الفهرس 
ANATOMICAL CONSIDERATIONSOnly 14 pages are availabe for public view
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Abstract
Adenocarcinoma of the colon and rectum is one of the most common cancers occurring in the western world and in Egypt. Almost half of these tumors occur in the rectum and almost three-quarters are within reach of the flexible sigmoidoscope.
Colorectal cancer in Egypt has no age predilection and more than one-third of tumors affect a young population. The disease usually presents at an advanced stage, and predisposing adenomas are rare.
Due to the vast improvements in the surgical techniques, the emerging of the total mesorectum excision concept, the wide use of the different staplers that made coloanal anastomosis much easier than the older hand sewn anastomosis, a step that revolutionised and reduced the need for abdominoperineal resection and recently the introduction of the laparoscopic anterior, low anterior and ultra low anterior resection, the oncological outcomes started to improve prominently. To keep pace with such improvements in the oncological outcomes, the physiological outcomes became under focus. Although reports seem to favor the use of a J-pouch, there are yet limited data to suggest that the post operative function and complications of J-pouch is better than a straight colo anal anastomosis and to whether it is a gold standard after anterior resection.
The combination of frequency, urgency and soiling has been termed ‘anterior resection syndrome. Frequency and urgency have been attributed to loss of the rectal reservoir, although there is some improvement over time that may result from progressive dilatation of the neorectum.
A number of studies have described significant impairment in functional outcomes after straight colo anal anastomosis. Some studies advocate that Colonic J-pouch reconstructions result in a better functional outcome than straight coloanal anastomosis in terms of continence and frequency of defecation after rectal resection. The improved perfusion of the side-to-end anastomosis in pouch-anastomosis reduces the rate of anastomotic leakages as well. In published retrospective studies, the oncological outcome is completely comparable to straight coloanal anastomosis.
The aim of our study is to compare results of colonic J-pouch reservoir reconstruction with conventional straight colo anal anastomosis in regard to post operative morbidity and complications including anastomosis leak and the anterior resection syndrome which consists of increased stool frequency, urgency, and incontinence after six months post surgery.
We conducted a comparative randomized prospective study at Ain Shams University hospital in the period from March 2008 to March 2011. Thirty patients requiring anterior resection for rectal cancer were included in the study. Patients were randomised to two groups, 15 patients each. Group 1 underwent conventional colo anal anastomosis without reservoir reconstruction; Group 2 underwent short colonic J-pouch reservoir reconstruction of 6-8 cm long reconstructed from the descending colon.
All patients were investigated preoperatively by
• Ultrasound abdomen and pelvis
• Abdomino- Pelvic CT Scan
• Lower GIT endoscopy and Biopsy
The operative technique either open or laparoscopic followed the standard Total Mesorectal Excision concept. We intended to use the laparoscopic resection whenever possible and feasible. Limitations and oppositions were sometimes due to anesthesia or technical factors.
We followed the patients in the outpatient clinic for the next 6 months after discharge. During each visit the patient was assesed generally and locally for any sign of recurrence being local or systemic. Attention was given to the anterior resection syndrome components namely frequency of bowel motion per 24 hours, continence status and the presence or absence of urgency.
We found that the three components of the anterior resection syndrome are improved by the construction of J pouch. The frequency of bowel motion specifically was the most affected parameter as evidenced by the statistical analysis (Sig 2-tailed independent T-test: P value 0.006)
The other two components of the anterior resection syndrome as well showed better improvements with the j pouch construction. Continence and urgency were much better in the J pouch group than in the straight colo anal anastomosis (Sig 2-tailed independent T-test: P value 0.043 and 0.021 respectively).
Our results were comparable to those previously reported in randomized controlled studies in early 90s by Hallbook, Lazorthes, and Ho and also with more recent publications by Gross, Masliankov, Kovache, Zedan and Gotzinger. Also our results were comparable with the Meta analysis by Rink 2009.
We found limited publications concluding data that is incomparable to our work.
Many publications claim that the physiological outcomes in the straight colo anal anastomosis becomes better and improve over the first year post surgery to be comparable and indifferent from the j pouch after one year. Further studies to compare both J pouch reconstruction and straight colo anal anastomosis on the basis of long term is needed to decide whether J pouch is the gold standard after anterior resection on the long run.
We concluded that colonic J-pouch is better than straight colo anal anastomosis after anterior resection and total mesorectal excision at least for the short term when the bowel physiological outcomes are considered. Further studies are needed to prove this on the long term as well as to recommend a routine use of J pouch after each anterior resection.