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Goyal A, Mathew A, Joseph P, Kaushal G, Rakesh NR, Dhar P. Reconstructive techniques following low anterior resection for carcinoma of the rectum. Minerva Surg 2024; 79:59-72. [PMID: 38381031 DOI: 10.23736/s2724-5691.23.10115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied. EVIDENCE ACQUISITION PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023. EVIDENCE SYNTHESIS Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown. CONCLUSIONS In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.
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Affiliation(s)
- Anuj Goyal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Anvin Mathew
- Department of Surgical Gastroenterology, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, India -
| | - Princy Joseph
- National Health Systems and Research Center, New Delhi, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, India
| | - Nirjhar R Rakesh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Puneet Dhar
- Department of Surgical Gastroenterology, Amrita Hospitals, Faridabad, India
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Zaman S, Peterknecht E, Bhattacharya P, Ayeni AA, Gilbody H, Ahmad AN, Mohamedahmed AYY, Akingboye A. Comparison of the Colonic J-Pouch Versus Side-To-End Anastomosis Following Low Anterior Resection: A Systematic Review and Meta-Analysis. Am Surg 2024; 90:92-110. [PMID: 37507144 DOI: 10.1177/00031348231191769] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023]
Abstract
BACKGROUND The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP) anastomosis following anterior resection for rectal cancer. METHODS A PRISMA-compliant systematic review and meta-analysis was conducted using multiple electronic databases and clinical trial registers and all studies comparing side-to-end vs CJP anastomosis were included. Peri-operative complications, mortality rate, functional bowel, and anorectal outcomes were evaluated. RESULTS Eight randomized controlled trials (RCTs) and two observational studies with 1125 patients (side-to-end: n = 557; CJP: n = 568) were included. Of the entire functional bowel outcome parameters analyzed, only the sensation of incomplete bowel evacuation was significant in the CJP group at 6 months [OR: 2.07; 95% CI 1.06 - 4.02, P = .03]. Peri- and post-operative clinical parameters were comparable in both groups (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, anastomotic stricture formation and mortality). Equally, most of the analyzed anorectal physiology parameters (anorectal volume, anal squeeze pressure, maximum anal volume) were not significantly different between the two groups. However, anal resting pressure (mmHg) 2 years post-operatively was noted to be significantly higher in the side-to-end group than that of the CJP configuration [MD: -8.76; 95% CI - 15.91 - 1.61, P = .02]. DISCUSSION Clinical and functional outcomes following CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to low anterior resection syndrome in the short term but future well-designed; high-quality RCTs with long term follow-up are required.
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Affiliation(s)
- Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
- Cancer and Genomic Science, College of Medical and Dental Science, University of Birmingham, Edgbaston, Birmingham, UK
| | - Elizabeth Peterknecht
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Pratik Bhattacharya
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Adewale A Ayeni
- Department of General Surgery, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley, West Midlands, UK
| | - Helen Gilbody
- School of Medicine, University of Birmingham, Birmingham, West Midlands, UK
| | - Adil N Ahmad
- Department of General Surgery, Walsall Healthcare NHS Trust, Manor Hospital, Walsall, West Midlands, UK
| | - Ali Y-Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, West Midlands, UK
| | - Akinfemi Akingboye
- Department of General Surgery, Dudley Group of Hospitals NHS Trust, Russells Hall Hospital, Dudley, West Midlands, UK
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Liu H, Xiong M, Zeng Y, Shi Y, Pei Z, Liao C. Comparison of complications and bowel function among different reconstruction techniques after low anterior resection for rectal cancer: a systematic review and network meta-analysis. World J Surg Oncol 2023; 21:87. [PMID: 36899350 PMCID: PMC9999608 DOI: 10.1186/s12957-023-02977-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Anastomosis for gastrointestinal reconstruction has been contentious after low anterior resection of rectal cancer for the past 30 years. Despite the abundance of randomized controlled trials (RCTs) on colon J-pouch (CJP), straight colorectal anastomosis (SCA), transverse coloplast (TCP), and side-to-end anastomosis (SEA), most studies are small and lack reliable clinical evidence. We conducted a systematic review and network meta-analysis to evaluate the effects of the four anastomoses on postoperative complications, bowel function, and quality of life in rectal cancer. METHODS We assessed the safety and efficacy of CJP, SCA, TCP, and SEA in adult patients with rectal cancer after surgery by searching the Cochrane Library, Embase, and PubMed databases to collect RCTs from the date of establishment to May 20, 2022. Anastomotic leakage and defecation frequency were the main outcome indicators. We pooled data through a random effects model in a Bayesian framework and assessed model inconsistency using the deviance information criterion (DIC) and node-splitting method and inter-study heterogeneity using the I-squared statistics (I2). The interventions were ranked according to the surface under the cumulative ranking curve (SUCRA) to compare each outcome indicator. RESULTS Of the 474 studies initially evaluated, 29 were eligible RCTs comprising 2631 patients. Among the four anastomoses, the SEA group had the lowest incidence of anastomotic leakage, ranking first (SUCRASEA = 0.982), followed by the CJP group (SUCRACJP = 0.628). The defecation frequency in the SEA group was comparable to those in the CJP and TCP groups at 3, 6, 12, and 24 months postoperatively. In comparison, the defecation frequency in the SCA group 12 months after surgery all ranked fourth. No statistically significant differences were found among the four anastomoses in terms of anastomotic stricture, reoperation, postoperative mortality within 30 days, fecal urgency, incomplete defecation, use of antidiarrheal medication, or quality of life. CONCLUSIONS This study demonstrated that SEA had the lowest risk of complications, comparable bowel function, and quality of life compared to the CJP and TCP, but further research is required to determine its long-term consequences. Furthermore, we should be aware that SCA is associated with a high defecation frequency.
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Affiliation(s)
- Huabing Liu
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Ming Xiong
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yu Zeng
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yabo Shi
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Zhihui Pei
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Chuanwen Liao
- Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China.
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Mathew A, Ramachandra D, Goyal A, Nariampalli Karthyarth M, Joseph P, Raj Rakesh N, Kaushal G, Agrawal A, Bhadoria AS, Dhar P. Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis. Br J Surg 2023; 110:313-323. [PMID: 36630589 DOI: 10.1093/bjs/znac400] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/21/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques. METHODS A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used. RESULTS Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012). CONCLUSION Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.
