Clinical Outcome After Rectal Replacement With Side-to-End, Colon-J-Pouch, or Straight Colorectal Anastomosis Following Total Mesorectal Excision

Abstract

Objective: To compare, in a phase 3, prospective, randomized, multi-center clinical trial functional outcome of reconstruction procedures following total mesorectal excision (TME). Summary Background Data: Intestinal continuity reconstruction following TME is accompanied by postoperative defecation dysfunctions known as ''anterior resection syndrome.'' Commonly used reconstruction techniques are straight colorectal anastomosis (SCA), colon J-pouch (CJP), and side-toend anastomosis (SEA). Comparison of their functional outcomes in prospective, randomized, multi-center studies, including long-term assessments, is lacking. Methods: Patients requiring TME for histologically proven rectal tumor, with or without neoadjuvant treatment, age ! 18 years, normal sphincter function without history of incontinence, any pretreatment staging or adenoma, expected R0-resection, were randomized for standardized SCA, CJP, or SEA procedures. Primary endpoint was comparison of composite evacuation scores 12 months after TME. Comparison of composite evacuation and incontinence scores at 6, 18 and 24 months after surgery, morbidity, and overall survival represented secondary endpoints. Analysis was based on ''per protocol'' (PP) population, fully complying with trial requirements, and intention-to treat (ITT) population. Results: Three hundred thirty-six patients from 15 hospitals were randomized. PP population included 257 patients (JCP ¼ 63; SEA ¼ 95; SCA ¼ 99). Composite evacuation scores of PP and ITT populations did not show statistically significant differences among the 3 groups at any time point. Similarly, composite incontinence scores for PP and ITT populations showed no statistically significant difference among the 3 trial arms at any time point. Conclusions: Within boundaries of investigated procedures, surgeons in charge may continue to perform reconstruction of intestinal continuity following TME at their technical preference.

Clinical benefit of high resolution anorectal manometry for the evaluation of anal function after intersphincteric resection

“…However, the anastomosis of a J-pouch down to the level of the dentate line is not always technically feasible because of the bulk of mesocolic fat or inadequate length of preserved colon. A phase 3, prospective, multicentre randomized controlled trial that compared the functional outcomes of reconstruction procedures following total mesorectal excision showed no significant difference in composite incontinence scores among the three trial arms (straight CAA, J-pouch and side-to-end anastomosis) at any time point [28]. For reconstruction of intestinal continuity following ISR in our hospital, side-toend anastomosis is performed if the intestine has length to spare and the procedure is not technically difficult, and straight CAA is performed in all other cases.…”

Ultimate Functional Preservation With Intersphincteric Resection for Rectal Cancer

“…Different types of anastomosis such as colonic J-Pouch have been evaluated in order to improve the functional results after a proctectomy (64). A recent randomized controlled trial did not find the superiority of a reservoir confection by colonic J-Pouch or side-to-end anastomosis and straight anastomosis on the anal function (65). This controversial issue was not evaluated in the specific setting of ISR but in conventional coloanal anastomosis.…”

Long‐term urogenital assessment after elective laparoscopic sigmoid resection for diverticulitis: a comparison between central and peripheral vascular resection

“…Interestingly, all these cited studies evaluated urogenital outcomes over a short period of time based on the assumption that any dysfunction improves over time, thanks to patients’ related compensatory mechanisms. In the literature this is mainly accepted when comparing the different reconstructions after colorectal surgery for cancer, but little is validated for sigmoid resection for diverticular disease [29,30]. In this case the anastomosis is created at the level of the proximal/middle rectum and does not influence the postoperative functional outcomes; importantly, central ligation of the IMA is not mandatory.…”