Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Neorectal reservoir is not the functional principle of the colonic J-pouch: the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. Transverse coloplasty pouch and colonic J-pouch for rectal cancer--a comparative study. Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Comparison of defecatory function after colonic J-pouch anastomosis and straight anastomosis for stapled low anterior resection: results of a prospective randomized trial. Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis. Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial. Lothian and Borders large bowel cancer project: immediate outcome after surgery. The consultant surgeons and pathologists of the Lothian and Borders Health Boards.
To assess the efficacy of a novel coloplasty colonic pouch design in optimizing bowel function after ultralow anterior resection.
                A colonic J-pouch may reduce excessive stool frequency and incontinence after anterior resection, but at the risk of evacuation problems. Experimental surgery on pigs has suggested that a coloplasty pouch (CP) may be a useful alternative. Although CP has recently been shown to be feasible in patients, there is no randomized controlled trial comparing bowel function with the J-pouch.
                After anterior resection for cancer, patients were allocated to either J-pouch or CP-anal anastomoses. Continence scoring, anorectal manometry, and endoanal ultrasound assessments were made before surgery. All complications were recorded, and these preoperative assessments were repeated at 4 months. The assessments were repeated again at 1 year, and a quality of life questionnaire was added.
                Eighty-eight patients were recruited from October 1998 to April 2000. Both groups were well matched for age, gender, staging, adjuvant therapy, and mean follow-up. There were no differences in the intraoperative time and hospital stay. CP resulted in more anastomotic leaks. At 4 months, J-pouch patients had 10.3% less stool fragmentation but poorer stool deferment and more nocturnal leakage. However, there were no differences in the bowel function, continence score, and quality of life at 1 year. There were no differences in the anorectal manometry and endoanal ultrasound findings.
                Coloplasty pouches resulted in more anastomotic leaks and minimal differences in bowel function. At present, the J-pouch remains the benchmark for routine clinical practice, and due care (including defunctioning stoma) should be exercised in situations requiring CP. Low anterior resection with coloanal anastomosis prevents a definitive stoma in patients with distal rectal cancer. However, imperative stool urge, stool fragmentation, prolonged stooling sessions, and minor problems of incontinence are frequently observed in the postoperative situation and negatively affect quality of life. Therefore, the colonic J-pouch was originally constructed to create a stool reservoir. In a randomized, prospective study, the short (5 cm) colonic J-pouch was tested for function and continence vs. straight coloanal anastomosis.
                Over a period of 30 months, 74 consecutive patients (55 males) with rectal cancer in the lower and middle third of the rectum were included and randomized into two groups. Anastomosis was performed either as a coloanal or a colon-pouch-anal anastomosis. The standardized surgical procedure included mobilization of the left hemicolon, central ligation of the inferior mesenteric artery and vein, preaortal lymph node dissection, autonomic nerve preservation, and total mesorectal excision. The anastomosis was performed at the upper anal canal or at the intersphincteric level. All patients were evaluated preoperatively and six months postoperatively for fecal continence, including sphincter manometry and defecation habits. In addition, quality of life was determined by use of a standardized questionnaire (European Organization for Research and Treatment of Cancer, EORTC-QLQ-C30).
                Thirty-seven patients were randomized into each group. In general, problems with continence for liquids or gas occurred less frequently in the colonic J-pouch group 6 months after surgery. The frequency of bowel movements was lower in the J-pouch group (2.5 per day) than in the coloanal group (4.7 per day). Importantly, in a manometric study at the same postoperative point, neorectal capacity was decreased to a similar degree in both groups compared with the preoperative rectal volume. Thus, the expected and postulated reservoir effect could not be achieved by forming a 5-cm colonic J-pouch.
