Anorectal function after restorative proctocolectomy and low anterior resection with coloanal anastomosis

Is intraoperative neuromonitoring associated with better functional outcome in patients undergoing open TME? Results of a case-control study

AIMS

Intraoperative neuromonitoring (IONM) aims to control nerve-sparing total mesorectal excision (TME) for rectal cancer in order to improve patients' functional outcome. This study was designed to compare the urogenital and anorectal functional outcome of TME with and without IONM of innervation to the bladder and the internal anal sphincter.

METHODS

A consecutive series of 150 patients with primary rectal cancer were analysed. Fifteen match pairs with open TME and combined urogenital and anorectal functional assessment at follow up were established identical regarding gender, tumour site, tumour stage, neoadjuvant radiotherapy and type of surgery. Urogenital and anorectal function was evaluated prospectively on the basis of self-administered standardized questionnaires, measurement of residual urine volume and longterm-catheterization rate.

RESULTS

Newly developed urinary dysfunction after surgery was reported by 1 of 15 patients in the IONM group and by 6 of 15 in the control group (p = 0.031). Postoperative residual urine volume was significantly higher in the control group. At follow up impaired anorectal function was present in 1 of 15 patients undergoing TME with IONM and in 6 of 15 without IONM (p = 0.031). The IONM group showed a trend towards a lower rate of sexual dysfunction after surgery.

CONCLUSIONS

In this study TME with IONM was associated with significant lower rates of urinary and anorectal dysfunction. Prospective randomized trials are mandatory to evaluate the definite role of IONM in rectal cancer surgery.

Effectiveness of biofeedback therapy in the treatment of anterior resection syndrome after rectal cancer surgery

BACKGROUND

Although anterior resection syndrome commonly occurs after anal sphincter-saving surgery, no standard treatment option is currently available.

OBJECTIVE

The aim of the present study was to evaluate the clinical effectiveness of biofeedback in patients with anterior resection syndrome after sphincter-saving surgery for rectal cancer.

DESIGN

This study was a retrospective review of data collected during the course of treatment.

SETTINGS

Patients were treated at a teaching hospital (Asan Medical Center) in Seoul, Korea, from January 2003 through December 2008.

PATIENTS

Patients who received biofeedback therapy for anterior resection syndrome after rectal cancer surgery were included.

MAIN OUTCOME MEASURES

The Cleveland Clinic Florida fecal incontinence score, number of bowel movements per day, a visual analog scale for assessing patient satisfaction, and anorectal manometry were used to assess outcome of biofeedback treatment.

RESULTS

: After biofeedback therapy, significant improvements were observed in fecal incontinence score (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P = .010; maximum squeeze pressure, P = .006; rectal capacity, P = .003). Compared with patients who started biofeedback treatment less than 18 months after surgery, those who started biofeedback at 18 months or longer after surgery showed greater improvements in fecal incontinence score (P = .032). Only patients with fecal incontinence as the primary symptom showed significant improvements in all variables, including fecal incontinence score, P < .001; defecation frequency, P < .001; and anorectal manometry (maximum resting pressure, P = .027; maximum squeeze pressure, P = .021; rectal capacity, P = .004). Patients who received radiation therapy in addition to surgery reported a significantly higher satisfaction score than those receiving surgery alone (P = .041).

LIMITATIONS

This is a nonrandomized retrospective study. Anorectal manometry was not regularly performed in all patients.

CONCLUSIONS

Biofeedback therapy produced significant clinical benefits for patients with severe fecal incontinence and may be an effective treatment for patients with anterior resection syndrome after surgery for rectal cancer.

Pouch operation for rectal cancer

Many retrospective studies have found that the functional outcome after a low anterior resection for rectal cancer is better with colonic J-pouch reconstruction than with conventional straight anastomosis. This advantage was demonstrated in prospective, randomized trials and meta-analyses. However, despite its increasing popularity there are several areas of controversy about the use of the colonic J-pouch reconstruction. These issues include anastomotic leaks, the part of the colon used for the pouch, the pouch size, causes of difficulty in evacuation, indications (the optimum level of anastomosis), appropriateness for the elderly, and long-term (2 years or more after surgery) functional outcome. All relevant articles identified from MEDLINE databases were reviewed. The incidence of anastomotic leaks is apparently reduced by colonic J-pouch reconstruction. A 5-cm colonic J-pouch using the sigmoid colon increases the reservoir function without compromising evacuation, and provides better functional outcome than straight anastomosis, even 2 years or more after surgery, in patients whose anastomosis is less than 8 cm from the anal verge. Patients with ultralow anastomoses, less than 4 cm from the verge, appear to benefit the most. At a time when the indications for abdominoperineal excision appear to be reduced for low rectal cancer, the demand for colonic J-pouch reconstruction (the best technique in pouch operations) is therefore likely to increase.

