Transabdominal Anastomosis After Low Anterior Resection: A Prospective, Randomized, Controlled Trial Comparing Long-Term Results Between Side-to-End Anastomosis and Colonic J-Pouch

PURPOSE Colonic J-pouch has been constructed to overcome reservoir dysfunction after restorative rectal surgery, whereas no effort has been made for sphincter dysfunction. We conducted a prospective, randomized study comparing surgical and functional outcomes between side-to-end anastomosis and colonic J-pouch after low anterior resection in which the anastomosis was constructed from the abdomen. METHODS Fifty-six consecutive patients with middle-to-low rectal cancer undergoing low anterior resection were randomly assigned to side-to-end or colonic J-pouch group preoperatively. Surgical outcomes of all the patients were recorded. Patients underwent functional evaluation, including anorectal manometry and functional assessment, preoperatively and then 3 months, 6 months, 1 year, and 2 years postoperatively. RESULTS Twenty-four patients in each group completed the study. The demographic data and preoperative functional assessment did not differ between the two groups. There was no significant difference in surgical outcomes with regard to anastomotic height (5 cm), blood loss, protective colostomy, operative time, complications, and adjuvant therapy. Anal pressures showed no significant change postoperatively and during the follow-up period; there were no differences between the two groups. Temporal minor fecal incontinence was noted in the early postoperative period in both groups. With regard to bowel function, a significant reduction of volume of urgency and maximal tolerable volume was found postoperatively in both groups; however, a faster recovery was noted in the colonic J-pouch group. Stool frequency increased significantly after surgery in both groups; however, in contrast to rectal volume, a faster recovery was noted in the side-to-end group. CONCLUSIONS Anastomosis after low anterior resection for middle to low rectal cancer could be performed safely from the abdomen. It minimized sphincter injury and showed good continence preservation. On the other hand, the surgical outcomes and long-term functional results of side-to-end anastomosis were comparable with colonic J-pouch. Side-to-end anastomosis provides an easier, alternative way for reconstruction after restorative rectal surgery. Supported by Taipei Veterans General Hospital Research Fund (VGH 90-B-262). An erratum to this article is available at .     

Comparison of different J-pouchesvs. straight and side-to-end coloanal anastomoses

PURPOSE: Functional results after low anterior resection with straight coloanal anastomosis are poor. Although certain functional aspects are improved with coloanal J-pouch anastomosis, evacuation difficulties are encountered in some of these patients. The aim of the study was to investigate the functional results of different reconstruction methods after low anterior resection in a standardized pig model. METHODS: Thirty-two adult Göttinger mini pigs were randomly assigned either to straight end-to-end (Group 1), side-to-end (Group 2), small (4-cm limb length) J-pouch (Group 3), or large (8-cm limb length) J-pouch (Group 4) coloanal anastomosis after low rectal excision. The animals were investigated 12 weeks after the operation by measuring neorectal compliance and ceruletide-induced defecation. Eight pigs without operation were used as controls (Group 5). RESULTS: Compliance was lowest in Groups 1 and 2, which were significantly different compared with both pouch designs and controls. Neorectal compliance of pigs with either small or large pouches did not differ significantly compared with one another or controls. Defecation was significantly impaired in pigs with a large pouch compared with all other groups. Pigs with side-to-end anastomoses had as rapid an evacuation as animals with straight coloanal reconstruction. CONCLUSION: Coloanal J-pouch reconstruction adequately restores reservoir capacity after low anterior resection of the rectum. From a functional point of view, side-to-end is not superior to straight coloanal anastomosis. Compared with small pouches, a large pouch design does not lead to better neorectal compliance in the pig model, whereas pouch evacuation seems to be considerably compromised.     

Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch

PURPOSE: Functional outcome after low anterior resection with ultralow coloanal anastomosis for rectal cancer is improved by construction of a colonic J-pouch vs. straight anastomosis. Optimum size of this pouch has yet to be determined. Therefore, we initiated a prospective, randomized trial using 5-cm and 10-cm pouches to determine this size. METHODS: Patients with tumors 5 to 10 cm from the anal verge were included in the study. Before a low anterior resection anastomosis was performed, patients were randomized to either a 5-cm J-pouch group (5-J group) or a 10-cm J-pouch group (10-J group). Functional assessments were performed one year postoperatively. Clinical functions were evaluated using a functional scoring system. Physiologic functions, such as sphincter and reservoir function, were evaluated by anorectal manometry and evacuation function by the balloon expulsion and saline evacuation tests. RESULTS: Forty patients among 43 randomized patients were assessed for functional outcome one year postoperatively (5-J group, n=20; 10-J group, n=20). The functional score was similar for the two groups, although reservoir function in the 5-J group was significantly less than in the 10-J group. Sphincter function was similar between the two groups. Evacuation function in the 5-J group was significantly superior to that in the 10-J group. CONCLUSIONS: The 5-cm J-pouch conferred adequate reservoir function without compromising evacuation.Supported, in part, by a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare and a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, and Science.     

Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations

Between 25 and 80 % of patients undergoing a low or very low anterior resection will suffer postoperatively, from a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation and incontinence, collectively referred to as the low anterior resection syndrome (LARS). The etiology of LARS is multifactorial with the potential of sphincter injury during anastomosis construction, alterations in anorectal physiology, the development of a pudendal neuropathy, and a lumbar plexopathy with exacerbation of symptoms if there is associated anastomotic sepsis or the use of adjuvant and neoadjuavnt therapies. The symptoms of LARS may be obviated in part by the construction of a neorectal reservoir which may take the form of a colonic J-pouch, a transverse coloplasty, or a side-to-end anastomosis. This review outlines the factors contributing to LARS symptomatology along with the short- and medium-term functional results of comparative trials with the different types of neorectal reconstructions.     

Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer

PURPOSE: Functional outcome after anterior resection for rectal cancer is improved by colonic J-pouch reconstruction compared with straight anastomosis. The indications for colonic J-pouch reconstruction have yet to be determined. Therefore, we attempted to determine the level at which J-pouch reconstruction provides an advantage over straight anastomosis. METHODS: A total of 48 patients who underwent 5-cm colonic J-pouch reconstruction (J-pouch group) and 80 patients who underwent straight anastomosis (straight group) underwent functional assessment one year postoperatively. RESULTS: The functional outcome in the J-pouch group was significantly better than that in the straight group when the distance of the anastomosis from the anal verge was less than 8 cm. The difference was particularly obvious when the level of the anastomosis was below 4 cm. However, functional outcome in the straight group when the anastomosis was between 9 and 12 cm from the anal verge was also satisfactory and did not differ from that in the J-pouch group when the anastomosis was between 5 and 8 cm from the anal verge. CONCLUSIONS: Colonic J-pouch reconstruction is indicated when the distance of anastomosis from the anal verge is less than 8 cm, and it is essential when the distance is less than 4 cm.Supported in part by a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, and Science and a Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare.     

Safety and morbidity after ultra-low coloanal anastomoses: J-pouch vs end-to-end reconstruction

Background and aims Anastomotic failure after ultra-low anterior rectum resection is the most important complication, and it is influenced by the type of reconstruction. The aim of this study was to compare retrospectively the straight coloanal anastomosis with the J-pouch reconstruction concerning the development of anastomotic leakage. Materials and methods Fifty-six of 381 consecutive patients underwent low anterior rectum resection with total mesorectal excision and ultra-low coloanal anastomosis at 3–4 cm from the anocutan line. A 5-cm J-pouch (side-to-end) was performed in 25, a straight coloanal anastomosis in 25, and a coloplasty in 6 patients, respectively. Results/findings No influence by age, body mass index, and operating time on anastomotic leakage rate was found. Leakage was found in eight patients with straight coloanal anastomosis, resulting in a leakage rate of 32% compared to one patient in the J-pouch group (P = 0.023). Interpretation/conclusion Patient’s safety is higher after J-pouch reconstruction because of the lower anastomotic failure rate, and functional results had been reported as similar after J-pouch reconstruction and straight coloanal anastomosis. Therefore, we clearly argue for a J-pouch reconstruction as the standard method after ultra-low coloanal anastomosis.     

