OTS

Aobgiiabvrbappl

rodswrtot“

D

A

1d

utcomes Review of Reconstructiveechniques Following Proctectomy

ebastian G. de la Fuente, MD, and Christopher R. Mantyh, MD

Surgery continues to be essential in the management of colorectal tumors. For patientswith mid and low rectal tumors, sphincter-preserving techniques have become increasinglycommon and acceptable oncologic results can be achieved. In general, straight coloanalanastomoses are associated with relatively poor postoperative bowel function due to theloss of the rectal reservoir. To overcome this limitation, colonic reservoirs, such as thecolonic J-pouch or transverse coloplasty have been developed. Over the last several years,a significant number of trials have been published in the surgical literature comparing thesetechniques. This manuscript describes the basis of the functionality outcomes followingrestoration of intestinal continuity after protectomy for colorectal cancer.Semin Colon Rectal Surg 19:41-47 © 2008 Elsevier Inc. All rights reserved.

icp(bdbwChtpqaa

DTSfodt

wacad

pproximately 150,000 new cases of colorectal cancer arediagnosed each year in the United States and over 75%

f these patients are subjected to surgical resection.1 This isecause colorectal cancer continues to be the most commonastrointestinal malignancy in this country. Despite advancesn adjuvant therapy, surgery continues to be the cornerstonen the management of these tumors.2 For patients with midnd low rectal tumors, sphincter-preserving techniques haveecome increasingly common due to the advent of new de-ices that permit low anastomoses with acceptable oncologicesults and preserved sphincteric function. As surgeonsecome more familiar with the different reconstructivepproaches, the debate has focused on which techniquerovides superior long-term functionality outcomes, lowostoperative morbidity, and improved quality of life fol-

owing protectomy.Straight coloanal anastomoses (SCAA) are associated with

elatively poor postoperative bowel function due to the lossf the rectal reservoir. In normal individuals, the rectumistends as the colonic contents descend into its lumen, re-ulting in slow increments of the rectal filling. This, however,ill not affect rectal contraction until the rectal contents

each enough volume to stimulate the rectal mechanorecep-ors and evoke the defecation reflex.3 This storage capabilityf the rectum is due to the adaptability of its smooth muscleo small volume rectal distension, mechanisms known asreceptive relaxation.” In patients with SCAA this mechanism

epartment of Surgery, Duke University Medical Center, Durham, NorthCarolina.

ddress reprint requests to Christopher R. Mantyh, MD, DUMC, PO Box

f3117, Durham, NC 27710. E-mail: manty001@mc.duke.edu.

043-1489/08/$-see front matter © 2008 Elsevier Inc. All rights reserved.oi:10.1053/j.scrs.2008.01.009

s lost, resulting in evacuation difficulties. To prevent this,olonic reservoirs have been developed for patients requiringrotectomy. Colonic reservoirs such as the colonic J-pouchCJP) are associated with better postoperative functionalityut can be challenging to construct especially in males witheep pelvises.4 A third option, the transverse coloplasty, haseen developed to overcome the poor bowel function seenith straight anastomoses and the technical challenges of theJP.5 Over the last several years, a significant number of trialsave been published in the surgical literature comparinghese techniques. Most trials focused on the incidence ofostoperative complications as well as bowel function anduality of life. This review describes the basis of the function-lity outcomes following restoration of intestinal continuityfter protectomy for colorectal cancer.

ifferent Types of Reservoirshe Straight Coloanal Anastomosistraight coloanal anastomosis has been the traditional choiceor restoring bowel continuity after proctectomy. A numberf early studies, however, have shown the wide spectrum ofifficulties that patients experience after undergoing thisechnique.6,7

Technically, the anastomosis can be hand-sewn or stapledith a circular stapler, allowing the creation of a very low

nastomosis in patients with distal rectal tumors. Hand-sewnolorectal anastomoses can be done in one or two layers andre typically performed transanally or transabdominally if theistal end can be adequately visualized and is technically

easibly. Early studies comparing hand-sewn to stapled

41

appdosdlmsstbpwrmvewtmh

tlurani9pwstrsgastco

PSTcrqprctdwc

tgnisspsd

pwratPtdg(brtotaqo

CDotSvuofrltacf

PPugjbtqyue

42 S.G. de la Fuente and C.R. Mantyh

nastomoses raised concerns regarding the safety of sta-ler devices8; however, later trials demonstrated equivalentostoperative outcomes with either technique.9,10 In a well-esigned multicenter randomized prospective study donever a decade ago, Docherty and coworkers11 demonstrated aignificant higher incidence of radiologic leak in patients un-ergoing sutured anastomoses but this finding did not trans-