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Affiliation(s)
- Anvin Mathew
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Deepti Ramachandra
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Anuj Goyal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | | | - Princy Joseph
- National Health Systems Resource Centre, New Delhi, India
| | - Nirjhar Raj Rakesh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, India
| | - Abhishek Agrawal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Ajeet Singh Bhadoria
- Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, India
| | - Puneet Dhar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
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Wang Z. Colonic J-pouch versus side-to-end anastomosis for rectal cancer: a systematic review and meta-analysis of randomized controlled trials. BMC Surg 2021; 21:331. [PMID: 34419022 PMCID: PMC8379825 DOI: 10.1186/s12893-021-01313-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/29/2021] [Indexed: 02/08/2023] Open
Abstract
Background This study aims to compare colonic J-pouch and side-to-end anastomosis for rectal cancer in terms of surgical and bowel functional outcomes and quality of life (QoL). Methods A systematic literature search was performed in PubMed, Embase and Cochrane. The last search was performed on March 28, 2021. All randomized controlled trials comparing colonic J-pouch with side-to-end anastomosis for rectal cancer were enrolled. The main outcomes were bowel functional outcomes and QoL. The secondary outcomes were surgical outcomes including operative time, postoperative hospital stay, complications, and mortality. Results Nine articles incorporating 7 trials with a total of 696 patients (330 by J-pouch and 366 by side-to-end) were enrolled in this meta-analysis. The bowel functional outcomes were comparable between J-pouch and side-to-end groups in terms of stool frequency, urgency, and incomplete defecation at the short term (< 8 months), medium term (8–18 months), and long term (> 18 months) follow up evaluations. No difference was observed between groups with regards to QoL (SF-36: physical function, social function, and general health perception). Besides, surgical outcomes were also similar in two groups. Conclusion The currently limited evidence suggests that colonic J-pouch and side-to-end anastomosis are comparable in terms of bowel functional outcomes, QoL, and surgical outcomes. Surgeons may choose either of the two techniques for anastomosis. A large sample randomized controlled study comparing colonic J-pouch and side-to-end anastomosis for rectal cancer is warranted.
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Affiliation(s)
- Zheng Wang
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, China.
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Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes. Updates Surg 2021; 73:2137-2143. [PMID: 33993462 DOI: 10.1007/s13304-021-01061-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7 mL vs. 110.2 mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30 day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).
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Safety and efficacy of side-to-end anastomosis versus colonic J-pouch anastomosis in sphincter-preserving resections: an updated meta-analysis of randomized controlled trials. World J Surg Oncol 2021; 19:130. [PMID: 33882952 PMCID: PMC8061176 DOI: 10.1186/s12957-021-02243-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
Background The application of side-to-end anastomosis (SEA) in sphincter-preserving resection (SPR) is controversial. We performed a meta-analysis to compare the safety and efficacy of SEA with colonic J-pouch (CJP) anastomosis, which had been proven effective in improving postoperative bowel function. Methods The protocol was registered in PROSPERO under number CRD42020206764. PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials databases were searched. The inclusion criteria were randomized controlled trials (RCTs) that evaluated the safety or efficacy of SEA in comparison with CJP anastomosis. The outcomes included the pooled risk ratio (RR) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. All outcomes were calculated with 95% confidence intervals (CI) by STATA software (Stata 14, Stata Corporation, TX, USA). Results A total of 864 patients from 10 RCTs were included in the meta-analysis. Patients undergoing SEA had a higher defecation frequency at 12 months after SPR (WMD = 0.20; 95% CI, 0.14–0.26; P < 0.01) than those undergoing CJP anastomosis with low heterogeneity (I2 = 0%, P = 0.54) and a lower incidence of incomplete defecation at 3 months after surgery (RR = 0.28; 95% CI, 0.09–0.86; P = 0.03). A shorter operating time (WMD = − 17.65; 95% CI, − 23.28 to − 12.02; P < 0.01) was also observed in the SEA group without significant heterogeneity (I2 = 0%, P = 0.54). A higher anorectal resting pressure (WMD = 6.25; 95% CI, 0.17–12.32; P = 0.04) was found in the SEA group but the heterogeneity was high (I2 = 84.5%, P = 0.84). No significant differences were observed between the groups in terms of efficacy outcomes including defecation frequency, the incidence of urgency, incomplete defecation, the use of pads, enema, medications, anorectal squeeze pressure and maximum rectal volume, or safety outcomes including operating time, blood loss, the use of protective stoma, postoperative complications, clinical outcomes, and oncological outcomes. Conclusions The present evidence suggests that SEA is an effective anastomotic strategy to achieve similar postoperative bowel function without increasing the risk of complications compared with CJP anastomosis. The advantages of SEA include a shorter operating time, a lower incidence of incomplete defecation at 3 months after surgery, and better sphincter function. However, close attention should be paid to the long-term defecation frequency after SPR. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02243-0.
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Rasulov AO, Baichorov AB, Merzlykova AM, Ovchinnikova AI, Semyanikhina AV. [Surgical treatment of low anterior resection syndrome]. Khirurgiia (Mosk) 2020:53-60. [PMID: 33210508 DOI: 10.17116/hirurgia202011153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To compare functional outcomes of various rectal reconstruction after total mesorectal excision. MATERIAL AND METHODS A prospective randomized trial included 90 patients with mid-to-low rectal carcinoma who underwent total mesorectal excision. RESULTS There were 22 patients after J-pouch surgery, 30 patients with side-to-end anastomoses and 38 patients with end-to-end anastomoses. Eight patients (26.6%) required conversion of J-P to E-E (7 patients) and S-E (1) anastomosis for technical reasons. Postoperative morbidity was similar (13.6, 16.7 and 34.2% in J-P, S-E and E-E groups, respectively, p=0.705). Sensory threshold, earliest and constant defecation urge and maximal tolerable volume were higher for J-P surgery within 3-6-12 months after surgery. Stool frequency was significantly lower after J-P surgery compared to S-E and E-E anastomoses within 3-6-12 months. Wexner scores were 3, 5, 6 after 6 months (p<0.05) and 0, 1, 1 after 12 months for J-P, S-E and E-E, respectively (p>0.05). Evacuation dysfunction was observed in 59.1% with J-P, 33.3% with S-E and 21.1% with E-E anastomoses in 6 months after stoma closure. CONCLUSION J-pouch reconstruction demonstrates higher neorectal volume that ensures reduced stool frequency up to 12 months after stoma closure. However, technical challenges of J-pouch surgery and evacuation dysfunction restrain application of this procedure in clinical practice.
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Affiliation(s)
- A O Rasulov
- Lopatkin Research Institute of Urology and Interventional Radiology, Moscow, Russia.,Evdokimov Moscow State University of Medicine and Dentistry, Moscow, Russia
| | - A B Baichorov
- Blokhin Russian Cancer Research Center, Moscow, Russia
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Franke AJ, Skelton WP, George TJ, Iqbal A. A Comprehensive Review of Randomized Clinical Trials Shaping the Landscape of Rectal Cancer Therapy. Clin Colorectal Cancer 2020; 20:1-19. [PMID: 32863179 DOI: 10.1016/j.clcc.2020.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 12/31/2022]
Abstract
Colorectal carcinoma is the second leading cause of cancer-related deaths in the United States, with rectal cancer accounting for approximately one third of newly diagnosed cases. Surgery remains the cornerstone of curative therapy, with total mesorectal excision being the standard of care. Although minimally invasive procedures might be appropriate for a subset of patients with early-stage, superficial tumors, the standard of care for medically operable patients with nonmetastatic rectal cancer includes a comprehensive multimodality approach of neoadjuvant chemoradiotherapy, surgery with total mesorectal excision, and systemic chemotherapy. However, the morbidity and mortality related to both local and distant organ relapse have remained challenging. In the present review, we have discussed the trial-level evidence that has shaped the current clinical practice patterns in the treatment of curable, nonmetastatic rectal cancer. In addition, we have discussed the anticipated results of ongoing clinical trials and outlined pragmatic opportunities for future investigation to optimize the current status quo and, hopefully, provide prospective validation of novel approaches in the treatment of rectal cancer.
