Rectal Reconstruction after Total Mesorectumectomy: Functional Outcomes and Quality of Life

Background. The study aims to compare the functional outcomes and quality of life in patients having variant rectal reconstruction procedures after low anterior resection for cancer.

Materials and methods. A prospective randomised controlled trial enrolled 90 patients who underwent total mesorectumectomy with formation of J-pouch (J-P), side-to-end (STE) or end-to-end (ETE) anastomoses.

Results and discussion. We analysed 22 J-P, 30 STE and 38 ETE patients. For technical reasons, 26.6 % J-Ps were remodelled to other anastomoses. The neorectal sensory threshold, first and permanent defecation urges and maximal tolerated volume were higher in J-P at months 3–6–12 postoperatively.
Severe low anterior resection syndrome events at post-surgery month 6 were significantly more frequent in the ETE vs. J-P and STE cohorts (21, 0 and 3.3 %, respectively, p < 0.05). Stool frequency was significantly lower in J-P vs. STE and ETE at months 3–6–12. Wexner score was 3, 5, 6 at month 6 (p < 0.05) and 0, 1, 1 at month 12 for J-P, STE and ETE, respectively (p > 0.05). Evacuatory dysfunction was present at month 6 in 59.1 J-P, 33.3 STE and 21.1 % ETE.
Quality of life (FIQL) in J-P and STE was significantly higher vs. ETE anastomoses in the Lifestyle (3.21, 3.22 and 3.03, respectively, p < 0.05) and Coping (3.29, 3.21 and 2.95, respectively, p < 0.05) scales to month 12 postoperatively.

Conclusion. The J-pouch formation after low anterior resection ameliorates anal continence at months 3–6 post-surgery, reduces low anterior resection syndrome and improves quality of life (FIQL). The ease of implementation and irrelevance of evacuatory dysfunction in side-to-end anastomosis make it a superior choice over end-to-end surgery.

1. Bryant C.L., Lunniss P.J., Knowles C.H., Thaha M.A., Chan C.L. Anterior resection syndrome. Lancet Oncol. 2012;13(9):e403–8. DOI: 10.1016/S1470-2045(12)70236-X

2. Emmertsen K.J., Laurberg S. Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg. 2012;255(5):922–8. DOI: 10.1097/SLA.0b013e31824f1c21

3. Ribi K., Marti W.R., Bernhard J., Grieder F., Graf M., Gloor B., et al. Quality of life after total mesorectal excision and rectal replacement: comparing Side-to-End, Colon J-Pouch and straight colorectal reconstruction in a randomized, phase III trial (SAKK 40/04). Ann Surg Oncol. 2019;26(11):3568–76. DOI: 10.1245/s10434-019-07525-2

4. Marti W.R., Curti G., Wehrli H., Grieder F., Graf M., Gloor B., et al. Clinical outcome after rectal replacement with Side-to-End, Colon-J-Pouch, or straight colorectal anastomosis following total mesorectal excision: a swiss prospective, randomized, multicenter trial (SAKK 40/04). Ann Surg. 2019;269(5):827–35. DOI: 10.1097/SLA.0000000000003057

5. Pucciarelli S., Del Bianco P., Pace U., Bianco F., Restivo A., Maretto I., et al. Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer. Br J Surg. 2019;106(9):1147–55. DOI: 10.1002/bjs.11222

6. Rubin F., Douard R., Wind P. The functional outcomes of coloanal and low colorectal anastomoses with reservoirs after low rectal cancer resections. Am Surg. 2014;80(12):1222–9. PMID: 25513921

7. Rutkowski A., Olesiński T., Zając L., Bednarczyk M., Szpakowski M. The risk of anastomotic leakage after anterior resection: retrospective analysis of 501 rectal cancer patients operated without protective stoma. Minerva Chir. 2017;72(6):491–498. DOI: 10.23736/S0026-4733.17.07411-9

8. Lazorthes F., Gamagami R., Chiotasso P., Istvan G., Muhammad S. Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum. 1997;40(12):1409–13. DOI: 10.1007/BF02070703

9. Parray F.Q., Farouqi U., Wani M.L., Chowdri N.A., Shaheen F. Colonic J pouch neo-rectum versus straight anastomosis for low rectal cancers. Indian J Cancer. 2014;51(4):560–4. DOI: 10.4103/0019-509X.175341

10. Hou S., Wang Q., Zhao S., Liu F., Guo P., Ye Y. Safety and efficacy of side-to-end anastomosis versus colonic J-pouch anastomosis in sphincter-preserving resections: an updated meta-analysis of randomized controlled trials. World J Surg Oncol. 2021;19(1):130. DOI: 10.1186/s12957-021-02243-0

11. Dulskas A., Kavaliauskas P., Pilipavicius L., Jodinskas M., Mikalonis M., Samalavicius N.E., et al. Long-term bowel dysfunction following low anterior resection. Sci Rep. 2020;10:11882. DOI: 10.1038/s41598-020-68900-8

12. Sturiale A., Martellucci J., Zurli L., Vaccaro C., Brusciano L., Limongelli P., et al. Long-term functional follow-up after anterior rectal resection for cancer. Int J Colorectal Dis. 2017;32(1):83–8. DOI: 10.1007/s00384-016-2659-6

13. Sakr A., Sauri F., Alessa M., Zakarnah E., Alawfi H., Torky R., et al. Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl). 2020;133(15):1824–33. DOI: 10.1097/CM9.0000000000000852

