Abstract
Impaired neorectal function or sphincter incompetence have been respectively implicated as causative factors of increased frequency of defaecation or incontinence after low anterior resection of the rectum (LARR) for rectal carcinoma, although individual mechanisms of anorectal function have not been fully studied. Functional and laboratory results were evaluated in 19 subjects, who had a LARR for rectal carcinoma before and after the procedure, and were compared to those of normal subjects. LARR worsened anorectal function, mostly by significantly increasing the daily number of defaecations (p<0.001), while major incontinence was reported in three cases. Patients with rectal carcinoma have a decreased resting anal pressure on manometry, as compared to controls (p<0.001). LARR further reduces anal resting pressure (p<0.001) as well as all parameters that express internal sphincter activity, such as presence and amplitude of either slow (p<0.05 and p<0.01) or ultraslow waves. LARR also impaired external anal sphincter activity, as expressed by the reduction in anal squeeze pressure (p<0.001). Anorectal sampling was found reduced in incidence and frequency in LARR patients as compared to controls (p<0.01 and p<0.01), and was impaired even further postoperatively (p<0.001). Rectoanal inhibitory reflex was present in all but three patients postoperative, but significantly impaired as compared to controls. Rectal volumes to elicit transient or permanent desire to defecate, maximal tolerable rectal volume and rectal compliance were also significantly reduced after LARR (p<0.001, p<0.001, p<0.01 and p<0.001 respectively). Large bowel transit was significantly enhanced after LARR (p<0.001). On defaecography, the anorectal angle was found to be more obtuse but in higher position postoperatively as compared to controls (p<0.001). Bowel motion frequency was inversely related to rectal compliance (p<0.001) and length of remaining distal rectal stump, while patients with incontinence exhibited the lowest anal pressures. It is concluded that reduced neorectal capacity after removal of the rectum and impaired anal sphincter function because of stretching and damaged innervation, as well as impaired rectoanal coordination are all responsible for the functional problems after LARR.
Résumé
On attribue à une dysfonction du néorectum ou à une insuffisance sphinctérienne l'augmentation de fréquence des défécations et l'incontinence observée après des résection antérieures basses du rectum pour cancer rectal bien que les différents mécanismes de la fonction anorectale n'aient pas été totalement étudiés. Les résultats fonctionnels et les valeurs de laboratoire ont été déterminés chez 19 patients avant et après résection antérieure basse pour cancer du rectum; ces données ont été comparées à des sujets témoins. La résection antérieure basse du rectum péjore la fonction anale en augmentant essentiellement le nombre d'exonérations quotidiennes (P<0.001) alors que des incontinences majeures sont observées chez 3 patients. Les patients avec un cancer du rectum ont une diminution de la pression anale de repos à la manométrie en comparaison au témoin (P<0.001). La résection antérieure basse, par ailleurs, diminue la pression de repos (P<0.001) de même que tous les paramètres témoignant de l'activité du sphincter interne telles que la présence et l'amplitude d'ondes de contractions lentes (P<0.05 et P<0.01) ou de contractions ultra-lentes. La résection antérieure basse interfère avec l'activité du sphincter externe ainsi qu'en témoigne la réduction de la pression de contraction volontaire (P<0.001). L'échantillonage anorectal était réduit en incidence et fréquence chez des patients opérés comparativement au contrôle (P<0.01 et P<0.001) et était altéré en post-opératoire également (P<0.001). Le réflexe inhibiteur recto-anal était présent chez tous les patients à l'exception de 3 en post-opératoire mais était significativement altéré comparativement au contrôle. Le volume rectal entraînant le besoin trnsitoire ou permanent d'exonérer de méme que le volume maximal tolérable et la compliance rectale était significativement réduite après résection antérieure basse (P<0.001, P<0.001, P<0.01 et P<0.001 respectivement). Le temps de transit colique était significativement accéléré après résection antérieure basse (P<0.001). Sur les défécographies, l'angle ano-rectal était plus obtus et en position plus haute en post-opératoire comparativement au sujet témoin (P<0.001). La fréquence des exonérations était inversement proportionelle à la compliance rectale (P<0.001) et à la longueur du moignon rectal résiduel alors que les patients présentant une incontinence avaient des pressions anales les plus basses. On en conclut que les troubles fonctionnels secondaires à une résection antérieure basse résultent d'une diminution de la capacité du néo-rectum et d'une altération de la fonction sphinctérienne secondaire á la dilatation du néo-rectum et d'une altération de la fonction sphinctérienne secondaire à la dilatation anale et à une atteinte de l'innervation de même qu'à des troubles de la coordination recto-anale.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Nicholls RJ, Ritchie JK, Wadsworth J et al. (1979) Total excision or restorative resection for carcinoma of the middle third of the rectum. Br J Surg 66:625–627