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Affiliation(s)
- Aaron J Franke
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
| | - William Paul Skelton
- Department of Hematology and Oncology, H. Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL
| | - Thomas J George
- Department of Medicine, Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, FL
| | - Atif Iqbal
- Section of Colorectal Surgery, Department of Surgery, Baylor College of Medicine, Houston, TX.
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Nocera F, Angehrn F, von Flüe M, Steinemann DC. Optimising functional outcomes in rectal cancer surgery. Langenbecks Arch Surg 2020; 406:233-250. [PMID: 32712705 PMCID: PMC7936967 DOI: 10.1007/s00423-020-01937-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Background By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention. Purpose This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted. Conclusion Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.
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Affiliation(s)
- Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Fiorenzo Angehrn
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
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11
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Toiyama Y, Kusunoki M. Changes in surgical therapies for rectal cancer over the past 100 years: A review. Ann Gastroenterol Surg 2020; 4:331-342. [PMID: 32724876 PMCID: PMC7382427 DOI: 10.1002/ags3.12342] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/26/2020] [Accepted: 04/02/2020] [Indexed: 12/15/2022] Open
Abstract
Advances in surgical and adjuvant therapies have resulted in a dramatic improvement in outcomes of rectal cancer in terms of both oncology and functional preservation. Surgery plays a central role in therapy as it is the only means of achieving a complete cure. These surgical advancements result from extensive pioneering research in the fields of anatomy and physiology. Much history lies behind the recent surgical breakthroughs of total mesorectal excision (TME) and intersphincteric resection (ISR). This article outlines the changes that have taken place in surgical therapies for rectal cancer over more than a century based on clinical trials performed to provide scientific evidence for these therapies.
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Affiliation(s)
- Yuji Toiyama
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative MedicineInstitute of Life Sciences, Mie University Graduate School of MedicineTsuJapan
| | - Masato Kusunoki
- Department of Gastrointestinal and Pediatric Surgery, Division of Reparative MedicineInstitute of Life Sciences, Mie University Graduate School of MedicineTsuJapan
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12
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Hain E, Maggiori L, Zappa M, Prost À la Denise J, Panis Y. Anastomotic leakage after side-to-end anastomosis for rectal cancer: does leakage location matter? Colorectal Dis 2018; 20. [PMID: 29316129 DOI: 10.1111/codi.14005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/01/2017] [Indexed: 02/08/2023]
Abstract
AIM To assess outcome according to location of anastomotic leakage (AL) after side-to-end stapler or manual low colorectal or coloanal anastomosis following laparoscopic total mesorectal excision (TME) for rectal cancer. METHODS All patients presenting with symptomatic or asymptomatic AL after TME and side-to-end low anastomosis for rectal cancer performed from 2005 to 2014 were identified from our prospective database. CT-scans with contrast enema were reviewed to assess location of AL origin. RESULTS Among 279 patients who underwent TME with side-to-end anastomosis from 2005 to 2014, 70 patients presented with AL and were included: 43 (61%) patients with AL on the circular anastomosis (CAL) were compared to 27 (39%) with AL on the transverse stapling line of the colonic stump (TAL). CAL and TAL were associated with similar rates of symptomatic AL (63% versus 48%, respectively; p=0.339), severe postoperative morbidity rate (33% versus 18%; p=0.313), and long-term outcomes, including definitive stoma rate (10 versus 11%; p=0.622), and major low anterior resection syndrome rate (56% vs 57%; p=0.961). CONCLUSION Our study showed that whatever the location of AL on a side-to-end low colorectal or coloanal anastomosis after TME for cancer, both short and long-term outcomes are similar. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | | | - Magaly Zappa
- Department of Radiology, Beaujon Hospital, Assistance publique-Hôpitaux de Paris (AP-HP), Université Denis Diderot Paris VII, Clichy, France
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Abstract
Surgery remains the mainstay of treatment for colon and rectal cancers. Colon cancer outcomes have improved with laparoscopic techniques, enhanced recovery pathways, and adjuvant chemotherapy. Adjuvant 5-fluorouracil with or without oxaliplatin in stage III and possibly high-risk stage II colon cancer is associated with improved survival. Multimodality management of rectal cancer continues to evolve; total mesorectal excision is the cornerstone. Oncologic results do not support the use of laparoscopic resection in rectal cancer. Preoperative short- or long-course radiation for stage II or III rectal cancer is the standard of care. Long course chemoradiation is recommended for bulky tumors.
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Affiliation(s)
- Atif Iqbal
- Department of Surgery, University of Florida, 1600 Southwest Archer Road, PO Box 100106, Gainesville, FL 32610-0019, USA
| | - Thomas J George
- Department of Medicine, University of Florida, 1600 Southwest Archer Road, PO Box 100278, Gainesville, FL 32610-0278, USA.
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Ridolfi TJ, Berger N, Ludwig KA. Low Anterior Resection Syndrome: Current Management and Future Directions. Clin Colon Rectal Surg 2016; 29:239-45. [PMID: 27582649 DOI: 10.1055/s-0036-1584500] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Outcomes for rectal cancer surgery have improved significantly over the past 20 years with increasing rates of survival and recurrence, specifically local recurrence. These gains have been realized during a period of time in which there has been an increasing emphasis on sphincter preservation. As we have become increasingly aggressive in avoiding resection of the anus, we have begun accepting bowel dysfunction as a normal outcome. Low anterior resection syndrome, defined as a constellation of symptoms including incontinence, frequency, urgency, or feelings of incomplete emptying, has a significant impact on quality of life and results in many patients opting for a permanent colostomy to avoid these symptoms. In this article, we will highlight the most recent clinical and basic science research on this topic and discuss areas of future investigation.
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Affiliation(s)
- Timothy J Ridolfi
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicholas Berger
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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15
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Fan WC, Huang CC, Sung A, Hsieh JS. Laparoscopic total colectomy with transrectal specimen extraction and intraabdominal ileorectal anastomosis for slow-transit constipation (with video). J Visc Surg 2016; 153:309-10. [PMID: 27426682 DOI: 10.1016/j.jviscsurg.2016.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- W-C Fan
- Ta-Tung Municipal hospital, Kaohsiung, Taiwan
| | - C-C Huang
- Pingtung Hospital, Ministry of Health and Welfare, Pintung, Taiwan
| | - A Sung
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Kaohsiung Medical University, Department of Surgery, No. 100, Tzyou 1st Road, Kaohsiung City 807, Taiwan
| | - J-S Hsieh
- Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Kaohsiung Medical University, Department of Surgery, No. 100, Tzyou 1st Road, Kaohsiung City 807, Taiwan.
