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PubMed2005

Different role of the colonic pouch for low anterior resection and coloanal anastomosis.

BACKGROUND: Functional outcome after sphincter-saving operations can be improved by colonic pouch compared to the straight procedure. However, it is not clear whether the colonic pouch has a different behavior in patients treated by low anterior resection with colorectal (LAR) or coloanal anastomosis (CAA). METHODS: We evaluated the 1-year results of 75 patients who underwent a sphincter-saving operation for rectal carcinoma or villous tumor of the middle or lower third of the rectum: 18 patients underwent coloanal anastomosis (CAA), in 13 patients we performed a coloanal anastomosis with a colonic pouch (PCAA), 20 patients had low anterior resection (LAR) and 24 had LAR with pouch construction (PLAR). The two groups of patients were similar in terms of age and gender. Anorectal function was assessed 12 months after the initial operation by an interview and anorectal manometry. RESULTS: One year after surgery, the daily mean number of defecations was significantly higher in the LAR group than in the other groups (2.0+/-1.5 in CAA group, 2.2+/-1.0 in PCAA, 2.3+/-1.8 in PLAR, 4.1+/-0.7 in LAR; p<0.05). Frequent soiling was observed in all the groups except PLAR. A lower degree of incontinence and a lower frequency of urgency were found in PCAA than in CAA. There were no differences in anal resting pressure and squeeze pressure among the various groups. Greater distensibility and compliance of the neorectum were observed in CAA, PCAA and PLAR compared to LAR, respectively 8.5+/-7.0 ml air/mmHg for CAA, 8.7+/-5.0 ml air/mmHg for PCAA, 6.3+/-4.0 ml air/mmHg for PLAR and 3.1+/-2.7 ml air/mmHg for LAR. A significant inverse linear correlation was present between the mean daily number of defecations and compliance. No difference in sense of incomplete evacuation was observed among the groups of patients. CONCLUSIONS: Colonic J-pouch provides an advantage over straight anastomosis in sphincter-saving operations by reducing the daily number of defecations, and the frequencies of fecal soiling and urgency. The role of the pouch seems to be different in LAR compared to CAA. In fact, in LAR the pouch increases compliance and consequently decreases the daily number of defecations. In CAA, the pouch does not reduce the number of defecations or the compliance, but reduces the frequency of fecal soiling and urgency.

Adenoma, Villous↗
PubMed2001

[Colon pouch as neorectum. Technique, indications and results].

Colon pouch as neorectum. Technique, indications and results.The possibilities to preserve the intestinal continuity after surgery for rectal cancer have remarkably improved. After straight coloanal anastomosis the problem of a high stool frequency together with urgency was frequently to observe. The introduction of the colonic J-Pouch improved the functional outcome of rectal cancer-surgery very much. In a review of the literature the stool-frequency after one year was 0.5-4 bowel movements per day compared to 0.5-10 per day after straight coloanal anastomosis. Urgency was as well reduced. The parameter of urgency can be best expressed by measuring the urgency volume in balloon-volumetry. Here the volume for J-Pouch was 75 ml compared to 50 ml in straight coloanal anastomosis. At the beginning of colonic J-pouch-surgery evacuation disorders were more frequent observable. Clinical and experimental studies could demonstrate that a big pouch-size caused this problem. Since a pouch-length of 6 cm is used evacuation disorders are very rare. The improved perfusion of the side-to-end anastomosis in pouch-anastomosis reduces the rate of anastomotic leakage's (pouch 1.9 % vs. coloanal anastomosis 15.2 %). In published retrospective studies the oncological outcome is completely comparable to straight coloanal anastomosis. In the case of technical impossibility of J-pouch formation the ileocecal interponant is a possible alternative. This procedure has the same functional outcome.

Anal Canal↗
PubMed1998

Pseudoexstrophy associated with congenital pouch colon.

Pseudoexstrophy or covered exstrophy is a rare exstrophy variant. The authors report a case of covered exstrophy that presented as a newborn with widely separated pubic bones and rectus muscles, a low-set umbilicus, and a subcutaneous bladder. The anal opening was absent, and there was a complex malformation of the external genitalia consisting of a small, laterally displaced penis and a right-sided ectopic hemiscrotum. Micturition and urinary continence were normal. The child also had a high anorectal malformation with a coexistent type IV congenital pouch colon (CPC) malformation. Both kidneys were normal. Preliminary surgery consisted of a divided sigmoid colostomy proximal to the colonic pouch. The literature is reviewed and the embryogenesis of pseudoexstrophy and its associated malformations are discussed.

