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310
S. Parsi et al.
All the published studies address the issues of QoL and functional outcomes
based on established scales.
However, none of them clearly asked the patients if they were satised with their
surgery or whether they would prefer a permanent colostomy. We addressed this
issue in our study by asking the patients if they would have preferred having a colostomy rather than TATA.One-hundred percent of the patients preferred their current
level of function over a permanent colostomy, and more than 90% of the patients
responded that they never would have preferred to have a colostomy. This measurement reects that patients have a high level of subjective satisfaction with sphinctersparing surgery [17].
Furthermore, it has been demonstrated that psychological morbidity among
patients who have undergone SPS is lower than that experienced by patients after
APR [19]. When compared to non-stoma patients, stoma patients have higher levels
of psychologic distress and more restrictions in their level of social and sexual functioning [20].
Although it is clear that patients after rectal surgery will never have the same
bowel function that they enjoyed before developing rectal cancer, data support that
they develop a new normal, which, although not perfect, is one that they are very
pleased with and prefer over having a permanent colostomy [18]. However, patient
selection is very important. A large number of the patients included in our QoL
study came to be treated specically because they refused to accept a permanent
colostomy. This patient selection effect on the QoL and their satisfaction with the
outcome cannot be overstated, because this is clearly a very motivated population of
patients with rectal cancer.
Conclusion
Cancer of the distal third of rectum presents the greatest challenge for colorectal
surgeons. As of yet, the best surgical approach is still unclear. The two main goals
of any rectal cancer surgery are oncological outcomes and quality of life. SPR
should be offered when feasible following high-dose chemoradiation in a properly
motivated patient with good sphincter function. APR is recommended in patients
with poor sphincter function and whose cancer is xed to sphincter complex despite
neoadjuvant therapy.
Further standardization of technique and multicenter prospective randomized
studies to dene the best surgical approach for distal rectal cancer are needed.
Future direction of complete transanal approach by single-port robotic platform is
under investigations.
Acknowledgement This work was supported by the Harry Mirabile Colorectal Center fund of the
Marks Colorectal Surgical Foundation.
27 Optimizing Function forVery Low Rectal Tumors: Intersphincteric Resection…
311
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Optimal Coloanal Reconstruction:
J-pouch, Straight, Stapled,
28
andHand Sewn
AndreaM.Petrucci andStevenD.Wexner
Introduction
Coloanal anastomosis (CAA) is technically challenging given its distal location
within the limited connes of the pelvis. Different coloanal anastomotic techniques
including straight, colonic J-pouch, coloplasty, end-to-side (ETS), and other creative techniques including cecorectal anastomosis have all been described and
challenged in the literature. In addition, these anastomoses can be performed transabdominally or trans-perineally, using either a hand-sewn or a stapled technique.
They are undertaken for both benign and malignant diseases [1]. One concern following surgery is the possibility of impaired bowel function from the loss of the
rectal reservoir [2]. Regardless, the goal is to provide patients with intestinal continuity with acceptable function, while preserving anal sphincter anatomy and
physiology.
Construction of a coloanal anastomosis must follow basic anastomotic principles
that will allow healing and minimize complications. These steps include ensuring
that the anastomosis is well vascularized and is tension-free. In order to meet these
goals, regardless of the type of anastomosis performed, the splenic exure is mobilized in order to gain length, and the inferior mesenteric artery and vein are both
ligated at their respective origins to allow for the proximal colon to reach the deep
pelvis, thereby eliminating any tension. Another important consideration is the
patient’s sphincter function. Sphincter-preserving surgery has allowed surgeons to
provide patients with intestinal continuity; however, patients with poor sphincter
function prior to surgery may not be ideal candidates and may suffer from poor quality of life secondary to poor continence. A good history and physical exam help to
identify these patients. Furthermore, diagnostic tests such as a pelvic MRI, endoanal
ultrasound, and manometric studies assess sphincter integrity and allow surgeons to
A.M. Petrucci • S.D. Wexner (*)
Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
e-mail: apetru1@gmail.com; wexners@ccf.org
© Springer International Publishing AG 2018
C.M. Schlachta, P. Sylla (eds.), Current Common Dilemmas in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-70117-2_28
313
314
A.M. Petrucci and S.D. Wexner
select patients who would benet from having sphincter-preserving surgery as
opposed to having a permanent colostomy. Therefore a detailed discussion with the
patient must be undertaken prior to surgery.