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16
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Dulskas A, Miliauskas P, Tikuisis R, Escalante R, Samalavicius NE. The functional results of radical rectal cancer surgery: review of the literature. Acta Chir Belg 2016; 116:1-10. [PMID: 27385133 DOI: 10.1080/00015458.2015.1136482] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called "low anterior resection syndrome" (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.
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Ozgen Z, Ozden S, Atasoy BM, Ozyurt H, Gencosmanoglu R, Imeryuz N. Long-term effects of neoadjuvant chemoradiotherapy followed by sphincter-preserving resection on anal sphincter function in relation to quality of life among locally advanced rectal cancer patients: a cross-sectional analysis. Radiat Oncol 2015; 10:168. [PMID: 26264590 PMCID: PMC4554367 DOI: 10.1186/s13014-015-0479-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 08/04/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND There is growing recognition for the consequences of rectal cancer treatment to maintain an adequate functional sphincter in the long-term rather than preserving the anal sphincter itself. This study aims to evaluate long-term effects of neoadjuvant chemoradiotherapy (nCRT) followed by sphincter-preserving resection on anal sphincter function in relation to quality of life (QoL) among locally advanced rectal cancer patients. METHODS Twenty-nine patients treated with nCRT followed by low anterior resection surgery were included in this study. Data on patient demographics, tumor location and symptoms of urgency and fecal soiling were recorded and evaluated with respect to Wexner Fecal Incontinence Scoring Scale, European Organization for Research and Cancer (EORTC) cancer-specific (EORTC QLQ-C30) and colorectal cancer-specific (EORTC QLQ-CR38) questionnaires and anorectal manometrical findings. Correlation of manometrical findings with Wexner Scale, EORTC QLQ-CR38 scores and EORTC QLQ-C30 scores was also evaluated. RESULTS Median follow-up was 45.6 months (ranged 7.5-98 months. Higher scores for incontinence for gas (p = 0.001), liquid (p = 0.048) and solid (p = 0.019) stool, need to wear pad (p = 0.001) and alteration in life style (p = 0.004) in Wexner scale, while lower scores for future perspective (p = 0.010) and higher scores for defecation problems (p = 0.001) in EORTC QLQ-CR38 were noted in patients with than without urgency. Manometrical findings of resting pressure (mmHg) was positively correlated with body image (r = 0.435, p = 0.030) and sexual functioning (r = 0.479, p = 0.011) items of functional scale, while rectal sensory threshold (RST) volume (mL) was positively correlated with defecation problems (r = 0.424, p = 0.031) items of symptom scale in EORTC QLQ-CR38 and negatively correlated with social function domain (r = -0.479, p = 0.024) in EORTC QLQ-C30. RST volume was also positively correlated with Wexner scores including incontinence for liquid stool (r = 0.459, p = 0.024), need to wear pad (r = 0.466, p = 0.022) and alteration in lifestyle (r = 0.425, p = 0.038). CONCLUSION The high risk of developing functional anal impairment as well as the systematic registration of not only oncological but also functional and QoL related outcomes seem important in rectal cancer patients in the long-term disease follow-up.
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Affiliation(s)
- Zerrin Ozgen
- Clinic of Radiation Oncology, Marmara University Pendik Training and Research Hospital, Fevzi Cakmak Mah. Muhsin Yazicioglu Cad. No:10, 34899, Pendik, Istanbul, Turkey.
| | - Sevgi Ozden
- Clinic of Radiation Oncology, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey.
| | - Beste M Atasoy
- Department of Radiation Oncology, Marmara University Faculty of Medicine, Istanbul, Turkey.
| | - Hazan Ozyurt
- Clinic of Radiation Oncology, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey.
| | - Rasim Gencosmanoglu
- Department of General Surgery, Marmara University Faculty of Medicine, Istanbul, Turkey.
| | - Nese Imeryuz
- Department of Internal Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey. .,Marmara University Gastroenterology Institute, Istanbul, Turkey.
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Hüttner FJ, Tenckhoff S, Jensen K, Uhlmann L, Kulu Y, Büchler MW, Diener MK, Ulrich A. Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg 2015; 102:735-45. [PMID: 25833333 DOI: 10.1002/bjs.9782] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/23/2014] [Accepted: 01/13/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Options for reconstruction after low anterior resection (LAR) for rectal cancer include straight or side-to-end coloanal anastomosis (CAA), colonic J pouch and transverse coloplasty. This systematic review compared these techniques in terms of function, surgical outcomes and quality of life. METHODS A systematic literature search (MEDLINE, Embase and the Cochrane Library, from inception of the databases until November 2014) was conducted to identify randomized clinical trials comparing reconstructive techniques after LAR. Random-effects meta-analyses were carried out, and results presented as weighted odds ratios or mean differences with corresponding 95 per cent c.i. A network meta-analysis was conducted for the outcome anastomotic leakage. RESULTS The search yielded 965 results; 21 trials comprising data from 1636 patients were included. Colonic J pouch was associated with lower stool frequency and antidiarrhoeal medication use for up to 1 year after surgery compared with straight CAA. Transverse coloplasty and side-to-end CAA had similar functional outcomes to the colonic J pouch. No superiority was found for any of the techniques in terms of anastomotic leak rate. CONCLUSION Colonic J pouch and side-to-end CAA or transverse coloplasty lead to a better functional outcome than straight CAA for the first year after surgery.
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Affiliation(s)
- F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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Rubin FO, Douard R, Wind P. The Functional Outcomes of Coloanal and Low Colorectal Anastomoses with Reservoirs after Low Rectal Cancer Resections. Am Surg 2014. [DOI: 10.1177/000313481408001224] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Nearly half of patients undergoing low anterior rectal cancer resection have a functional sequelae after straight coloanal or low colorectal anastomoses (SA), including low anterior rectal resection syndrome, which combines stool fragmentation, urge incontinence, and incontinence. SA are responsible for anastomotic leakage rates of 0 to 29.2 per cent. Adding a colonic reservoir improves the functional results while reducing anastomotic complications. These colonic reservoir techniques include the colonic J pouch (CJP), transverse coloplasty (TC), and side-to-end anastomosis (STEA) procedures. The aim of this literature review was to compare the functional outcomes of these three techniques from a high level of evidence. CJP with a 4- to 6-cm reservoir is a good surgical option because it reduces functional impairments during the first year, and probably up to 5 years, but is not always feasible. TC appears to perform as well as CJP, is achievable in over 95 per cent of patients, but still with some doubts about a higher anastomotic leakage rate and worse functional outcomes. STEA appears equivalent to CJP in terms of morbidity and even better functional outcomes. STEA, with a terminal side segment size of 3 cm, is feasible in the majority of nonobese patients, combines good functional results, has low anastomotic leakage rates, and is easy to complete.