Evaluation of the use of computed tomography versus conventional orthogonal X-ray simulation in the treatment of rectal cancer

The aim of this study is to compare and contrast the treatment fields designed using CT versus conventional orthogonal X-ray simulation in the treatment of patients with rectal cancer given preoperative chemotherapy and radiotherapy. Nine patients participated in this study. The coverage of treatment fields, the volume of treatment fields, and the position of the anorectal junction in relation to the inferior border of the obturator foramen as the delineator of the pelvic floor were evaluated in each patient using CT and conventional orthogonal X-ray simulation. The results demonstrated undercoverage of the anterior border of the lateral fields of up to 2.5 cm in seven of nine patients when conventional orthogonal X-ray simulation was compared to CT simulation. In addition, the inferior border of the obturator foramen proved to be a poor delineator of the pelvic floor with the anorectal junction situated up to 2 cm superiorly in seven of nine patients. In conclusion, CT simulation is superior to conventional orthogonal X-ray simulation when designing treatment fields for patients with rectal cancer.

The colonic J-pouch in colo-anal anastomosis

Anastomosis of the colon to the anal canal is now an accepted technique in the surgical management of low and mid rectal cancers. Although significant postoperative bowel disturbance is often seen with straight colo-anal anastomosis, controversy exists over the benefit of adding a colonic pouch for low anastomoses. Several short and long-term studies have demonstrated the early functional superiority of pouch-anal over straight anastomosis. Pouch construction does not compromise anal physiological parameters. It is recommended the pouch be constructed from a length of descending colon and be small (5 cm) in size to adequately act as a neo-rectum; long-term evacuatory difficulties are encountered with the construction of large pouches (10 cm). Anastomotic complications appear to be less frequent with pouch surgery; construction of a pouch does not significantly add to operative time, patient morbidity and mortality. At present there is no compromise to long-term oncological survival. The data supporting these statements is weak and based largely upon retrospective studies. Furthermore the impact of improved function with pouch-anal anastomosis on overall quality of life has been poorly investigated. Further prospective randomized studies are required to ascertain whether the potential benefits of a colonic pouch are realized in the randomized setting.

Manometric assessment of anorectal function

A diagnostic test is useful if it can provide information regarding the underlying pathophysiology, confirm a clinical suspicion, or guide clinical management. In a prospective study, anorectal manometry was shown not only to confirm a clinical impression, but also to provide new information that was not detected clinically. The information obtained from these studies influenced the management and outcome of patients with defecation disorders (Table 1). These findings have been confirmed further by another study that showed colorectal physiologic tests provided a definitive diagnosis in 75% of patients with constipation, 66% of patients with incontinence, and 42% of patients with intractable anorectal pain. A systematic and careful appraisal of anorectal function can provide invaluable information that can guide treatment of patients with anorectal disorders. A more uniform method of performing these tests and interpreting the results is needed to facilitate a wider use of this technology for the assessment of patients with anorectal disorders.

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.

Preoperative anal sphincter high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity predict early postoperative defecatory function after low anterior resection for rectal cancer

PURPOSE

The aims of this study were to correlate postoperative defecatory function after low anterior resection with clinical factors and physiologic parameters and to explore the possibility of predicting early postoperative defecatory function after low anterior resection.

METHODS

Thirty-two patients who underwent low anterior resection for rectal cancer were studied. Anorectal physiologic studies were performed preoperatively and six months postoperatively; maximum resting pressure, maximum squeeze pressure, length of the high pressure zone, neorectal sensory threshold, neorectal maximum tolerable volume, and anal mucosal electrosensitivity were recorded. Preoperative and postoperative defecatory function was scored between 0 (worst) and 6 (best) on the basis of bowel frequency, fecal incontinence, and urgency.

RESULTS

In univariate regression analyses, a longer preoperative high pressure zone and a more sensitive anal mucosa were associated with better postoperative defecatory function. Using multiple regression analysis, in which age, gender, the level of anastomosis, and preoperative physiologic parameters were examined as independent variables, a longer preoperative high pressure zone, a larger preoperative maximum tolerable volume, and lower sensory threshold of the anal canal were associated with better postoperative defecatory function. Postoperative function score was found to be predictable using the following formula: 1.47 + 0.496 x high pressure zone (cm) + 0.007 x maximum tolerable volume (ml) - 0.247 x sensory threshold (mA) of the anal canal.

