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Guner OS, Tumay LV. Turnbull-Cutait technique without ileostomy after total mesorectal excision is associated with acceptably low early post-operative morbidity. ANZ J Surg 2020; 91:132-138. [PMID: 33124139 PMCID: PMC7984288 DOI: 10.1111/ans.16412] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 11/29/2022]
Abstract
Background This study aimed to compare the standard one‐stage coloanal anastomosis (CAA) technique plus diverting ileostomy and the Turnbull–Cutait (T–C) technique with delayed CAA in terms of early post‐operative morbidity in patients with low rectal cancer. Methods A total of 33 patients with non‐metastatic distal rectal cancer who were operated with one of the two different reconstruction methods (one‐stage CAA plus diverting ileostomy or two‐stage T–C technique with delayed CAA) after total mesorectal excision were included in this retrospective study. The two groups were compared for early post‐operative morbidity within 30 post‐operative days using complication frequency, Clavien–Dindo classification and Comprehensive Complication Index scores. Results The two groups did not differ in terms of morbidity parameters, including frequency of any morbidity, presence of grade 3b morbidity requiring management under general anaesthesia, as well as Comprehensive Complication Index score (P > 0.05 for all). Conclusion Our findings suggest that the two techniques did not differ in terms of early post‐operative morbidity. Owing to its comparable morbidity and safety to CAA plus concomitant ileostomy performed at the same session, the T–C technique may be considered in distal rectal cancer patients refusing to have a temporary stoma and in patients in whom CAA poses technical difficulties during the initial operation.
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Affiliation(s)
- Osman Serhat Guner
- Department of Surgery, Acibadem Bodrum Hospital, Bodrum, Turkey.,Operating Room Services, Acibadem University, Vocational School of Health Sciences, Istanbul, Turkey
| | - Latif Volkan Tumay
- Operating Room Services, Acibadem University, Vocational School of Health Sciences, Istanbul, Turkey.,Department of Surgery, Acibadem Bursa Hospital, Bursa, Turkey
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2
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de León-Rendón JL, Vallribera-Valls F, Caspari C, Espín-Basany E. [Turnbull-cutait technique in low rectal cancer: Case report]. CIR CIR 2016; 84:425-8. [PMID: 26769521 DOI: 10.1016/j.circir.2015.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 05/19/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND The surgical treatment for low rectal cancer involves an ultra-low anterior resection with complete mesorectal resection and coloanal anastomosis. Two-stage coloanal anastomosis such as the Turnbull-Cutait technique represents an option for patients with low rectal cancer. CLINICAL CASE A 69 year-old female patient with a diagnosis of adenocarcinoma (T2N1), located 4 cm from the anal margin. She received neoadjuvant radiotherapy. An ultra-low anterior resection and total resection of the mesorectum were performed. The intestinal transit was reconstructed by coloanal anastomosis using the Turnbull-Cutait technique. CONCLUSION Coloanal anastomosis with the Turnbull-Cutait technique represents a primary option for patients with low rectal cancer, avoiding a loop ileostomy, its economic impact and on their quality of life.
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Affiliation(s)
- Jorge Luis de León-Rendón
- Servicio de Cirugía General, Hospital General de México Dr. Eduardo Liceaga, Ciudad de México, México.
| | - Francesc Vallribera-Valls
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - Cristina Caspari
- Center of Colorectal and Pelvic Floor Surgery, Waldfriede Hospital, Berlín, Alemania
| | - Eloy Espín-Basany
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitario Vall d'Hebron, Barcelona, España
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Malgras B, Pocard M, Valleur P. Ileoanal anastomosis by eversion following laparoscopic total proctocolectomy for benign disease. J Visc Surg 2014; 151:45-51. [PMID: 24524871 DOI: 10.1016/j.jviscsurg.2013.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- B Malgras
- Service de chirurgie digestive, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
| | - M Pocard
- Service de chirurgie digestive, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
| | - P Valleur
- Service de chirurgie digestive, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France
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Mohamed AAA, Abdel-Fatah AFS, Mahran KM, Mohie-Eldin ABM. External coloanal anastomosis without covering stoma in low-lying rectal cancer. Indian J Surg 2012; 73:96-100. [PMID: 22468056 PMCID: PMC3077168 DOI: 10.1007/s12262-010-0179-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Accepted: 10/31/2010] [Indexed: 11/26/2022] Open
Abstract
The aim of this study was to evaluate the safety and functional outcome of external coloanal anastomosis without covering stoma in treating low-lying rectal cancer. All patients undergoing the coloanal anastomosis for low lying rectal carcer in the Department of General Surgery, Minia University Hospital, between May 2006 and May 2009 were included. Seventy two patients underwent coloanal anastomosis, and follow up was available for all patients. Mean follow up period was 12.6 ± 4.7 months. Postoperatively, fecal continence was normal in 84.7% of patients. Postoperative complications included anastomotic fistula in 3 patients (4.2%) and anastomotic stenosis in 6 patients (8.3%). There was no effect of pre or postoperative adjuvant therapy on the procedure outcome. There was no local recurrence during follow up period. Three patients died at the end of follow up period due to distant metastasis. In treatment of low-lying rectal cancer, abdominoperineal resection should be avoided if coloanal anastomosis provides similar control of the disease as it is safe and has good functional results and acceptable complication rate.
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Biondo S, Trenti L, Espín E, Frago R, Vallribera F, Jiménez LM, Gálvez A, Sánchez JL, Kreisler E. Complicaciones y mortalidad postoperatorias tras anastomosis coloanal en dos tiempos según técnica de Turnbull-Cutait. Cir Esp 2012; 90:248-53. [DOI: 10.1016/j.ciresp.2011.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 12/13/2011] [Indexed: 10/28/2022]
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Cerroni M, Cirocchi R, Morelli U, Trastulli S, Desiderio J, Mezzacapo M, Listorti C, Esperti L, Milani D, Avenia N, Gullà N, Noya G, Boselli C. Ghost Ileostomy with or without abdominal parietal split. World J Surg Oncol 2011; 9:92. [PMID: 21849090 PMCID: PMC3170210 DOI: 10.1186/1477-7819-9-92] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Accepted: 08/18/2011] [Indexed: 01/04/2023] Open
Abstract
Background In patients who undergo low anterior rectal resection, the fashioning of a covering stoma (CS) is still controversial. In fact, a covering stoma (ileostomy or colostomy) is worsened by major complications related to the procedure, longer recovery time, necessity of a re-intervention under general anesthesia for stoma closure and poorer quality of life. The advantage of Ghost Ileostomy (GI) is that an ileostomy can be performed only when there is clinical evidence of anastomotic leakage, without performing further interventions with related complications when anastomotic leak is absent and therefore the procedure is not necessary. Moreover, in case of anastomotic dehiscence and necessity of delayed stoma opening, mortality and morbidity in patients with GI are comparable with the ones that occur in patients which had a classic covering stoma. On the other hand, is simple to think about the possible economic saving: avoiding an admission for performing the closure of the ileostomy, with all the costs connected (OR, hospitalization, post-operative period, treatment of possible complications) represents a huge saving for the hospital management and also raise the quality of life of the patients. Methods In this study we prospectively analyzed 20 patients who underwent anterior extra-peritoneal rectum resection for rectal carcinoma with TME and fashioning of GI realized with or without abdominal parietal split. Results In the group of patients that received a GI without split laparotomy mortality was absent and in one case an anastomotic leak occurred. In the group of patients in which GI with split laparotomy was fashioned, one death occurred and there were one case of infection and one respiratory complication. Clinical follow-up was 12 months. Conclusions The use of different techniques for fashioning a GI do not present significant differences when they are performed by expert surgeons, but further evidence is needed with more randomized trials, in order to have more data supporting the clinical observation.
