or Colonic J-Pouch Coloanal Anastomosis

or Colonic J-Pouch Coloanal Anastomosis

Guillaume Portier, Ivan Platonoff, Frank Lazorthes

G. Portier ( u)

Service de Chirurgie Digestive, CHU Purpan, Place du Dr. Baylac, 31059 Toulouse, France

e-mail: portier.g@chu-toulouse.fr

Abstract

Proctectomy followed by straight coloanal anastomosis (CAA) often results in poor functional outcome known as the anterior resection syndrome. It is now based on evidence that a colonic J-pouch CAA improves outcome in the first 2 years. We assessed the very late functional outcome of CAA patients with or without a pouch. These results show that the functional benefit of the J-pouch anastomoses is sustained over the very long term.

Introduction

Proctectomy and coloanal anastomosis makes it possible to cure a majority of patients with cancer of the mid and low rectum. However, functional results are often disappointing and patients’ quality of life can be altered seriously. Attempts to ameliorate the function have been made. The colonic J-pouch, first described in 1986, is now being challenged by other techniques, still under evaluation. The aim of this work was to assess the very long-term functional results of coloanal anastomoses (CAA) with or without a colonic J-pouch (CJP).

Patients and Methods

Among all consecutive patients treated for rectal cancer between 1980 and 1996, we specifically analyzed CAA for mid and lower rectal tumors, after at least 5 years of follow-up.

In June 2001, a functional questionnaire was sent to patients who were still alive, without recurrence.

Items recorded were increased stool frequency, stool fragmentation, evacuating difficulties, and continence. Quality of life related to incontinence was also assessed

Springer-Verlag Berlin Heidelberg 2005c

by the FIQL (Fecal Incontinence Quality of Life) questionnaire [1]. Patients who had had postoperative radiotherapy were excluded.

Statistical analysis was comparative between straight and J-pouch anastomoses.

A multivariate analysis was made including factors such as preoperative radiother- apy, age, gender, and partial internal sphincter resection.

Results

A total of 190 consecutive patients were treated in the study period. In 2001, 95 were alive without recurrence. Six postoperatively irradiated patients were excluded, and seven were lost to follow-up. Mean follow-up was 156 months (SE, 54). There were 52 males and 30 females. Mean age was 71.5 years (SE, 9.1). Patient characteristics are detailed in Table 1.

There were no significant differences between the two groups for age, sex ratio, neoadjuvant radiotherapy, partial internal sphincter excision.

Functional results are detailed in Table 2.

Table 1. Characteristics of 82 patients after proctectomy and coloanal anastomosis

n %

Dukes’ A 41 50

B 25 30.5

C 15 18.3

M+ 1 1.2

Radiotherapy None 43 52.4

Preoperative 33 40.2

postoperative 6 7.3

Table 2. Long-term functional results after proctectomy between straight coloanal anastomosis (CAA) and colonic J-pouch coloanal anastomosis (CJP)

CAA (%) CJP (%) p

Continence Fazio I+II 53 72 0.04

III+IV 47 28

Cleveland score 6.44 4.56 NS

Nocturnal soiling 56.3 32 0.03

Gas/stool discrimination 84.5 92 NS

Evacuation disorders Yes 59 48

Urgencies 47 21 0.014

>2 movements /24h 68.8 50 0.03

Need to stay near toilets 22 6 0.038

Incomplete evacuation 50 27 0.028

Table 3. Long-term Fecal Incontinence Quality of Life scores after proctectomy between straight coloanal anastomosis (CAA) and colonic J-pouch coloanal anastomosis (CJP); n=45. Scales are from 0 (worse) to 4 (excellent)

CAA CJP p

Lifestyle 3.07 3.35 NS

Coping/behavior 2.95 3.25 NS

Depression/self-perception 3.71 3.81 NS

Embarrassment 3.1 3.29 NS

No patients had a diverting stoma attributable to functional reasons.

