J. S. Köninger, M. Butters, J. D. Redecke, K. Z’graggen J.S. Köninger ( u)

J. S. Köninger, M. Butters, J. D. Redecke, K. Z’graggen J.S. Köninger ( u)

Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany e-mail: joerg_koeninger@med.uni-heidelberg.de

Abstract

Colon pouch reconstruction after deep rectal resection is functionally superior to straight colorectal/anal anastomosis. However, stool evacuation difficulties could jeopardize the functional benefit of neorectal reservoirs. Beside the well proven colon J-pouch, the transverse coloplasty pouch may represent a viable alternative.

We examined evacuation and functional outcome after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and distal third of rectum underwent a total mesorectal ex- cision. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoper- atively. Eight months after surgery, video defecography, anal manometry and pouch volumetry were performed and the patients were interviewed according to a standardized continence questionnaire. Rectal resection and reconstruction with transverse coloplasty pouch anastomosis could be performed in all patients.

No insufficiency of the pouch occurred. In the follow-up, no patient had difficul- ties to evacuate the pouch, none of these patients needed enemas or suppositories to facilitate defecation. All patients were continent for solid stools. Twenty-five of 27 patients had up to three bowel movements per day. Patients with reduced pelvic floor movement in the defecography proved more likely to suffer from urgency, fragmented evacuation and incontinence. Transverse coloplasty pouch reconstruction after total mesorectal excision is not associated with stool evacua- tion problems. Urgency and incontinence, which are rarely seen after this type of reconstruction, correlate with impaired pelvic floor movement rather than with pouch size or anal sphincter tonus.

Introduction

The surgical strategy of rectal cancer has seen significant modification over the last 15 years. The concept of total mesorectal excision (TME) [1–5] in combination Recent Results in Cancer Research, Vol. 165

Springer-Verlag Berlin Heidelberg 2005 c

with a smaller tumor-free distal margin [6–9] leads to a higher rate of continence- preserving surgeries. Nevertheless, anal dysfunction following low colorectal or coloanal anastomosis may impair quality of life in as many as 40% of patients.

As a consequence of the complete removal of the rectum, patients may suffer from complex disturbances of defecation concerning both continence and stool evacuation. This is especially true over the 1st year after rectal resection [10–15].

It has already been well documented that a short colon J-pouch (CJP) is func- tionally superior to straight coloanal anastomosis (CAA) [16–22]. Lower stool frequencies, less urgency and an almost normal social life can be predicted for the majority of patients. Nevertheless, incomplete evacuation and constipation may be a problem after CJP [20, 23, 24]. Up to 35% of the elderly patients will need laxatives or enemas to avoid constipation and fecal impaction [20, 25, 26].

At present, it is widely accepted that construction of a short CJP reduces these problems. Whether routine resection of the sigmoid colon will improve functional outcome is still uncertain [14, 15, 17, 22, 27].

In 1997, Z’graggen and Büchler from Bern, Switzerland, described a novel technique of constructing a small-volume colonic reservoir designed in analogy to a stricturoplasty [28, 29]. This technique was originally described as the transverse coloplasty pouch (TCP), but is variably termed as colonic coloplasty or coloplasty pouch in the literature [30]. The comparison with a short colonic J-pouch (CJP) and straight coloanal anastomosis (CAA) in pigs demonstrated superior functional outcome and morphometric data [29]. Pigs with TCP showed a moderately reduced velocity of colonic transit compared to those with CAA and there were no signs of marker accumulation above the pouch or fecal impaction. The stool frequency after TCP lies between the results of the CAA and those of the CJP. In contrast, the colonic transit time after CJP was significantly delayed. In the colon passage with opaque radio markers, a relative J-pouch obstruction led to substantial fecal impaction and marker accumulation above rather than in the J-pouch [29] and this was in accordance with the known evacuation problems in humans with CJPs.

Clinical series demonstrated that patients with TCP did not develop evacuation difficulties in the follow-up [31, 32]. Defecography is the currently used standard examination to investigate impaired defecation. Defecography results after TME and TCP reconstruction have not yet been reported and the aim of the current study was to prospectively investigate functional outcome after TCP and correlate the results with defecography.

Patients and Methods

Thirty consecutive patients with cancer of the middle and lower third of the rectum underwent a TME. All interventions were done by three experienced surgeons who had each performed more than 50 TMCs. The trial was approved by the local ethical committee and informed consent was given by all patients. Table 1 shows patient data. R0 resection was confirmed in all patients by the pathologist.