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Affiliation(s)
- Michele Cerroni
- Department of General Surgery, University of Perugia, St, Maria Hospital, Terni, Italy
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Delayed colo-anal anastomosis is an alternative to prophylactic diverting stoma after total mesorectal excision for middle and low rectal carcinomas. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2011; 37:127-33. [DOI: 10.1016/j.ejso.2010.12.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Revised: 10/15/2010] [Accepted: 12/06/2010] [Indexed: 11/17/2022]
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Holzer B, Rosen HR, Zaglmaier W, Klug R, Beer B, Novi G, Schiessel R. Sacral nerve stimulation in patients after rectal resection--preliminary report. J Gastrointest Surg 2008; 12:921-5. [PMID: 18278538 DOI: 10.1007/s11605-008-0485-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Accepted: 01/18/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Sacral nerve stimulation is a widely accepted therapeutic option for neurogenic fecal incontinence. More recently, case reports showed a positive effect of sacral nerve stimulation in patients with fecal incontinence following low anterior resection. The purpose of this study was to gain more information for this selected indication for sacral nerve stimulation through a nationwide survey. MATERIAL AND METHODS In the period 2002 to 2005, three Austrian departments reported data of patients who underwent SNS for fecal incontinence following rectal resection. Data were available of seven patients (two female, five male) with a median age of 57 years (min 42; max 79). Six patients had undergone rectal resection as a treatment for low rectal cancer. One patient had undergone rectal resection for Crohn's disease, one patient subtotal colectomy and ileorectostomy for slow colon transit constipation. RESULTS Test stimulation was performed in the foramen S3 unilaterally over a median period of 14 days (2-21 days). Seven patients reported a marked reduction of episodes of incontinence during the observation period and received a permanent stimulation system. After a median follow-up of 32 months (17-46), five patients reported a marked improvement of their continence situation. CONCLUSION Despite a nationwide survey experiences with SNS as a treatment for fecal incontinence following rectal resection is still limited. Our observations show an improvement of the continence function following SNS. However, the promising results of our series as well as others need further research and more clinical data by a larger number of patients in a prospective trial.
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Affiliation(s)
- Brigitte Holzer
- Surgical Department, Danube Hospital-SMZ-Ost, Vienna, Austria
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Baik SH, Kim NK, Lee KY, Sohn SK, Cho CH. Hand-sewn coloanal anastomosis for distal rectal cancer: long-term clinical outcomes. J Gastrointest Surg 2005; 9:775-80. [PMID: 15985232 DOI: 10.1016/j.gassur.2005.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2004] [Accepted: 03/15/2005] [Indexed: 01/31/2023]
Abstract
As the oncologic safety of coloanal anastomosis (CAA) has been proved by many other authors, the incidence of CAA following ultralow anterior resection has increased. The purpose of this study is to evaluate the functional outcome and complications of patients who underwent ultralow anterior resection and CAA for distal rectal cancer. Fifty-seven patients underwent CAA following ultralow anterior resection between July 1997 and November 2003. Forty-four patients, who were followed up more than 6 months after diverting ileostomy closure, were evaluated for recurrence, complications, and functional outcomes. The mean follow-up period was 36.3 +/- 22.8 months (range, 8-83 months). The complications were multiple fistula (n = 3), fistula with anal stenosis (n=1), local recurrence with anal stenosis (n = 1), and anal stenosis (n = 7). Anal incontinence (Kirwan grade III) was noted in 14 patients, and bowel movements were observed more than six times per day in 16 patients. Overall recurrence occurred in six patients (13.6%). The 5-year survival rate was 85.3%, and the disease-free 5-year survival rate was 73.3%. Although CAA in patients with rectal cancer provides excellent long-term survival, a low risk of recurrence, and tolerable function, complications and poor functional outcomes of CAA do occur. Therefore, the choice of this method should be considered carefully.
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Affiliation(s)
- Seung Hyuk Baik
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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10
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Ratto C, Grillo E, Parello A, Petrolino M, Costamagna G, Doglietto GB. Sacral neuromodulation in treatment of fecal incontinence following anterior resection and chemoradiation for rectal cancer. Dis Colon Rectum 2005; 48:1027-36. [PMID: 15785890 DOI: 10.1007/s10350-004-0884-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Fecal incontinence may occur in patients who have undergone anterior resection for rectal cancer without presenting sphincter lesions. Chemoradiation may contribute to disrupting continence mechanisms. Treatment is controversial. Assessment of fecal incontinence in patients who agreed to integrate treatment for rectal cancer and treatment with sacral neuromodulation are reported. METHODS Fecal incontinence following preoperative chemoradiation and anterior resection for rectal cancer was evaluated in four patients. A good response was observed during the percutaneous sacral nerve evaluation test, and so permanent implant of sacral neuromodulation system was performed. Reevaluation was performed at least two months after implant. RESULTS After device implantation, the mean fecal incontinence scores decreased, and the mean number of incontinence episodes dropped from 12.0 to 2.5 per week (P < 0.05). Permanent implant resulted in a significant improvement in fecal continence in three patients, and incontinence was slightly reduced in the fourth. Manometric parameters agreed with clinical results: maximum and mean resting tone and the squeeze pressure were normal in three patients and reduced in one. In these same three patients, neorectal sensation parameters increased when the preoperative value was normal or below normal and decreased when the preoperative value was higher than normal, whereas in one patient in whom extremely low values were recorded all of the parameters decreased significantly. CONCLUSIONS Fecal incontinence following anterior resection and neoadjuvant therapy should be carefully evaluated. If a suspected neurogenic pathogenesis is confirmed, sacral neuromodulation may be proposed. If the test results are positive, permanent implant is advisable. Failure of this approach does not exclude the use of other, more aggressive treatment.
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Affiliation(s)
- Carlo Ratto
- Department of Clinica Chirurgica, Catholic University, 00168 Rome, Italy.