ate into higher clinical leak rates, morbidity, or mortality. Aore recent meta-analysis done by MacRae and McLeod as-

essed all randomized controlled studies comparing hand-ewn to stapled anastomoses. This study included 13 trialshat met inclusion criteria.12 The two significant differencesetween the techniques were intraoperative difficulties andostoperative strictures in the stapled group. No differencesere observed in clinical or radiologic leak rates, local cancer

ecurrence, or mortality. These technical obstacles have beenostly resolved with the current commercially available de-

ices. In a recent systemic review by Lustosa and cowork-rs,13 the overall anastomotic leak for stapled anastomosesas 13.0% compared with 13.4% for the hand-sewn pa-

ients. Postoperative stricture, wound infection, and specificortality were also undistinguishable between stapled andand-sewn anastomoses.Most surgeons agree that stapled anastomoses provide less

issue manipulation, uniformity of staples in the anastomoticine, and rapidity to the procedure. In a series of 103 consec-tive patients undergoing surgery for adenocarcinoma of theectum, Miller and Moritz randomized patients to a single- or

double-stapling technique.14 A statistical difference wasoted in the distal margin as well as bacterial contamination

n favor of the double technique. Clinical leaks were noted in.5% of the single stapled patients compared with 2.4% ofatients undergoing the double technique. No differencesere documented in the rate of local recurrences or overall

urvival between groups. Multivariate analyses have shownhat low anastomoses (�6 cm), preoperative radiation, ste-oids, diabetes mellitus, use of pelvic drainage, duration ofurgery, presence of intraoperative adverse events, and maleender are independent risk factors for anastomotic leak-ge.15-17 Following completion, the integrity of the anastomo-is should be tested intraoperatively by insufflating air intohe rectum while keeping the anastomosis submerged be-ause the presence of air leaks has been correlated with post-perative complications.18,19

ostoperative Outcomes oftraight Coloanal Anastomosishe most limiting factor that influences postoperative out-omes in these patients is what has been termed anterioresection syndrome.20 This syndrome is characterized by fre-uency and fragmentation of the stool, sensation of incom-lete evacuation, tenesmus, and urgency. A wide variety ofeasons have been associated with the syndrome. These in-lude damage to the autonomic and the enteric innervation ofhe anal sphincter mechanism and the neorectum21,22 andirect injury to the anal sphincters.23 In a study of patientsith incontinence following low anterior resections, Rao and

oworkers determined that major incontinence in these pa- c

ients is secondary to neurotenesis of the inferior mesentericanglia and the hypogastric plexus, whereas minor inconti-ence represents a localized neurotenesis/neuropraxia of the

nferior mesenteric plexus.24 Most of the evidence in thesetudies point toward denervation as the mechanism respon-ible for anterior resection syndrome. Overall, up to 50% ofatients will experience some degree of anterior resectionyndrome in the first 6 months after surgery, but this rateecreases with time.The degree of bowel dysfunction after surgery is higher if

atients require adjuvant radiotherapy. Nathanson and co-orkers reported 109 patients that underwent low anterior

esection with straight coloanal anastomosis and neo- and/ordjuvant therapy at standard doses.25 A subgroup of patientshat were not treated with radiotherapy was used as controls.atients were assessed with a standardized questionnaire at 2o 8 years after the operation. In this trial, patients that un-erwent postoperative radiotherapy reported a significantlyreater number of bowel movements per 24-hour periodP � 0.01) and significantly more episodes of clusteredowel movements (P � 0.02) than either the preoperativeadiotherapy group or the no radiotherapy group. Evenhough no differences were noted in the anal continence orverall satisfaction between groups, the authors concludedhat postoperative pelvic radiotherapy significantly effectsnorectal function, with higher rates of clustering and fre-uency of defecation than patients that had undergone pre-perative radiotherapy.