14. Keane C., Wells C., O’Grady G., Bissett I.P. Defining low anterior resection syndrome: a systematic review of the literature. Colorectal Dis. 2017;19:713–22. DOI: 10.1111/codi.13767

15. Gavaruzzi T., Pace U., Giandomenico F., Pucciarelli S., Bianco F., Selvaggi F., et al. Colonic J-pouch or straight colorectal reconstruction after low anterior resection for rectal cancer: impact on quality of life and bowel function: a multicenter prospective randomized study. Dis Colon Rectum. 2020;63(11):1511–23. DOI: 10.1097/DCR.0000000000001745

16. Hida J., Yasutomi M., Fujimoto K., Okuno K., Ieda S., Machidera N., et al. Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch. Prospective randomized study for determination of optimum pouch size. Dis Colon Rectum. 1996;39(9):986–91. DOI: 10.1007/BF02054686

17. Huber F.T., Herter B., Siewert J.R. Colonic pouch vs. side-to-end anastomosis in low anterior resection. Dis Colon Rectum. 1999;42(7):896– 902. DOI: 10.1007/BF02237098

18. Lee G.C., Cavallaro P.M., Savitt L.R., Hodin R.A., Kunitake H., Ricciardi R., et al. Bowel function after J-pouch may be more complex than previously appreciated: a comprehensive analysis to highlight existing knowledge gaps. Dis Colon Rectum. 2020;63(2):207–16. DOI: 10.1097/DCR.0000000000001543

19. Wang Z. Colonic J-pouch versus side-to-end anastomosis for rectal cancer: a systematic review and meta-analysis of randomized controlled trials. BMC Surg. 2021;21(1):331. DOI: 10.1186/s12893-021-01313-0

20. Doeksen A., Bakx R., Vincent A., van Tets W.F., Sprangers M.A., Gerhards M.F., et al. J-pouch vs side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision for rectal cancer: a multicentre randomized trial. Colorectal Dis. 2012;14(6):705–13. DOI: 10.1111/j.1463-1318.2011.02725.x

21. Siddiqui M.R., Sajid M.S., Woods W.G., Cheek E., Baig M.K. A meta-analysis comparing side to end with colonic J-pouch formation after anterior resection for rectal cancer. Tech Coloproctol. 2010;14(2):113– 23. DOI: 10.1007/s10151-010-0576-1

22. Okkabaz N., Haksal M., Atici A.E., Altuntas Y.E., Gundogan E., Gezen F.C., et al. J-pouch vs. side-to-end anastomosis after hand-assisted laparoscopic low anterior resection for rectal cancer: A prospective randomized trial on short and long term outcomes including life quality and functional results. Int J Surg. 2017;47:4–12. DOI: 10.1016/j.ijsu.2017.09.012

23. Parc Y., Ruppert R., Fuerst A., Golcher H., Zutshi M., Hull T., et al. Better function with a colonic J-pouch or a Side-to-end anastomosis? A randomized controlled trial to compare the complications, functional outcome, and quality of life in patients with low rectal cancer after a J-Pouch or a Side-to-end anastomosis. Ann Surg. 2019;269(5):815–26. DOI: 10.1097/SLA.0000000000003249

24. Rybakov E.G., Pikunov D.Yu., Budtuev A.S., Fomenko O.Yu. The results of comparative randomised study side-to-end vs. straight colorectal anastomosis after low anterior resection. Koloproktologia. 2015;4:4–10 (In Russ.).

25. Harris G.J., Lavery I.J., Fazio V.W. Reasons for failure to construct the colonic J-pouch. What can be done to improve the size of the neorectal reservoir should it occur? Dis Colon Rectum. 2002;45(10):1304–8. DOI: 10.1007/s10350-004-6414-7

26. Yun J.A., Cho Y.B., Park Y.A., Huh J.W., Yun S.H., Kim H.C., et al. Clinical manifestations and risk factors of anastomotic leakage after low anterior resection for rectal cancer. ANZ J Surg. 2017;87(11):908–14. DOI: 10.1111/ans.13143

27. Marković V., Dimitrijević I., Barišić G., Krivokapić Z. Comparison of functional outcome of colonic J-pouch and latero-terminal anastomosis in low anterior resection for rectal cancer. Srp Arh Celok Lek. 2015;143(3–4):158–61. DOI: 10.2298/sarh1504158m

28. Keane C., Fearnhead N.S., Bordeianou L.G., Christensen P., Basany E.E., Laurberg S., et al. International consensus definition of low anterior resection syndrome. Dis Colon Rectum. 2020;63(3):274–84. DOI: 10.1097/DCR.0000000000001583

29. Croese A.D., Lonie J.M., Trollope A.F., Vangaveti V.N., Ho Y.H. A meta-analysis of the prevalence of low anterior resection syndrome and systematic review of risk factors. Int J Surg. 2018;56:234–41. DOI: 10.1016/j.ijsu.2018.06.031

30. Park J.G., Lee M.R., Lim S.B., Hong C.W., Yoon S.N., Kang S.B., et al. Colonic J-pouch anal anastomosis after ultralow anterior resection with upper sphincter excision for low-lying rectal cancer. World J Gastroenterol. 2005;11(17):2570–3. DOI: 10.3748/wjg.v11.i17.2570