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11
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Lim SB, Heo SC, Lee MR, Kang SB, Park YJ, Park KJ, Choi HS, Jeong SY, Park JG. Changes in outcome with sphincter preserving surgery for rectal cancer in Korea, 1991-2000. Eur J Surg Oncol 2005; 31:242-9. [PMID: 15780558 DOI: 10.1016/j.ejso.2004.11.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2004] [Indexed: 01/13/2023] Open
Abstract
AIM To report the clinical and oncological data of patients operated on for rectal cancers 3-5 cm from the AV over a 10 year period, including the Sphincter preservation (SP) rate. METHODS We reviewed medical records of 304 patients with rectal cancers 3-5 cm from the AV who underwent surgical resection from January 1991 through December 2000. The 10 years were divided into three periods based on the introduction of new surgical techniques, specifically, ultralow anterior resection (ULAR) with double stapling in March 1994 and ULAR with coloanal anastomosis in April 1997. The rates of SP, complications and patient survival during these periods were compared. RESULTS The SP rate increased significantly over the 10 years, from 16.4% in period I (January 1991-February 1994), to 53.0% in period II (March 1994-March 1997), to 86.5% in period III (April 1997-December 2000) (p<0.001). Over time, the age of the patients increased (p=0.004), the length of the distal resection margin became shorter (p=0.005), and the rate of lymph node metastasis increased (p=0.016). The factors significantly influencing SP were the period (p<0.001) and the distance from the AV (p<0.001). Over time, morbidity did not increase, and overall and disease free survival rates did not decrease. In contrast, the overall survival of N2 cases significantly increased over time (p=0.0492). CONCLUSION Over 10 years, the SP rate in rectal cancers 3-5 cm from the AV was significantly increased by the introduction of the double stapling and coloanal anastomosis techniques. These surgical methods, however, had no effect on morbidity, disease free survival and overall survival rates.
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Affiliation(s)
- S-B Lim
- Department of Surgery, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, South Korea
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12
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Affiliation(s)
- Victor W Fazio
- Department of Colorectal Surgery, Cleveland Clinic Foundation, OH 44118, USA.
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de Calan L, Gayet B, Bourlier P, Perniceni T. Chirurgie du cancer du rectum par laparotomie et par laparoscopie. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.emcchi.2004.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chen JCC, Chen JB, Wang HM. Laparoscopic coloanal anastomosis for low rectal cancer. JSLS 2002; 6:345-7. [PMID: 12500834 PMCID: PMC3043440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Low anterior resection with hand-sutured coloanal anastomosis for low rectal cancer is technically feasible, and it does not compromise oncologic results. We describe herein the effectiveness of the operation in treating low rectal cancer by a laparoscopic approach followed by intraanal canal dissection. METHODS From February 1999 to October 1999, we used a laparoscopic procedure to divide the inferior mesenteric vessels and to dissect downward into the pelvic cavity as low as possible. A purse-string suture 1-cm distal to the lower margin of the tumor was secured and transection of the rectum was performed circumferentially via the anal canal near the dentate line. The specimen was removed by the pull-through method and coloanal anastomosis was completed with hand suture. A protective loop ileostomy was fashioned. RESULTS We operated on 8 patients (4 males) with low tumor localization (average 4-cm above the dentate line). The age ranged from 45 to 83 years, with a median age of 64. The average operation time was 210 minutes (150 to 360 minutes), and the average blood loss was 250 cc (minimal to 750 cc). No operative mortalities occurred, but 2 patients had minor anastomotic slough complications. The average hospital stay was 13 days (7 to 26 days). The postoperative pathologic stage was T2N0M0 in 4 patients, T3N0M0 in 2 patients, T2N1M0 in 1 patient, and T3N2M0 in 1 patient. No local recurrence or distant metastasis occurred during the median 14 months (12 to 20 months) of follow-up. CONCLUSION Laparoscopic coloanal anastomosis combined with intraanal canal dissection is safe and technically feasible. The oncologic results seem not to be compromised, but need further evaluation.
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Affiliation(s)
- Johnson C C Chen
- Department of Surgery, Taichung Veterans General Hospital, Taichung City, Taiwan
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15
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Pappalardo G. Technique for ileoanal anastomosis. Dis Colon Rectum 2001; 44:1386. [PMID: 11584222 DOI: 10.1007/bf02234803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Barrier A, Martel P, Dugue L, Gallot D, Malafosse M. [Direct and reservoir colonic-anal anastomoses. Short and long term results]. ANNALES DE CHIRURGIE 2001; 126:18-25. [PMID: 11255967 DOI: 10.1016/s0003-3944(00)00452-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
STUDY AIM This retrospective study was designed to assess the operative, oncologic and functional results of total proctectomy with coloanal anastomosis (CAA). PATIENTS AND METHOD Between 1990 and 1994, 81 patients (44 males/37 females: mean age: 59 years) were operated for a cancer (n = 67) or a benign lesion (n = 14) of the rectum. Sixty-four patients had a straight CAA and 17 patients had a colonic J-pouch. RESULTS There was no operative mortality. Two patients were reoperated for colonic necrosis and underwent abdominoperineal resection. An anastomotic leak was observed in 11 patients and its severity was decreased by a diverting stoma. An anastomotic stricture was observed in 10 patients. Of the 67 patients with cancer, 19 (28%) developed metastases and 11 (16%) developed local recurrence. The 5-year survival rate was 69%. Twelve months after the operation, continence was similar with the two types of CAA, but the mean daily stool frequency was lower in patients with a reservoir. With a long follow-up (mean = 9 years), functional results were good with regard to continence and stool frequency, almost similar with the two types of CAA; functional disorders (noctumal stools, fragmentation, urgency) were reported by 25 to 40% of patients. CONCLUSION Total proctectomy with coloanal anastomosis yields good oncologic results. With regard to functional results, the superiority of the colonic J-pouch, which is observed in the first postoperative year, was lost beyond this period; long-term results are good for continence and stool frequency, but some disorders persist in a significant proportion of patients.
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Affiliation(s)
- A Barrier
- Service de chirurgie digestive, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris, France
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Régimbeau JM, Panis Y, Pocard M, Hautefeuille P, Valleur P. Handsewn ileal pouch-anal anastomosis on the dentate line after total proctectomy: technique to avoid incomplete mucosectomy and the need for long-term follow-up of the anal transition zone. Dis Colon Rectum 2001; 44:43-50; discussion 50-1. [PMID: 11805562 DOI: 10.1007/bf02234819] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE During ileal pouch-anal anastomosis, both conservation of the anal transitional zone during the stapled technique and incomplete mucosectomy in the standard Park's procedure may expose the patient to disease recurrence. We propose here an technique whose aim is to solve both problems by performing handsewn ileal pouch-anal anastomosis on the dentate line after rectal eversion and total proctectomy. METHODS We reviewed the records of 172 consecutive patients who had undergone ileal pouch-anal anastomosis since 1984 for chronic ulcerative colitis (n = 80), familial adenomatous polyposis (n = 48), selected cases of Crohn's disease (n = 42), or other causes (n = 2). RESULTS One patient (0.5 percent) died postoperatively. Operative morbidity was similar to that reported after the Park's and stapled procedures. Of our 128 patients with a five-year follow-up, anastomotic stricture occurred in 15 (12 percent), and 4 patients (3 percent) had to have pouch removal. Stool frequency per 24 hours was 4.8 +/- 1.6 (range, 1-11), continence was perfect in 104 patients (81 percent), and sexual activity was estimated to be unchanged in 120 (94 percent). No evidence of disease recurrence was noted in the patients with familial adenomatous polyposis or ulcerative colitis. CONCLUSIONS During ileal pouch-anal anastomosis, Park's procedure carries the risk of incomplete mucosectomy and disease recurrence, and the stapled procedure requires a long-term follow-up of the anal transitional zone. Our alternative technique with total proctectomy avoids both problems and gives similar long-term functional results.