Overview ofSphincter-Preserving Coloanal Anastomotic
Techniques
The original coloanal anastomosis described by Parks in 1982 included performing
a mucosectomy and a hand-sewn coloanal anastomosis (HCAA) at the level of the
dentate line [3]. Shortly thereafter in 1986, the colonic J-pouch (CJP) reconstruction
was described by both Lazorthes etal. [4] and Parc etal. [5], who published their
techniques during the same year. The CJP quickly became the preferred method for
creating a new reservoir as the efferent limb provides no functional peristalsis and
creates a pouch [6]. This design allows accommodation of more volume and acts as
a neorectum, which results in better function when compared to a straight coloanal
anastomosis (SCAA) [7]. After resecting the diseased colon, the proximal colon is
either exteriorized through the abdomen or through the anus. Regardless, the CJP is
created the same way, by using 6cm of the distal ends of a well-mobilized descending colon, folded onto itself to create a J limb (Fig.28.1) [8].
The antimesenteric borders are then stapled together using a 60mm linear cutting stapler where each arm of the stapler is inserted through a common colotomy
made at the apex of the pouch. Ensuring that the antimesenteric borders are reapproximated helps eliminate the incorporation of small vessels located near the
Fig. 28.1 The colonic
J-pouch (CJP). With
permission from [8]. ©
2011 Wolters Kluwer
Health, Inc
28 Optimal Coloanal Reconstruction: J-pouch, Straight, Stapled, andHand Sewn
315
mesenteric side and decreases bleeding from the staple line. The afferent limb is
secured to the efferent limb with 3.0 polydioxanone sutures. It may be desirable to
suture the afferent limb to the efferent limb prior to ring the stapler, especially
when the CJP is constructed through the transanal approach. Once the pouch is created, the colotomy is used as the proximal end and is anastomosed to the anus either
using a stapled or hand-sewn approach. When using a stapled approach, a ≥ 2cm
cuff above the dentate line is preserved in order to accommodate the circular stapler,
as opposed to a hand-sewn approach which can be undertaken at any level. A pursestring suture using a 0-polypropylene is placed around the proximal colotomy, and
the anvil is inserted and secured by tying the purse string around the anvil shaft. A
tight seal is necessary in order to avoid displacement of the anvil proximally into the
J-pouch. The proximal limb is then returned into the abdominal cavity either through
the abdominal incision or pushed into the pelvis through the perineal opening.
When using a trans-perineal approach, the distal end must also be purse-stringed
with a 0-polypropylene suture. In this approach, the proximal colon containing the
secured anvil is connected to the spike of the end-to-end anastomotic stapler. Only
then is the stapler advanced into the anal canal and the distal purse string is secured
and tied down around the trocar. Once secured, the stapler is closed and red, and
the anastomosis is created.
If using a transabdominal approach, the circular stapler is inserted into the stapled
distal cuff with the spike piercing through the stapled rectum, preferably through the
staple line. The anvil is mated to the stapler, which is then closed, and the stapler is
red, creating the CJP anastomosis.