                The colonic J-pouch was superior with regard to continence for gas and liquids compared with a straight coloanal anastomosis. Furthermore, stool frequency was significantly lower in the J-pouch group than in the coloanal reconstruction group. However, because neorectal capacity decreased equally in both groups, we speculate that the advantage of the colonic J-pouch is not in the creation of a larger neorectal reservoir but rather may be related to decreased motility. The introduction of the colonic J-pouch has markedly improved the functional outcome of restorative rectal cancer surgery. However colonic J-pouch surgery can be problematic and may present some late evacuatory problems. To overcome these limitations a novel pouch has been proposed: the transverse coloplasty pouch. The purpose of our study was to compare the functional outcomes of these two different types of pouches--the transverse coloplasty pouch (TCP) and the colonic J-pouch (CJP)--during the first 12 months postoperatively.
                A prospective randomized trial was conducted in which a total of 30 patients with mid and low rectal cancer were submitted either to a transverse coloplasty pouch or a colonic J-pouch. Clinical defaecatory function was assessed and anorectal physiological assessment was carried out, pre-operatively and at 3, 6 and 12 months postoperatively, by means of a standard clinical questionnaire and by anorectal manometry.
                No statistically significant differences were found between the two groups regarding bowel function. The postoperative frequency of daily bowel movements was lower in the TCP group in all the phases of the study (3.9 vs. 4.1 at 3 months; 3.1 vs. 3.4 at 6 months; 2.1 vs. 2.8 at 12 months), the same occurring with fragmentation (33% vs. 40% at 3 months; 26.6%vs. 33.3% at 6 months; 7.1%vs. 14.3% at 12 months). Less urgency was also seen in the TCP group during the first 6 months (20%vs. 26.7%), with identical values at 12 months (14.3% vs. 14.3%). No significant differences were also found concerning incontinence grading and scoring, with TCP patients having less nocturnal leaks. At one year two CJP patients (14.3%) needed the use of enemas to evacuate the pouch and provoke defaecation, a problem never seen in TCP patients. The anorectal manometry data was similar in both types of pouches. The local complication rates were also identical in the two groups (20%); more anastomotic leaks were seen in TCP patients (13.2% vs. 6.6%), without reaching a statistical significance.
                The transverse coloplasty pouch has similar functional results but fewer evacuation problems than the J-Pouch, making it a safe and reliable alternative to the colonic J-pouch. The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 +/- 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 +/- 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 +/- 2.8 vs. 49 +/- 1.4/week; p < 0.05) and less soiling at passing flatus (38% vs. 73.7%; p < 0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 +/- 0.4 vs. 8 +/- 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p < 0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch. The authors compared clinical bowel function and complications of a low anterior resection with either a straight or colonic J pouch anastomosis.
                Urgency and frequent bowel movements after rectal resection with a low anastomosis have been related to the loss of rectal reservoir function. Reconstruction with a colonic J pouch possibly can obviate some of this dysfunction. Earlier reports have been favorable, but they must be verified in randomized trials.
                One hundred patients with rectal cancer in whom a sphincter-saving procedure was appropriate were randomized to reconstruction with either a straight or a colonic J pouch anastomosis.
                The incidence of symptomatic anastomotic leakage was lower in the pouch group (2% vs. 15%, p = 0.03). Eighty-nine patients could be evaluated after 1 year. The pouch patients had significantly fewer bowel movements per 24 hours, and less nocturnal evacuations, urgency, and incontinence. Overall well-being owing to the bowel function was rated significantly higher by the pouch patients.
                Reconstruction with a colonic J pouch was associated with a lower incidence of anastomotic leakage and better clinical bowel function when compared with the traditional straight anastomosis. Functional superiority was especially evident during the first 2 months. Although defecatory function after low anterior resection for rectal cancer is reported to be better following colonic J-pouch than straight anastomosis, few prospective randomized trials comparing the two forms of anastomosis have been reported. We performed a prospective randomized trial comparing straight anastomosis with colonic J-pouch anastomosis both clinically and physiologically in patients undergoing stapled low colorectal anastomosis.
                A total of 42 consecutive patients were intraoperatively randomized to undergo either straight anastomosis or colonic J-pouch anastomosis. Clinical defecatory function was evaluated by a questionnaire answered preoperatively, then 6 and 12 months postoperatively. Anorectal physiological assessment was also carried out before surgery, then 12 months postoperatively.