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.     

Colonic pouchvs. side-to-end anastomosis in low anterior resection

PURPOSE: Colonic pouches have gained increasing popularity in reconstruction after low anterior resection. In this prospective, randomized trial colonic pouch reconstruction is compared with side-to-end anastomosis for functional outcome. METHODS: From October 1995 to October 1996, 29 patients had colonic pouch and 30 patients had side-to-end anastomosis reconstruction after low anterior resection. Patients were matched for age, gender, and tumor stage and localization. All patients underwent functional evaluation preoperatively and at three and six months post-operatively. RESULTS: There was no difference in preoperative anorectal function. The operating time was higher in the colonic pouch group (167vs. 149 minutes). Twenty-three patients (79.3 percent) with colonic pouch had a protective stoma compared with 21 patients (70 percent) with side-to-end anastomosis. Postoperative complications were 10.3 and 13.3 percent, respectively. There was no difference in manometric pressure of the anus, in anorectal angle, and in continence status after three and six months. Stool frequency was higher in the side-to-end anastomosis group, with 2.2vs. 5.4 per day at three months and 2.3vs. 3.1 per day at six months. Constipation was noted in two patients with colonic pouch (7 percent) and none in the side-to-end anastomosis group at three months and twovs. none at six months. Maximum tolerated volume and threshold volume was higher in the colonic pouch group at three and at six months. CONCLUSION: Both forms of reconstruction have similar satisfactory long-term functional results. The major advantage of colonic pouch was seen in the immediate postoperative phase.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

Long-Term Functional Outcome of Low Anterior Resection With Colonic J-Pouch Reconstruction for Rectal Cancer in the Elderly

PURPOSE: Bowel function after low anterior resection for rectal cancer with colonic J-pouch reconstruction is more normal than after conventional straight anastomosis. However, few reports have examined the function of colonic J-pouch reconstruction in the elderly. Good function would obviate the need for colostomy, which is sometimes performed because of concern about fecal incontinence, which increases with age. This study evaluated the function of colonic J-pouch reconstruction in elderly patients aged 75 years or older.METHODS: Functional outcome was compared in 20 patients aged 75 years or older (older group) and 27 patients aged 60 to 74 years (old group) and 60 patients aged 59 years or younger (young group), 3 years after colonic J-pouch reconstruction, using a functional scoring system with a 17-item questionnaire (score range, 0 (overall good) to 26 (overall poor)).RESULTS: The functional scores in the three age groups were satisfactory and similar. Among patients with anastomoses 1 cm to 4 cm from the anal verge, all 17 categories on the questionnaire in the three age groups were similar. Among patients with anastomoses 5 cm to 8 cm from the anal verge, only the use of laxatives or glycerine enemas was more common in the older group than in the old and young group (90 vs. 38.5 percent and 43.3 percent; P = 0.01).CONCLUSIONS: Low anterior resection with colonic J-pouch reconstruction provides excellent functional outcome, including continence, for elderly patients. Colonic J-pouch reconstruction is a highly preferable alternative to permanent colostomy in elderly patients undergoing low anterior resection.This work was supported in part by a Grant-in-Aid for Scientific Research from the Japanese Ministry of Education, Culture, Sports, Science and Technology, and a grant for Cancer Research from the Osaka Cancer Foundation.     

Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer

AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CM) in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CM in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vsthe straight CM. METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales]. RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown. Furthermore, we found that FISI scores highly correlated with FIQL scales. CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE for low-lying rectal cancer.     