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Affiliation(s)
- FranÇ Ois Rubin
- General and Digestive Surgical Department, Avicenne AP-HP University Hospital, Bobigny, Paris, France; and
| | - Richard Douard
- General and Digestive Surgical Department, Avicenne AP-HP University Hospital, Bobigny, Paris, France; and
- UFR SMBH, Paris-Nord University, Bobigny, France
| | - Philippe Wind
- General and Digestive Surgical Department, Avicenne AP-HP University Hospital, Bobigny, Paris, France; and
- UFR SMBH, Paris-Nord University, Bobigny, France
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21
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Si C, Zhang Y, Sun P. Colonic J-pouch versus Baker type for rectal reconstruction after anterior resection of rectal cancer. Scand J Gastroenterol 2013; 48:1428-35. [PMID: 24131322 DOI: 10.3109/00365521.2013.845905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE. There is no consensus regarding reconstruction type after anterior resection for rectal cancer. We conducted a meta-analysis of relevant randomized controlled trials (RCTs) to compare outcomes of colonic J-pouch (CJlP) and side-to-end anastomosis (STEA) after anterior resection of rectal cancer. METHODS. Electronic databases were searched in January 2013, with six RCTs selected for further analysis, for a total of 451 patients (229 CJP, 222STEA). Outcome measures included surgical, physiologic, and functional outcomes, as well as postoperative complications. The odds ratio (OR) was used in the statistical analysis; in other circumstances, qualitative descriptions were performed. RESULTS. As far as surgical outcomes and postoperative complications, there was no difference between groups. While functional outcomes were substantially impaired, this was similar between groups. CJP demonstrated better function in the early postoperative period. No difference was seen between groups with regards to physiologic outcome. CONCLUSION. CJP and STEA are comparable when choosing the type of reconstruction for restoration of bowel continuity in anterior resection for rectal cancer.
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Affiliation(s)
- Chengshuai Si
- Department of General Surgery, Shanghai Huashan Hospital, Fudan University , Shanghai , China
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Lai X, Wong FKY, Ching SSY. Review of bowel dysfunction of rectal cancer patients during the first five years after sphincter-preserving surgery: a population in need of nursing attention. Eur J Oncol Nurs 2013; 17:681-92. [PMID: 23871359 DOI: 10.1016/j.ejon.2013.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 06/14/2013] [Accepted: 06/21/2013] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of the review was to summarize the longitudinal changes in bowel dysfunction among patients with rectal cancer within the first five years following sphincter-preserving resection. METHODS A series of literature searches were conducted on six English-language electronic databases. Articles published after 1990 were searched. A total of 29 articles (reporting 27 studies) was found. RESULTS Bowel dysfunction, including an alteration in the frequency of bowel movements, incontinence, abnormal sensations, and difficulties with evacuation, is reported among patients with rectal cancer within the first five years after sphincter-preserving resection. These problems are most frequent and severe within the first year, especially within the first six months, and stabilize after one year. Some of the problems may last for years. CONCLUSION Supportive care for bowel dysfunction is needed, and should include the provision of information and psychological support delivered in multiple steps. Oncology nurses can play an important role in providing supportive care for rectal cancer patients with bowel dysfunction.
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Affiliation(s)
- Xiaobin Lai
- School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China.
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23
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Long-term functional results from a randomized clinical study of transverse coloplasty compared with colon J-pouch after low anterior resection for rectal cancer. Surgery 2013; 153:383-92. [DOI: 10.1016/j.surg.2012.08.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 08/10/2012] [Indexed: 01/02/2023]
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24
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Tarchi P, Moretti E, de Manzini N. Reconstruction. Updates Surg 2013. [DOI: 10.1007/978-88-470-2670-4_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ziv Y, Zbar A, Bar-Shavit Y, Igov I. Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations. Tech Coloproctol 2012; 17:151-62. [PMID: 23076289 DOI: 10.1007/s10151-012-0909-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 09/20/2012] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Y Ziv
- Department of General Surgery B, Assaf Harofeh Medical Center, Zerifin, Israel.
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Doeksen A, Bakx R, Vincent A, van Tets WF, Sprangers MAG, Gerhards MF, Bemelman WA, van Lanschot JJB. J-pouch vs side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision for rectal cancer: a multicentre randomized trial. Colorectal Dis 2012; 14:705-13. [PMID: 21831100 DOI: 10.1111/j.1463-1318.2011.02725.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Comparison of functional and surgical outcome of the J-pouch with the side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision in rectal cancer patients. METHOD In a multicentre study, patients with a carcinoma of the lower two-thirds of the rectum were randomized to either a J-pouch or a side-to-end reconstruction. Primary outcome was function of the neorectum 1 year after surgery. A functional outcome [COloREctal Functional Outcome (COREFO)] questionnaire, and two quality of life questionnaires (EORTC-QLQ-CR38 and SF-36) were to be completed by all participants preoperatively, and 4 and 12 months postoperatively. Independent data managers recorded surgical outcome. A group size of 30 patients in each group was calculated based on a 15-point difference of the COREFO scale. RESULTS In total, 107 patients were randomized, 55 in the J-pouch group and 52 in the side-to-end anastomosis group. The COREFO incontinence scale at 4 months and the total functional outcome at 4 and 12 months showed better results for the J-pouch group in comparison with the side-to-end anastomosis group. The remaining COREFO scales (frequency, social impact, stool-related aspects and bowel medication), surgical outcome (complications, reoperations, length of hospital stay, readmissions and mortality) and quality of life did not show significant differences between treatment groups. CONCLUSION The overall results of a coloanal J-pouch and a side-to-end anastomosis are comparable, although functional results are slightly better with a J-pouch. The side-to-end anastomosis is technically less demanding and therefore a justified alternative in sphincter-saving surgery.
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Affiliation(s)
- A Doeksen
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands.