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Affiliation(s)
- J M Régimbeau
- Service de Chirurgie Générale et Digestive, Hôpital Lariboisière, Paris, France
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Olagne E, Baulieux J, de la Roche E, Adham M, Berthoux N, Bourdeix O, Gerard JP, Ducerf C. Functional results of delayed coloanal anastomosis after preoperative radiotherapy for lower third rectal cancer. J Am Coll Surg 2000; 191:643-9. [PMID: 11129813 DOI: 10.1016/s1072-7515(00)00756-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to assess functional outcomes of patients who had a delayed coloanal anastomosis for a lower third rectal cancer after preoperative radiotherapy. STUDY DESIGN From January 1988 to December 1997, 35 patients with an adenocarcinoma of the lower third of the rectum received preoperative radiotherapy (45Gy) followed by a rectal resection, combining an abdominal and transanal approach. Colorectal resection was performed about 32 days after the end of the radiotherapy. The distal colon stump was pulled through the anal canal. On postoperative day 5 the colonic stump was resected and a direct coloanal anastomosis performed without colostomia diversion. RESULTS There was no mortality. There was no leakage. One patient had a pelvic abscess. One patient had a necrosis of the left colon requiring reoperation. Another delayed coloanal anastomosis could be performed. Median followup was 43 months (range 6 to 113 months). Functional results were evaluated with a new scoring system including 13 items. Function was considered good in 59% and 70% at 1 and 2 years, respectively. CONCLUSIONS This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma for patients with rectal cancer of the lower third of the rectum. This technique is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results. Further adaptation could be imagined for a coelioscopic approach.
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Affiliation(s)
- E Olagne
- Department of General and Digestive Surgery, Croix Rousse Hospital, Lyon, France
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Chaudhry V, Nittala M, Prasad ML. Preoperative Chemoradiation and Coloanal J Pouch Reconstruction for Low Rectal Cancer. Am Surg 2000. [DOI: 10.1177/000313480006600412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Our objective was to determine clinical outcomes of treatment of low rectal adenocarcinoma with neoadjuvant chemoradiation, rectal excision, and coloanal J pouch reconstruction. A retrospective review of 69 patients with stage B2 or higher lesions was performed. Preoperative chemoradiation was followed by low anterior resection and coloanal J pouch anastomosis, with end loop ileostomy. Data were analyzed using the SPSS computer software. There were 46 males and 23 females, with a median age of 63 years. Pathologic staging showed no tumor in the specimen, i.e.: stage 0,14 per cent; stage A, 14 per cent; stage B, 53 per cent; stage C, 18 per cent; and stage D, 1.4 per cent. Postoperative mortality was 2.8 per cent, and the pelvic leak rate was 4.3 per cent. After curative resection, 89 per cent patients are alive and 83 per cent are disease free with a mean follow-up of 50 months. The local recurrence rate is 7.2 per cent. Nodal status was the most important predictor of survival and disease-free survival. Most (96%) have fewer than two bowel movements a day and are satisfied with the functional results. We conclude that preoperative chemoradiation and coloanal J pouch reconstruction can achieve low recurrence rates and prolonged survival for most patients with low rectal cancer with an acceptable quality of life.
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Berger A, Tiret E, Cunningham C, Dehni N, Parc R. Rectal excision and colonic pouch-anal anastomosis for rectal cancer: oncologic results at five years. Dis Colon Rectum 1999; 42:1265-71. [PMID: 10528762 DOI: 10.1007/bf02234211] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Preservation of the anal sphincter is now accepted as a primary aim in surgical treatment of rectal cancer. The use of colonic J-pouch-anal anastomosis after complete rectal excision is one method that permits retention of continence without compromising oncologic principles. This study aimed to assess carcinologic results of rectal excision followed by colonic J-pouch anal anastomosis, with particular reference to rate of locoregional recurrence. METHOD From 1984 to 1990 complete rectal excision and colonic pouch-anal anastomosis were performed in 167 patients for cancer of the middle or low rectum. A total of 154 patients were followed for this study for a minimum of five years, with evaluation of the frequency of locoregional recurrence. RESULTS Sixty-five patients died during the period of surveillance, giving a five-year survival rate of 68.8 percent. Twenty patients (13 percent) presented with locoregional recurrence at an average of 31 months after surgery. In 11 cases (7 percent) the local recurrence was not associated with metastatic disease, and six of these patients underwent further curative surgery. CONCLUSIONS These results confirm that coloanal anastomosis after complete rectal excision is a valuable option in the surgical treatment of rectal cancer and is accompanied by a frequency of isolated locoregional recurrence of less than 7 percent, of which half underwent surgical resection with curative intent.
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Affiliation(s)
- A Berger
- Department of Surgery, Saint Antoine Hospital AP-HP and Faculty of Medicine, University of Pierre and Marie Curie, Paris, France
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22
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Barrier A, Martel P, Gallot D, Dugue L, Sezeur A, Malafosse M. Long-term functional results of colonic J pouch versus straight coloanal anastomosis. Br J Surg 1999; 86:1176-9. [PMID: 10504373 DOI: 10.1046/j.1365-2168.1999.01224.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There are very few studies evaluating the long-term functional outcome of coloanal anastomoses. This retrospective study aimed to compare long-term functional results of straight and colonic J pouch anastomoses. METHODS Thirty-seven patients, 25 with a straight anastomosis and 12 with a J pouch anastomosis, responded to a standardized telephone questionnaire. The mean time since surgery was 10 (range 4-18) years. RESULTS The mean daily stool frequency was similar in both groups of patients (1.1 in patients with a reservoir, 1.5 in patients with a straight anastomosis). In both groups, two-thirds of patients had perfect continence or limited gas incontinence. Faecal incontinence was reported by two patients with a straight anastomosis and one patient with a pouch. Nocturnal stools and fragmentation were slightly more frequent in patients with a straight anastomosis. Half of the patients regularly used medication. Thirty-five of the 37 patients reported satisfaction with functional results. CONCLUSION Long-term functional results of coloanal anastomoses are satisfactory and, unlike early results, similar for both types of anastomosis. The functional benefit of a reservoir, seen in the first year after operation, is less evident with increasing time.