Abnormalities, Multiple↗
PubMed2000

Colon pouch (Mainz pouch III) for continent urinary diversion after pelvic irradiation.

OBJECTIVES: Urinary diversion after previous pelvic irradiation is challenging. The use of irradiated bowel in particular is associated with an increased rate of early and late complications. We therefore performed continent cutaneous urinary diversion using exclusively nonirradiated bowel segments in this group of patients. METHODS: A continent colon pouch for urinary diversion was performed in 44 female patients after pelvic irradiation. The indications were irreparable vesical fistula in 20, local recurrence of gynecologic tumors in 22, and radical cystectomy for bladder cancer in 2 patients. Depending on the length of the nonirradiated bowel segment, a transverse-ascending colon pouch (n = 8) or transverse-descending colon pouch (n = 36) was performed. The efferent segment was created from a tapered bowel segment embedded in the pouch wall. The ureters were implanted using a submucosal (n = 67) or subserosal (n = 17) extramural tunnel. RESULTS: No pouch-related complications were observed during the immediate postoperative period. In long-term follow-up (mean 52.2 months), upper urinary tract dilation was seen in five renal units. All five of these had been dilated preoperatively, and none required ureteral reimplantation. Incontinence occurred in 2 patients; both underwent reoperation with subsequent continence. Umbilical stoma stenosis was observed in 6 patients. CONCLUSIONS: The technique of the colon pouch for continent urinary diversion in previously irradiated patients is safe and has a low complication rate. The use of nonirradiated bowel segments should be the method of choice in this group of patients.

Adult↗
PubMedDate not supplied

Use of a colonic pouch as a rectal substitute after rectal excision.

Mid or distal rectal resection with straight coloanal anastomosis effectively treats distal rectal cancer and avoids a permanent stoma. However, the straight colonic segment is a poor reservoir for stools, and patients usually experience varying degrees of impaired rectal function after operation, including frequent bowel movements, incontinence, tenesmus, and soiling. In contrast, a J-shaped colonic pouch provides an adequate neorectal reservoir after operation. Patients with a colonic pouch-anal canal anastomosis have fewer bowel movements per day than patients with straight colorectal or coloanal anastomosis. Furthermore, the morbidity of the colonic pouch is not greater than that of the straight coloanal anastomosis. An important technical aspect of the colonic pouch procedure is that the limbs used to form the pouch must be no longer than 5 to 6 cm. Patients with larger pouches experience emptying difficulties. Also, the level of the anastomosis between the pouch and the anal canal must be no more than 4 cm from the anal verge, again to avoid problems with defecation. With these caveats, the operation should be considered in patients who require excision of the mid and distal rectum for cancer.

Anastomosis, Surgical↗
PubMed2005

Congenital pouch colon with prune belly syndrome and megalourethra.

Congenital pouch colon (CPC), an unusual high anorectal malformation in which a varying length of colon is replaced by a dilated pouch, has appeared in a number of case reports and series published in the English literature. There is only one case report of its association with prune belly syndrome (also known as triad syndrome, Eagle-Barrett syndrome, and abdominal muscle deficiency syndrome). We report the description and management of this rare association in a male neonate with CPC, prune belly syndrome, and congenital megalourethra.

Colon↗
PubMed2001

[Colo-anal anastomosis: improvement of early function outcome by reconstruction with the colonic pouch].