Characteristic findings on defecography according to reconstruction method and defecatory disorder following sphincter-saving surgery for rectal cancer

BACKGROUND AND AIMS: This study used postoperative defecography to characterize morphological features of defecatory disorders in patients following rectal resection. We also evaluated differences in dynamic defecatory condition depending on reconstruction methods for sphincter-saving surgery. MATERIALS AND METHODS: Subjects comprised 62 patients (male/female, 41/21; mean age, 61 years) who underwent defecography after sphincter-saving surgery for rectal cancer. Semisolid barium (100 ml) was introduced into the rectum, and images were taken in a sitting position. Characteristic dynamic findings in defecography were evaluated according to operative methods and were compared with symptoms of defecatory disorders. RESULTS: Defecographic findings closely associated with postoperative defecatory disorder were as follows: (1) low volume of neorectum in patients with worse incontinence grade (p < 0.05), (2) low evacuation fraction in patients with significantly impaired function such as soiling, urgency, and worsened incontinence score (p < 0.05), (3) minor alteration of anorectal angle at evacuation in patients with major soiling and worsened incontinence score (p < 0.05), and (4) barium shadow in the anal canal at rest in patients with urgency (p < 0.05). By reconstruction method, the J-pouch displayed a larger volume than straight anastomosis but a significantly wider anorectal angle than high anterior resection (HAR). Side-to-end anastomosis offered a moderate volume and a sharp anorectal angle as in HAR. CONCLUSIONS: Defecography is useful for visualizing and characterizing defecatory disorders following rectal resection. Based on defecography, J-pouch reconstruction offers advantageous volume, while side-to-end anastomosis provides a more acute anorectal angle for patients who have received rectal resection with low anastomosis. A new reconstruction method offering both advantages was discussed.     

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch

AIM: This study was designed to analyze the functional and clinical outcomes of straight coloanal anastomosis compared with colonic J-pouch performed after low anterior resection. MATERIALS AND METHODS: Between September 1989 and June 1996, all patients who underwent low anterior resection with anastomosis less than 4 cm from the dentate line were classified into two groups based on the restoration of intestinal continuity: “straight” coloanal anastomosis (n=39) or colonic J-pouch (n=44). Both groups were assessed according to the level of anastomosis, anastomotic complications (stricture, leak, pelvic abscess), age, and gender. For comparison of functional outcome, daily bowel movements, tenesmus, urgency, incontinence score (range, 0–20), and anorectal manometric findings were evaluated preoperatively and at six months, and one and two years after surgery. RESULTS: There were no significant differences between the groups relative to age: (coloanal anastomosis, 66.3±10.1 (range, 46–86),vs. colonic J-pouch, 64.9±13.2 (range, 39–88) years); gender (females): (coloanal anastomosis, 46.2 percentvs. colonic J-pouch; 38.6 percent); diagnosis: (rectal carcinoma: coloanal anastomosis, 84.6 percent,vs. colonic J-pouch, 77.3 percent); preoperative incontinence score (coloanal anastomosis, 1.5±4.6,vs. colonic J-pouch, 1.1±4); bowel movements: (coloanal anastomosis, 2.1±2.3,vs. colonic J-pouch, 2.1±1.9/day); level of anastomosis: (coloanal anastomosis, 1.8±1.3,vs. colonic J-pouch, 1.5±1.3 cm from the dentate line); history of perioperative radiation therapy: (coloanal anastomosis, 15.4 percent,vs. colonic J-pouch, 20.5 percent); or manometric findings. There was also no significant difference in postoperative mortality: (coloanal anastomosis, 5.1 percent,vs. colonic J-pouch, 2.3 percent); or anastomotic complications: (coloanal anastomosis, 7/39 (17.9 percent),vs. colonic J-pouch, 2/44 (4.5 percent)P=0.08); strictures: (10.3vs. 0 percent); leaks: (5.1vs. 2.3 percent); bleeding: (2.6vs. 0 percent); rectovaginal fistula: (0vs. 2.3 percent). Also, in the colonic J-pouch group, two patients developed pouchitis, and one patient experienced difficult evacuation one year after surgery. There was a statistically significant better function judged by less frequent bowel movements (4±2vs. 2.4±1.3/day;P<0.005) and urgency (36.7vs. 7.7 percent;P<0.05), incontinence score (2.2±3.7vs. 0.8±1.6;P<0.05) up to one year after surgery. At two years, the coloanal anastomosis group did not show statistical improvement in functional results compared with one year postoperatively. Rectal compliance in manometric findings was significantly increased in the coloanal anastomosis group at one year after surgery (12.4±12.6vs. 4.2±1.5 ml/mmHg;P<0.05). However, these differences were less profound after two years. CONCLUSION: The functional superiority of the colonic J-pouch was greatest at one year after surgery. By two years, adaptation of the “straight” coloanal anastomosis yielded similar functional results. However, the almost fourfold reduction in anastomotic complications in the colonic J-pouch group reveals a second potential advantage of this technique.     