olonic J-pouchifferent types of colonic reservoirs have been developed tovercome the functional limitations of the SCAA. Amonghese types, the J-pouch is the most commonly performed.tudies have demonstrated that creation of a colonic reser-oir improves postoperative function by increasing the vol-me capacity of the neorectum (Fig. 1).26-28 Indeed, numer-us well-designed randomized studies have validated theunctional benefits of the CJP over the SCAA after low ante-ior resection.29,30 Overall, postoperative complications,ength of stay, and perioperative mortality of CJP are similaro those of straight coloanal anastomoses. The incidence ofnastomotic leak following CJP construction is 9%, J-poucholoanal anastomosis stricture approximately 7%, wound in-ections 7%, and rectovaginal fistula 2%.31

ostoperative Functional Outcomesatients with colonic J-pouches tend to have less frequency,rgency, and evacuation difficulties immediately after sur-ery and up to a year postoperatively32 than patients sub-ected to SCAA (Fig. 2). As expected, this translates intoetter quality of life.33 This short-term functional benefit ofhe CJP levels with time28,34 and the difference in stool fre-uency and urgency is similar between both techniques 2ears or beyond the procedure. After 2 years, patients thatnderwent a large CJP tend to require more laxatives andnemas to evacuate their reservoir.26

These functional benefits of a CJP are directly related to the

onstruction of the pouch. The pouch has to be neither too

sdr(pfawqmwybfiaocc

ibvlpcai

TAcsbir

1) with

Reconstructive techniques following proctectomy 43

mall to prevent urgency nor too large, which would result inifficult evacuation. Lazorthes and coworkers prospectivelyandomized 59 consecutive patients to undergo either a small6 cm) or large (10 cm) CJP for reconstruction followingroctectomy for rectal cancer.35 Patients were evaluated forrequency, urgency, continence, and laxative and enema uset 3, 6, 12, and 24 months after the operation. No differencesere noted between groups in the rate of defecation fre-uency, urgency, or fecal continence at 3, 6, 12, and 24onths; however, the requirement for laxatives and enemasas higher in patients randomized to the larger size pouch 2ears after the operation. This was subsequently confirmedy other investigators in prospective trials.36,37 Due to thesendings, current recommendations are that the pouch bepproximately 6 to 7 cm. Another factor that influences post-perative outcomes of the pouch is the height of the J-poucholoanal reconstruction. Hida and colleagues determined in a

Figure 1 Forrest plot of stool frequency per 24 hour afterare mean (SD). Weighted mean differences (WMDs) ashown at three time intervals: within 6 months of the oriand at 2 years or more. From Heriot and coworkers (ref.3

omparative study of 48 patients that the functional outcome t

n those undergoing J-pouch reconstructions is significantlyetter when the distance of the anastomosis from the analerge is 4 to 8 cm.38 The authors noted that anastomosesocated 9 to 12 cm from the anal verge are associated withostoperative outcomes similar to those seen with straightoloanal anastomoses, whereas anastomoses �3 cm from thenal verge have been associated with higher postoperativencontinence scores.39

ransverse Coloplastypproximately 5 to 25% of patients are not suitable for CJPonstruction due to both technical and nontechnical rea-ons.4,30,40-43 Technical reasons include a narrow pelvis,ulky anal sphincters, need for mucosectomy, diverticulosis,

nsufficient colon length, or pregnancy. The nontechnicaleasons are complex surgery or the presence of distal metas-

ch versus straight coloanal anastomosis (CAA). *Valueswn with 95% confidence intervals. The outcomes arerocedure or reversal of the proximal diversion, at 1 year,permission. (Color version of figure is available online.)

J-poure shoginal p

ases. In these circumstances, a transverse coloplasty (TC)

htfiawdqt2aa2ms

FMr

paoslphbs

Cutcoa

line.)

44 S.G. de la Fuente and C.R. Mantyh

as been proposed to provide improved functionality in pa-ients that are not candidates for a CJP. This technique wasrst described in a porcine model44 and subsequentlydopted in humans.45 It offers excellent functional resultsith acceptable postoperative complications.46 In fact, ran-omized trials have validated this approach for patients re-uiring reconstruction of bowel continuity.47 In a prospec-ive phase I/II trial published by Z’graggen and coworkers5 in001, the anastomotic leak was 7% in those undergoing TCnd this was later confirmed by another prospective trial.47 Inretrospective review by the senior author of this article, of0 patients undergoing TC, only one postoperative anasto-otic leak was identified in a patient with no defunctioned

toma.46

unctional Outcomes of Transverse Coloplastiesost studies show similar early postoperative functional