INTRODUCTION: Early functional outcome after ultra-low anterior resection with coloanal anastomosis (CAA) may be improved by construction of a colonic pouch. The aim of this prospective observational study was to compare results of colonic pouch-anal anastomosis (CPAA) with conventional CAA including the learning curve. METHODS: From February 1996 through May 1998, 45 consecutive patients underwent CAA or CPAA following radical rectal resection for cancer. The technique of resection was identical in both groups, and all patients received a diverting stoma. The colonic pouch was constructed using linear staplers. Three and 12 months following stoma closure subjective continence and bowel habits were assessed; anal manometry was performed at 3 months. RESULTS: 20 patients with CPAA (9 F, 11 M, age 62 +/- 9 years) were compared to 25 CAA patients (11 f, 14 m, age 64 +/- 10 years). There was no mortality, and morbidity was comparable between groups. Three months following stoma closure, in the CPAA group bowel frequency was significantly diminished (1.4 vs 5.8; P < 0.0001), fewer patients had liquid motions (0/20 vs 12/25 patients; P < 0.0001), and more were continent (20/20 vs 4/25; P < 0.001) and able to defer defaecation (20/20 vs 2/25; P < 0.0001). Functional anal canal length was significantly shorter in CPAA patients (2.9 vs 3.5 cm; P < 0.008). Although at 12 months follow-up continence had improved in patients with CAA, bowel frequency (2.5 vs 1.3; P < 0.002), and number of patients with liquid motions (10/25 vs 0/20; P < 0.007) and passive incontinence (12/25 vs 0/20; P < 0.0001) were still significantly higher than the CPAA group. CONCLUSION: Even including the learning curve, CPAA may yield superior functional results at 3 months and 1 year compared to conventional CAA without increasing morbidity.

Adult↗
PubMed1994

Rapid construction of right colon pouch: initial clinical experience.

Between December 1992 and July 1993, 7 patients who underwent urinary diversion after cystectomy or bladder augmentation had colon pouches constructed with an "absorbable" staple. Our "one-step" technique of colon pouch construction incorporates standard principles of bowel detubularization and refashioning using absorbable GIA staples. The technique is easily learned and decreases operative time and blood loss. Herein we report follow-up of the first 7 patients undergoing this modification.

Adolescent↗
PubMed2006

The congenital pouch colon can be used for vaginal reconstruction by longitudinal splitting.

Congenital pouch colon (CPC) is a rare malformation in which the distal part of a shortened colon forms a dilated pouch. It is associated with an anorectal malformation. We report 2 patients with CPC, one with a cloaca and one with vestibular fistula and vaginal atresia. It is the first description of CPC, vestibular fistula, and vaginal atresia. The purpose of this report was to demonstrate that the pouch can be split longitudinally--in analogy with Bianchi's intestinal lengthening procedure [Bianchi A. Intestinal loop lengthening: a technique for increasing small intestinal length. J Pediatr Surg 1980;15:145-51]--to create a vagina and to reconstruct the anorectum with preserved blood supply.

Abnormalities, Multiple↗
PubMed1996

Prediction of optimum dimensions of colonic pouch reservoir.

PURPOSE: A mathematic model was developed to quantify colonic reservoir pouch capacity and to allow comparison with capacity of the parent colonic segment from which the pouch was fashioned. METHODS: Using geometry, pouch capacity was calculated and various capacities were enumerated. RESULTS: From this model, ideal pouch dimensions can be predicted, which are 6 to 7 cm of undistended bowel circumference with limb lengths of 8 to 10 cm. CONCLUSIONS: Such a pouch maximizes the pouch colon capacity ratio and has a calculated undistended capacity between 60 and 105 ml.

Colon↗
PubMed2004

Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma.

BACKGROUND: Intersphincteric resection can provide tumour-free margins for rectal tumours located 0-1 cm above the dentate line. However, the internal anal sphincter (IAS) is partially or totally resected and some degree of anal incontinence may develop. A novel technique of smooth muscle plasty of the IAS and colonic pouch construction is described, along with an assessment of morbidity, oncological results and functional outcome. PATIENTS AND METHODS: Between 1997 and 2002, 27 patients (16 men; median age 55 (range 26-75) years) were operated on for T2-3 N0-1 M0 rectal carcinoma located a median of 1.0 (range 0.5-1.5) cm from the dentate line. Resection of the IAS was performed transanally. A smooth muscle cuff, fashioned from the muscular layer of colon, and a colonic pouch were used for anorectal reconstruction. RESULTS: There were no perioperative deaths. Anastomotic leakage developed in two patients. After a median follow-up of 38 (range 14-66) months no local recurrence was detected. Distant metastases occurred in three patients, two of whom died. Perfect functional outcome was achieved in 22 of 26 patients. At 6 months after surgery the mean(s.d.) resting anal pressure was 49(8) mmHg. CONCLUSION: In selected patients intersphincteric resection does not compromise the oncological result. The suggested anorectal reconstruction may improve the functional outcome.

