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ORIGINAL ARTICLE
Year : 2014  |  Volume : 51  |  Issue : 4  |  Page : 560-564
 

Colonic J pouch neo-rectum versus straight anastomosis for low rectal cancers


Department of Surgery and Allied Specialities, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India

Date of Web Publication1-Feb-2016

Correspondence Address:
M L Wani
Department of Surgery and Allied Specialities, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.175341

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 » Abstract 

Aim: The development of sphincter saving procedures for low carcinoma rectum has been the consequence of oncological and technological factors. The major disadvantage associated with these procedures is the development of anterior resection syndrome because of the resection of rectal reservoir. Colonic J pouch (CJP) neorectum has been practiced as an antidote to overcome this problem. We are working at a tertiary care center, which is a high volume center for rectal cancers. We thought it worthwhile to assess the efficacy of J Pouch neorectum viz.-a-viz. a straight coloanal anastomosis for low rectal cancers. Materials And Methods: Hospital based prospective randomized study (June 2007-December 2009) low rectal cancers (4-12 cm from the anal verge). One group (20 patients) subjected to low/ultralow anterior resection with straight anastomosis (SA) and other group (22 patients) to CJP. The two groups were compared on the basis of functional outcome. Results: Anastomotic leak, strictures, frequency of bowel movements, nocturnal bowel movements, use of retarding medication and incontinence to solids, liquids and gases were seen more in SA group. All these findings were statistically significant. Conclusions: We conclude that CJP has a significant functional advantage over SA and improves the overall quality-of-life in patients of low rectal cancers and the advantage persisted over a period of more than 30 months.


Keywords: Anastomosis, colon cancer, colonic J pouch


How to cite this article:
Parray F Q, Farouqi U, Wani M L, Chowdri N A, Shaheen F. Colonic J pouch neo-rectum versus straight anastomosis for low rectal cancers. Indian J Cancer 2014;51:560-4

How to cite this URL:
Parray F Q, Farouqi U, Wani M L, Chowdri N A, Shaheen F. Colonic J pouch neo-rectum versus straight anastomosis for low rectal cancers. Indian J Cancer [serial online] 2014 [cited 2019 Dec 16];51:560-4. Available from: http://www.indianjcancer.com/text.asp?2014/51/4/560/175341



 » Introduction Top


The surgical practice for middle and low rectal cancers has dramatically changed over the past two decades. Most patients are now undergoing curative resection with preservation of the anal sphincter with restoration of intestinal continuity; thus, avoiding a permanent stoma in about 90% of all rectal carcinomas with same or even better oncological results.[1],[2],[3]

The development the sphincter saving procedures has been the consequences of oncological and technological factors, total mesorectal excision with nerve sparing and impact of neoadjuvant therapy.[4],[5],[6]

The major advantage of anterior resection (AR) is the avoidance of colostomy. On the other hand, the re-establishment of intestinal continuity often results in poor functional outcome as a consequence of alteration of pelvic physiology. These continence disorders are called anterior resection syndrome (ARS).[7],[8],[9],[10] The ARS is because of loss of reservoir function of the rectum and is characterized by continence disorders ranging from the inadvertent and uncontrollable passage of flatus to frank fecal incontinence as well as urgency and increased frequency of evacuation. This syndrome may affect up to 90% of patients with straight coloanal anastomosis and may worsen the quality-of-life in about 39% of them.[7],[9]

Lazorthes et al. in 1986 described the use of a colonic J pouch (CJP) following an AR to overcome the problems of ARS by increasing neorectal volume.[11],[12] Since, we are working in a tertiary care institute, which is a high volume center for colorectal malignancy; we thought it worthwhile to compare the outcome of CJP neorectum and straight coloanal anastomosis for low carcinoma rectum.


 » Materials and Methods Top


The present study was a prospective study (June 2007 to December 2009) of patients of rectal carcinoma randomly allotted to two groups. One group (20 patients) was subjected to low AR with straight anastomosis (SA) and other group (22 patients) to CJP anastomosis in the Department of Surgery. Randomization was performed pre-operatively in blocks of four with sealed envelopes in numerical order; odd serials were subjected to SA and even serials to CJP. The plan was changed in three patients per-operatively and was excluded from the study. The cases were worked up as per the prefixed proforma which included: A detailed history, thorough physical examination, digital rectal examination, proctoscopic, sigmoidoscopic or colonoscopic examination with a pre-operative biopsy, routine and specialized biochemical investigations, specialized radiological investigations such as multi-detector computed tomography, trans-rectal ultra sonography or endorectal coil magnetic resonance imaging for pre-operative staging and assessment of operability. Carcino-embryonic antigen (CEA) level was done pre-operatively and on follow-up. Pre-operative staging was done using Duke's staging.