Figure 2 Forrest plot of fecal urgency after J-pouch versuwith 95% confidence intervals. The outcomes are shoprocedure or reversal of the proximal diversion, at 1 yeawith permission. (Color version of figure is available on

esults between a TC and a CJP. Proponents of the colo- g

lasty agree that it is a relatively simpler operation thatvoids the late CJP evacuation problems.47 The frequencyf bowel movements as well as urgency, fragmentation oftools, and incontinence tend to decrease over time. This isikely due to the incremental increase of the volume ca-acity of the TC with time.48 Some retrospective studiesave demonstrated that quality of life is similar or evenetter in those receiving a TC compared with other recon-tructive techniques.49

The first study that clinically compared TC to SCAA orJP was published back in 2001 and included all consec-tive patients operated at the Cleveland Clinic Founda-ion.46 Twenty of the patients underwent a TC with theolorectal anastomosis within 3 cm of the dentate line; 16thers had a CJP, and a remaining 17 patients underwentSCAA. In this series, major complications in the TC

ht coloanal anastomosis (CAA). Odds ratios are shownthree times intervals: within 6 months of the originalat 2 years or more. From Heriot and coworkers (ref.31)

s straigwn atr, and

roup occurred in five cases, including two small-bowel

obosincpjttthaaotfaiitpc

TTAwtnriptsedalarto

stodvtpauf

DPImssbflaetrw

dgfwbodes

“tvaffsmpoMtti

cttrptMohcftfrT

Reconstructive techniques following proctectomy 45

bstructions, one anal stricture requiring dilation, oneladder dysfunction requiring self-catheterization, andne anastomotic leak. Functional comparisons demon-trated that resting and squeeze pressures were not signif-cantly different among the three groups. Statistically sig-ificant elevated maximum tolerated volume andompliance were found in the TC and CJP group com-ared with the SCAA patients. Clinically, patients sub-

ected to a TC or CJP had fewer bowel movements per dayhan the SCAA group. Furthermore, the percentage of pa-ients requiring medications to slow down their bowels,heir continence scores, and the percentage of patientsaving a major complication were statistically similarmong the groups. These findings were later confirmed inprospective trial where patients were randomized to a TCr a CJP.42 These investigators found no differences be-ween groups regarding bowel function. The postoperativerequency of daily bowel movements, stool fragmentation,nd urgency within the first 6 months of surgery was lowern the TC group. In this study, no differences were foundn the incidence of incontinence or manometric data be-ween groups. The patients in the TC group did have moreostoperative anastomotic leaks, but this was not statisti-ally significant.

he Need foremporary Stoma Constructioncontroversial aspect that surgeons are often confronted

ith is whether to divert patients temporarily while allowinghe newly constructed pouch or anastomoses to heal. Propo-ents of temporary stomas agree that postoperative leakageates are lower in those diverted27,40,50; however, some stud-es have shown that leakage rates remain the same despiterophylactic diversion.51,52 Unfortunately, small randomizedrials have failed to settle this debate.53,54 A recent prospectivetudy of 1078 patients by Wong and Eu showed no differ-nces in the anastomotic leak rate between diverted and non-iverted patients.55 The authors concluded that even thoughdiverting stoma does not reduce postoperative anastomotic

eak rate, it reduces the otherwise catastrophic effects of annastomotic leak such as fecal peritonitis and septicemia. Theeal issue is, however, that approximately 50% of patientshat leak will eventually require a permanent colostomy sec-ndary to poor function.Some authors have suggested that stoma construction

hould be advocated for patients who are deemed preopera-ively high risk for anastomotic leak56 such as obese patientsr patients with low anastomoses (�6 cm), preoperative ra-iation, steroids, diabetes mellitus, and males, since multi-ariate analysis has shown that these patients are predisposeo postoperative anastomotic leakage.15-17 Our practice is toerform diversion for all patients with colorectal or coloanalnastomoses within 6 cm of the anus, especially if they havendergone preoperative radiation therapy or have other risk

actors for postoperative complications. m

etermination ofostoperative Functionality

n patients presenting with postoperative symptoms, deter-ination of the functionality of any restorative technique