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Affiliation(s)
- A Barrier
- Department of General and Digestive Surgery, Rothschild Hospital, Paris, France
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23
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Paty PB, Cohen AM. The role of surgery and chemoradiation therapy for cancer of the rectum. Curr Probl Cancer 1999; 23:229-49. [PMID: 10536747 DOI: 10.1016/s0147-0272(99)90011-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- P B Paty
- Department of Surgery, Cornell University Medical College, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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24
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Baulieux J, Olagne E, Ducerf C, De La Roche E, Adham M, Berthoux N, Bourdeix O, Gérard JP. [Oncologic and functional results of resections with direct delayed coloanal anastomosis in previously irradiated cancers of the lower rectum]. CHIRURGIE; MEMOIRES DE L'ACADEMIE DE CHIRURGIE 1999; 124:240-50; discussion 251. [PMID: 10429297 DOI: 10.1016/s0001-4001(99)80089-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM OF THE STUDY The aim of this study was to assess the oncology and functional outcome after preoperative radiotherapy and delayed coloanal anastomosis for cancers of the lower third of the rectum. PATIENTS AND METHODS From January 1988 to December 1997, 35 patients received preoperative radiotherapy (45 Gy) followed by rectal resection through a combined abdominal and transanal approach. Thirty patients had preoperative tumor staging with endorectal ultrasonography: uT1N0 = 2, uT2N0 = 6, uT2N+ = 2, uT3N0 = 6, and uT3N+ = 14. Colorectal resection was performed on average 32 days after the conclusion of radiotherapy, and the distal colon stump was pulled through the anal canal. On postoperative day 5, the colonic stump was resected and a direct coloanal anastomosis performed. RESULTS Pathological examination of the specimens revealed complete tumor sterilization in two cases, pT1N0 = 3, pT2N0 = 14, pT2N+ = 1, pT3N0 = 6, and pT3N+ = 9. There was no postoperative mortality and there was no leakage. One patient had a pelvic abscess, and another one had left colon necrosis which required re-operation. Median follow-up was 43 months (range 6-113). Two patients had locoregional recurrence, seven had distant metastasis, and 3 had both. Actuarial survival rate at 1, 3 and 5 years was 97%, 86%, and 72% respectively. The rate of local control at 5 years was 78%. Functional results were evaluated by a new scoring system. Function was considered good in 59 and 70% at 1 and 2 years respectively. CONCLUSION This new procedure is a safe and effective sphincter-preserving operation that avoids a diverting stoma. It is well adapted for patients receiving preoperative radiotherapy, with low local morbidity and good functional results.
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Affiliation(s)
- J Baulieux
- Service de chirurgie générale, digestive et de la transplantation hépatique, Hôpital de la Croix-Rousse, Lyon
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25
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Abstract
Since the colonic J-pouch with a colo-anal anastomosis was first introduced in 1986, many reports have shown the superiority of this design as compared to a "straight" colo-anal anastomosis. These advantages have been demonstrated in retrospective, prospective, and prospectively randomized reports. Furthermore, these attributes are realized for at least 12 and possibly more than 24 months after surgery.
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Affiliation(s)
- S D Wexner
- Cleveland Clinic Florida, Department of Colorectal Surgery, Fort Lauderdale 33309, USA
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26
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Nagamatsu Y, Shirouzu K, Isomoto H, Ogata Y, Tsuchida I, Akagi Y. Surgical treatment of lower rectal cancer with sphincter preservation using handsewn coloanal anastomosis. Surg Today 1998; 28:696-700. [PMID: 9697261 DOI: 10.1007/bf02484614] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
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Affiliation(s)
- Y Nagamatsu
- First Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan
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27
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Pocard M, Panis Y, Malassagne B, Nemeth J, Hautefeuille P, Valleur P. Assessing the effectiveness of mesorectal excision in rectal cancer: prognostic value of the number of lymph nodes found in resected specimens. Dis Colon Rectum 1998; 41:839-45. [PMID: 9678368 DOI: 10.1007/bf02235362] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to determine whether the number of involved or uninvolved lymph nodes in resected specimens can be used to predict the effectiveness of surgical resection for rectal cancer. METHODS Local recurrence and survival rates for 118 patients undergoing curative resection for rectal carcinoma, without adjuvant therapy, were retrospectively studied. RESULTS Mean follow-up was 62+/-37 months. Mean number of involved or uninvolved lymph nodes per resected specimen was 12+/-7. Overall local recurrence rate was 15.2 percent. In patients without involved lymph nodes (N0 patients) and with T1 or T2 tumors, the local recurrence rate ranged from 0 to 8 percent (not significant), depending on the number of lymph nodes on the specimen. In patients without involved lymph nodes and those with T3 tumors, the actuarial survival rate at ten years was significantly lower (P < 0.05), and the local recurrence rate was higher (P < 0.02) in patients with fewer than ten lymph nodes than in those with more than ten nodes. In patients with involved lymph nodes, the mean number of nodes on the resected specimen correlated closely with the mean number involved by the tumor. CONCLUSION The assessment of the effectiveness of rectal excision for cancer is in part helped by the number of involved or uninvolved lymph nodes found on the resected specimen. This is of particular interest in patients without involved lymph nodes and those having infiltrating T3 tumors, for whom the long-term survival and local recurrence rates were significantly better when more than ten lymph nodes were present. On the other hand, when fewer than ten nodes were found, whatever the cause, adjuvant radiotherapy had to be considered, because of the high risk of local failure rate.
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Affiliation(s)
- M Pocard
- Department of Surgery, Hôpital Lariboisière, Paris, France
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28
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Mohiuddin M, Regine WF, Marks GJ, Marks JW. High-dose preoperative radiation and the challenge of sphincter-preservation surgery for cancer of the distal 2 cm of the rectum. Int J Radiat Oncol Biol Phys 1998; 40:569-74. [PMID: 9486606 DOI: 10.1016/s0360-3016(97)00842-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE Sphincter-preserving surgery for the management of distal rectal cancer is gaining recognition as an alternative to abdominoperineal resection and loss of anal function. The use of high-dose preoperative radiation appears to enhance the options for sphincter preservation, even in the most distal segments of the rectum. MATERIALS AND METHODS Seventy patients with tumors located in the distal 2 cm of the rectum received a minimum dose of 40 to 45 Gy over 4 1/2 weeks at 1.8 to 2.5 Gy per fraction. Patients with unfavorable tumors were given an additional boost of 10 to 15 Gy. Surgery was performed 5 to 10 weeks following completion of radiation. Radical surgical resection was performed in 48 patients and full thickness local excision in 22. Follow-up ranged from a minimum of 1 year to a maximum of 10 years, with a median of 4 years. RESULTS There was one perioperative mortality. Two patients did not have their colostomy closed because of complications. Late diversion was required in 4 patients, primarily for recurrent disease. Sixty patients (86%) maintained long-term satisfactory sphincter function. Local recurrence was observed in 9 patients (13%) and distant metastases in 12 patients (17%). The overall five-year actuarial survival rate was 82%. The 5-year survival and local recurrence for postradiation pathological stage of disease was: T0, T1, T2, N0--95% and 8%, T3, T4, N0--91% and 4%, T(any) N+--50% and 41%, respectively. CONCLUSION High-dose preoperative radiation, in properly selected patients with rectal cancers of the distal 2 cm, offers opportunities for sphincter-preserving surgical resection with excellent local control, survival, and enhanced quality of life.
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Affiliation(s)
- M Mohiuddin
- University of Kentucky, Department of Radiation Medicine, Lexington 40536-0084, USA
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29
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30
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Panis Y, Ettorre G, Chafai N, Valleur P. Transanal resection of a low rectal stenosis by rectal advancement and rectoanal anastomosis. Br J Surg 1997. [DOI: 10.1002/bjs.1800840134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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31
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Audisio RA, Filiberti A, Geraghty JG, Andreoni B. Personalized surgery for rectal tumours: the patient's opinion counts. Support Care Cancer 1997; 5:17-21. [PMID: 9010985 DOI: 10.1007/bf01681957] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In recent times there have been many important changes in the surgical management of rectal cancer. The general thrust of these changes has been towards a less invasive approach with preservation of intestinal continuity and avoidance of the psychological sequelae of a stoma. It is also becoming increasingly apparent that profound sexual and autonomic dysfunction can be associated with abdominoperineal resection. This paper highlights these issues and the conflict between performing an adequate oncological procedure and reducing the incidence of postoperative psychological morbidity. It outlines the great changes there have been in surgical technique and their relevance to psychological problems after surgery for rectal cancer. The need for auditing psychological morbidity when assessing the outcome of surgical series is emphasised, as is the importance of involving the patient in the medical decision making.