This optimal CJP length was studied by Lazorthes etal. [9] in a prospective randomized controlled trial (RCT) wherein they compared a small (6cm) versus a
larger (10cm) CJP.The authors showed that, despite no differences in frequency,
urgency, and fecal incontinence at 2years, 30% of the larger-pouch patients compared to 10% of the small-pouch group used laxatives or enemas for stool evacuation and constipation [9]. As a result, the authors determined that the “ideal” length
of the CJP to avoid long-term evacuatory complications is 6–7cm [1, 7, 9]. These
ndings were conrmed by Hida etal. who demonstrated that the enlargement and
the horizontal inclination of the longitudinal axis of the CJP in patients with longer
pouches (10 vs 5cm) lead to evacuation difculty [10, 11].
Alternatives to the CJP are the ETS anastomosis, also known as the “Baker” anastomosis (Fig.28.2) [12], and anastomosis with transverse coloplasty (TC), originally
described by Z’graggen in 2001 (Fig.28.3) [13]. Both of these techniques can be
considered if a CJP is not feasible. A study by Harris etal. [14] that assessed reasons
for failure to construct a CJP found seven factors overall, which were divided into
technical factors including a narrow pelvis, bulky anal sphincters, the need for mucosectomy, diverticulosis, insufcient colon length, or pregnancy and nontechnical factors including complex surgery or distant metastases.
The ETS anastomosis is created by inserting the anvil through the proximal
opened end of the healthy colon, and the tip of the anvil is pierced through the
colonic wall, roughly 3cm from the colotomy edge. The colotomy is then stapled
closed, and the stapled anastomosis is created using the circular stapler, leaving a
small efferent limb that acts as the reservoir.
316
Fig. 28.2 The end-to-side
“Baker” anastomosis
(ETS). With permission
from [8]. © 2011 Wolters
Kluwer Health, Inc
A.M. Petrucci and S.D. Wexner
Fig. 28.3 The transverse
coloplasty (TC). With
permission from [8]. ©
2011 Wolters Kluwer
Health, Inc
Transverse coloplasty is performed prior to the CAA.Early studies showed that
a TC is a feasible alternative to CJP [14, 15]. After securing the anvil around a purse
string of the proximal colon, a neorectal reservoir is created by performing an
8–10cm longitudinal colotomy in the distal colonic end of the proximal limb, with
the most distal point located 2–4cm from the anvil. The defect is closed in a transverse fashion, using a single layer of absorbable interrupted or running sutures [8,
28 Optimal Coloanal Reconstruction: J-pouch, Straight, Stapled, andHand Sewn
317
16]. Unfortunately, due to the prohibitively high rate of sepsis mostly attributed to
anastomotic leaks, this procedure has been largely abandoned [17].
The SCAA is still performed in situations when constructing a colonic reservoir
is not feasible. The anastomosis is created in the standard fashion, either hand sewn
(Fig.28.4) or using a circular stapler (Fig.28.5). Although not the preferred method
Fig. 28.4 The hand-sewn
straight coloanal
anastomosis. With
permission from [8]. ©
2011 Wolters Kluwer
Health, Inc
Fig. 28.5 The stapled
straight coloanal
anastomosis. With
permission from Wexner
SD, Fleshman JW, eds.
Colon and Rectal Surgery:
Abdominal Operations. ©
Wolters Kluwer Health,
Inc., Philadelphia, 2011 [8]
318
for reconstruction for reasons described later, a SCAA may be the only available
option in specic cases. Unfortunately, due to the loss of the rectal reservoir, many
patients experience the low anterior resection syndrome, consisting of increased
stool frequency, urgency, and fecal incontinence, which has a great impact on the
patient’s quality of life [7].
Another creative option for constructing a reservoir is the ileocecal interposition
(ICI), also known as the “cecum pouch,” which was introduced in 1994 by von Flüe
and Harder as a new technique for pouch reconstruction following rectal surgery
[18]. This technique of rectal replacement consists of creating an antiperistaltic
cecoproctostomy that is rotated 180° counterclockwise to anastomose to the residual rectum or anal canal [18]. It can be used following subtotal colectomy after
recurrent low anterior resection or in the case of metachronous rectal cancers [18].