Colonic J-pouch decreases bowel frequency by improving the evacuation ratio

BACKGROUND/AIMS: To compare the functional outcome of ultra-low anterior resection for rectal cancer with colonic J-pouch reconstruction with that of straight reconstruction. METHODOLOGY: Twenty-three patients who underwent ultra-low anterior resection with or without J-pouch reconstruction underwent bowel transit study, videodefecography, and answered a questionnaire survey 4 months and 1 year after surgery. Eleven healthy subjects underwent similar testing as controls. RESULTS: Patients with a J-pouch had less frequent stools than patients with straight reconstruction 4 months after surgery (p<0.05), but the two groups were similar at 1 year. Bowel transit time was similar at both study points. The evacuation ratio was higher after J-pouch than straight reconstruction 4 months after surgery (p<0.05). However, the ratio improved in the straight group, and no difference existed at 1 year. Colonic contraction was seen only near the anastomosis 4 months after surgery, but the contraction proximal to the anastomosis improved over the next 8 months. CONCLUSIONS: J-pouch reconstruction facilitates evacuation by improving the evacuation ratio. Although straight anastomosis caused excessive stool frequency 4 months after surgery, colonic function continued to improve and was comparable with J-pouch and straight reconstruction 1 year after surgery because the contraction ratio proximal to the anastomosis improved.     

Comparison of anastomotic microcirculation in coloanal J-pouches versus straight and side-to-end coloanal reconstruction: an experimental study in the pig

Several studies have shown a lower rate of anastomotic leakages in patients with coloanal J-pouch reconstruction than in those with straight coloanal anastomosis following anterior resection of the rectum. This study investigated whether this difference is due to a better anastomotic microcirculation. Thirty-two healthy, adult Göttinger mini-pigs underwent anterior rectal resection. They were subsequently randomized to following four groups (eight pigs per group): straight end-to-end, side-to-end, small pouch (4 cm), and large pouch (8 cm) coloanal anastomosis. Bowel perfusion was measured before and after vessel ligature at predefined locations using laser Doppler flowmetry. After completion of the anastomosis microcirculation was investigated 1 cm above, below, and directly at the anastomotic site. Following vessel ligature there was a 25% drop in blood flow. After completion of the anastomosis there was a further decrease of 25% in the distal segment, while no changes were observed above the anastomosis. There were no statistical differences either before or after completion of the anastomosis between the various groups. It is concluded that anastomotic blood flow does not depend on the type of coloanal reconstruction in healthy pigs.     

Horizontal inclination of the longitudinal axis of the colonic J-pouch: defining causes of evacuation difficulty

PURPOSE: Functional outcome after low anterior resection for rectal cancer is improved by the construction of a colonic J-pouch. One disadvantage of this type of reconstruction is evacuation difficulty, which has been associated with large pouches. The purpose of this study was to elucidate the causes of evacuation difficulty in large pouches using pouchography. METHODS: The angle between the longitudinal axis of the pouch and the horizontal line (pouch-horizontal angle) on lateral pouchography was determined in 26 patients with 10-cm J-pouch reconstructions (10-J group) and 27 patients with 5-cm J-pouch reconstructions (5-J group). Measurement were made at three months, one year, and two years after surgery. Clinical function was evaluated using a questionnaire one year postoperatively. RESULTS: The pouch-horizontal angle in the 10-J group was significantly smaller than that in the 5-J group at all three time points. In both groups the pouch-horizontal angle at one year was significantly smaller than that at three months. There were no significant differences between the pouch-horizontal angles at one and two years. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. CONCLUSIONS: The evacuation difficulty observed in patients with large colonic J-pouch reconstructions may be attributed to the development of a horizontal inclination within one year of surgery.     