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Affiliation(s)
- R A Audisio
- European Institute of Oncology (EIO), Milan, Italy
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32
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Panis Y, Ettorre G, Chafai N, Valleur P. Transanal resection of a low rectal stenosis by rectal advancement and rectoanal anastomosis. Br J Surg 1997; 84:92-3. [PMID: 9043466 DOI: 10.1046/j.1365-2168.1997.02434.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Y Panis
- Department of Surgery, Hôpital Lariboisière, Paris, France
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33
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34
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Leo E, Belli F, Andreola S, Baldini MT, Gallino GF, Giovanazzi R, Mascheroni L, Patuzzo R, Vitellaro M, Lavarino C, Bufalino R. Total rectal resection, mesorectum excision, and coloendoanal anastomosis: a therapeutic option for the treatment of low rectal cancer. Ann Surg Oncol 1996; 3:336-43. [PMID: 8790845 DOI: 10.1007/bf02305662] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND There is recent and sporadic evidence indicating that patients with very low rectal cancer may be treated via a sphincter-saving procedure, obviating the need for abdominoperineal resection and definitive colostomy. This study confirms these findings. METHODS From March 1990 to October 1994, 79 patients affected with primary low rectal cancers were submitted for total rectal resection, mesorectum excision, and coloendoanal anastomosis. All lesions were located within 8 cm of the anal verge (within 6 cm in 64 cases). RESULTS Eight patients relapsed at the pelvic level, and one patient only at the paraanastomotic site. Postoperative morbidity attributable to the procedure was low. A perfect continence was documented in 66% of cases after colostomy closure, and many patients (63%) had one or two bowel movements a day. Sixty-two patients of this series are alive, 49 without actual evidence of disease. Follow-up ranged from 2 to 56 months (median 23). CONCLUSIONS The clinical and pathological data derived from this study suggest that radical mesorectum excision more than a large clearance margin of resection remains the most important factor in reducing the incidence of local relapse after low rectal cancer surgery and that total rectal resection and coloendoanal anastomosis is a suitable and safe option to traditional, demolitive surgical techniques.
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Affiliation(s)
- E Leo
- Division of General Surgery B, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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35
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Abstract
BACKGROUND Patients with Crohn's disease (CD) are not commonly considered as candidates for ileal pouch/anal anastomosis (IPAA). This approach has been avoided because of the poor results observed, retrospectively, in patients with an initial diagnosis of ulcerative colitis who were found to have CD on examination of the resected specimen. However, in 1985, we decided to investigate an alternative to coloproctectomy with definitive end-ileostomy by a prospective study of IPAA for selected patients with CD. METHODS Between 1985 and 1992, 31 patients with CD, but with no evidence of anoperineal or small-bowel disease, were recruited to our study. They comprised 15 men and 16 women whose mean age was 36 years (SD 14; range 16-72). All CD patients underwent IPAA. The short-term and long-term functional results of this procedure were compared with those of 71 ulcerative colitis patients who also underwent IPAA during the same period in our unit. Mean follow-up was 59 (SD 25) months. FINDINGS No significant differences were observed between patients with CD and ulcerative colitis in the postoperative complication rate. Of the 31 CD patients, six (19%) experienced specific complications 9 months to 6 years after surgery: three had pouch-perineal fistulas, which required pouch excision in two cases; one had a pouch-vaginal fistula that was treated by gracilis muscle interposition; and one had an extrasphincteric abscess, which was treated surgically. Two patients (6%), one of whom was treated for an extrasphincteric abscess, experienced CD recurrence on the reservoir, and were treated successfully with azathioprine. At 5-year follow-up, there were no significant differences between patients with CD and ulcerative colitis in stool frequency (5.0 [2.0] vs 4.7 [1.4] per day; p=0.68), continence, gas/stool discrimination, leak or need for protective pads, and sexual activity. INTERPRETATION Our results show that in selected cases of CD without anoperineal or small-bowel manifestations, IPPA can be recommended as an alternative to coloprotectomy with definitive end-ileostomy, when rectal resection is essential.
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Affiliation(s)
- Y Panis
- Department of Surgery, Höpital Lariboisière, Paris, France
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36
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Abstract
Apart from the occasional tumour which is suitable for local excision, most low rectal cancers are best treated by anterior resection with complete removal of the rectum; the construction of a coloanal reservoir should allow routine sphincter saving. This surgery may be carried out independently of adjuvant radiotherapy which, if given, should be administered before operation.
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Affiliation(s)
- R J Nicholls
- Department of Surgery, St Mark's Hospital, Harrow, UK
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37
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Cavaliere F, Pemberton JH, Cosimelli M, Fazio VW, Beart RW. Coloanal anastomosis for rectal cancer. Long-term results at the Mayo and Cleveland Clinics. Dis Colon Rectum 1995; 38:807-12. [PMID: 7634975 DOI: 10.1007/bf02049837] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to determine functional outcomes and rates of survival and recurrence of coloanal anastomosis in rectal cancer patients. METHODS Between 1981 and 1991, 117 patients underwent coloanal anastomosis. Fifteen percent of the patients had a J-pouch; the rest had a straight coloanal anastomosis. Thirty-eight percent had no diverting stoma. Median distance of the tumor from the anal verge was 6.7 cm. RESULTS Local recurrence rate was 7 percent. Five-year survival was fully 69 percent. Satisfactory fecal continence was achieved by 78 percent of patients; no J-pouch patient had frequent incontinence. Sixty-two percent of the patients had major (anastomotic leak = 18 percent) or minor complications; complications were not mitigated by a diverting stoma or worsened by adjuvant therapy. CONCLUSION Although coloanal anastomosis is associated with a high chance of complications, the long-term outcome, in terms of disease-free survival and satisfactory function, is excellent.
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Affiliation(s)
- F Cavaliere
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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38
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Glättli A, Barras JP, Metzger U. Is there still a place for abdominoperineal resection of the rectum? EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1995; 21:11-5. [PMID: 7851543 DOI: 10.1016/s0748-7983(05)80060-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
During the past two decades, low anterior resection (LAR) with colo-rectal or colo-anal anastomosis has replaced abdominoperineal resection (APR) as the primary surgical therapy for rectal cancer. Several studies, although not prospectively randomized, have shown that the outcome after LAR with deep anastomosis and APR is comparable concerning mortality, local recurrence rate and survival. Adequate clearance of the tumour, and not the surgical procedure performed, is the determinant factor influencing the outcome. Whereas most tumours in the upper third and mid-rectum are amenable to a sphincter-saving procedure (SSP), the lower third of the rectum is of debate in this respect. Small tumours (T1) in the lower third can be treated by peranal local excision. Low grade tumours with a T2 or T3 stage located above 3 cm from the dentate line are treated by SSP. There is still a place for for advanced tumours (T3 and T4) below 5 cm from the anal verge, in case of deficiency of the anal sphincter, and when the sphincter complex is infiltrated by the tumour. Preoperative staging measures are essential for patients selection in relation to height of the tumour above the anal canal, depth of tumour invasion into the rectal wall, and presence or absence of regional lymph node metastases. Biology of rectal cancer and its implication on surgery, preoperative staging of rectal cancer, technique and results of the main three surgical options, and the advent of laparoscopy are discussed in this article.