A randomized controlled trial comparing ICI with CJP construction after TME
for rectal cancer showed similar quality of life outcomes between both approaches
at up to 5years after surgery, although patients with ICI had higher frequency of
defecation and more complications including bowel obstruction and stricture formation [19]. This procedure has been popularized by Sarli etal. from Perna, Italy.
They showed that the antiperistaltic cecorectal anastomosis is safe and effective for
patients with colonic inertia following total colectomy. The 10 female patients in the
study reported an average of 2.2 bowel movements per day, with no major morbidity
and good quality of life at 1year following surgery [20].
A.M. Petrucci and S.D. Wexner
Stapled Vs Hand-Sewn (Transabdominal Vs Transperineal)
Coloanal Anastomosis andtheImpact ofIntersphincteric
Resection
The use of staplers in the eld of colorectal surgery has revolutionized how anastomoses are created. Ever since their introduction in 1979 by Ravitch and Steichen
[21], stapled anastomoses have been found to have lower complications such as
leaks and contribute to a shorter operative time [22]. The distal point of transection
inuences whether a stapled CAA is technically feasible. In certain cases of very
low anastomoses, the hand-sewn technique is the only option. In the case of sphincter preservation surgery, the main concern is functional outcome as this will affect
the patient’s quality of life. The superiority of the hand-sewn or stapled approaches
has been a topic of great debate for years. A prospective study in 2002 by Takase
etal. [23] included 15 patients who underwent intersphincteric resection with handsewn CAA for rectal cancer over a 59-month period and compared these patients to
16 who underwent stapled CAA.Overall, patients with a hand-sewn coloanal anastomosis (HCAA) had impaired internal sphincter muscle function at 12 months,
although overall evacuatory function in both groups was similar. In addition, oncologic outcome such as local recurrence was found in four patients in the HCAA
group who went on to have a curative abdominal perineal resection (APR). Although
tumor height was lower in the HCAA group, all patients had adequate distal resection margins [23]. A prospective randomized study by Laurent etal. [24] compared
28 Optimal Coloanal Reconstruction: J-pouch, Straight, Stapled, andHand Sewn
319
the stapled versus hand-sewn techniques specically for CJP anastomoses in 37
patients undergoing restorative proctectomy with total mesorectal excision for rectal cancer. The authors found no difference in function and morbidity at 12months
between the groups; however, there was a decrease in operating time in the stapled
group. Moreover, three patients in the HCAA group developed anastomotic stricture
requiring dilation, but this was not statistically signicant. The authors concluded
that a stapled CJP anastomosis should be considered when technically feasible [24].
An earlier systematic review by Lustosa etal. [25] in 2002 comparing stapled versus hand-sewn colorectal anastomosis found insufcient evidence to state that one
technique is superior to the other, regardless of the level of anastomosis. Ten years
later, an updated systematic review comparing both types of colorectal anastomoses
in 1233 patients was also not able to demonstrate superiority of one anastomotic
technique over the other. However, the authors did nd that stapled anastomosis had
a higher incidence of anastomotic stricture when compared to HCAA, whereas the
latter took longer to complete [26]. Nonetheless, this review classied the level of
anastomosis as either above or below the peritoneal reection and found no signicant differences between both [26].
For patients with very low rectal cancer, an intersphincteric resection (ISR) is a
method of sphincter preservation performed in an effort to achieve negative distal
resection margins and has been shown to have acceptable oncologic outcomes [27].
In select patients who do not have tumor invasion of the external sphincter or levator
muscles and have good sphincter function, it is feasible to perform either a partial
(distal resection margin at the level of the dentate line) or a complete (distal resection
margin at the intersphincteric groove) ISR with a hand-sewn coloanal anastomosis.
The type of ISR is dictated by the level of the tumor in relation to the anorectal ring
as described by Rullier et al. [28] where a partial ISR is appropriate for tumors
located less than 1cm from the sphincter complex (juxta-anal Type II) and a
complete ISR for those with internal sphincter invasion (intra-anal Type III).
