Kolonpouch als Rektumersatz

Colon pouch as neorectum. Technique, indications and results

Summary

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.

Zusammenfassung

Die Möglichkeiten des Erhalts der Darmkontinuität nach tiefer anteriorer Rektumresektion wegen Rektumkarzinom haben sich deutlich erweitert. Dennoch bestand nach der direkten koloanalen Anastomose häufig die Problematik, daß eine hohe Stuhlfrequenz und ein starker imperativer Stuhldrang das funktionelle Ergebnis stark beeinträchtigt haben. Der Kolon-J-Pouch hat hier im Vergleich zur direkten koloanalen Anastomose erhebliche Vorteile erbracht. Bereits nach einem Jahr geht hier die Stuhlfrequenz im Literaturvergleich auf 0,5 bis 4 Stuhlgänge pro Tag zurück (koloanale Anastomose: 0,5 bis 10 Stuhlgänge pro Tag). Der imperative Stuhldrang ist ebenfalls deutlich vermindert, was sich experimentell in dem deutlich höherem Ballonvolumen der ersten Wahrnehmung messen läßt (Pouch: 75 ml vs. Koloanale Anastomose: 50 ml). Die zu Beginn Kolon-Pouch-Ära zu beobachtenden Evakuationsstörungen waren auf zu große Kolonpouchs zurückzuführen. Experimentelle und klinische Studien haben gezeigt, daß ein J-Pouch mit einer Schenkellänge von 6 cm hier ein optimales funktionelles Ergebnis bringt. Die besseren Durchblutungsverhältnisse der beim Pouch vorliegenden Seit-zu-End Anastomose bewirken zusätzlich eine geringe Rate von Anastomoseninsuffizienzen (Pouch 1,9 % vs. koloanale Anastomose 15,2 %). Das onkologische Outcome ist zumindest in bisher vorliegenden retrospektiven Studien vergleichbar zur koloanalen Anastomose. Bei technischen Schwierigkeiten bzw. Unmöglichkeit der J-Pouch-Anlage steht als Reserveverfahren das ileokökale Interponat zur Verfügung, welches ähnliche funktionelle Daten wie der J-Pouch aufweist, jedoch technisch aufwendiger ist.