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Affiliation(s)
- A Glättli
- Department of Surgery, City Hospital Triemli, Zurich, Switzerland
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39
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Rouanet P, Fabre JM, Dubois JB, Dravet F, Saint Aubert B, Pradel J, Ychou M, Solassol C, Pujol H. Conservative surgery for low rectal carcinoma after high-dose radiation. Functional and oncologic results. Ann Surg 1995; 221:67-73. [PMID: 7826163 PMCID: PMC1234496 DOI: 10.1097/00000658-199501000-00008] [Citation(s) in RCA: 134] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Using a prospective, nonrandomized study, the authors evaluated the morbidity and functional and oncologic results of conservative surgery for cancer of the lower third of the rectum after high-dose radiation. SUMMARY BACKGROUND DATA Colo-anal anastomosis has made sphincter conservation for low rectal carcinoma technically feasible. The limits to conservative surgery currently are oncologic rather than technical. Adjuvant radiotherapy has proven its benefit in terms of regional control, with a dose relationship. METHODS Since June 1990, 27 patients with distal rectal adenocarcinoma were treated by preoperative radiotherapy (40 + 20 Gy delivered with three fields) and curative surgery. The mean distance from the anal verge was 47 mm (27-57 mm), and none of the tumors were fixed (15 T2, 12 T3). RESULTS Mortality and morbidity were not increased by high-dose preoperative radiation. Twenty-one patients underwent conservative surgery (78%-17 total proctectomies and colo-anal anastomoses, 4 trans-anal resections). After colo-anal anastomosis, all patients with colonic pouch had good results; two patients had moderate results and one patient had poor results after straight colo-anal anastomosis. With a mean follow-up of 24 months, the authors noted 1 postoperative death, 2 disease-linked deaths, 1 controlled regional recurrence, 2 evolutive patients with pulmonary metastases, and 21 disease-free patients. CONCLUSIONS These first results confirm the possibility of conservative surgery for low rectal carcinoma after high-dose radiation. A prospective, randomized trial could be induced to determine the real role of the 20 Gy boost on the sphincter-saving decision.
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Affiliation(s)
- P Rouanet
- Department of Surgery, Montpellier Cancer Institute, France
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40
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Yoon WH, Song IS, Chang ES. Intraluminal bypass technique using a condom for protection of coloanal anastomosis. Dis Colon Rectum 1994; 37:1046-7. [PMID: 7924715 DOI: 10.1007/bf02049323] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Most surgeons carry out temporary diverting colostomy in coloanal anastomosis for mid-rectal or lower-rectal carcinomas. It has been reported that proximal fecal diversion provides no guarantee against anastomotic leaks. Some have proposed the use of the intracolonic bypass tube to prevent anastomotic leakage and colostomy, but colonic necrosis has been reported; it is important to use a safe technique that obviates this. METHODS The rectum is fully mobilized and transected at the level of the levator diaphragm. The mobilized sigmoid and rectum are resected with their mesenteries, and the prepared distal colon is everted 5 cm using Babcock clamps. The ring of a sterilized condom is then sutured to the mucosa and submucosa of the colon with 4/0 chromic catgut sutures. After completion of coloanal anastomosis, the condom is brought to the exterior, and the mid part is transected. RESULTS We have used a condom for intraluminal bypass procedures in ten rectal carcinoma patients including five preoperative radiation cases. There was no anastomotic dehiscence, leakage, or colonic necrosis because of a condom. CONCLUSION We believe that the intraluminal bypass technique using a condom is a very safe, cost-effective, and easily available alternative for coloanal anastomosis.
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Affiliation(s)
- W H Yoon
- Department of Surgery, Chungnam National University, School of Medicine, Taejon, South Korea
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41
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Peitgen K, Walz MK, Krause U, Eigler FW. [Experimental studies of laparoscopically-assisted rectum resection with colo-anal or colorectal anastomosis]. LANGENBECKS ARCHIV FUR CHIRURGIE 1994; 379:237-40. [PMID: 7934583 DOI: 10.1007/bf00186365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A minimally invasive procedure for radical resection of tumors in the deep rectum without laparoscopic anastomosis was developed in seven domestic pigs. The length of resected rectosigmoid and mesenterium was adequate on all oncologic counts.
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Affiliation(s)
- K Peitgen
- Abteilung für Allgemeine Chirurgie, Universitätsklinikum, Essen
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42
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Anatomische Physiologie des Sphinkterorgans — funktionelle Grundlage beim sphinktererhaltenden Therapiekonzept des Rektumkarzinoms. Eur Surg 1994. [DOI: 10.1007/bf02620012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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43
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Leo E, Belli F, Baldini MT, Vitellaro M, Mascheroni L, Andreola S, Bellomi M, Rebuffoni G, Lombardi F, Audisio R. Total rectal resection and colo-anal anastomosis with colonic reservoir for low rectal cancer. Int J Colorectal Dis 1994; 9:82-6. [PMID: 8064195 DOI: 10.1007/bf00699418] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
From March 1990 to December 1992, 47 patients with primary or recurrent low rectal cancer underwent total rectal resection and a coloendoanal anastomosis. Rectal resection was extended downward to the ano-rectal junction. The restorative technique included a colo-endoanal anastomosis between the dentate line and a J-shaped colic reservoir. All lesions were located within 7 cm of the anal verge (within 6 cm in 33 primary cases). Macroscopic and histological radicality was documented in all cases. Pelvic recurrence occurred in six patients and was para-anastomotic in one case. Post-operative morbidity was low. Perfect continence was documented in 36 patients and 72 of the cases had one or two bowel movements a day. All but four patients are alive at a follow-up ranging from 6 to 40 months (median 20 months). This approach is a safe option to conventional total rectal excision with permanent colostomy for lower third rectal carcinoma.