More patients were continent to stools in the CJP group than in the straight CAA group (72% vs. 53%; p=0.04). They also had less nocturnal soiling (32% vs. 56%), fewer urgencies (21% vs. 47%), lower frequency, and less incomplete evacuation.

FIQL scores are detailed in Table 3.

FIQL scores were available for 45 patients. The four domains studied were higher in the CJP group, but did not reach statistical significance.

Discussion

Proctectomy results in a well-described functional outcome : the anterior resec- tion syndrome [2]. This syndrome associates several troubles such as increased stool frequency, stool fragmentation, incomplete exoneration, incapacity to defer exoneration, soiling or incontinence.

This is due to the loss of rectal capacity and compliance, and by sphincter alter- ations due to partial internal resection (for ultralow CAA) and adjuvant treatments [3, 4].Its severity is increased by the extent of rectal resection, and thus is mostly observed after straight coloanal anastomosis [5]. In addition, pelvic septic com- plications due to anastomotic leakages occur in about 15% of cases after straight CAA in published series [6–9].

The colonic J-pouch, described in 1986 [10, 11], offered several theoretical ad- vantages: it creates a neorectal reservoir, with the aim of increasing rectal capacity [12]. In a scintigraphic randomized study, retention of colonic liquids was im- proved in the pouch group [13]. It also brings more healthy tissue to the pelvis.

The tension-free anastomosis is lateroterminal, with, in theory, better vasculariza- tion, and less anastomotic leakages.

Since 1986, a large number of comparative prospective, and even randomized trials between CJP and straight CAA have been published. In all studies, CJP resulted in a better functional outcome in the first 2 years [5, 8, 9, 14–17].

Fragmentation, urgency, nocturnal defecation and continence were all improved in these series. They also confirmed a decreased anastomotic leakage rate with J- pouches, compared to straight anastomosis [6–9].

A new problem appeared in the first experience, represented by evacuation

difficulties, probably due to a J-pouch that was too long (10 cm) [18]. A randomized

trial assessed this problem specifically, and showed that a 5-cm J-pouch can avoid this poor outcome [19].

More recent studies assessed quality of life, and were concordant with previous results.

Evidence-based studies have now led to the conclusion that a pouch offers a functional benefit, at least in the first 2 years.

Since straight anastomosis patients usually experience a functional improve- ment with time [16], it is not known whether the functional superiority of pouch anastomoses is sustained in the long term.

Very few data about long-term functional outcome are available since only one series had more than 5 years of follow-up [20].

Our work compared functional results between CJP and straight CAA after more than 10 years.

It suggests that the functional benefit of a colonic pouch persists, and moreover, that no outlet obstruction appears, as has been previously described with 10-cm pouches [18].

Still, about 30% of our patients experience occasional soiling or stool fragmen- tation. The satisfactory quality-of-life scores in our study reflect that in the long term, most of them are adapted to this situation and prefer not to have a definitive stoma. FIQL scores were all higher in the CJP group but not significantly different, probably because of a lack of statistical power, since only 45 patients returned the questionnaire.

Our data do not predict the individual functional outcome. This is why exper- imental studies must carry on with new techniques of rectal reconstruction after proctectomy, such as transverse coloplasty pouch, or lateroterminal anastomosis [21]. Influence of adjuvant treatments, especially preoperative chemoradiother- apy, and of partial sphincter excision, must be taken into consideration for the subgroup analysis.

Conclusion

The functional benefit of a colonic J-pouch is now based on evidence, at least for the first 2 years. Our study suggests that this superiority is maintained over the very long term, and that CJP function does not deteriorate with time. Nevertheless, these results are not perfect, and efforts should be made to ameliorate patients’

anorectal function and quality of life after curative proctectomy for cancer.