Williams NS, Dixon MF, Johnston D (1989) Reappraisal of the 5 cm rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients's survival. Br J Surg 70:150–154
Williams NS, Johnston D (1984) Survival and recurrence after sphincter saving resection and abdominoperineal resection for carcinoma of the middle third of the rectum. Br J Surg 71:278–282
Kirwan WO, Drumm J, Hogan JM, Keohane C (1988) Determining safe margin of resection in low anterior resection for rectal cancer. Br J Surg 75:120
McDonald PJ, Heald RJ (1983) A survey of postoperative function after rectal anastomosis with circular stapling devices. Br J Surg 70:727–729
Leff EI, Hoexter B, Labow SB, Eisenstat TE, Rubin RJ, Salvati EP (1982) The EEA stapler in low colorectal anastomosis: initial experience. Dis Colon Rectum 25:704–707
Gillen P, Peel ALG (1986) Comparison of the mortality, morbidity and incidence of local recurrence in patients with rectal cancer treated by either stapled anterior resection or abdominoperineal resection. Br J Surg 73:339–341
Nakahara S, Itoh H, Mibu R et al. (1988) Clinical and manometric evaluation of anorectal function following low anterior resection with low anastomotic line using an EEA stapler for rectal cancer. Dis Colon Rectum 31:762–766
Nicholls RJ, Lubowski DZ, Donaldson DR (1988) Comparison of colonic reservoir and straight colo-anal reconstruction after rectal excision. Br J Surg 75:318–320
Karanjia ND, Schache DJ, Heald RJ (1992) Function of the distal rectum after low anterior resection for carcinoma. Br J Surg 79:114–116
Lee JF, Maurer VW, Block GE (1973) Anatomic relations of pelvic autonomic nerves to pelvic operations. Arch Surg 107:324–328
Horgan PG, O'Connell PR, Shinkwin CA, Kirwan WO (1989) Effect of anterior resection on anal sphincter function. Br J Surg 76:783–786
Johnston D, Holdsworth PJ, Nasmyth DG et al. (1987) Preservation of the entire anal canal in conservative proctocolectomy for ulcerative colitis: a pilot study comparing end-to-end ileo-anal anastomosis without mucosal resection with mucosal proctectomy and endo-anal anastomosis. Br J Surg 74:940–944
Read NW, Haynes WG, Bartolo DCC, Hall J, Read MG, Donnelly TC, Johnson AG (1983) Use of anorectal manometry during rectal infusion of saline to investigate sphincter function in incontinent patients. Gastroenterology 85:105–112
Henry MM (1987) Pathogenesis and management oaf faecal incontinence in the adult. Gastroenterol Clin N Am 16:35–45
Pedersen D, Hint K, Olsen J, Christiansen J, Jensen P, Mortensen P (1986) Anorectal function after low anterior resection for carcinoma. Ann Surg 204:133–135
Pappalardo G, Toccaceli S, Dionisio P, Castrini G, Ravo B (1988) Preoperative evaluation by manometric study of the anal sphincter after coloanal anastomosis for carcinoma. Dis Colon Rectum 31:119–122
Batignati G, Monaci I, Ficari F, Tonelli F (1991) What affects continence after anterior resection of the rectum. Dis Colon Rectum 34:329–335
Williams NS, Price R, Johnston D (1980) The long term effect of sphincter preserving operations for rectal carcinoma on function of the anal sphincter in man. Br J Surg 67:203–208
Hancock B, Smith K (1975) The internal sphincter and Lord's procedure for haemorrhoids. Br J Surg 62:833–836
Hallgren T, Fasth S, Delbro D, Nordgen S, Oresland T, Hulten L (1993) Possible role of the autonomic nervous system in sphincter impairment after restorative proctocolectomy. Br J Surg 80:631–635
Sun WM, Read NW, Donnelly TC (1989) Impaired anal sphincter in a subgroup of patients with idiopathic fecal incontinence. Gastroenterology 97:130–135
Parks AG, Porter NH, Melzak J (1962) Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Dis Colon Rectum 5:407–414
Lane RHS, Parks AG (1977) Function of the anal sphincter following colo-anal anastomosis. Br J Surg 64:596–599
Duthie HL, Bennett RC (1963) The relation of sensation in the anal canal to the functional sphincter length: a possible factor in anal continence. Gut 4:179–182
Miller R, Bartolo Dcc, Cervero F, Mortensen NJMcC (1988) Anorectal sampling: a comparison of normal and incontinent patients. Br J Surg 75:44–47
Parks AG, Porter NH, Hardcastle J (1966) The syndrome of the descending perineum. Proc R Soc Med 59:477–482
Bartolo DCC, Read NW, Jarratt JA, Read MG, Donnelly TC, Johnson AG (1983) Differences in anal sphincter function and clinical presentation with pelvic floor descent. Gastroenterology 85:68–75
Browning GGP, Parks AG (1983) Postanal repair for neuropathic faecal incontinence: correlation of clinical results and anal canal presures. Br J Surg 70:101–104
Bartolo DCC, Duthie GS (1990) The physiological evaluation of operative repair for incontinence and prolapse. In: Ciba Foundation Symposium 151: Neurobiology of incontinence. Wiley, Chichester, pp 223–245
Miller R, Bartolo DCC, Locke-Edmunds JC, Mortensen NJMcC (1988) A prospective study of conservative and operative treatment of faecal incontinence. Br J Surg 75:101–105
Lazorthes F, Fages P, Chiotasso P, Lemozy J, Bloom E (1986) Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg 73:136–138
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Vassilakis, J.S., Pechlivanides, G., Zoras, O.J. et al. Anorectal function after low anterior resection of the rectum. Int J Colorect Dis 10, 101–106 (1995). https://doi.org/10.1007/BF00341207
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/BF00341207