The inclusion criteria were:

  • Rectal adenocarcinoma 4-12 cm from the anal verge
  • A sphincter saving resection deemed appropriate on both oncological and functional grounds
  • Patients with T3/T4 lesions and/or node positive disease included only after neoadjuvant and assessment of down staging.


Functional outcome was assessed mainly by focusing on the following points:

  • Frequency of bowel movement per 24 h
  • Nocturnal bowel movements (NBM)
  • Ability of defer defecation for more than 30 min
  • Composite incontinence score (CIS)[13] [Table 1]
  • Regular use of medication
  • Ability to evacuate the bowel within 15 min
  • Sensation of incomplete evacuation.
Table 1: Composite incontinence score

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The patients in whom a covering ileostomy was done were evaluated for these functional results only after their ostomies were closed.

The study was approved by the ethical committee of our institute.

Patients were advised to follow-up on 15th day, 1st month, 2nd month and at 6 months. Functional outcome assessment was done at 7th day, 2nd month and at 6th month. CEA levels, chest radiogram, ultra sonogram of the abdomen, sigmoidoscopy was done at 6 monthly interval to rule out any recurrence or metastasis. The diverting ileostomy was closed at 3-4 month interval.

Statistical analyses were carried out using Fisher's exact test and Chi-square test using SPSS statistical package (2011 edition).


 » Results Top


The type of growth and histopathology is shown in [Table 2]. In CJP, 10 (45.5%), 3 (13.6%), 8 (36.4%) and 1 (4.5%) while as in SA 7 (35.0%), 2 (10%), 9 (45%) and 2 (10%) belonged to Duke's A, B, C1 and C2 respectively.
Table 2: Type of growth and histopathology of the studied group

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Nearly, 63.6% (14) descending colon and 36.4% (8) sigmoid colon was used for making the pouch (0.031 sig).

Post-operative complications in the studied patients are shown in [Table 3]. Frequency of bowel movement per 24 h in the studied patients is shown in [Table 4]. NBM comparison is shown in [Figure 1].
Table 3: Post-operative complications in the studied patients

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Table 4: Frequency of bowel movement per 24 h

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Figure 1: Nocturnal bowel movements in the Studied Patients

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CIS in the studied patients is shown in [Table 5] and [Table 6].
Table 5: Composite incontinence score in the studied patients

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Table 6: Grades of incontinence

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 » Discussion Top


The mean age of presentation in CJP was 50.7 (±8.8). The mean age of presentation in SA was 47.8 (±16.9) years; similar to the observation of others.[14] Male to female ratio was 1:1 in both groups as observed by others.[13] Patients were randomized to two groups in concordance with various other studies irrespective of age and sex characteristics.[13],[14],[15] Similarly, the values of hemoglobin, albumin and CEA were not significantly different in two groups. These findings were more or less similar to that reported in the literature.[16]

Bleeding per rectum (100%) was the most common symptom in both groups followed by tenesmus and frequency, which is in co-relation with other study.[17]

All patients were M0. 45.5% of CJP were in Duke's A and 45% of SA were in Duke's C1 which doesn't co-relate exactly with other studies.[13],[18]

R0 resection was achieved in 81.8% of CJP and 75.0% of SA group. Descending colon was predominantly used to make the pouch as compared with the sigmoid colon as was done by others.[3] The sigmoid colon has a presence of diverticula, more propulsive motility and a fatty mesentery.[19]

One patient from each group died due to pulmonary embolism. SA group had 3.3 times more chances of anastomotic leak than CJP and anastomotic stricture was 2 times more common in SA group. Other studies [13],[20],[21],[22] also show lesser leak rates for CJP as compared with SA because micro-circulation at the apex of the pouch is better preserved as confirmed by laser Doppler flowmetry.[23]

Other factors may be reduced risk of pelvic hematoma due to better filling of the presacral space with the pouch.[13] They also found that reduction in incidence of stricture is significant (P = 0.000058).

