent proctectomy as the initial operation. Although a rectum-preserving operation was initially performed in ten patients, a subsequent proctectomy was required in five of them within a median of 9 years (range, 6–34 years). Therefore, eight patients had their rectum removed during the study period; five had an ileal pouch–anal anastomosis, one had a Koch pouch as a restorative surgery, and two had an end ileostomy. No relation was observed between the number of colonic and rectal polyps and the type of surgery or the need for proctectomy. Patients were followed up a median of 3 years (range, 2–24 years) after their ultimate operations. During this period, one patient (20 percent) who underwent restorative proctectomy and 4 patients (80 percent) whose rectums were preserved required multiple endoscopic polypectomies for recurrent polyps in the pouch (first patient) or their rectums (the other four patients). The patient who underwent the Koch procedure required surgery for recurrent polyps in her pouch.CONCLUSIONS One-half of the patients who initially underwent rectal preservation required subsequent proctectomy. The number of colonic or rectal polyps does not influence the choice of the surgical procedure. Both restorative proctocolectomy and subtotal colectomy with ileorectal anastomosis need endoscopic follow-up because of the high recurrence rates of juvenile polyps in the remnant rectum or pouch.     

结肠J型贮袋在高龄低位直肠癌患者保肛手术后控便功能中的作用

目的评价采用J型贮袋在高龄患者保肛手术后改善排便机能中的价值。方法选取2002年2月至2003年8月诊治的39例高龄（≥75岁）低位直肠癌患者。按手术方式分成两组,传统的结肠断端与直肠肛管直接端端吻合组（直吻组）,结肠J型贮袋与直肠肛管行端侧吻合组（贮袋组）,对保肛手术后控便情况进行调查研究。结果术后排便次数正常的时间：贮袋组优于直吻组（P〈0.01）。术后3个月、半年,贮袋组平均排便次数明显少于直吻组（P〈0.05）;延缓排便控制能力、失禁综合评分、区分排便排气能力等指标均优于直吻组（P〈0.05）;但术后1年及1年半,两组控便能力差异无显著性（P〉0.05）。贮袋组直肠测压值优于直吻组。术后控便情况满意率贮袋组高于直吻组。采用贮袋吻合术后便秘的发生率高于直接吻合术（P〈0.01）。结论（1）高龄不是结肠贮袋直肠肛管吻合术的禁忌证;（2）采用结肠贮袋直肠肛管吻合术能够明显改善高龄患者术后1年内控便功能。     

Preoperative Chemoradiation for Rectal Cancer Causes Prolonged Pudendal Nerve Terminal Motor Latency

Purpose A worsened anorectal function after chemoradiation for high-risk rectal cancer is often attributed to radiation damage of the anorectum and pelvic floor. Its impact on pudendal nerve function is unclear. This prospective study evaluated the short-term effect of preoperative combined chemoradiation on anorectal physiologic and pudendal nerve function. Methods Sixty-six patients (39 men, 27 women) with localized resectable (T3, T4, or N1) rectal cancer were included in the study. All patients received 45 Gy (1.8 Gy/day in 25 fractions) over five weeks, plus 5-fluorouracil (350 mg/m²/day) and leucovorin (20 mg/m²/day) concurrently on days 1 to 5 and 29 to 33. Patients who had rectal cancer with a distal margin within 6 cm of the anal verge had the anus included in the field of radiotherapy (Group A, n = 26). Patients who had rectal cancer with a distal margin 6 to 12 cm from the anal verge had shielding of the anus during radiotherapy (Group B, n = 40). The Wexner continence score, anorectal manometry and pudendal nerve terminal motor latency were assessed at baseline and four weeks after completion of chemoradiation. Results The median Wexner score deteriorated significantly (P < 0.0001) from 0 to 2.5 for both Groups A (range, 0–8) and B (range, 0–14). The maximum resting anal pressures were unchanged after chemoradiation. The maximum squeeze anal pressures were reduced (mean = 166.5–157.5 mmHg) after chemoradiation. This change was similar in both Groups A and B. Eighteen patients (Group A = 7, Group B = 11) developed prolonged pudendal nerve terminal motor latency after chemoradiation. These 18 patients similarly had a worsened median Wexner continence score (range, 0–3) and maximum squeeze anal pressures (mean = 165.5–144 mmHg). The results obtained were independent of tumor response to chemoradiation. Conclusions Preoperative chemoradiation for rectal cancer carries a significant risk of pudendal neuropathy, which might contribute to the incidence of fecal incontinence after restorative proctectomy for rectal cancer. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

H-Pouch: New Isoperistaltic Colonic Pouch For Coloanal Anastomosis After Rectal Resection For Cancer. A Pilot Study

PURPOSE To date, there is a consensus to consider colonic J-pouch-anal anastomosis as the standard form of reconstruction after proctectomy for cancer. However, one drawback of colonic J-pouch is evacuation difficulties, which are observed at some degree in almost one-half of patients. To improve functional outcome after coloanal anastomosis, we describe a new technique of isoperistaltic colonic H-pouch.METHODS The functional results after construction of this pouch were assessed prospectively in ten patients and compared with those obtained in a control group of matched patients with a colonic J-pouch.RESULTS At six months and one year, there were no differences between both pouches for bowel function, continence score, and evacuation difficulties.CONCLUSIONS This preliminary study showed that the creation of a new isoperistaltic colonic H-pouch did not improve the functional results after coloanal anastomosis compared with colonic J-pouch. Because colonic H-pouch is technically more complex to fashion, it should not be performed routinely and the J-pouch remains the benchmark for routine clinical practice.Presented at the meeting of the French Society of Digestive Surgery, Paris, France, March 29 to April 2, 2003.     