The important steps during reconstruction included: mobilization of the splenic

flexure up to the middle colic artery and resection of the sigmoid colon. After

Table 1. Characteristics of 30 consecutive patients with rectal cancer who underwent TME and reconstruction with the transverse coloplasty pouch

Gender (F/M) n=9/21

Median age in years (range) 65 (52–80)

Median body mass index (range) 25.3 (16.2–35.3)

Dukes’ stage A 11

B 7

C 12

Mean operating time in minutes (range) 168 (130–220)

Median follow up in weeks (range) 34 (24–72)

insertion of the anvil of a circular stapler (all anastomoses were performed by means of a circular stapling device, Proximate ILS, Ethicon Endosurgery, Johnson- Johnson, Cincinnati, OH), the descending colon was opened longitudinally at the antimesocolic border, starting 2 cm proximal to the rim of the anvil, over a distance of 10 cm. In analogy to a stricturoplasty (Heineke-Mikulicz), the incision was then closed transversally, by a two-layered running suture (4.0 PDS). Twenty-five patients had a protective loop ileostomy. Continuity was restored in median 6 weeks (2–18 weeks) after surgery. All the anastomoses were checked on the 10th postoperative day by radiografin enema. All patients with Dukes’ B and C stage of the disease underwent adjuvant radiochemotherapy.

Patients were reexamined within 8 months after ileostomy-closure by interview and defecography. The standardized questionnaire according to Kirwan and Parks contained questions about incontinence, stool frequency, urgency and fragmented evacuation. A fragmented bowel movement was defined as an evacuation in a mul- tiple consecutive manner within 1 h after defecation. Urgency was defined as the inability to defer defecation for more than 15 min.

Defecography was performed according to a standard procedure as an enema with semi-solid water-soluble contrast medium, with the patient in a squatting position. The following sequence was standardized:

1. The patient was asked to squeeze the levator ani muscles, especially the pu- borectalis sling contracts maximally, causing an impression at the posterior border of the anorectal junction and an acute anorectal angulation.

2. The patient was asked to relax the levator ani muscles. At this stage the puborectalis remains in a state of contraction, but not as accentuated as while squeezing. This can be observed by the partial obliteration of the impression, a slight decrease of the anorectal angle and a slight descent of the anorectal junction.

3. The patient was requested to defecate: a further obliteration of the impres- sion, a decrease of the anorectal angle, a descent of the anorectal junction and a widening of the anal canal could be seen.

4. At the end of defecation, the ampulla recti should be empty ( <10 ml), and

there should be no further urge to defecate.

The change of the anorectal angle was noted during the squeezing, relaxing and defecation as an expression of the motility of the pelvic floor as well as the completeness of evacuation.

Anal manometry was performed with a water-perfused four-channel mano- metric catheter (MUI Scientific, Mississagua, ON, Canada). Normal values are 37–114 cm H

O for maximum resting pressure and 37–213 cm H

O for maximum squeeze increment pressure.

Volumetry was performed by means of a balloon inserted into the pouch, which was then filled with water at 37

C in portions of 10 ml. The first sensation was taken as threshold volume. The balloon was filled in further 10-ml steps up to the point when the patient had any discomfort or pain (maximum tolerable volume).

Results

The transverse coloplasty pouch was constructed in all 30 patients. One 78-year-old patient with severe cardiac risks died of myocardial infarction on the 3rd post- operative day (3% mortality). One patient without ileostomy underwent another operation on the 4th day because of anastomotic dehiscence and pelvic sepsis.

A lavage of the abdominal cavity and a protective ileostomy were performed.

In four patients, asymptomatic anastomotic leakage was detected radiologically (4/30; 13%). No insufficiency of the pouch, e.g., leakage from the transverse suture, occurred. One patient died of toxic agranulocytosis following adjuvant chemother- apy 7 weeks after surgery. One 81-year-old patient could not be examined because of rapid deterioration of his general condition (Table 2). Twenty-seven patients entered the follow-up.

Table 2. Postoperative complications

Surgical complications Number of patients

Anastomotic leakage

Clinically detected 2

Radiologically detected 4

Pelvic sepsis 1

Anastomotic stricture 0

Urinary dysfunction 0

Other complications

Acute heart failure 1

Toxic agranulocytosis 1

Defecography

The TCP was constructed according to a stricturoplasty. The shortening of the

anterior wall led to angulation and gave the pouch a shape similar to that of

the original rectum as seen in a lateral radiograph control. Measurement of the anorectal angle could therefore be performed in analogy to that in patients who did not undergo colorectal surgery.