The anastomotic leak rate following an ISR is quite variable ranging from 0.9 to
48% and thus should be performed by experienced surgeons [27]. An interesting
study looked at complications and functional outcomes in patients undergoing laparoscopic ISR with a stapled CAA and retrospectively compared these patients to a
group who had undergone hand-sewn CAA.None of these patients were diverted,
and the median tumor distance from the dental line was 2.1cm. The stapled CAA
group had signicantly lower rates of anastomotic leak and stricture formation compared to the hand-sewn group at the 24-month follow-up; functional outcomes,
however, were surprisingly similar [29]. Despite these problems, some patients are
willing to accept the complications over having a permanent colostomy.
Outcomes: Which Coloanal Anastomotic Technique is Best?
The technical decision regarding which anastomotic technique to employ is
frequently made in the operating room while preparing for the anastomosis as many
intraoperative factors including patient’s body habitus, bowel vascularization, and
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A.M. Petrucci and S.D. Wexner
anatomy play a signicant role. Short- and long-term outcomes such as anastomotic
leak, bowel function, and quality of life have been studied for each type of coloanal
anastomotic technique. The most devastating complication besides recurrent carcinoma following a coloanal anastomosis is anastomotic leak. A recent study found
anastomoses less than 10cm from the anal verge to be an independent risk factor for
anastomotic leak regardless whether the anastomosis was hand sewn or stapled
[30]. The denition of an anastomosis ≤ 10 cm from the anal verge as being “high
risk” has been included in many recent studies” [31–34]. The majority of patients
who undergo coloanal anastomosis after restorative proctectomy for rectal cancer
are proximally diverted as diversion has been shown to decrease the incidence of
anastomotic leak requiring urgent or emergent surgery [35]. Anastomotic leaks are
not only problematic in the immediate postoperative period but also lead to functional problems in the long term. Ashburn etal. [36, 37] looked at function following anastomotic leak in patients who had undergone proctectomy for rectal cancer
and found that function was worse in those who had leaked; patients suffered more
day- and nighttime bowel movements as well as worse control of solid stool and
worse physical and metal scores.
Poor functional outcomes following restorative proctectomy have a signicant
impact on the patient’s quality of life. It has been shown that poor preoperative function with high incontinence scores and low anastomoses (<5cm) following proctectomy for rectal cancer predict persistent incontinence after a restorative procedure
[36]. Moreover, oncologic outcomes may be worse following anastomotic leak [38].
CJP Vs SCAA
Many studies have compared CJP with the standard SCAA. In 1995, a small RCT
that included 40 patients who underwent ultralow anterior resection (median distance from the anal verge of 3.25cm) with either CJP (n=20) or SCAA (n=20)
and diverting loop ileostomy found that anal function was signicantly better with
CJP.These patients experienced less frequency (p<0.05), use of antidiarrheal medications (p < 0.008), and number of bowel movements per day (p < 0.05) at
12months following ileostomy closure [39]. In addition, at the 12-month follow-up,
all patients with CJP had return of normal continence after ileostomy reversal compared to only 70% of patients with a SCAA [39]. Hallböök etal. [40] randomized
100 patients with rectal cancer located within 12cm from the anal verge to undergo
either CJP or SCAA with or without a diverting loop ileostomy. Patients randomized to the CJP group were found to have a lower postoperative anastomotic leak
rate (2% vs 15%, p=0.03) as well as fewer bowel movements per 24h, less nocturnal evacuations, urgency, and incontinence at 2months and 1year following surgery
(after temporary stoma closure in applicable patients) [38]. Moreover, these patients
rated their overall well-being signicantly higher than patients who received a
SCAA after 1year [40]. In an early study, Joo etal. [1] assessed long-term functional and clinical outcomes between SCAA and CJP.They found patients with CJP
had superior function compared to those with SCAA at up to 1year after surgery;