CONCLUSION

Early postoperative defecatory function after low anterior resection is predictable from preoperative high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity.

Anterior resection following posterior transsacral stapling and transection of the anal canal for low-lying rectal cancer in males

In anterior resection with anastomosis using the double-staple technique for low-lying rectal cancer in male patients, the approach to the anal canal with a stapling instrument via the abdominal area is limited by the narrow pelvis. The stapling and transection of the anal canal via the posterior transsacral approach prior to performing an anterior resection thus enables the lower rectum and anal canal to be visualized, so that the anal canal can be accurately stapled and transected even in male patients with a narrow pelvis.

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.

Total anorectal reconstruction supported by electrostimulation gracilis neosphincter

PURPOSE

To review and to update the results of Total Anorectal Reconstruction with Electrostimulated Graciloplasty (ES-TAR) at the same time as or following abdominoperineal resection (APR).

SETTING

A university hospital in Italy.

METHODS

Retrospective study.

POPULATION

A series of 98 consecutive anorectal cancer patients who had undergone ES-TAR (in 88 cases at the same time as APR; in 10 cases following APR), 61 of whom are still evaluable in respect of continence (median follow-up period 55 months).

RESULTS

There was no mortality. Thirty-seven percent of patients had postoperative complications with no impact on survival or functional outcome. The 5-year survival rate in 50 patients was 61% and the 5-year estimated cumulative probability of survival in 81 patients was 65%. Local recurrence rate was 16%. Continence was achieved in 87% of patients with a chronically stimulated TAR, and in 69% of patients with short-term stimulation.

CONCLUSION

ES-TAR is a safe and effective method for both curing anorectal cancer and restoring continence. It may be considered a reliable alternative to sphincter-saving procedures in lower rectal cancer patients.

Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch: is the functional superiority of colonic J-pouch sustained?

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 percent vs. 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: (10.3 vs. 0 percent); leaks: (5.1 vs. 2.3 percent); bleeding: (2.6 vs. 0 percent); rectovaginal fistula: (0 vs. 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 +/- 2 vs. 2.4 +/- 1.3/day; P < 0.005) and urgency (36.7 vs. 7.7 percent; P < 0.05), incontinence score (2.2 +/- 3.7 vs. 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 +/- 12.6 vs. 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.

Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: determining the optimum level of anastomosis

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.

USE OF ANORECTAL MANOMETRY FOR OBJECTIVE ASSESSMENT OF ANORECTAL FUNCTION AFTER POUCH ILEOANAL ANASTOMOSIS

Sixteen patients of ulcerative colitis and two of familial adenomatous polyposis were subjected to anorectal manometry, a minimal of three months after Pouch Ileo-Anal Anastomosis and closure of ileostomy. Using a perfusion catheter the parameters measured were resting anal pressure (RAP), maximum squeeze pressure (MSP), pouch volume and compliance at maximum tolerated volume. Subjective evaluation included anal continence and frequency of stools. The subjective functional results after surgery were then correlated with the objective findings of manometry. 4/18 patients (22%) had nocturnal incontinence only, while one patient (5%) had incontinence both by day and night. Frequency of stools was < 8/day in 10/18 patients (55%). Only 1/5 patients (20%) with incontinence had anal sphincter pressures greater than the controls while only 3/13 continent patients (22%) had anal sphincter pressures less than the controls. The study shows that low anal sphincter pressures are associated with post-operative incontinence and that there is a correlation between decreased frequency of stools and increased pouch volume as well as pouch compliance.

Comparison between the colonic J pouch-anal anastomosis and healthy rectum: clinical and physiological function

BACKGROUND

Colonic pouch anastomosis after restorative rectal excision obviates much of the early dysfunction which is commonly experienced with the traditional straight coloanal anastomosis. A disadvantage with colonic pouch reconstruction, however, appears to be impaired evacuation.

METHODS

Distal bowel function was investigated in 30 patients with a colonic J pouch anastomosis at 1 year after surgery and in 39 control subjects.