There was a wide variety of anorectal angles under defecation (normal values, 25–40

). The median value was 20

(range, 0–40

). Eighteen patients (67%) showed a normal mobility of the pelvic floor with a change of the ano-neorectal angle of 20–40

during defecation. All but one patient (96%) could evacuate the pouch spontaneously during defecography. One patient with Parkinson’s disease was not able to evacuate the pouch during defecography (4%). All other patients emptied the neorectum according to the above-mentioned criteria, with seven patients

Figure 1A–C. Defecography after TME and TCP reconstruction. Patient with perfect continence status after rectal resection. Preserved continence due to acute anorectal angulation of approximately 25

, which is the result of the contraction state of the puborectalis and levator ani muscle at rest. As a result of the forward pull exerted by the puborectalis on the dorsal border of the anorectal junction, the posterior and anterior wall of this region are forced together and act as a mechanical flutter valve occluding the anal canal. During defecation, the puborectalis and levator ani muscle relaxes, resulting in obliteration of the impression of the posterior wall of the anorectal junction, abasement of the pelvic floor and the anus, with a consequent widening of the anorectal angulation. The anorectum is converted into a tunnel-like shape, enabling passage of the rectal content. The evacuation of the rectum is a result of an interaction of propulsive forces of the rectal wall and reflectory relaxation of the sphincter muscles. During defecography, the interaction between the levator ani musculature and the sphincter ani muscles with the dorsal part of the anorectum can be observed

Figure 2A–C. Defecography after TME and TCP reconstruction. Patient suffering from urgency and fecal

incontinence after TME and TCP reconstruction. The patient has fragmented evacuation but no evacuation

difficulties with need for medical treatment or enemas. In the defecography, nearly complete evacuation of

the pouch despite of minimal pelvic movement

retaining less than 10 ml of the semiliquid contrast medium after defecation.

Two patients showed no pelvic floor movement, but spontaneous defecation was possible. There were no signs of neorectal intussusception or mucosal prolapse in any of the patients (Figs. 1, 2).

Manometry

Maximum resting sphincter pressure was moderately reduced in a majority of the patients (Table 3), but all exceeded the lower limit of normal values (35 cm H

O). Seven patients had a reduced maximum increment squeeze pressure and did not reach normal values (38 cm H

O). Patients with reduced pelvic floor movement (0–25

) tended to have reduced maximum sphincter pressure, although this observation failed to reach statistical significance.

Table 3. Postoperative anorectal physiology (n=27)

Maximum resting pressure in cm H

O 70 (40–140)

Maximum squeeze pressure in cm H

O 40 (30–80)

Threshold volume in ml 110 (60–130)

Maximum tolerated volume in ml 220 (180–270)

Change of anorectal angle under defecation in degrees 25 (0–40)

a

All values are median (range).

Pouch Volumetry

The median threshold volume was 110 ml (range, 60–130 ml), the median maxi- mum tolerated volume (MTV) 220 ml (range, 180–270 ml). The sensation described by the patients was heterogenous and only few described it similar to urgency. We discontinued the filling of the neorectal reservoir as soon as the patients reported discomfort or pain, but most (17) of the patients could not define an exact limit.

Functional Outcome

Seven months after TME and TCP anastomosis, 25 of 27 patients had one to three

bowel movements per day, with a median of 2.7 patients reported occasionally

uncontrolled flatus and five were occasionally incontinent for liquid stools. Two

patients had difficulties to defer defecation for more than 15 min. Fourteen of 27

patients reported stool fragmentation, but all could evacuate the pouch without

the help of enemas or suppositories. None of the patients used laxatives or enemas

to facilitate defecation. Twenty-five of 27 patients had no limitations in social life or

daily activities (see Table 4). Patients with reduced pelvic floor movement tended to

have worse functional results; however, this was not statistically significant. There

Table 4. Functional results 7 months after TME and TCP anastomosis

Number of patients

Stool frequency/day <1 5

1–3 20

>3 2

Uncontrolled flatus Always –

Sporadic 7

No 20

Incontinence for liquid stool Always 0

Sporadic 5

No 22

Incontinence for solid stool Always 0

Sporadic 2

No 25

Ability to defer defecation always for more than 15 min Yes 25

No 2

Fragmented stools Yes 14

No 13

Inability to evacuate pouch 0

was no correlation between anal sphincter tonus and pouch volume and func- tional results. In addition, statistical analysis did not reveal a correlation between anastomotic leakage, postoperative radiation therapy and anal continence.

