Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma.

Between 1977 and 1987, 519 patients underwent operation for rectal carcinoma. Sixty-three patients underwent intersphincteric resection with direct coloanal anastomosis (CAA), and 77 had an abdominoperineal resection (APR). Curative surgery was achieved in 57 and 65 patients, respectively. Both groups were comparable regarding age, stage of tumors, and localization of tumors. During the mean period of 6.7 years (range: 3 to 13.6 years), all patients were examined according to a predefined follow-up plan. From those patients with curative surgery, 11% presented with pelvic recurrence and 33% with distant metastases after coloanal anastomosis; the rates of recurrence and distant metastases after APR were 17% and 35%, respectively. The corrected 5-year survival rates were 62% following CAA and 53% following APR. Eighty-five percent of the patients with CAA reported good functional results regarding anal continence. Our study demonstrates that the intersphincteric resection with CAA is a valuable surgical technique for rectal carcinoma with the benefit of preservation of continence. It is suitable for neoplasms with high- and medium-grade differentiation (G1 to G2) and a localization that allows a minimum distal clearence of 3 cm.     

Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum

Rectal resection with colo-anal anastomosis was performed in 65 patients with carcinoma of the lower rectum. In 20 a pelvic colonic reservoir was constructed while in 45 a direct anastomosis was carried out. There were no postoperative deaths and morbidity was comparable in the two groups. Functional results were determined by clinical examination and manometry. The frequency of bowel movements was inversely related to the maximum tolerated volume (P less than 0.001). During the first year 60 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two stools per day (P less than 0.05). After one year, 86 per cent of the patients with a reservoir and 33 per cent of the patients without had one or two bowel movements per day (P less than 0.01). The maximum tolerated volume was increased by the reservoir (P less than 0.05). The loss of reservoir capacity of the rectum increases frequency of bowel movements in colo-anal anastomosis. The creation of a colonic reservoir improves function by increasing the maximum tolerated volume without any increase in mortality or morbidity.     

Cancer of the rectum--sphincter-saving operation. A new technique of coloanal anastomosis

The authors describe their technique providing total excision of the rectum and its muscular wall with an anastomosis between the colon and the anal canal at the level of the pectinate line for cancer of the low rectum. Of 20 patients, 17 had good functional results, two required later abdominoperineal resection for local recurrence, and one died of diffuse metastatic spread.     

Stapled coloanal anastomosis with reservoir procedure.

A closed-lumen procedure of coloanal anastomosis with a reservoir, performed exclusively with staplers to reduce spillage, is described. This stapling procedure provides three advantages: simplicity, reduction of spillage, and the preservation of sphincteric structures. In 33 procedures performed, 2 (6%) anastomotic leakages and 5 (15%) dilatable stenoses occurred.     

Sphincter-preserving surgery: per anal coloanal anastomosis

Since the introduction of the stapling technique, sphincter-preserving surgery for treatment of rectosigmoid and upper rectum carcinoma has been widely performed in the view of its radicality and postoperative quality of life. Sphincter preservation is still controversial in carcinoma of the lower rectum. Since we introduced per anal coloanal anastomosis (PAA) in 1980 and per anal intersphincteric dissection and coloanal anastomosis (PIDCA) in 1993 for the treatment of lower rectal carcinoma, the sphincter has been preserved in 78.7% of patients. There was no significant difference in the 5-year survival rate between patients in whom the sphincter was preserved and those who underwent abdominoperineal resection during the same period. PAA and PIDCA are safe when anastomosis must be performed at the dentate line. They are the best sphincter-preserving techniques for lower rectal carcinoma and do not result in serious postoperative dysfunction.     

Surgical treatment of lower rectal cancer with sphincter preservation using handsewn coloanal anastomosis

The present study was designed to evaluate the technical feasibility and oncologic results of performing handsewn coloanal anastomosis (CAA). A total of 46 patients treated for lower rectal cancer using CAA were retrospectively studied, and the oncologic results were compared with those of 105 patients treated with abdominoperineal resection (APR). CAA was performed in patients who had both good mobility of the tumor and a distal clearance margin of more than 1.0 cm. No significant difference was noted in the mortality rates following the two operations (CAA 2.2% vs APR 1.9%). Pelvic recurrence was detected in two patients (4.5%) after CAA and in six patients (7.2%) after APR. The 5-year survival rate after CAA was 79.2% and that after APR was 72.6%. No significant difference was noted in the incidence of pelvic recurrence or the survival rates between the two operations. These results show that CAA could be an excellent reconstructive option in the treatment of lower rectal carcinoma for selected patients.     