RESULTS

While the degree of urgency and incontinence were similar, the patients with a pouch experienced more difficult evacuation. The maximum volume of the pouch (median 235 ml) and rectum (221 ml) was similar, but the rectum was more compliant (3.5 versus 2.6 ml per cmH2O, P < 0.01). The sensory function in terms of initial sensation of filling, urge to defaecate and maximum distension pressure was impaired in those with pouches. The amplitude of the neorectal and anal canal motility pattern was threefold that of controls. Maximum volume of the pouch was significantly associated with degree of impaired evacuation; the larger the volume the more difficult the evacuation.

CONCLUSION

To reduce evacuation difficulty the pouch should not be fashioned too large. No conclusion about optimal pouch size could be drawn. In spite of fundamental physiological differences between a pouch and healthy anorectum, patients with a colonic pouch will usually experience satisfactory clinical bowel function.

Vaginal fistula following restorative proctocolectomy

Vaginal fistula (VF) is a devastating complication following restorative proctocolectomy.

PURPOSE

This study was designed to examine the perioperative factors influencing the outcome and management of vaginal fistula.

METHOD

Between October 1983 and September 1994, 526 women underwent restorative proctocolectomy. Nineteen develop VF (3.6 percent), and six were referred from other institutions with this complication. These 25 women were followed for a minimum of nine months.

RESULTS

Preoperative diagnosis of ulcerative colitis was made in 23 of the patients with VF (92 percent), and indeterminate colitis and familial adenomatous polyposis was determined in the rest of the patients. Postoperatively, 12 of the 23 women (52 percent) with a preoperative diagnosis of ulcerative colitis had clinical/pathologic findings of Crohn's disease, and 1 woman was reclassified as having indeterminate colitis. Postoperative pelvic sepsis was significantly higher in women with VF than in those without VF (26.3 vs. 6.3 percent; P = 0.003). Median time until occurrence of VF following loop ileostomy closure was later for women with delayed findings of Crohn's disease at 16.5 (range, <1-72) months, compared with women without Crohn's disease at 0.5 (range, <1-67) months (P < 0.05). Of the 163 women with handsewn anastomosis performed at our institution, 12 developed VF (7.4 percent). In contrast, 7 of the 363 patients with stapled anastomosis had VF (1.9 percent; P = 0.003). Site of VF was found at the anastomosis in 12 patients, below in 12 patients, and above in 1 patient. Presence of Crohn's disease and anastomotic technique did not influence the site of VF. Initial management of VF consisted of transanal repair in 20 patients (advancement flap, 12; direct repair, 6; and neoileoanal anastomosis, 2), seton in 1 patient, transabdominal approach in 1 patient, transvaginal in 1 patient, observation in 1 patient, and pouch excision in 1 patient. Of the 13 women without Crohn's disease, 12 had transanal repair (10 healed, 1 had recurrence, and 1 had pouch excision), and 1 had successfully repair with transabdominal technique, for an overall success rate of 84.6 percent. Of the 12 women with VF and delayed findings of Crohn's disease, transanal repair was performed on 9, 1 had pouch excision without repair, 1 had seton placement and pouch excision, and 1 underwent observation. Transanal technique of repair in women with Crohn's disease successfully healed three women (33.3 percent). Overall, of the 12 women with delayed findings of Crohn's disease, 6 had pouch excision, 3 had recurrences, and 3 healed.

CONCLUSION

VF is an uncommon complication following restorative proctocolectomy and is associated with a high incidence of pelvic sepsis and handsewn anastomosis. Late presentation of VF is more common with Crohn's disease and is associated with a poor prognosis and pouch salvage rate. Transanal techniques are an effective means of VF repair.

What happens to a pelvic pouch when a fistula develops?

PURPOSE

The aim of this article is to determine the outcome of the pelvic pouch after the occurrence of a fistula.

MATERIALS AND METHODS

From 1983 to 1995, 1,040 pelvic pouch surgeries were done at our institution. We reviewed the records of all patients with pouch-related fistulas. Data were collected from chart reviews and our pouch registry.

RESULTS

Among 59 patients (22 males) with fistulas, mean age was 33 (range, 19-57) years. Preoperative diagnosis was mucosal ulcerative colitis (n = 52), indeterminate colitis (n = 6), and familial polyposis (n = 1). Site of fistulas included pouch/vaginal (n = 24), pouch/ cutaneous (n = 11), pouch/perineal (n = 16), and pouch/ presacral (n = 8). Postoperative diagnosis was mucosal ulcerative colitis (n = 40), Crohn's disease (n = 14), indeterminate colitis (n = 4), and familial polyposis (n = 1). One hundred eleven (range, 1-7) surgeries for treatment were performed. At a mean follow-up of 26 (range, 1-121) months, 19 pouches (32 percent) had been excised, 34 patients had functioning pouches and no fistula, 5 patients had a closed fistula but refused ileostomy closure, and 1-patient had died of unrelated causes (but the fistula was closed). Pouch type and preoperative diagnosis did not statistically affect pouch failure rates (P = 0.43 and 0.10. respectively).