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27
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Objective measurable anoneorectal function poorly correlates with the overall quality of life after mesorectal excision for rectal cancer. Eur Surg 2012. [DOI: 10.1007/s10353-012-0078-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kwaan MR. Bowel Function After Rectal Cancer Surgery: A Review of the Evidence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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The long-term gastrointestinal functional outcomes following curative anterior resection in adults with rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum 2011; 54:1589-97. [PMID: 22067190 DOI: 10.1097/dcr.0b013e3182214f11] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Significant variability and a lack of transparency exist in the reporting of anterior resection outcomes. OBJECTIVES This study aimed to qualitatively analyze the long-term functional outcomes and assessment tools used in evaluating patients with rectal cancer following anterior resection, to quantify the incidence of these outcomes, and to identify risk factors for long-term incontinence. DATA SOURCES MEDLINE, Embase, and CINAHL were searched using the terms rectal neoplasms, resection, and gastrointestinal function. STUDY SELECTION The studies included were in English and evaluated adults with rectal cancer, curative anterior resection, and a minimum 1-year follow-up. Patients with recurrent/metastatic disease were excluded. Of the 805 records identified, 48 articles were included. INTERVENTION The intervention performed was anterior resection. MAIN OUTCOME MEASURES The main outcome measure was incontinence (gas, liquid stool, and solid stool). RESULTS The histories of 3349 patients from 17 countries were summarized. Surgeries were conducted between 1978 to 2004 with a median follow-up of 24 months (interquartile range, 12, 57). Sixty-five percent of studies did not use a validated assessment tool. Reported outcomes and incidence rates were variable. The reported proportion of patients with incontinence ranged from 3.2% to 79.3%, with a pooled incidence of 35.2% (95% CI 27.9, 43.3). Risk factors for incontinence, identified by meta-regression, were preoperative radiation 0.009 and, in particular, short-course radiation (P = .006), and study quality (randomized controlled trial P = .004, observational P = .006). LIMITATIONS The meta-analysis was limited by the significant heterogeneity of the primary data. CONCLUSIONS Functional outcomes are inconsistently assessed and reported and require common definitions, and the more regular use of validated assessment tools, as well. Preoperative radiation and, in particular, short-course radiation may be a strong risk factor for incontinence; however, further studies are needed.
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Abstract
OBJECTIVE This systematic review was designed to determine postoperative complication rates of radical surgery for rectal cancer (abdominal perineal resection and anterior resection). SUMMARY OF BACKGROUND DATA Lack of accepted complication rates for rectal cancer surgery may hinder quality improvement efforts and may impede the conception of future studies because of uncertainty regarding the expected event rates. METHODS All prospective studies of rectal cancer receiving radical surgery published between 1990 and August 2008 were obtained by searching Ovid MEDLINE, EMBASE, as well as ASCO GI, CAGS, and ASCRS meeting abstracts between 2004 and 2008. There was no language restriction. The outcomes extracted were anastomotic leak, pelvic sepsis, postoperative death, wound infection, and fecal incontinence. Summary complication rates were obtained using a random effects model; the Z-test was used to test for study heterogeneity. RESULTS Fifty-three prospective cohort studies and 45 randomized controlled studies with 36,315 patients (24,845 patients had an anastomosis) were eligible for inclusion. Most of the studies found were based in continental Europe (58%), followed by Asia (25%), United Kingdom (10%), North America (5%), and Australia/New Zealand. The anastomotic leak rate, reported in 84 studies, was 11% (95% CI: 10, 12); the pelvic sepsis rate, in 29 studies, was 12% (9, 16); the postoperative death rate, in 75 studies, was 2% (2, 3); and the wound infection rate, in 50 studies, was 7% (5, 8). Fecal incontinence rates were reported in too few studies and so heterogeneously that numerical summarization was inappropriate. Year of publication, use of preoperative radiation, use of laparoscopy, and use of protecting stoma were not significant variables, but average age, median tumor height, and method of detection (clinical vs. radiologic) showed significance to explain heterogeneity in anastomotic leak rates. Year of publication, study origin, average age, and use of laparoscopy were significant, but median tumor height and preoperative radiation use were not significant in explaining heterogeneity among observed postoperative death rates. With multivariable analysis, only average age for anastomotic leak and year of publication for postoperative death remained significant. CONCLUSIONS Benchmark complication rates for radical rectal cancer surgery were obtained for use in sample size calculations in future studies and for quality control purposes. Postoperative death rates showed improvement in recent years.
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Siddiqui MRS, Sajid MS, Woods WGA, Cheek E, Baig MK. A meta-analysis comparing side to end with colonic J-pouch formation after anterior resection for rectal cancer. Tech Coloproctol 2010; 14:113-23. [DOI: 10.1007/s10151-010-0576-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 03/24/2010] [Indexed: 01/07/2023]
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Park J, Neuman HB, Weiser MR, Wong WD. Randomized clinical trials in rectal and anal cancers. Surg Oncol Clin N Am 2010; 19:205-23. [PMID: 19914567 DOI: 10.1016/j.soc.2009.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This article reviews randomized clinical trials (RCTs) published between April 2001 and November 2008 on the management of patients with rectal cancer. In total, the authors reviewed 78 RCTs on therapy for rectal cancer. Of these, five met the authors' criteria for level 1a evidence. The article discusses the major RCTs and relevant findings that have impacted clinical management most and includes most but not all RCTs on therapy for rectal cancer published during this period.
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Affiliation(s)
- Jason Park
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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Abstract
The trend towards preoperative adjuvant and neoadjuvant therapies in selected patients with rectal cancer has led to increases in sphincter preservation with a limited understanding of the factors governing unsatisfactory functional outcomes. Data would suggest the need for a more selective use of standard radiotherapeutic fields in low- to intermediate-risk cases where there appears to be limited survival or locoregional recurrence benefit and where there is under-reported toxicity. This article discusses the complex factors which impact on functional outcome following open rectal cancer surgery particularly when it is accompanied by adjuvant therapy.
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Tsunoda A, Kamiyama G, Narita K, Watanabe M, Nakao K, Kusano M. Prospective randomized trial for determination of optimum size of side limb in low anterior resection with side-to-end anastomosis for rectal carcinoma. Dis Colon Rectum 2009; 52:1572-7. [PMID: 19690484 DOI: 10.1007/dcr.0b013e3181a909d4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE Functional outcome after low anterior resection with side-to-end anastomosis is comparable with that after a colonic J-pouch construction. The optimum size of the side limb has yet to be determined. This prospective randomized trial compared a 3-cm (short) and 6-cm (long) side limb. METHODS Forty-four patients with a mid or low rectal cancer undergoing low anterior resection were randomly assigned to each group. Physiologic and clinical assessments were performed preoperatively and at 3, 6, and 12 months after ileostomy closure. Defecography was performed at six months after ileostomy closure. RESULTS Twenty patients in each group completed the study. Among them, one patient with a short limb and two others with a long limb developed leakage. Sphincter function and reservoir function were similar between the groups. Bowel function or incontinence scoring was similar between the groups. The incidence of incomplete evacuation assessed by defecography in the long limb group was significantly greater than in the short limb group (13/20 long and 5/20 short, P = 0.025). One patient in the long limb group experienced fecal impaction. CONCLUSION The study showed similar clinical results in patients with either a short limb or a long limb but seemed to be underpowered. A long limb may be associated with fecal impaction in patients undergoing low anterior resection with side-to-end anastomosis.
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Affiliation(s)
- Akira Tsunoda
- Department of Gastroenterological and General Surgery, Showa University School of Medicine, Tokyo, Japan.