tarts with a detailed physical examination. Patients are as-essed in the first postoperative visit for the frequency ofowel movements, tenesmus, urgency, incontinence to stool,atus, or urine, the use of laxatives, any changes in the bowelctivity since surgery, and sexual function. It is crucial tovaluate the severity of these symptoms and temporal rela-ionship to surgery, since many of these symptoms tend toesolve with time. Persistence of these symptoms, however,arrants further assessment of the restorative technique.This can be evaluated with a variety of diagnostic tools to

etermine the volume, elasticity, functionality, and contin-ence of the pouch. Many of the symptoms of colonic dys-unctionality have been attributed to ischemic changesithin the bowel wall, changes in the elastic properties of theowel, decreased sensation, and lower anal pressures amongther factors. Technical aspects can also play a role.57,58 In-eed, patients with larger pouches are more likely to havevacuation difficulties and require more medications for con-tipation.35

In general, the diagnostic algorithm starts with the lessinvasive” tools and advances through as the situation dic-ates. Anoscopy is performed in the office setting and pro-ides valuable information about the coloanal anastomosisnd any areas of stenosis. If anastomotic stenosis is suspected,urther testing with a barium enema is recommended. De-ecography (evacuation pouchography) is a dynamic fluoro-copic examination performed with rectal contrast to deter-ine the anatomy and function of the newly constructedouch during defecation. Poor results caused by rapid fillingr impaired evacuation can lead to increase stool frequency.anometry is also a valuable tool for the diagnosis of sphinc-

eric function as it is anal endosonography. If any of theseests reveal an obvious technical defect, surgical correctiventervention is indicated.

Despite all the diagnostic tools available to the surgeon, thelinical picture will dictate any need for intervention. Overhe last several years, multiple surveys and bowel assessmentools have been published but the lack of uniformity in theseeports make comparison of trials difficulty, and more im-ortantly, determination of superiority of one technique overhe other challenging. Recently, a group of researchers from

emorial Sloan-Kettering Cancer Center in New York devel-ped an instrument to assess bowel function in patients whoad undergone surgery for rectal cancer.59 The study in-luded a 41-item bowel function survey that was developedrom a literature review, expert opinions, and 59 patient in-erviews. This instrument allows the measurement of bowelunction in patients after sphincter-preserving surgery forectal cancer and the evaluation of postoperative outcomes.he authors from this study concluded that the instrument

ay be easily incorporated into trials comparing different

to

aeSiocqc

CBMtfpaspptpHMctatssl

CScSbcdtpgtpsunsUcl

R

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

46 S.G. de la Fuente and C.R. Mantyh

herapies for rectal cancer and could be incorporated into post-perative follow-up evaluating the surgeon’s own outcomes.

The presence of symptoms of bowel dysfunction will neg-tively impact quality of life in most patients. Most studiesvaluate quality of life with standardized scales such as theF-36 or the fecal incontinence severity index in those withncontinence to stool or gas.60 These scales allow evaluationf progression of symptoms in a particular patient as well asomparisons between trails. In general, patients respond touestionnaires with specific questions that permit the clini-ian to determine the severity of the symptoms.

omparisonetween Techniquesore than 50 prospective studies have been conducted in

he last two decades comparing reconstructive techniquesollowing proctectomy. Recently, Heriot and colleaguesublished an excellent meta-analysis of all randomizednd nonrandomized trials comparing colonic reservoirs totraight coloanal anastomoses.31 Most of the randomizedrospective studies included in this meta-analysis com-ared straight coloanal anastomoses to CJP and only fiverials compared CJP to TC. No prospective study has beenublished to date comparing TC to SCAA. The analysis byeriot and colleagues included a total of 2240 patients.ore recently, Fazio and coworkers published a multi-

enter study comparing complications, long-term func-ional outcome, and quality of life of patients undergoingTC, CJP, or an SCAA.61 In most cases, these studies show

hat immediate postoperative complications are relativelyimilar between groups; however, colonic reservoirs areuperior in terms of functionality compared with SCAA ateast within the first 2 years postoperatively.