Key words

Rectal cancer - colonpouch - review - anastomostic leakage - stool frequency

Schlüsselwörter

Kolonpouch - Rektumkarzinom - Review - Stuhlfrequenz - Anastomoseninsuffizienz

Literatur

• 1 Becker J M, Raymond J L. Ileal pouch-anal anastomosis. A single surgeon's experience with 100 consecutive cases.  Ann Surg. 1986;  204 375-383
• 2 Berger A, Tiret E, Parc R, Frileux P, Hannoun L, Nordlinger B, Ratelle R, Simon R. Excision of the rectum with colonic J pouch-anal anastomosis for adenocarcinoma of the low and mid rectum.  World J Surg. 1992;  16 470-477
• 3 Braun J, Treutner K H, Winkeltau G, Heidenreich U, Lerch M M, Schumpelick V. Results of intersphincteric resection of the rectum with direct coloanal anastomosis for rectal carcinoma.  Am J Surg. 1992;  163 407-412
• 4 Carter S, Winslet M. Delay in the presentation of colorectal carcinoma: a review of causation.  Int J Colorectal Dis. 1998;  13 27-31
• 5 Haboubi N Y, Abdalla S A, Amini S, Clark P, Dougal M, Dube A, Schofield P. The novel combination of fat clearance and immunohistochemistry improves prediction of the outcome of patients with colorectal carcinomas: a preliminary study.  Int J Colorectal Dis. 1998;  13 99-102
• 6 Hallbook O, Sjodahl R. Comparison between the colonic J pouch-anal anastomosis and healthy rectum: clinical and physiological function.  Br J Surg. 1997;  84 1437-1441
• 7 Hautefeuille P, Valleur P, Perniceni T, Martin B, Galian A, Cherqui D, Hoang C. Functional and oncologic results after coloanal anastomosis for low rectal carcinoma.  Ann Surg. 1988;  207 61-64
• 8 Kroesen A J, Stern J, Herfarth C. Kontinenzerhaltende Colon- und Ileumreservoire im funktionellen Vergleich.  Langenbecks Arch Chir . 1994;  (Suppl Kongressber) 330-335
• 9 Kwok H, Bissett I P, Hill G L. Preoperative staging of rectal cancer.  Int J Colorectal Dis. 2000;  15 9-20
• 10 Lazorthes F, Fages P, Chiotasso P, Lemozy J, Bloom E. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum.  Br J Surg. 1986;  73 136-138
• 11 Lee S J, Park Y S. Serial evaluation of anorectal function following low anterior resection of the rectum.  Int J Colorectal Dis. 1998;  13 241-246
• 12 Leong A F, Seow-Choen F, Tang C L. Diminutive cancers of the colon and rectum: comparison between flat and polypoid cancers.  Int J Colorectal Dis. 1998;  13 151-153
• 13 McAnena O J, Heald R J, Lockhart-Mummery H E. Operative and functional results of total mesorectal excision with ultra-low anterior resection in the management of carcinoma of the lower one-third of the rectum.  Surg Gynecol Obstet. 1990;  170 517-521
• 14 Meijer S, Rahusen F D, van der Plas L G. Palliative cryosurgery for rectal carcinoma.  Int J Colorectal Dis. 1999;  14 177-180
• 15 Nicholls R J, Lubowski D Z, Donaldson D R. Comparison of colonic reservoir and straight colo-anal reconstruction after rectal excision.  Br J Surg. 1988;  75 318-320
• 16 Pahlman L. Neoadjuvant and adjuvant radio- and radio-chemotherapy of rectal carcinomas.  Int J Colorectal Dis. 2000;  15 1-8
• 17 Parc R, Tiret E, Frileux P, Moszkowski E, Loygue J. Resection and colo-anal anastomosis with colonic reservoir for rectal carcinoma.  Br J Surg. 1986;  73 139-141
• 18 Petersen S, Freitag M, Hellmich G, Ludwig K. Anastomotic leakage: impact on local recurrence and survival in surgery of colorectal cancer.  Int J Colorectal Dis. 1998;  13 160-163
• 19 Pikarsky A J, Belin B, Efron J, Weiss E G, Nogueras J J, Wexner S D. Complications following formalin installation in the treatment of radiation induced proctitis.  Int J Colorectal Dis. 2000;  15 96-99
• 20 Sailer M, Debus E S, Fuchs K H, Beyerlein J, Thiede A. Comparison of anastomotic microcirculation in coloanal J-pouches versus straight and side-to-end coloanal reconstruction: an experimental study in the pig.  Int J Colorectal Dis. 2000;  15 114-117
• 21 Schwandner O, Schiedeck T H, Killaitis C, Bruch H P. A case-control-study comparing laparoscopic versus open surgery for rectosigmoidal and rectal cancer.  Int J Colorectal Dis. 1999;  14 158-163
• 22 Seow-Choen F, Goh H S. Prospective randomized trial comparing J colonic pouch-anal anastomosis and straight coloanal reconstruction.  Br J Surg. 1995;  82 608-610
• 23 Shafik A, Doss S, Asaad S, Ali Y A. Rectosigmoid junction: anatomical, histological, and radiological studies with special reference to a sphincteric function.  Int J Colorectal Dis. 1999;  14 237-244
• 24 Sjoqvist U, Ost A, Lofberg R. Increased expression of proliferative Ki-67 nuclear antigen is correlated with dysplastic colorectal epithelium in ulcerative colitis.  Int J Colorectal Dis. 1999;  14 107-113
• 25 Sokmen S, Terzi C, Unek T, Alanyali H, Fuzun M. Multivisceral resections for primary advanced rectal cancer.  Int J Colorectal Dis. 1999;  14 282-285
• 26 Sternfeld T, Foss H D, Kruschewski M, Runkel N. The prognostic significance of tumor vascularization in patients with localized colorectal cancer.  Int J Colorectal Dis. 1999;  14 272-276
• 27 von Flüe M O, Degen L P, Beglinger C, Hellwig A C, Rothenbuhler J M, Harder F H. Ileocecal reservoir reconstruction with physiologic function after total mesorectal cancer excision.  Ann Surg. 1996;  224 204-212