Better functional outcome provided by short-armed sigmoid colon-rectal side-to-end anastomosis after laparoscopic low anterior resection: a match-paired retrospective study from China

Purpose  

Side-to-end anastomosis using the descending colon has been proved to be as effective as J pouch in alleviating low anterior resection syndrome. However, using the sigmoid colon, which is less compliant for reconstruction after rectal cancer surgery, is common in China due to less prevalence of diverticulosis. The effectiveness of using the sigmoid colon for a side-to-end colorectal anastomosis in improving bowel dysfunction after laparoscopic low anterior resection of rectal cancer has not been investigated. This study was designed to compare the functional and surgical outcomes between the two anastomoses.     

Scintigraphic comparison of neorectal emptying between colonic J-pouch anastomosis and straight anastomosis after stapled low anterior resection

BACKGROUND AND AIMS. Colonic J-pouch anastomosis after low anterior resection of the rectum has been reported to be associated with an increased risk of evacuation difficulty. Using scintigraphy we compared neorectal emptying after stapled low anterior resection between colonic J-pouch anastomosis and straight anastomosis. PATIENTS AND METHODS. We studied 19 patients after colonic J-pouch anastomosis and 22 after straight anastomosis. After the introduction of an artificial stool containing (99m)Tc-DTPA into the neorectum sequential lateral gamma images were obtained. From the time activity curve of radioactivity in the whole pelvis the time taken to evacuate one-half of the introduced artificial stool ( t(1/2)) and the percentage of artificial stool evacuated in 1 min (Evac(1)) were calculated. Fourteen volunteers were also studied as the reference group. RESULTS. The t(1/2) was significantly longer and Evac(1) significantly lower in patients after low anterior resection than in the reference group. t(1/2) was significantly longer in the pouch group than in the straight group. Anastomotic height was significantly correlated with both t(1/2) and Evac(1). Neither t(1/2) nor Evac(1) was correlated with the severity of impaired defecatory function. CONCLUSION. Although neither of the two parameters of neorectal emptying was correlated with the severity of impaired defecatory function, less effective neorectal emptying in patients after colonic J-pouch anastomosis than in those after straight anastomosis may be a factor causing evacuation difficulty after colonic J-pouch anastomosis.     

Colonic J-Pouch vs. Coloplasty Following Resection of Distal Rectal Cancer

PURPOSE: In terms of functional outcome, there is evidence of the superiority of the colonic J-pouch over a straight coloanal anastomosis. Even though the colonic J-pouch was created to restore a neorectal reservoir, manometric data show that the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. We speculate that the advantage of the colonic J-pouch is not in creating a larger neorectal reservoir, but rather related to decreased motility. Maurer and Zgraggen recently described a new colonic pouch design, performing a transverse coloplasty pouch. The purpose of this pilot study was to compare the feasibility and functional outcome of the 5-cm colonic J-pouch vs. the coloplasty pouch. METHODS: From February 2000 to June 2001, we randomized 40 consecutive patients with distal rectal cancer (<12 cm from the anal verge) into the J-pouch or coloplasty group. A low rectal resection and coloanal anastomosis was performed in all patients. Functional data were collected by a standardized questionnaire and anorectal manometry, preoperatively and six months postoperatively. Primary end points of the study were potentially differences of both groups regarding technical feasibility, stool frequency, and anorectal manometry. RESULTS: The construction of a coloplasty pouch was feasible in all cases of the coloplasty group, but not in 5 of 20 (25 percent) patients of the J-pouch group, because of colonic adipose tissue. Six months after operation or stoma closure, respectively, stool frequency was 2.75 ± 1 per day in the J-pouch group and 2 ± 2 per day in the coloplasty group. There was no significant difference in resting and squeeze pressure and neorectal volume between both groups, but an increased neorectal sensitivity in the coloplasty group. CONCLUSION: We found similar functional results in the coloplasty group compared to the J-pouch group. The neorectal sensitivity was increased in the coloplasty group. Therefore, the colonic coloplasty seems to be an attractive pouch design because of its feasibility, simplicity, and effectiveness.     