                The clinical defecatory function assessed 6 months and 12 months after surgery did not differ between the two groups. However, while the length of high-pressure zone was significantly shortened, and (neo)rectal capacity was significantly reduced postoperatively in the straight group, none of these physiological parameters were significantly altered in the pouch group.
                Although the aim of colonic J-pouch to preserve reservoir function was physiologically achieved, the improvement in clinical defecatory function was not significant. Thus, further prospective studies are needed to confirm the functional superiority of colonic J-pouch anastomosis for stapled low colorectal anastomosis after low anterior resection. Functional outcome after rectal excision with coloanal anastomosis is improved by construction of a colonic J pouch. Present prospective randomized studies lack follow-up beyond 1 year. The aim of this study was to assess the clinical outcome at both short- and long-term follow-up.
                Forty patients with low rectal cancer were randomized prospectively to either J colonic pouch-anal anastomosis or a straight coloanal anastomosis. Clinical assessments were performed 3, 12 and 24 months after colostomy closure using a standard questionnaire and physical examination.
                There was no significant difference in the complication rate between the two groups. There was a significant (P < 0.01) improvement in frequency of defaecation at 3, 12 and 24 months for patients with a reservoir. Similarly, fragmentation (clustering of stools) was significantly less at 3 and 12 months (P < 0.01) in the reservoir group, and incontinence occurred less frequently in the first year (P = 0.09). By 24 months no patient in either group suffered from major or minor incontinence.
                The functional improvement gained from a colonic reservoir in coloanal anastomosis continues to benefit the patient for at least 2 years. To compare a colonic J-pouch or a side-to-end anastomosis after low-anterior resection for rectal cancer with regard to functional and surgical outcome.
                A complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis.
                One-hundred patients with rectal cancer undergoing total mesorectal excision and colo-anal anastomosis were randomized to receive either a colonic pouch or a side-to-end anastomosis using the descending colon. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively.
                Fifty patients were randomized to each group. Patient characteristics in both groups were very similar regarding age, gender, tumor level, and Dukes' stages. A large proportion of the patients received short-term preoperative radiotherapy (78%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height (4 cm), perioperative blood loss (500 ml), hospital stay (11 days), postoperative complications, reoperations or pelvic sepsis rates. Comparing functional results in the 2 study groups, only the ability to evacuate the bowel in <15 minutes at 6 months reached a significant difference in favor of the pouch procedure.
                The data from this study show that either a colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results. A prospective audit of all large bowel cancer resections is being conducted in the adjacent Health Boards of Lothian and Borders. The results of surgery in 750 consecutive patients recruited during the first 2 years are presented. In this time, 249 (33.2 per cent) patients presented as an emergency, 490 (65.3 per cent) had resection of a colonic cancer, and 36 (4.8 per cent) patients died within 30 days. Abdominal resection was performed in 741 patients and intestinal continuity was restored in 646 (87.2 per cent). Of all anastomoses performed, 31 (4.8 per cent) leaked (15 of 467 (3.2 per cent) and 16 of 179 (8.9 per cent) after resection of colonic and rectal cancers, respectively). Of the patients presenting with a rectal cancer, 251 (96.5 per cent) underwent abdominal resection and intestinal continuity was restored in 179 (71.3 per cent). Five of 28 consultants were responsible for half of these patients. Patients treated by these five consultants were no more likely to undergo anastomosis, but when an anastomosis was performed it was less likely to leak (four of 95 (4.2 per cent) versus 12 of 84 (14.3 per cent) (chi 2 = 4.63, P < 0.05)). The overall outcome of surgery appears to be improved when compared to previous similar audits. Considerable intersurgeon variation remains in the results of resection of rectal cancer.
In several randomized controlled trials, the CJP has been shown to be superior to the SCA in bowel function outcomes in patients with rectal cancer for at least 18 months after gastrointestinal continuity is re-established. The TC and STE anastomoses have been shown to have similar bowel function outcomes when compared to the CJP in small randomized controlled trials; further study is necessary to determine the role of these alternative coloanal anastomotic strategies.