Adult↗
PubMedDate not supplied

Functional outcome after coloanal anastomosis with J-colonic pouch for rectal cancer.

This study was designed to determine functional outcomes of restorative resections for carcinoma of the rectum. Between 1992 and 1995, 16 patients (8 male) of median age 75 (range 58-88) years underwent resection and coloanal anastomosis with J-colonic pouch reconstruction for rectal cancer. The distance of the lower border of tumor from the anal verge was 5 cm in 7 patients (43.70-0), 6 to 7 cm in 6 patients (37.0%) and 8 to 10 cm in 3 patients (18.7%). The Dukes staging was A in 4 patients (25%), B in 8 patients (50%) and C in 4 patients (25%). Coloanal anastomosis was performed by hand in 4 patients (25%) or with stapler in 12 patients (75%). Seven patients (43.7%) had diverting stoma. No patient died following surgery. Pelvic sepsis and anastomotic dehiscence that required pouch excision occurred in two patients (12.5%). Fourteen patients were evaluated. The mean follow-up was 15 (range 5-23) months. No patient developed recurrent pelvic tumor. Satisfactory fecal continence was achieved by 85.7% of patients. Stool frequency was 1-2 per day in 12 patients (85.7%). Three patients (21.4%) had minor soiling. Five patients (35.7%) occasionally complained urgency. There was no apparent difference between the patients with manual or stapled coloanal anastomosis. Coloanal anastomosis with J-colonic pouch is associated with an excellent long-term outcome.

Aged↗
PubMed1999

[Colonic pouch].

The tendency towards sphincter-preserving resection for distal rectal cancers has led to a revival of the technique of coloanal anastomosis (CAA) in recent years. In order to improve functional results, creation of a colonic J-pouch in conjunction with a coloanal anastomosis (CPA) was proposed. Two different operation techniques exist: i) Double-stapling with the anastomosis close to the dentate line and ii) intersphincteric resection with the anastomosis located immediately at the dentate line. A long rectal remnant after double-stapling leads to urgency in 15% of the patients due to stool retention in the atonic remnant. No propulsive motility patterns were recorded from the pouch which is emptied passively by upper colonic peristalsis. Therefore colonic pouches should be fashioned of descending colon and should not exceed a length of 6 cm in order to prevent stool fragmentation. Under these conditions the average stool frequency is reduced from 2-6/d after CAA to 1-3/d after CPA. This effect is maximal during the first postoperative months, but is still significant after 3 years. Colonic pouch construction also leads, due to better blood supply and prevention of pelvic hematomas, to a significant decrease of the anastomotic insufficiency rate from 10.0% after CAA to 5.4% after CPA. Therefore creation of a colonic J-pouch should be combined with coloanal reconstruction if the oncologic situation allows a sphincter-preserving procedure.

Anastomosis, Surgical↗
PubMed2001

A comparison between open versus laparoscopic assisted colonic pouches for rectal cancer.

The aim of this prospective study was to compare the surgical outcomes in patients undergoing laparoscopic assisted vs. open ultralow anterior resection (ULAR) with the creation of a colonic pouch-anal anastomosis. Patients undergoing ULAR with creation of a colonic pouch and who either had conventional open (CO) or laparoscopic assisted (LA) surgery in colorectal cancer were studied and compared. There were 33 patients, 22 in CO group and 11 in LA group. The groups were comparable for age, sex, tumour and anastomotic heights from anal verge, stage of disease, length of specimen removed and duration of surgery. Incisions were significantly shorter in the LA group (median, 9 cm vs. 16 cm, p = 0.01). Less parenteral analgesia was required in the LA group (2 days vs. 3 days, p = 0.05), but there were no significant differences in the time to passage of flatus, commencement of oral fluids or solid foods and length of hospital stay. There was no difference in morbidity or mortality. With regards to patients with Dukes A to C disease only, at a median of 12 months of follow-up, there was no patient with local or port site recurrence in the LA group. In the CO group, there was one local recurrence and two with distal metastases. In conclusion, laparoscopic assisted ULAR with colonic J pouch anal anastomosis is feasible, easy to perform and safe. It s advantages include significantly shorter incision and lower analgesic requirements postoperatively. Return of bowel function and length of hospital stay, however, are comparable to those of conventional open surgery.

