Optimal reconstruction after resection of the rectum in cancer surgery

The efficacy of colon-J-pouch anal anastomosis (CPAA) in reducing defecatory frequency and urgency and the incidence of anastomotic fistulas has been proved by several studies but only as compared to straight colo-anal anastomosis (CAA) of the end-to-end type. We investigated the role played by the colon pouch in the strict sense, without the influence of a different CAA model, in a randomised prospective study comparing CPAA and straight side-to-end CAA. Over the period from 1994 to 1998 we selected 66 of 118 patients operated on for rectal cancer: a CPAA was constructed in 35 (group P) and a direct side-to-end CAA in 31 (group D). The two groups were well matched for surgeon, type of patient, stage of disease and incidence of radiotherapy and presented no differences in operative mortality, general and anastomotic morbidity, or need for reoperation. Functional results: after 3, 12 and 36 months, defecatory frequency > or = 4 movements/day was observed in 93.4, 67.7 and 41.6% of cases, respectively, in group D as against 25.7, 14.2 and 13%, respectively, in group P (P < 0.05), while defecatory urgency was recorded in 77.4, 35.4 and 27.9% of cases, respectively, in group D as against 34.2, 17.1 and 9%, respectively, in group P (p < 0.05). In the long term, incontinence was also significantly lower in group P. The colon pouch improves sphincter rehabilitation after anal recanalization compared to straight side-to-end CAA. It does not affect anastomotic morbidity but affords a protective effect on function in irradiated patients. CPAA proves to be the optimal reconstruction option after excision of the rectum.