Discussion

Functional outcome after TME for rectal cancer depends on the quality of the primary surgery, the technique of reconstruction and the functional state of the pelvic floor and sphincter apparatus. A distinct “anterior resection syndrome”

consists of increased stool frequency, urgency to defecate and minor degrees of incontinence/fecal leakage. Anal continence is widely reported to improve over time postoperatively. Most patients achieve relatively normal bowel function by the end of the 1st year after the operation. However, in about one-third of patients after CAA, these symptoms persist and have significant impact on the quality of life [15, 22, 24, 25, 33, 34]. The ideal rectal surgery therefore combines an optimal TME involving the preservation of nerves, bladder and genital functions and preservation of continence with a reconstruction that minimizes early and late functional problems.

Compared with CAA, functional results after CJP are superior, mainly in the

1st year after surgery, but in the long term, evacuation difficulties can jeopardize

the functional benefit that results from the formation of a colonic pouch [31].

Even in the case of smaller J-pouches with a limb length of 5–7 cm, up to 20% of patients [25, 34, 35], and more frequently elderly patients [26], need suppositories and small enemas to avoid fecal impaction as early as 6 months after surgery.

A possible explanation for this phenomenon is the design of the J-pouch with its anisoperistaltic limb resulting in a neutralization of the properistaltic vector (the counter-current principle) [14, 23, 28, 36, 37]. It is also documented that size of the reservoir may play a role in the malfunctioning CJP. Larger pouches tend to dilate and favor constipation and fecal impaction [14, 36].

Seow-Choen and colleagues, however, could not show a significant difference in neorectal volume, compliance or rectal sensation after J-pouch-anal and straight descendoanal anastomosis, but nevertheless the functional results have proven to be better after pouch-anal anastomosis [14]. This implies that the brake on the propulsive wave may be more important than the volume of the neorectal reservoir [31].

The TCP may represent an ideal compromise between CAA and short CJP.

A relatively small volume pouch is formed without a complete anisoperistaltic segment. This design leads to a certain degree of counter-current action, which seems to result in a moderate braking of the propulsive wave and perhaps retaining enough propulsion to allow complete evacuation.

In our series of defecographies, evacuation of the pouch was possible in all but one patient suffering from advanced Parkinson’s disease who was not able to follow the instructions. All other patients evacuated the pouch spontaneously and completely—less than 10 ml of contrast medium retention—during defecography.

Preservation of anal continence depends mainly on proper function of the levator ani and the sphincter ani muscles. During defecography, the interaction between these functional units can be appreciated. A decisive factor seems to be the acute anorectal angulation. It is the result of the contraction and positioning of the puborectalis sling and the levator ani muscle at rest. As a result of the forward pull exerted by the puborectalis sling on the anorectal junction, the posterior and anterior wall are forced together and act as a mechanical flutter valve occluding the anal canal. During defecation, the puborectalis and levator ani muscle relax, which leads to an abasement of the pelvic floor and the anus with a widening of the anorectal angulation. The anorectum is converted into a tunnel-like shape, enabling passage of the rectal content. The evacuation of the rectum is then a result of an interaction of propulsive forces of the rectal wall and reflectory relaxation of the sphincter muscles.

The neorectal reservoir does not functionally replace the normal rectum. We

have observed that evacuation after TME and pouch reconstruction depends on

proper function of the pelvic floor and straining. There was a wide variety of

pelvic floor movement in our patients. Change in anorectal angle under defecation

was between 0 and 40

and correlated with functional results. In the subgroup of

ten patients with physiologic floor movement (change in anorectal angle between

25–40

), none suffered from urgency and only a single patient was sporadically

incontinent for flatus. Urgency and incontinence were more frequent in patients

with limited pelvic floor motility. A lack of pelvic floor movement seemed to be

associated with fragmented evacuation.

Besides evacuation, functional outcome significantly depends on the preserva- tion of anal continence. Reduced anal sphincter tonus can be expected after low anterior rectal resection [15, 36]. In our study, patients with physiologic pelvic floor movement tended to have higher sphincter tonus, but in accordance with other investigators [23, 33, 35] there was no correlation between anal sphincter tonus and continence.

During pouch volumetry, we found an average threshold volume of 70 ml and average maximum tolerated volume of 220 ml after TCP, which is comparable to other reports on short J-pouches [18, 23, 36]. No correlation was found between threshold/maximum tolerated volume and either urgency, fragmented evacuation or continence status. These findings again underline that it is not so much the volume of the reservoir, but rather its antipropulsive effect that is fundamental for the functional outcome after TME.

Conclusion

Transverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems.

Urgency and incontinence correlate more with impaired pelvic floor movement than with pouch size or anal sphincter tonus. It may be interesting to investigate whether preoperative defecography can predict functional outcome after total mesorectal excision.

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