onclusionsphincter-preserving procedures have become increasinglyommon for the treatment of mid and low rectal cancers.everal reconstructive options are available for restoringowel continuity, including the SCAA, CJP, and TC. Straightoloanal anastomoses are commonly performed; however,ue to postoperative symptoms of defunctionality, other al-ernatives such a CJP or TC have been developed. Immediateostoperative complications are relatively similar betweenroups but colonic reservoirs are superior in terms of func-ionality compared with SCAA at least within the first 2 yearsostoperatively. Patients presenting with postoperativeymptoms of colonic dysfunction should be thoroughly eval-ated. Available tests include anoscopy, defecography, ma-ometry, anal endosonography, etc. The need for correctiveurgery will be determined by the degree of the symptoms.ntil level 1 data become available comparing all three re-onstructive techniques, the chosen technique should be tai-

ored to each patient individually. 2

eferences1. Ries LAG, Melbert D, Krapcho M, et al: SEER Cancer Statistics Review,

1975-2004, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2004

2. Chessin DB, Guillem JG: Surgical issues in rectal cancer: a 2004 update.Clin Colorectal Cancer 4:233-240, 2004

3. Shafik A, Mostafa RM, Shafik I, et al: Functional activity of the rectum:A conduit organ or a storage organ or both? World J Gastroenterol28(12):4549-4552, 2006

4. Harris GJ, Lavery IJ, Fazio VW: Reasons for failure to construct thecolonic J-pouch. What can be done to improve the size of the neorectalreservoir should it occur? Dis Colon Rectum 45:1304-1308, 2002

5. Z’graggen K, Maurer CA, Birrer S, et al: A new surgical concept for rectalreplacement after low anterior resection: the transverse coloplastypouch. Ann Surg 234:780-785, 2001

6. Batignani G, Monaci I, Ficari F, et al: What affects continence afteranterior resection of the rectum? Dis Colon Rectum 34:329-335, 1991

7. Lewis WG, Holdsworth PJ, Stephenson BM, et al: Role of the rectum inthe physiological and clinical results of coloanal and colorectal anasto-mosis after anterior resection for rectal carcinoma. Br J Surg 79:1082-1086, 1992

8. McGinn FP, Gartell PC, Clifford PC, et al: Staples or sutures for lowcolorectal anastomoses: a prospective randomized trial. Br J Surg 72:603-605, 1985

9. Everett WG, Friend PJ, Forty J: Comparison of stapling and hand-suture for left-sided large bowel anastomosis. Br J Surg 73:345-348,1986

0. West of Scotland and Highland Anastomosis Study Group. Suturing orstapling in gastrointestinal surgery: a prospective randomized study.Br J Surg 78:337-341, 1991

1. Docherty JG, McGregor JR, Akyol AM, et al: Comparison of manuallyconstructed and stapled anastomoses in colorectal surgery. West ofScotland and Highland Anastomosis Study Group. Ann Surg 221:176-184, 1995

2. MacRae HM, McLeod RS: Handsewn vs. stapled anastomoses in colon andrectal surgery: a meta-analysis. Dis Colon Rectum 41:180-189, 1998

3. Lustosa SA, Matos D, Atallah AN, et al: Stapled versus handsewn meth-ods for colorectal anastomosis surgery. Cochrane Database of System-atic Reviews (3):CD003144, 2001

4. Miller K, Moritz E: Circular stapling techniques for low anterior resec-tion of rectal carcinoma. Hepatogastroenterology 43:823-831, 1996

5. Vignali A, Fazio VW, Lavery IC, et al: Factors associated with theoccurrence of leaks in stapled rectal anastomoses: a review of 1,014patients. J Am Coll Surg 185:105-113, 1997

6. Matthiessen P, Hallbook O, Andersson M, et al: Risk factors for anas-tomotic leakage after anterior resection of the rectum. Colorectal Dis6:462-469, 2004

7. Konishi T, Watanabe T, Kishimoto J, et al: Risk factors for anastomoticleakage after surgery for colorectal cancer: results of prospective sur-veillance. J Am Coll Surg 202:439-444, 2006

8. Beard JD, Nicholson ML, Sayers RD, et al: Intraoperative air testing ofcolorectal anastomoses: a prospective, randomized trial. Br J Surg 77:1095-1097, 1990

9. Davies AH, Bartolo DC, Richards AE, et al: Intra-operative air testing:an audit on rectal anastomosis. Ann R Coll Surg Engl 70:345-347, 1988

0. Ortiz H, Armendariz P: Anterior resection: do the patients perceive anyclinical benefit? Int J Colorectal Dis 11:191-195, 1996

1. Sun WM, Read NW, Katsinelos P, et al: Anorectal function after restor-ative proctocolectomy and low anterior resection with coloanal anas-tomosis. Br J Surg 81:280-284, 1994