References

1. Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43:9–16; discussion 16–17

2. Lewis WG, Martin IG, Williamson ME, Stephenson BM, Holdsworth PJ, Finan PJ, Johnston D (1995) Why do some patients experience poor functional results after anterior resection of the rectum for carcinoma? Dis Colon Rectum 8:259–263

3. Dahlberg M, Glimelius B, Graf W, Pahlman L (1998) Preoperative irradiation affects functional results after surgery for rectal cancer: results from a randomized study. Dis Colon Rectum 41:543–549; discussion 549–551

4. Gervaz P, Rotholtz N, Wexner SD, You SY, Saigusa N, Kaplan E, Secic M, Weiss EG, Nogueras JJ, Belin B (2001) Colonic J-pouch function in rectal cancer patients: impact of adjuvant chemoradiotherapy. Dis Colon Rectum 44:1667–1675

5. Hida J, Yasutomi M, Maruyama T, Fujimoto K, Nakajima A, Uchida T, Wakano T, Tokoro T, Kubo R, Shindo K (1998) Indications for colonic J-pouch reconstruction after anterior re- section for rectal cancer: determining the optimum level of anastomosis. Dis Colon Rectum 41:558–563

6. Hallbook O, Sjodahl R (1996) Anastomotic leakage and functional outcome after anterior resection of the rectum. Br J Surg 83:60–62

7. Ho YH, Tan M, Seow-Choen F (1996) Prospective randomized controlled study of clinical function and anorectal physiology after low anterior resection: comparison of straight and colonic J pouch anastomoses. Br J Surg 83:978–980

8. Hallbook O, Pahlman L, Krog M, Wexner SD, Sjodahl R (1996) Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg 224:58–65 9. Joo JS, Latulippe JF, Alabaz O, Weiss EG, Nogueras JJ, Wexner SD (1998) Long-term functional

evaluation of straight coloanal anastomosis and colonic J-pouch: is the functional superiority of colonic J-pouch sustained? Dis Colon Rectum 41:740–746

10. Lazorthes F, Fages P, Chiotasso P, Lemozy J, Bloom E (1986) Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum.

Br J Surg 73:136–138

11. Parc R, Tiret E, Frileux P, Moszkowski E, Loygue J (1986) Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma. Br J Surg 73:139–141

12. Hallbook O, Sjodahl R (1997) Comparison between the colonic J pouch-anal anastomosis and healthy rectum: clinical and physiological function. Br J Surg 84:1437–1441

13. Ho YH, Yu S, Ang ES, Seow-Choen F, Sundram F (2002) Small colonic J-pouch improves colonic retention of liquids—randomized, controlled trial with scintigraphy. Dis Colon Rec- tum 45:76–82

14. Ortiz H, De Miguel M, Armendariz P, Rodriguez J, Chocarro C (1995) Coloanal anastomosis:

are functional results better with a pouch? Dis Colon Rectum 38:375–377

15. Kusunoki M, Shoji Y, Yanagi H, Hatada T, Fujita S, Sakanoue Y, Yamamura T, Utsunomiya J (1991) Function after anoabdominal rectal resection and colonic J pouch – anal anastomosis.

Br J Surg 78:1434–1438

16. Lazorthes F, Chiotasso P, Gamagami RA, Istvan G, Chevreau P (1997) Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis.

Br J Surg 84:1449–1451

17. Seow-Choen F, Goh HS (1995) Prospective randomized trial comparing J colonic pouch-anal anastomosis and straight coloanal reconstruction. Br J Surg 82:608–610

18. Hida J, Yasutomi M, Maruyama T, Tokoro T, Wakano T, Uchida T (1999) Enlargement of colonic pouch after proctectomy and coloanal anastomosis: potential cause for evacuation difficulty. Dis Colon Rectum 42:1181–1188

19. Lazorthes F, Gamagami R, Chiotasso P, Istvan G, Muhammad S (1997) Prospective, ran- domized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum 40:1409–1413

20. Harris GJ, Lavery IC, Fazio VW (2001) Function of a colonic J pouch continues to improve with time. Br J Surg 88:1623–1627

21. Mantyh CR, Hull TL, Fazio VW (2001) Coloplasty in low colorectal anastomosis: manometric and functional comparison with straight and colonic J-pouch anastomosis. Dis Colon Rectum 44:37–42