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Ooi BS, Lai JH. Colonic J-Pouch, Coloplasty, Side-to-End Anastomosis: Meta-Analysis and Comparison of Outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2009. [DOI: 10.1053/j.scrs.2009.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hennequin S, Benoist S, Penna C, Prot T, Nordlinger B. [Functional outcome after hand-sewn versus stapled colonic J pouch anastomosis for rectal carcinoma]. JOURNAL DE CHIRURGIE 2009; 146:143-149. [PMID: 19539935 DOI: 10.1016/j.jchir.2009.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
STUDY AIM The aim of this study was to compare the surgical and functional results of hand-sewn and stapled colonic J-pouch anastomoses after proctectomies for cancer. PATIENTS AND METHODS Over a 6-year period, 120 patients had a laparotomic conservative rectal excision with total mesorectal excision but without intersphincteric dissection, for cancer of the mid- and lower rectum: the colonic J-pouch anastomosis was hand-sewn for 49 and stapled for 71 patients. The functional results were assessed at 1 year, by a questionnaire completed by the patient. RESULTS Morbidity was 37% in the hand-sewn group and 38% in the stapled group (ns). Mean duration of surgery in the hand-sewn group was 288 minutes and in the stapled group, 246 minutes (p<0.001). At 1 year, the rate of perfect continence was 71% for the hand-sewn group and 76% for the stapled group (ns). Significantly, more patient from the hand-sewn groups used enemas (16% versus 3%, p<0.005). On the other hand, there was no significant difference between the two groups for wearing protection, urgency, number of stools a day or gas/stool discrimination. CONCLUSIONS There is no major difference in either the surgical or functional results between hand-sewn or stapled colonic J-pouch anastomosis by laparotomy for rectal cancer. Because it is simpler and faster to perform, a stapled pouch is preferable when the tumor site so permits.
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Affiliation(s)
- S Hennequin
- Service de chirurgie digestive et oncologique, hôpital Ambroise-Paré, AP-HP, Boulogne, France
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Abstract
INTRODUCTION Rectal cancer is a common disease in Western populations. Improved treatment modalities have resulted in increased survival and tumour control. With increasing survival there is a growing need for knowledge about the long-term side effects and functional results after the treatment. AIM To describe the long-term functional outcome in patients treated for rectal cancer through a systematic review of the current literature and to provide an outline of the promising developments within this area. RESULTS Standard resectional surgery with loss of the rectal reservoir function results in poor functional results in up to 50-60% of the patients. New methods of surgery including the construction of a neoreservoir and improvement of the technique for local excision have been developed to minimize the functional disturbances without compromising the oncological result. The addition of chemo and/or radiotherapy approximately doubles the risk of poor functional results. During the last decades the techniques for chemo/radiotherapy has been markedly improved with a positive impact on functional outcome. New methods for treatment of functional disturbances e.g. bowel irrigation and sacral nerve stimulation are currently under development. PERSPECTIVES To improve the functional outcome in this growing patient population several approaches can be taken. The primary cancer treatment must be improved by minimizing the surgical trauma and optimizing the imaging and radiation techniques. Population screening should be considered in order to find the cancers at an earlier stage, hereby increasing the proportion of patients eligible for local excision without the need for chemo/irradiation. All patients recovering from rectal resection should be examined and registered systematically regarding their functional results and treatment should be offered to the severely affected patients. More studies are still needed to evaluate the efficacy of irrigation and nerve stimulation in this patient group.
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Ulrich AB, Seiler CM, Z'graggen K, Löffler T, Weitz J, Büchler MW. Early results from a randomized clinical trial of colon J pouch versus transverse coloplasty pouch after low anterior resection for rectal cancer. Br J Surg 2008; 95:1257-63. [DOI: 10.1002/bjs.6301] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Background
Patients with primary rectal cancer undergoing low anterior resection are often reconstructed using a pouch procedure. The aim of this trial was to compare colon J pouch (CJP) with transverse coloplasty pouch (TCP) reconstruction with regard to functional results, perioperative mortality and morbidity. As there is considerable uncertainty over the true anastomotic leak rate in patients with a TCP, the study analysed short-term outcome data.
Methods
Elective patients suitable for either procedure after sphincter-saving low anterior resection were eligible. Randomization took place during surgery. The primary endpoint was the rate of late evacuation problems after 2 years; secondary endpoints were anastomotic leak rate, perioperative morbidity and mortality.
Results
Between 21 October 2002 and 5 December 2005, 149 patients were randomized. All 76 patients randomized to TCP had the procedure compared with 68 of the 73 patients (93 per cent) randomized to CJP. Both groups were comparable with regard to demographic and clinical characteristics. Surgical complications (CJP: 19 per cent; TCP: 18 per cent) and the overall anastomotic leak rate (8 per cent) were equally distributed in both groups.
Conclusion
This trial demonstrated a comparable early outcome for TCP and CJP. This contradicts previous reports suggesting a higher leak rate after TCP. Registration number: ISRCTN78983587 (http://www.controlled-trials.com).
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Affiliation(s)
- A B Ulrich
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - C M Seiler
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - K Z'graggen
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - T Löffler
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - J Weitz
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
| | - M W Büchler
- Department of General, Visceral and Trauma Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
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Rink AD, Sgourakis G, Sotiropoulos GC, Lang H, Vestweber KH. The colon J-pouch as a cause of evacuation disorders after rectal resection: myth or fact? Langenbecks Arch Surg 2008; 394:79-91. [DOI: 10.1007/s00423-008-0364-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2008] [Accepted: 06/26/2008] [Indexed: 12/30/2022]
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Abstract
BACKGROUND Total mesorectal resection (TME) has led to improved survival and reduced local recurrence in patients with rectal cancer. Straight coloanal anastomosis after TME can lead to problems with frequent bowel movements, fecal urgency and incontinence. The colonic J pouch, side-to-end anastomosis and transverse coloplasty have been developed as alternative surgical strategies in order to improve bowel function. OBJECTIVES The purpose of this study is to determine which rectal reconstructive technique results in the best postoperative bowel function. SEARCH STRATEGY A systematic search of the literature (MEDLINE, Cancerlit, Embase and Cochrane Databases) was conducted from inception to Feb 14, 2006 by two independent investigators. SELECTION CRITERIA Randomized controlled trials in which patients with rectal cancer undergoing low rectal resection and coloanal anastomosis were randomized to at least two different anastomotic techniques. Furthermore, a measure of postoperative bowel function was necessary for inclusion. DATA COLLECTION AND ANALYSIS Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers. Data from included trials was collected using a standardized data collection form. Data was collated and qualitatively summarized for bowel function outcomes and meta-analysis statistical techniques were used to pool data on postoperative complications. MAIN RESULTS Of 2609 relevant studies, 16 randomized controlled trials (RCTs) met our inclusion criteria. Nine RCTs (n=473) compared straight coloanal anastomosis (SCA) to the colonic J pouch (CJP). Up to 18 months postoperatively, the CJP was superior to SCA in most studies in bowel frequency, urgency, fecal incontinence and use of antidiarrheal medication. There were too few patients with long-term bowel function outcomes to determine if this advantage continued after 18 months postop. Four RCTs (n=215) compared the side-to-end anastomosis (STE) to the CJP. These studies showed no difference in bowel function outcomes between these two techniques. Similarly, three RCTs (n=158) compared transverse coloplasty (TC) to CJP. Similarly, there were no differences in bowel function outcomes in these small studies. Overall, there were no significant differences in postoperative complications with any of the anastomotic strategies. AUTHORS' CONCLUSIONS In several randomized controlled trials, the CJP has been shown to be superior to the SCA in bowel function outcomes in patients with rectal cancer for at least 18 months after gastrointestinal continuity is re-established. The TC and STE anastomoses have been shown to have similar bowel function outcomes when compared to the CJP in small randomized controlled trials; further study is necessary to determine the role of these alternative coloanal anastomotic strategies.