We found a statistically significant difference in frequency of bowel movements at 2 and 6 months in CJP and SA groups which co-relates well with other studies.[11],[13],[19] An intragroup comparison revealed that the frequency of bowel movement improved with time in both groups. But in comparison to CJP, the frequency in SA group was still more, which correlates with other studies.[11],[24] We saw a statistically significant difference between the two groups viz.-a-viz. NBM at 2 and 6 months as shown in other studies.[13],[25]

The ability to defer defecation for 30 min was significantly better in CJP group. However, this property did not improve over the period, but it did improve in SA group, which is supported by some studies,[13],[26] but negated by others.[19],[27]

Retarding medication (P < 0.05); was used more by SA group, which is supported by other studies.[12],[13],[18] Bulking medication was more used by CJP group similar to what is reported by other studies.[13],[21],[27] Also, there was a statistically significant difference (P < 0.05) in the ability to differentiate between gas and stool more effectively in CJP group not in co-relation with other studies.[13],[24]

Ability to evacuate bowel within 15 min was more pronounced for SA group. CJP patients complained of evacuation difficulties,[13],[28] which may be tackled by reducing pouch size.[28],[29]

In our study, we found CJP patients were more continent to gases than SA at 2 and 6 months. However on intra group comparison, the continence to liquids showed an improvement as compared to gases in both groups. At 2 and 6 months, continence to solids was better for CJP and an intragroup comparison showed an improvement in both groups.

CIS was noted in the study group. At 2 months, 12 patients (63.2%) of the CJP group had a nil score whereas two patients (10.5%) of SA group had a severe score.

At 6 months, all patients of CJP had a nil score, whereas five patients (26.3%) of SA group had a moderate score. CIS showed a similar improvement in both groups with time.

We conclude that the continence to gases, liquids and solids had significantly improved in the CJP patients as compared to SA group, which is consistent with other studies.[11],[12],[13],[14] However, Hallbook [28] found no significant difference between CJP and SA group at 1 year in continence, which was confirmed by other studies.[30],[31]

Batignani et al.[32] observed a significant decrease in the anal canal resting pressure. This was due to decreased activity of the internal sphincter, but they did not notice a significant decrease in maximum voluntary contraction. This type of reduction is also reported by other authors.[33],[34] This resulted in fecal soiling after low anterior resection.

Even though, CJP reservoir has shown many advantages to overcome the problems of ARS in most of the studies, but it has come with problems of evacuation in some studies.[35] In our study group, we used 6-8 cm pouches and preferred to fix the pouch with presacral fascia with a hitching stitch to prevent horizontal angling in order to decrease the evacuation difficulty. Even after following these patients over a period of 3 years; the CJP group persisted with the advantage over its counterpart in all the described parameters. Over a period of all these years, we have continued the procedure and the numbers are increasing every year.

The coloplasty pouch seems to be more physiological, decreases the evacuation problems and technically possible even in difficult cases but comes with an increased incidence of leak rates as here again the anastomosis is end-to-end.[36],[37]

Meta-analysis published in British Journal of Surgery in 2006 confirmed that CJP after AR showed significant functional advantage over SA and this persisted overtime and seems to be a procedure of choice.[38]

Meta-analyses suggest that CJP is able to obviate some functional problems of SA, but comes with an additional problem of pouch evacuation. Therefore, alternative techniques such as transverse coloplasty and side to end coloanal anastomosis have been adopted.[39]

To conclude, we recommend that CJP is an excellent option for low rectal cancers with a better functional outcome in properly selected patients and smaller pouches (6-8 cm) with a presacral fixation suture; however, it is still too early to label it as a gold standard. We cannot right now comment on coloplasty pouch as that is a research project under our trial right now.

 
 » References Top

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Hida J, Yasutomi M, Maruyama T, Fujimoto K, Nakajima A, Uchida T, et al. Indications for colonic J-pouch reconstruction after anterior resection for rectal cancer: Determining the optimum level of anastomosis. Dis Colon Rectum 1998;41:558-63.  Back to cited text no. 14
    
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25.
Hallböök O, Johansson K, Sjödahl R. Laser Doppler blood flow measurement in rectal resection for carcinoma – Comparison between the straight and colonic J pouch reconstruction. Br J Surg 1996;83:389-92.  Back to cited text no. 25
    
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27.
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31.
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32.
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33.
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36.
Harris GJ, Lavery IJ, Fazio VW. Reasons for failure to construct the colonic J-pouch. What can be done to improve the size of the neorectal reservoir should it occur? Dis Colon Rectum 2002;45:1304-8.  Back to cited text no. 36
    
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Ho YH, Brown S, Heah SM, Tsang C, Seow-Choen F, Eu KW, et al. Comparison of J-pouch and coloplasty pouch for low rectal cancers: A randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Ann Surg 2002;236:49-55.  Back to cited text no. 37
    
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Heriot AG, Tekkis PP, Constantinides V, Paraskevas P, Nicholls RJ, Darzi A, et al. Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection. Br J Surg 2006;93:19-32.  Back to cited text no. 38
    
39.
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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