CONCLUSION

Successful treatment of fistula from a pelvic pouch can be achieved in more than 60 percent of patients. However, multiple procedures may be needed for a successful outcome. Ultimately, 32 percent had their pouches excised.

Physiologic characteristics of straight and colonic J-pouch anastomoses after rectal excision for cancer

PURPOSE

The colonic J-pouch anastomosis has been advocated to obviate urgent and frequent defecations following a sphincter-saving rectal excision. Physiologic characteristics of the colonic J-pouch were compared with those of the traditional straight anastomosis and related to clinical function.

METHOD

Patients with total mesorectal excision for carcinoma were randomized to either a straight (n = 23) or a colonic pouch anastomosis (n = 23). The patients were examined before and at one year after surgery (n = 42), which included laboratory studies, and a questionnaire regarding anorectal function was completed.

RESULTS

Preoperative compliance of the rectum was restored after surgery in the pouch group, 2.9 (2.2-3.4) ml/cm H2O, but there was a significant decrease after surgery in the straight anastomosis group, 1.9 (1.1-2.3) P < 0.001 (median (interquartile range)). Sphincter pressures in both groups were similar. In a multiple regression analysis, high compliance was associated with favorable clinical function, and hypermotility of the anal canal was associated with adverse clinical function.

CONCLUSIONS

Colonic pouch-anal anastomosis restores neorectal compliance, which is important for good function after low anterior resection. Presence of an unstable internal sphincter is a negative factor for clinical function in both straight and pouch anastomoses.

Transposition of the anorectum to the abdominal wall

A unique procedure is described in which the anorectum is mobilized on the inferior mesenteric vascular pedicle and transposed to the anterior abdominal wall. The aim is to preserve maximal intestinal length in patients with short bowel syndrome and intractable diarrhoea. Unique physiological data provided by the second case demonstrate that the specialized sensory functions of the rectum reside in the rectal wall and are subserved by an autonomic nervous supply that is independent of the pudendal nerves.

Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch. Prospective randomized study for determination of optimum pouch size

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.

Salvage surgery for ileal pouch outlet obstruction

Sixteen patients with ileal pouch outlet mechanical obstruction had major abdominal revision of the ileoanal anastomosis. Before operation all had severe difficulty in evacuation which required catheterization in 11. Eleven patients had a long efferent limb and/or long anorectal cuff, and five had a persistent stricture at the ileoanal anastomosis. None had pouchitis. The pouch was fully mobilized abdominally and the obstructing lesion resected. A new handsewn ileoanal anastomosis was formed. In two cases pouch volume was increased by incorporating an additional loop of ileum. All anastomoses but one were covered by a loop ileostomy. There were no deaths. Major complications occurred in two patients. Function was assessed in 15 patients; in one the ileostomy had not been closed. Median (interquartile range) frequency of defaecation per 24 h fell from 15 (7.3-19.5) to 6 (4.5-6.0) (P = 0.0033). Of the 11 patients who required a catheter before operation six evacuated spontaneously, three were improved but intubated on some occasions and two were unchanged after revisional surgery. Of the ten incontinent patients, five became continent, four were improved and one remained unchanged. There was a new continence disturbance in four (minor nocturnal in three) of the remaining five patients. One patient underwent further abdominal salvage surgery and another required establishment of an ileostomy because of poor function. Combined abdominoanal salvage surgery for outlet mechanical obstruction was successful in averting an ileostomy in 13 of 16 patients, and significantly improved pouch function in 12 of 15.

Total anorectal reconstruction results in complete anorectal sensory loss

Six patients underwent objective measurement of anorectal sensory function following abdominoperineal excision of the rectum and total anorectal reconstruction. No patient perceived neorectal distension as a desire to defaecate or as a feeling of flatus. Anal mucosal sensation was preserved in two patients in whom some anal mucosa was retained. These sensory deficiencies may result in faecal retention and incontinence in patients undergoing reconstructive surgery. The loss of rectal sensation suggests that the prime sensors of rectal filling may lie within the rectum itself.