2. Fegiz G, Trenti A, Bezzi M, et al: Sexual and bladder dysfunctionsfollowing surgery for rectal carcinoma. Ital J Surg Sci 16:103-109, 1986

3. Horgan PG, O’Connell PR, Shinkwin CA, et al: Effect of anterior resec-tion on anal sphincter function. Br J Surg 76:783-786, 1989

4. Rao GN, Drew PJ, Lee PW, et al: Anterior resection syndrome is sec-ondary to sympathetic denervation. Int J Colorectal Dis 11:250-258,1996

5. Nathanson DR, Espat NJ, Nash GM, et al: Evaluation of preoperative

2

2

2

2

3

3

3

3

3

3

3

3

3

3

4

4

4

4

4

4

4

4

4

4

5

5

5

5

5

5

5

5

5

5

6

6

Reconstructive techniques following proctectomy 47

and postoperative radiotherapy on long-term functional results ofstraight coloanal anastomosis. Dis Colon Rectum 46:888-894, 2003

6. Lazorthes F, Chiotasso P, Gamagami RA, et al: Late clinical outcome ina randomized prospective comparison of colonic J pouch and straightcoloanal anastomosis. Br J Surg 84:1449-1451, 1997

7. Dehni N, Schlegel RD, Cunningham C, et al: Influence of a defunction-ing stoma on leakage rates after low colorectal anastomosis and colonicJ pouch-anal anastomosis. Br J Surg 85:1114-1117, 1998

8. Joo JS, Latulippe JF, Alabaz O, et al: Long-term functional evaluation ofstraight coloanal anastomosis and colonic J-pouch: is the functionalsuperiority of the colonic J-pouch sustained? Dis Colon Rectum 41:740-746, 1998

9. Seow-Choen F, Goh HS: Prospective randomized trial comparing Jcolonic pouch-anal anastomosis and straight coloanal reconstruction.Br J Surg 82:608-610, 1995

0. Hallbook O, Pahlman L, Krog M, et al: Randomized comparison ofstraight and colonic J pouch anastomosis after low anterior resection.Ann Surg 224:58-65, 1996

1. Heriot AG, Tekkis PP, Constantinides V, et al: Meta-analysis of colonicreservoirs versus straight coloanal anastomosis after anterior resection.Br J Surg 93:19-32, 2006

2. Koh PK, Tang CL, Eu KW, et al: A systematic review of the function andcomplications of colonic pouches. Int J Colorectal Dis 22:543-548,2007

3. Sailer M, Fuchs KH, Fein M, et al: Randomized clinical trial comparingquality of life after straight and pouch coloanal reconstruction. Br J Surg89:1108-1117, 2002

4. Ho YH, Seow-Choen F, Tan M: Colonic J-pouch function at six monthsversus straight coloanal anastomosis at two years: randomized con-trolled trial. World J Surg 25:876-881, 2001

5. Lazorthes F, Gamagami R, Chiotasso P, et al: Prospective, randomizedstudy comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum 40:1409-1013, 1997

6. Hida J, Yasutomi M, Fujimoto K, et al: Functional outcome after lowanterior resection with low anastomosis for rectal cancer using thecolonic J-pouch. Prospective randomized study for determination ofoptimum pouch size. Dis Colon Rectum 39:986-991, 1996

7. Hida J, Yasutomi M, Maruyama T, et al: Enlargement of colonic pouchafter proctectomy and coloanal anastomosis: potential cause for evac-uation difficulty. Dis Colon Rectum 42:1181-1188, 1999

8. Hida J, Yasutomi M, Maruyama T, et al: Indications for colonic J-pouchreconstruction after anterior resection for rectal cancer: determiningthe optimum level of anastomosis. Dis Colon Rectum 41:558-563,1998

9. Amin AI, Hallbook O, Lee AJ, et al: A 5-cm colonic J pouch colo-analreconstruction following anterior resection for low rectal cancer resultsin acceptable evacuation and continence in the long term. ColorectalDis 5:33-37, 2003

0. Ho YH, Brown S, Heah SM, et al: Comparison of J-pouch and coloplastypouch for low rectal cancers; a randomized controlled trial investigat-ing functional results and anastomotic leak rates. Ann Surg 236:49-55,2002