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Affiliation(s)
- E Leo
- Division of Surgical Oncology B, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milano, Italy
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Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994; 219:365-73. [PMID: 8161262 PMCID: PMC1243153 DOI: 10.1097/00000658-199404000-00007] [Citation(s) in RCA: 142] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Our institution's experience with low anterior resection in combination with coloanal anastomosis (LAR/CAA) for primary rectal cancer was reviewed (1) to determine cancer treatment results, 2) to identify risk factors for pelvic recurrence, and 3) to assess the long-term success of sphincter preservation. SUMMARY BACKGROUND DATA Use of sphincter-preserving resection for mid-rectal and selected distal-rectal cancers continues to increase. As surgical techniques and adjuvant therapy evolve, treatment results must be carefully assessed. METHODS One hundred thirty-four patients treated for primary rectal cancer by LAR/CAA between 1977 and 1990 were studied retrospectively. All pathologic slides were reviewed. Median follow-up was 4 years. RESULTS Actuarial 5-year survival for all patients was 73%. Among 36 patients who relapsed, distant metastatic disease had developed at the time of first clinical relapse in most (86%). Pelvic recurrence was detected in 13 patients, an actuarial rate of 11% at 5 years. Mesenteric implants, positive microscopic resection margin, T3 tumor, perineural invasion, blood vessel invasion, and high tumor grade were associated with increased risk for pelvic recurrence. Eleven patients ultimately required permanent colostomy, and in eight instances the cause was pelvic recurrence. CONCLUSIONS Low anterior resection combined with coloanal anastomosis provides good treatment for mid-rectal cancers and for some distal rectal cancers. Pelvic recurrence is not associated with short distal resection margins but is correlated with the presence of histopathologic markers of aggressive disease in the primary tumor. Long-term preservation of anal sphincter function depends primarily on control of pelvic tumor and can be achieved in more than 90% of patients.
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Affiliation(s)
- P B Paty
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
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Leo E, Belli F, Baldini MT, Vitellaro M, Mascheroni L, Andreola S, Bellomi M, Zucali R. New perspective in the treatment of low rectal cancer: total rectal resection and coloendoanal anastomosis. Dis Colon Rectum 1994; 37:S62-8. [PMID: 8313796 DOI: 10.1007/bf02048434] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Presently abdominoperineal resection still remains the most diffuse modality of treatment of low rectal cancer. However, a new surgical approach is now available to avoid such a demolitive surgery and a definitive colostomy. METHODS From March 1990 to March 1993, 58 total rectal resections were performed in 55 patients affected with primary or recurring cancers of the low rectum. As a restorative procedure, a colic J-shaped pouch and a handsewn pouch-endoanal anastomosis was adopted. All of the primary lesions were within 7 cm of the anal verge; in 74 percent the distal tumor margin was located less than 6 cm from the cutaneous edge. RESULTS Histologic clearance of the rectum cut edge was documented in all cases. Seven patients relapsed locally from 7 to 14 months after surgery and in 3 more cases distant metastases were documented. Postoperative morbidity is low. After colostomy closure in 78 percent of patients, perfect continence was achieved and in 74 percent less than two bowel movements a day were recorded. Fifty patients are presently alive, 46 without evidence of disease. The follow-up ranged from 2 to 37 (median, 13) months. CONCLUSION This experience, along with data obtained from last year's literature, indicates that a conservative surgical procedure, such as total rectal resection and coloendoanal anastomosis, can be considered a feasible and radical option for treatment of low rectal cancer.
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Affiliation(s)
- E Leo
- Division of Surgical Oncology B, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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Bezzi M, Casella M, Batori M, Angelini L. A simple technique for sutureless very low colorectal anastomosis. Int J Colorectal Dis 1992; 7:227-9. [PMID: 1293245 DOI: 10.1007/bf00341227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M Bezzi
- Fourth Department of Surgery, University of Rome, Medical School, La Sapienza, Italy
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Abstract
Functional results in 33 patients who underwent a coloanal anastomosis with reservoir were prospectively evaluated three months after colostomy closure and later (16.2 +/- 5.7 months) and were compared with those of 36 healthy controls. We were unable to demonstrate any significant difference between patients and controls concerning frequency of stools, feeling of the need to defecate, continence of stools and flatus, differentiation between flatus and feces, urgency, and need to wear a protective pad. There was a statistically significant difference concerning the ability to evacuate, which was better in the control group (score = 1.03) than in the patients (score = 1.63) (P less than 0.001). These results suggest that coloanal anastomosis with reservoir provides nearly normal function except for the ability to evacuate.
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Affiliation(s)
- E P Pélissier
- Department of Digestive Surgery, Clinique Saint Vincent, Besançon, France
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Abstract
Rectal cancer often in the past was believed to require abdominoperineal resection with permanent colostomy to achieve a cure. Several surgical alternatives to colostomy currently are available for selected patients. Understanding of the methods of preoperative staging is increasing, and new techniques, such as intrarectal ultrasound, have provided improved accuracy. By applying this and other methods of preoperative staging, selection of a surgical approach appropriate to the tumor stage increasingly is possible. Curative treatment for rectal cancer often can be achieved while preserving anorectal function.
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Affiliation(s)
- R P Billingham
- Department of Surgery, University of Washington, Seattle 98122
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Berger A, Tiret E, Parc R, Frileux P, Hannoun L, Nordlinger B, Ratelle R, Simon R. Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum. World J Surg 1992; 16:470-7. [PMID: 1589983 DOI: 10.1007/bf02104450] [Citation(s) in RCA: 112] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The results of rectal excision with colonic pouch-anal anastomosis are reviewed from a series of 162 patients covering 7 years. All patients have been operated upon in the same institution and consecutively. The follow-up is now sufficient to allow an accurate evaluation of the outcome of the patients. The main goal of this study was to provide a detailed report of the functional results. Continence was satisfactory in 96% of the patients, with either a perfect continence or minor troubles that would not have been detectable other than by a rigorous questioning. The mean number of bowel movements was 2 per 24 hours. Fragmentation of the defecation and urgency were absent. Twenty-five per cent of the patients had to elicit the evacuation of the reservoir with a suppository or an enema. Improvement of function yielded by a reservoir over straight colo-anal and low colo-rectal anastomoses are significant and, as suggested by manometric studies, are directly related to the restoration of a reservoir function.
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Affiliation(s)
- A Berger
- Department of Digestive Surgery, Hopital Saint Antoine, Paris, France
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Braun J, Treutner KH, Winkeltau G, Heidenreich U, Lerch MM, Schumpelick V. Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma. Am J Surg 1992; 163:407-12. [PMID: 1532699 DOI: 10.1016/0002-9610(92)90042-p] [Citation(s) in RCA: 80] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Between 1977 and 1987, 519 patients underwent operation for rectal carcinoma. Sixty-three patients underwent intersphincteric resection with direct coloanal anastomosis (CAA), and 77 had an abdominoperineal resection (APR). Curative surgery was achieved in 57 and 65 patients, respectively. Both groups were comparable regarding age, stage of tumors, and localization of tumors. During the mean period of 6.7 years (range: 3 to 13.6 years), all patients were examined according to a predefined follow-up plan. From those patients with curative surgery, 11% presented with pelvic recurrence and 33% with distant metastases after coloanal anastomosis; the rates of recurrence and distant metastases after APR were 17% and 35%, respectively. The corrected 5-year survival rates were 62% following CAA and 53% following APR. Eighty-five percent of the patients with CAA reported good functional results regarding anal continence. Our study demonstrates that the intersphincteric resection with CAA is a valuable surgical technique for rectal carcinoma with the benefit of preservation of continence. It is suitable for neoplasms with high- and medium-grade differentiation (G1 to G2) and a localization that allows a minimum distal clearence of 3 cm.
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Affiliation(s)
- J Braun
- Department of Surgery, Medical Faculty, Rhenish-Westphalian Technical University Aachen, Federal Republic of Germany
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