Aged↗
PubMed2002

[Construction of a neorectum after rectal excision: colonic pouches].

Rectal excision followed by low anastomosis is associated with high bowel frequency, urgency and faecal incontinence. These functional disorders results from the loss of the rectal pouch and may be also related to the damage of the anal sphincter or the loss of normal anorectal sensation. Formation of a colonic J pouch reduces the severity of the symptoms of the anterior resection syndrome mainly by decreasing bowel frequency. Creation of a J pouch may also improve the healing of coloanal anastomoses. However, there is no evidence of the role of the colonic J pouch in long term functional outcome of coloanal anastomoses. Moreover, the size of the J pouch increases with time and this may induce evacuation difficulties. Finally, the J pouch cannot be used in all patients, because of technical difficulties especially in obese men. Because the results after colonic J pouch are not perfect, new colonic pouches are developed. The caecal pouch is performed by using an ileocoecal interposition graft between the sigmoid and the anus. The transverse coloplasty is similar to that of stricturoplasty. The side-to-end coloanal anastomosis, giving a colonic blind end, is an other type of pouch. The first procedure seems technically complex with no demonstrated advantage. The second procedure is easy to construct and may be performed in all patients; however, there is a potential higher risk of leakage and functional results must be evaluated. The third procedure showed few advantages compared to a straight anastomosis.

Anal Canal↗
PubMed2006

A systematic review of the function and complications of colonic pouches.

PURPOSE: This is a meta-analysis of randomized, controlled trials to compare the function and complications of a straight coloanal anastomosis to a colonic J-pouch after rectal excision at 1 year postoperatively. MATERIALS AND METHODS: A search for articles from 1980 to 2005 was conducted on Medline, PubMed, and the Cochrane Controlled Trials Register using the keywords "colonic pouches, J-pouch, straight and coloanal anastomosis, rectal cancer, function and complications," either singularly or in combination. Reference lists from short-listed articles were also manually searched for relevant articles, journals, and conference proceedings. Randomized controlled trials (RCTs) in English publications comparing colonic J-pouches to straight coloanal anastomosis were selected. Trials with similar patient characteristics, duration of follow-up, and outcome measures were pooled for analysis. Stool frequency and fecal continence at 1 year postoperatively were used as measures of functional outcome. Complication rates in terms of anastomotic leak and stricture formation were analysed. RESULTS: Ten RCTs with satisfactory methodology were identified. One trial reported the results at 2 years, while another reported results at 5 years only and were excluded from the meta-analysis, leaving only eight studies for further analysis. Overall, a colonic J-pouch appeared more favorable in terms of stool frequency (weighted mean difference of -1.21, 95% CI: -1.92 to -0.49) and continence (Odds ratio 0.23, 95% CI: 0.08-0.69), with a slightly lower risk of anastomotic dehiscence compared to a straight coloanal anastomosis (relative risk, RR 0.36; 95% CI: 0.12-1.08). Anastomotic stricture was reported in only two trials. They seemed more likely to occur after a pouch-anal anastomosis (RR 2.45, 95% CI: 0.79-7.57). However, the small numbers available for pooled analysis cannot allow these conclusions to be drawn with confidence. CONCLUSIONS: A straight coloanal anastomosis resulted in poorer function due to loss of a rectal reservoir, while colonic J-pouches have improved frequency and continence up to a year. Although retrospective reports seem to favor the use of a pouch, there are limited longer term randomized trial data to suggest that the function and complications of a coloanal J-pouch is better than a straight coloanal anastomosis. Larger randomized studies are required to further verify the longer-term benefits of a coloanal pouch.

Anastomosis, Surgical↗
PubMed2004

Congenital pouch colon associated with anorectal agenesis.

This article presents a review of the history and development of the various types of congenital pouch colon. Also described are the criteria for diagnosis, the treatment modalities and the results of follow-up studies to emphasize the post-operative problems. The problem of pre-operative and post-operative fecal incontinence is dealt with in more detail.

Abnormalities, Multiple↗
PubMed2003

Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial.

OBJECTIVES: 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. SUMMARY BACKGROUND DATA: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Adult↗