Functional results after “high” coloanal anastomosis and “low” coloanal anastomosis with a colonic J-pouch for rectal carcinoma

The aim of this study was to determine the postoperative function of neorectoanal components using two different types of very low coloanal reconstruction. The two groups of patients assessed were 22 who underwent abdominal rectal resection and stapled “high” coloanal anastomosis without a pouch, being the HCAA-P group; and 34 who underwent anoabdominal rectal resection and “low” coloanal anastomosis with a colonic J-pouch, being the LCAA+P group. Manometric metric examination was performed 1, 3, 6, and 12 months postoperatively, and the patients were also assessed by a questionnaire. The LCAA+P group had remarkably less daily stool frequency and urgency, but there were no significant differences in the other functional parameters. Maximum resting pressure (MRP) was significantly less, while threshold volume (TV) and maximum tolerable volume (MTV) were greater in the LCAA+P group than in the HCAA-P group. The colonic J-pouch compensated for decreased MRP. Thus, when HCAA-P is performed, 3.0 cm of residual rectum with internal anal sphincter may be required, and construction of the pelvic pouch is desirable in low coloanal anastomosis.     

Extended low anterior resection with stapled colorectal or coloanal anastomosis

The use of extended low anterior resection with the aid of the circular stapler for carcinomas of the middle third or upper part of the lower third of the rectum is discussed and salient technical points are emphasized. A collective survey of the results of the operation for such growths has led to the following conclusions: The immediate mortality and morbidity are not excessive. In most cases, even with anastomoses as low as 3.5-4.5 cm from the anal verge, anorectal function eventually reaches a satisfactory state, though there may be quite troublesome diarrhoea and possibly some incontinence during the initial 3-6 months after operation. Adequate data regarding 5-year survival are still lacking, but the high incidence of local recurrence in some reports is perplexing and disappointing and demands continued close attention.     

Resection of the stomach with Roux anastomosis

Results of surgical treatment of patients with gastric ulcer and cancer of the stomach using resection of the stomach with Roux technique were analyzed. Acid-producing and evacuatory functions of the stomach were assessed in different periods after surgery. Dynamic scintigraphy provided evaluation of indices of duodenogastric reflux and state of gastric mucous barrier after various types of surgeries. Quality of life was studied late after surgery with original questionnaire. It is concluded that Roux resection of the stomach is not inferior to Bilrot-I resection by functional results, but it has advantages by quality life and rate of operated stomach diseases compared with Bilrot-I and Bilrot-II techniques.     

Sphincter preserving techniques: from anterior resection to coloanal anastomosis

Nowadays surgery offers a complete spectrum of techniques for the treatment of rectal cancers. Progress in preoperative diagnostic techniques, especially in endoluminal ultrasound, and in the knowledge of anorectal physiology allows the surgeon to adopt a very individual strategy for the various tumor types. The situation has changed even for tumors of the middle and distal thirds of the rectum, which formerly were treated predominantly by abdominoperineal exstirpation. These can also be treated by sphincter-preserving techniques, the most ambitious of which is intersphincteric resection with coloanal anastomosis. Our experience shows that this method is not only comparable to the alternatives of conventional anterior resection and extirpation in terms of postoperative morbidity and mortality but also achieves excellent oncological results. Of course, anorectal function is significantly altered by this type of surgery. Still, after an adaptive period of about 6–12 months a very satisfactory functional result is reached. Further functional improvement, especially in the early postoperative period, can possibly be expected from reconstruction with creation of a colon pouch. Received: 21 November 1997 / Accepted: 10 September 1998     

Long-term prospective assessment of functional results after proctectomy with coloanal anastomosis

The objective of this study was to prospectively assess the long-term functional results after restorative proctectomy with coloanal anastomosis for rectal cancer. Thirty consecutive patients (18 males; mean age 59.6 ±9.8 years, range 40 to 75 years) underwent proctectomy with coloanal anastomosis for rectal cancer between January 1990 and March 1997. Cancers were located between 5 and 12 cm from the anal verge. Differences existed in the administration of adjuvant therapy and in the kind of anastomotic reconstruction. An 8 cm colonie J-pouch was fashioned in 11 patients. The coloanal anastomosis was protected by a diverting loop ileostomy in 22 patients. All patients were evaluated using a prospective patient-completed protocol to record daily bowel activity over a 1-week period at 3, 6, and 12 months, and yearly thereafter. Mean follow-up extends to 55.5 ±27 months (range 7 to 117 months). There were no perioperative deaths. Four patients (13.3%) developed a clinically evident anastomotic dehiscence. Overall, stool frequency decreased from 4.4 ±2.5 bowel movements per day at 3 months to 3.0 ±2.8 bowel movements per day at 5 years. Patients with a J-pouch had a lower stool frequency in comparison to patients with an end-to-end coloanal anastomosis during the entire study period (from 3.2 ±2.2 vs. 3.9 ± 2.7 bowel movements per day at 6 months to 2.8 ±1.9 vs. 3.4 ±4.0 bowel movements per day at 5 years; no statistical significance). The percentage of continent patients increased from 50% at 6 months to 75% at 5 years; the percentage of patients with incontinence for solid stool and with frequent incontinence (≥7 episodes per week) decreased from 35.7% at 6 months to 12.5% at 5 years. The influence of the type of anastomosis, dehiscence, protective stoma, J-pouch, radiation therapy, and gender was evaluated with univariate analysis. Although there was no statistically significant correlation between any of these variables and the development of incontinence, when incontinence occurred, a history of anastomotic dehiscence increased the number of episodes of incontinence per week and the percentage of episodes of incontinence for solid stools at 6 months, 2 years, and 5 years (P <0.05 and P <0.001, respectively); the use of preoperative radiation therapy increased the number of episodes of incontinence per week at 6 months, 1 year, 2 years, and 5 years (P <0.01) and the percentage of episodes of incontinence for solid stools at 3 and 6 months and 1 and 2 years (P <0.04); and the presence of a J-pouch increased the number of episodes of incontinence per week at 1 and 2 years (P <0.03 and 0.005, respectively) and the percentage of episodes of incontinence for solid stools at 2, 3, and 4 years (P <0.05). These data suggest that the functional results after proctectomy with coloanal anastomosis improve at least over the course of the first 5 postoperative years. Furthermore, when incontinence develops, its severity is made worse by the occurrence of an anastomotic dehiscence, the use of preoperative radiation therapy, and the presence of a J-pouch. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000.     