1. Furst A, Suttner S, Agha A, et al: Colonic J-pouch vs coloplasty follow-ing resection of distal rectal cancer: early results of a prospective, ran-domized, pilot study. Dis Colon Rectum 46:1161-1166, 2003

2. Pimentel JM, Duarte A, Gregorio C, et al: Transverse coloplasty pouch

and colonic J-pouch for rectal cancer—a comparative study. ColorectalDis 5:465-470, 2003

3. Oya M, Komatsu J, Takase Y, et al: Comparison of defecatory functionafter colonic J-pouch anastomosis and straight anastomosis for stapledlow anterior resection: results of a prospective randomized trial. SurgToday 32:104-110, 2002

4. Z’graggen K, Maurer CA, Mettler D, et al: A novel colon pouch and itscomparison with a straight coloanal and colon J-pouch–anal anastomo-sis: preliminary results in pigs. Surgery 125:105-112, 1999

5. Fazio VW, Mantyh CR, Hull TL: Colonic “coloplasty”: novel techniqueto enhance low colorectal or coloanal anastomosis. Dis Colon Rectum43:1448-1450, 2000

6. Mantyh CR, Hull TL, Fazio VW: Coloplasty in low colorectal anasto-mosis: manometric and functional comparison with straight and co-lonic J-pouch anastomosis. Dis Colon Rectum 44:37-42, 2001

7. Ulrich A, Z’graggen K, Weitz J, et al: Functional results of the colonJ-pouch versus transverse coloplasty pouch in Heidelberg. Recent Re-sults Cancer Res 165:205-211, 2005

8. Maurer CA, Z’graggen K, Zimmermann W, et al: Experimental study ofneorectal physiology after formation of a transverse coloplasty pouch.Br J Surg 86:1451-1458, 1999

9. Kanne V, Kim NH, Ulrich B: The Transverse Coloplasty Pouch (TCP)—function and subjective judgement in comparison with the surgicallymore complicated J-pouch. Zentralbl Chir 127:781-785, 2002

0. Karanjia ND, Corder AP, Holdsworth PJ, et al: Risk of peritonitis andfatal septicaemia and the need to defunction the low anastomosis. Br JSurg 78:196-198, 1991

1. Machado M, Hallbook O, Goldman S, et al: Defunctioning stoma in lowanterior resection with colonic pouch for rectal cancer: a comparisonbetween two hospitals with a different policy. Dis Colon Rectum 45:940-945, 2002

2. Mealy K, Burke P, Hyland J: Anterior resection without a defunctioningcolostomy: questions of safety. Br J Surg 79:305-307, 1992

3. Pakkastie TE, Ovaska JT, Pekkala ES, et al: A randomised study ofcolostomies in low colorectal anastomoses. Eur J Surg 163:929-933,1997

4. Graffner H, Fredlund P, Olsson SA, et al: Protective colostomy in lowanterior resection of the rectum using the EEA stapling instrument. Arandomized study. Dis Colon Rectum 26:87-90, 1983

5. Wong NY, Eu KW: A defunctioning ileostomy does not prevent clinicalanastomotic leak after a low anterior resection: a prospective, compar-ative study. Dis Colon Rectum 48:2076-2079, 2005

6. Grabham JA, Moran BJ, Lane RH: Defunctioning colostomy for lowanterior resection: a selective approach. Br J Surg 82:1331-1332, 1995

7. Mathur P, Hallan RI: The colonic J-pouch in colo-anal anastomosis.Colorectal Dis 4:304-312, 2002

8. Hallböök O, Sjödahl R: Surgical approaches to obtaining optimal bowelfunction. Semin Surg Oncol 18:249-258, 2000

9. Temple LK, Bacik J, Savatta SG, et al: The development of a validatedinstrument to evaluate bowel function after sphincter-preserving sur-gery for rectal cancer. Dis Colon Rectum 48:1353-1365, 2005

0. Rockwood TH, Church JM, Fleshman JW, et al: Patient and surgeonranking of the severity of symptoms associated with fecal incontinence:the fecal incontinence severity index. Dis Colon Rectum 42:1525-1532, 1999

1. Fazio VW, Zutshi M, Remzi FH, et al: A randomized multicenter trial tocompare long-term functional outcome, quality of life, and complica-tions of surgical procedures for low rectal cancers. Ann Surg 246:481-

488, 2007