[Colonic pouch and other procedures to improve the continence after low anterior rectal resection with TME].
In 75 to 90 % of patients with rectal cancer, a sphincter-preserving resection can be performed without violating oncological principles. However, almost 50 % of the patients suffer from an anterior resection syndrome after total or subtotal rectal resection with a straight colorectal or coloanal anastomosis. This syndrome describes the characteristic complaints of minor or major incontinence. The anastomosis with the colonic pouch has been proved to result in better continence in the short- and long-terms compared to the straight anastomosis. Based on grade 1 evidence, the colonic pouch should be recommended as a standard procedure after low anterior resection with total mesorectal excision (TME). Both the colonic J pouch of 6-cm length and the coloplasty have been shown to be of equal value in respect to function and morbidity. With regard to the complicated procedure and the poorer functional outcome, the ileocecal pouch should only be applied in cases without the option of an alternative pouch design. The temporary loss of the rectoanal inhibitory reflex, the sphincter lesion caused by the instrumental dilatation in stapling or peranal hand-sutured anastomosis and the disturbed function of the internal sphincter due to the autonomous nerve damage additionally contribute to the anterior resection syndrome. In the intersphincteric resection, the loss of the transitional zone and the hemorrhoidal cushion as well as the removal of the upper part of the internal sphincter aggravate the incontinence. For better continence, two operative procedures should be recommended: By applying the inverse double stapling technique in anastomizing the colonic J pouch, the sphincter lesion as a consequence of the dilatation can be avoided. The nerve-sparing mesorectal excision helps to preserve the function of the internal sphincter.
Gross
E
E
I. Chir. Abt., Asklepios Klinik Barmbek, Hamburg. e.gross@aslepios.com
Möslein
G
G
D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical; D003106:Colon / Q000601:surgery*; D039021:Colonic Pouches; D005242:Fecal Incontinence / Q000209:etiology / Q000517:prevention & control*; D005500:Follow-Up Studies; D006801:Humans; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D013577:Syndrome; D013997:Time Factors