Enlargement of colonic pouch after proctectomy and colonanal anastomosis

PURPOSE: Although the functional outcome after low anterior resection for rectal cancer using colonic J-pouch reconstruction is superior to that using conventional straight reconstruction, the one drawback of colonic J-pouch reconstruction is difficulty with evacuation. Recently it has been suggested that construction of a larger colonic J-pouch causes the evacuation difficulty. The purpose of this study was to elucidate the cause of evacuation difficulty with colonic J-pouch reconstruction. METHODS: We compared pouchography of 26 patients with 10-cm colonic J-pouch reconstructions (10-J group) and 27 patients with 5-cm colonic J-pouch reconstructions (5-J group) at three months, one year, and two years after surgery. Functional assessments were performed one year postoperatively. Clinical function was evaluated using a questionnaire. Evacuation function was evaluated by the balloon expulsion and saline evacuation tests. RESULTS: The greatest width of the pouch in the 10-J group in the anteroposterior view was significantly greater than that in the 5-J group at all three measurement times (3 months, 4.9 vs. 4 cm; P = 0.0011; 1 year, 9 vs. 5.6 cm; P < 0.0001; 2 years, 9.2 vs. 5.8 cm; P < 0.0001). The value in the 10-J group at one year after surgery was 1.9 times that at three postoperative months; in the 5-J group this ratio was 1.4. There was a significant difference between these ratios (P < 0.0001). No significant difference existed between the values at two years and one year after surgery in either the 10-J or the 5-J group. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. Evacuation function in the 10-J group was significantly inferior to that in the 5-J group. CONCLUSIONS: The evacuation difficulty observed in patients with larger colonic J-pouch reconstructions is associated with excessive distention of the pouch occurring within one year of surgery.     

Coloplasty in low colorectal anastomosis

PURPOSE: After resection of the distal rectum with a straight reanastomosis, poor bowel function can occur. This is felt to be because of the loss of the rectal reservoir. To overcome this, a neoreservoir using a colonic J-pouch has been advocated in low colorectal and coloanal anastomosis. However, difficulties in reach, inability to fit the pouch into a narrow pelvis, and postoperative evacuation problems can make the colonic J-pouch problematic. Coloplasty is a new technique that may overcome the poor bowel function seen in the straight anastomosis and the problems of the colonic J-pouch. The purpose of this study was to compare the functional results after a low colorectal anastomosis among patients receiving a coloplasty, colonic J-pouch, or straight anastomosis. METHODS: Twenty patients underwent construction of a coloplasty with a low colorectal anastomosis. Postoperative manometry and functional outcome of these patients was compared with a matched group of 16 patients who had a colonic J-pouch and low colorectal anastomosis and 17 patients who had a straight low colorectal anastomosis. RESULTS: Maximum tolerated volume was significantly favorable in the coloplasty (mean, 116.9 ml) and colonic J-pouch group (mean, 150 ml) vs. the straight anastomosis group (mean, 83.3; P < 0.05) The compliance was also significantly favorable for the coloplasty (mean, 4.9 ml/mmHg) and the colonic J-pouch group (mean, 6.1 ml/mmHg) vs. the straight anastomosis group (mean, 3.2 ml/mmHg; P < 0.05) The coloplasty (mean, 2.6; range, 1-5) and colonic J-pouch (mean, 3.1; range, 2-6) had significantly fewer bowel movements per day than the straight anastomosis group (mean, 4.5; range, 1-8; P < 0.05). Similar complication rates were noted in the three groups. CONCLUSIONS: Patients with a coloplasty and low colorectal anastomosis seem to have similar functional outcome along with similar pouch compliance compared with patients with colonic J-pouch and low colorectal anastomosis. However, the coloplasty may provide an alternative method to the colonic J-pouch for a neorectal reservoir construction when reach or a narrow pelvis prohibits its formation. Technically it also may be easier to construct.