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Affiliation(s)
- C J Brown
- University of Toronto, Surgery, 449-600 University Avenue, Toronto, Ontario, Canada, M5G 1X5.
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Bucher P, Wutrich P, Pugin F, Gonzales M, Gervaz P, Morel P. Totally intracorporeal laparoscopic colorectal anastomosis using circular stapler. Surg Endosc 2007; 22:1278-82. [PMID: 17943355 DOI: 10.1007/s00464-007-9607-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 05/26/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND A number of surgical techniques for colorectal anastomosis have been described for laparoscopic left-sided colectomies. Due to the complexity of these procedures, open preparation of the proximal bowel for circular stapler anastomosis through a Pfannenstiel incision has become the gold standard. We report a new laparoscopic technique for totally intracorporeal colorectal circular anastomosis (TLCCA) using a circular stapler. METHODS Preliminary experience using TLCCA in three patients scheduled for laparoscopic left colectomies (two) and sigmoidectomy (one). RESULTS Side-to-end colorectal anastomosis through TLCCA was feasible in all patients scheduled for preliminary experience. Median time from anvil insertion into abdominal cavity to anastomosis was 14 (11-17) minutes. No postoperative complications were recorded. CONCLUSION Side-to-end anastomosis can be easily and safely performed using conventional circular stapler through TLCCA. TLCCA is performed using four laparoscopic ports without additional skin incision (except trocars incision) and allows the retrieval of surgical pieces through a specimen bag.
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Affiliation(s)
- Pascal Bucher
- Visceral Surgery, Department of Surgery, Geneva University Hospital, 24, Rue Micheli-du-Crest, 1211, Geneva 14, Switzerland.
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Liang JT, Lai HS, Lee PH, Huang KC. Comparison of functional and surgical outcomes of laparoscopic-assisted colonic J-pouch versus straight reconstruction after total mesorectal excision for lower rectal cancer. Ann Surg Oncol 2007; 14:1972-9. [PMID: 17431725 DOI: 10.1245/s10434-007-9355-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2006] [Accepted: 12/26/2006] [Indexed: 01/03/2023]
Abstract
BACKGROUND To compare the functional and surgical outcomes of colonic J-pouch and straight anastomosis in the context that both reconstruction procedures were performed laparoscopically. METHODS The present study was a randomized prospective clinical trial. Patients with lower rectal cancer requiring laparoscopic total mesorectal excision were equally randomized to either laparoscopic-assisted colonic J-pouch reconstruction or laparoscopic straight end-to-end anastomosis. The techniques of the laparoscopic-assisted colonic J-pouch reconstruction are shown in the attached video. The primary end point was the comparison of functional results in both reconstruction methods. The secondary end points included the safety (surgical morbidity and mortality), surgical efficiency, and postoperative recovery. RESULTS A total of 48 patients were recruited within 2-year periods, in consideration of statistical power of 90% for comparison. There was no marked difference between patient groups undergoing colonic J-pouch surgery (n = 24) and straight anastomosis (n = 24) in various demographic and clinicopathogic parameters. The anorectal function of patients by colonic J-pouch were better than those by straight anastomosis in 3 months after operation, as evaluated by stool frequency (mean +/- standard deviation: 4.0 +/- 2.0 vs. 7.0 +/- 2.4 times/day, P < .001); use of antidiarrheal agents (29.2% [n = 7] vs. 75.0% [n = 18], P = .004); and perineal irritation (45.8% [n = 11] vs. 79.2% [n = 19], P = .037). Because of the relatively better bowel function in immediate postoperative period, patients by colonic J-pouch reconstruction were less disabled after surgery and had quicker return to partial activity (P = .039), full activity (P < .001), and work (P < .001). Both reconstruction methods were performed with similar amounts of blood loss, complication rates, and postoperative recovery. However, the operation time was significantly longer in the colonic J-pouch group (274.4 +/- 34.0 vs. 202.0 +/- 28.0 minutes, P < .001). CONCLUSIONS Because laparoscopic-assisted creation of a colonic J-pouch achieved better short-term functional results of the anorectum and did not increase surgical morbidity, as compared with laparoscopic straight anastomosis, this reconstruction procedure could be recommended to patients with lower rectal cancer requiring laparoscopic total mesorectal excision.
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Affiliation(s)
- Jin-Tung Liang
- Department of Surgery, National Taiwan University Hospital and College of Medicine, No. 7, Chung-Shan South Road, Taipei, Taiwan, Republic of China.
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Abou-Zeid AA, Makki MT. Combined abdominal and perineal approach for delayed restoration of bowel continuity after low anterior resection in females. Dis Colon Rectum 2007; 50:544-7. [PMID: 17285231 DOI: 10.1007/s10350-006-0845-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Restoration of bowel continuity after Hartmann's operation is the surgeon's goal and the patient's hope. This operation is technically demanding with reportedly high morbidity and mortality. A short distal rectal stump often makes the operation more difficult. In this article, we describe a combined abdominal and perineal approach, which can possibly make delayed restoration of bowel continuity after low anterior rectal resection an easier procedure.
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Affiliation(s)
- Ahmed A Abou-Zeid
- Department of Surgery, Ain Shams University, 11 El Ensha Street, Nasr City, Cairo, Egypt, 11371.
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Murphy J, Hammond TM, Knowles CH, Scott SM, Lunniss PJ, Williams NS. Does Anastomotic Technique Influence Anorectal Function after Sphincter-Saving Rectal Cancer Resection? A Systematic Review of Evidence from Randomized Trials. J Am Coll Surg 2007; 204:673-80. [PMID: 17382228 DOI: 10.1016/j.jamcollsurg.2007.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Revised: 12/26/2006] [Accepted: 01/02/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Jamie Murphy
- Centre for Academic Surgery, Bart's and The London, The Royal London Hospital, Whitechapel, London, UK.
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