Improvement of Colonic Healing by Preoperative Rectal Irrigation With Short-Chain Fatty Acids in Rats Given Radiotherapy

BACKGROUND We investigated the effect of preoperative rectal irrigation with short-chain fatty acids on irradiated colonic anastomosis in rats.METHODS Sixty male Wistar rats were divided into four groups. Group I (control group, n = 15) underwent left colon resection and primary anastomosis. Group II (Short-chain fatty acids pretreatment group, n = 15) had short-chain fatty acids rectal irrigation for five days preoperatively. Group III (preoperative radiotherapy group, n = 15) underwent irradiation to the whole pelvis eight and four days before the operation, for a total dose of 20 Gy. Group IV (preoperative radiotherapy group + short-chain fatty acids pretreatment group, n = 15) had rectal irrigation with short-chain fatty acids for five days after the second irradiation. Within each group, animals were anesthetized to assess the clinical, mechanical, histologic, and biochemical parameters of anastomotic healing on either the third or seventh postoperative days.RESULTS The mean bursting pressure was significantly low in Group III on Day 3 and was significantly high in Group IV on Day 7 (P = 0.001, P = 0.021). The burst occurred at the anastomoses in all animals tested on the third postoperative day, and outside of the anastomoses in all animals tested on the seventh postoperative day. The histologic parameters of anastomotic healing, such as epithelial regeneration and formation of granulation tissue, were significantly improved by use of preoperative rectal irrigation with short-chain fatty acids on Day 7. The amount of total and salt-soluble collagen concentrations significantly increased in Group IV compared with the control group on Day 3 (P = 0.008, P = 0.004).CONCLUSION Some mechanical and histologic aspects of colonic anastomotic healing can be adversely affected by preoperative radiotherapy, but rectal irrigation with short-chain fatty acids may improve anastomotic healing.Supported by The Turkish Surgical Society, as funded by a grant from the Sanofi Pharma.     

Proctectomy and coloanal reconstruction for rectal cancer

There is increasing interest in the use of coloanal reconstruction following proctectomy for low rectal cancer. The authors review the surgical options for such sphincter-saving approaches, and report their pilot experience with eight patients receiving high-dose preoperative radiation with subsequent proctectomy and endoanal anastomosis. There were no anastomotic leaks.     

Predicting polyposis severity by proctoscopy

PURPOSE: Patients with familial adenomatous polyposis need prophylactic colectomy and ileorectal anastomosis or restorative proctocolectomy. Preoperative rectal polyp counts have been used as one factor to determine which operation should be done, triaging patients according to risk of rectal cancer or completion proctectomy after ileorectal anastomosis. This study was designed to examine the reliability of preoperative proctoscopy in predicting familial adenomatous polyposis severity and outcome after ileorectal anastomosis. METHODS: Familial adenomatous polyposis patients were categorized according to preoperative proctoscopy as follows: Group 1, 5 or fewer adenomas; Group 2, 6 to 19 adenomas; Group 3, 20 or more adenomas. Familial adenomatous polyposis severity was defined as mild if there were <1,000 polyps in the colon at colectomy and severe if there were >1,000 polyps. RESULTS: A total of 213 patients were reviewed, 80 in Group 1, 59 in Group 2, and 74 in Group 3. There was no difference among the groups in mean age at presentation. Patients with fewer than five rectal adenomas were predominately females. They rarely had symptoms (22.8 percent), had mostly mild polyposis (86.5 percent), and in 74 of 80 cases underwent ileorectal anastomosis. Only six underwent restorative proctocolectomy. Of those having an ileorectal anastomosis, five needed later proctectomy, none for cancer. Patients with 6 to 19 rectal polyps were a similar group to those with 5 or fewer. Most were asymptomatic (67.8 percent), most had mild polyposis (81.6 percent), and 54 of 59 underwent ileorectal anastomosis (5 had restorative proctocolectomy). Only 3 of the 54 having ileorectal anastomosis needed subsequent proctectomy, 2 for rectal cancer. The patients with 20 or more rectal polyps were different. They usually presented with symptoms (86 percent), the majority (56.6 percent) had severe polyposis, and only 50 percent (37/74) underwent ileorectal anastomosis, the other half having restorative proctocolectomy. Of the 37 patients with an ileorectal anastomosis, 13 needed later proctectomy (35.1 percent), 4 for cancer (10.8 percent). CONCLUSION: Fewer than five rectal adenomas at presentation almost always predicts mild disease, and patients do well after ileorectal anastomosis. Twenty or more adenomas usually means severe disease. Patients with 6 to 19 adenomas are often mildly affected, but their phenotype is less benign than that of patients with fewer than five polyps. Although not foolproof, proctoscopy is a useful test in triaging patients with familial adenomatous polyposis according to disease severity.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.