Coloanal J-pouch reconstruction following low rectal resection

From an oncological point of view, a distal resection border of 2 cm is sufficient after deep anterior rectal resection and total mesorectal excision. This conclusion has led to extending the indications for ultradeep rectal resection in recent years. The classical end-to-end coloanal anastomosis, however, has been shown to be associated with several functional drawbacks, for example, increased stool urgency and in some cases incontinence, especially in the first 6-12 months after the operation. It was to improve these aspects that the coloanal pouch was introduced. In a pilot study we performed a coloanal pouch in 25 patients (median age 65 years, range 32-85). The coloanal pouch anastomosis was generally performed by a stapling device. A transanal hand-sewn anastomosis was performed in the section down to the sphincter level. Indications included rectal cancer, recurrent villous adenoma, and in one case recto-vaginal fistula. The pouch was also constructed by a linear stapling device, and its length was usually 5-7 cm. The level of the anastomosis averaged 2 cm above the dentate line. In 16 patients a protective ileostomy was also carried out. We observed four cases of anastomotic leak and in one an abscess. Results showed full continence after 6 months and in 85% after 1 year. Urgency was observed in four patients after 3 months, and in only one after 1 year. In summary, we obtained encouraging results for initiating a randomized trial in the future to confirm the advantages of this type of reconstruction after deep anterior rectal resection.