Functional results of colorectal and coloanal anastomosis with and without pouch

In the last two decades one of the main targets of anorectocolonic surgery has been to develop sphincter saving procedure able to achieve good results with acceptable five-years survivals, optimal local control of the diseases and low rate of local cancer recurrence. Partially the development of new operative techniques such as low colorectal and coloanal anastomoses with or without pouch, the TME operation and the nerve sparing procedure have reach this target. In fact, often after these operations we can observe a functional syndrome called "Post Anterior Resection Syndrome". The basis of this syndrome have to researched in anatomical and physiological alterations that followed a reconstructive operation. It is characterized by frequency and fragmentation of the stool, feeling of incomplete evacuation, tenesmus and urgency. Fecal continence may be compromised to different levels: usually with alteration limited to soiling and impaired control of flatus, occasionally with loss of liquid stool, rarely with loss of solid stools. The anorectal function will be altered for long time following the surgical procedure and the stabilization of functional results may require 1-3 years. On the basis of these considerations, the authors examine the etiopathogenesis and clinical presentation of the "Post Anterior Resection Syndrome", suggesting some expedients to prevent the functional problems. Analysing our experience and a wide specific bibliography, they also underline the indispensable point to achieve a good functional results after a reconstructive procedure. The author conclude asserting that the absence of these points have to be carefully valued because, in these situations, a simply colostomy is able to guarantee a better quality of life that a colorectal/coloanal anastomoses with or without pouch but associated to functional problems.     

Role of the rectum in the physiological and clinical results of coloanal and colorectal anastomosis after anterior resection for rectal carcinoma.

This study investigated the relationships between length of residual anorectum, anorectal physiological function and clinical outcome after anterior resection for rectal carcinoma. Thirty-four patients were studied a median of 13 (range 4-100) months after anterior resection. They were compared with a control group of ten patients who had undergone sigmoid colectomy for carcinoma without rectal excision. Resting anal pressure was found to be lower after coloanal than after colorectal anastomosis, and the capacity of the (neo)rectum was less after coloanal than after colorectal anastomosis. The (neo)rectoanal inhibitory reflex was found to be present in each patient, but maximum anal pressure during this 'sampling' reflex was significantly lower (P < 0.01) after coloanal than after colorectal anastomosis, and the volume required for maximal inhibition of the sphincter was also less (P < 0.01). At 1 year after operation, median bowel frequency was greater after coloanal (4 per day) than after colorectal (2 per day) anastomosis and the degree of urgency of defaecation was also greater (P < 0.01). Quality of life in terms of anorectal function after anterior resection is thus significantly influenced by the length of rectum that is left. This, in turn, influences the functional capacity of the neorectum and the degree of inhibition of the anal sphincter during the neorectoanal inhibitory reflex.     

Giant rectal villous adenoma: Surgical approach with rectal eversion and perianal coloanal anastomosis

INTRODUCTION

Colorectal cancer is an important cause of death. Most cases of colon and rectal cancer arise from a preexisting adenomatous polyp. However, if colorectal polyps are very large or not accessible for endoscopic ablation, or if they cannot be removed without an increased risk of perforation, surgical procedures are required.

PRESENTATION OF CASE

The case of a patient with a giant villous adenoma of the rectum is described. The patient had diarrhea for 2 years associated with asthenia. Colonoscopy revealed a sessile lesion in the rectum measuring 14 cm in the largest diameter. Rectal eversion technique was used, resecting the lesion under direct visibility and an external coloanal anastomosis was performed. Surgery was satisfactory and the resection margins were free.

DISCUSSION

Removal of these polyps should be performed aiming to reduce the incidence of colorectal cancer, as well as to control local and systemic symptoms, such as diarrhea and fluid and electrolyte disorders, mainly in villous adenomas. Various surgical techniques are proposed, but in extensive circumferential lesions of the rectum they are difficult to apply. The rectal stump eversion technique was described by Maunsell (1892), for rectal cancer.

CONCLUSION

Eversion of the rectal stump and external coloanal anastomosis may be a good surgical alternative for resecting giant rectal adenomas.     

Hand-sewn coloanal anastomosis for distal rectal cancer: Long-term clinical outcomes

As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n = 1), and anal stenosis (n = 7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.