Abstract
The colonic J-pouch (pouch group) functions better than the straight coloanal anastomosis (straight group) immediately after ultra-low anterior resection, but there are few studies with long-term follow-up. This randomized controlled study compared functional outcome, anal manometry, and rectal barostat assessment of these two groups over a 2-year period. Forty-two consecutive patients were recruited, of which 19 of the straight group [17 men with a mean age of 62.1 ± 2.3 (SEM) year] and 16 of the pouch group (11 men with a mean age of 61.3 ± 3.2 year) completed the study. Four died from metastases and two emigrated; there was no surgical morbidity or local recurrence. At 6 months the Pouch patients had significantly less frequent stools (32.9 ± 2.8 vs. 49 ± 1.4/week; p<0.05) and less soiling at passing flatus (38% vs. 73.7%; p<0.05). At 2 years both groups had improved with no longer any differences in stool frequency (7.3 ± 0.4 vs. 8 ± 0.2/week) and soiling at passing flatus (38% vs. 53%). Defecation problems remained minimal in both groups. Anal squeeze pressures were significantly impaired in both groups up to 2 years (p<0.05). The rectal maximum tolerable volume and compliance were not different between groups. Rectal sensory testing on the barostat phasic program showed impairment at 6 months and recovery at 2 years, suggesting that postoperative recovery of residual afferent sympathetic nerves may play a role in functional recovery. In conclusion, stool frequency and incontinence were less in the Pouch patients at 6 months; but after adaptation at 2 years the straight group patients yielded similar results. Nonetheless, this functional advantage can be given to patients with minimal added effort or complications by using the colonic J-pouch.
Résumé
Après résection antérieure du rectum ultra-basse, le réservoir colique en J (POUCH) fonctionne mieux que l’anastomose coloanale sans réservoir (STRAIGHT), mais il existe peu d’études avec un suivi à long terme. Cette étude randomisée, contrôlée, compare l’évolution fonctionnelle et la manométrie anale ainsi que l’évaluation barostatique dans ces deux groupes de patients pendant une période de deux ans. Quarante-deux patients consécutifs ont été inclus, dont 19 STRAIGHT (17 hommes; âge moyen 62,1 (ETS: 2,3) ans) et 16 POUCH (11 hommes; âge moyen 61,3 (3,2) ans). Quatre patients sont décédés de métastases (et deux ont émigré), mais il n’y avait aucune morbidité ou de récidive locale. A 6 mois, les patients POUCH allaient significativement moins fréquemment à la selle (32,9) (2,8) vs. 49 (l,4)/semaine; p<0,05) et avaient moins de souillures lorsqu’ils passaient des gaz (38% vs. 73,7%; p<0,05). A 2 ans, les résultats des deux groupes se sont améliorés avec aucune différence en ce qui concernait la fréquence des selles (7,3 (0,4) vs. 8 (0,2)/semaine) ou la souillure en passant des gaz (38% vs. 53%). Les problémes de défécation sont restés minimes dans les deux groupes. Les pressions de contraction anale étaient significativement perturbées dans les deux groupes, jusqu’à deux ans (p<0,05). Le volume rectal maximal tolérable et la compliance n’étaient pas significativement différents entre les deux groupes. Selon les résultats de la barostatique phasique on a mis en évidence une perturbation à 6 mois mais avec une récupération à 2 ans, suggerérant que la récupération postopératoire de nerfs sympathiques afférents joue peut-être un rôle dans la récupération fonctionnelle. En conclusion, à 6 mois, la fréquence des selles et de l’incontinence sont moindres après une anastomose POUCH, mais après 2 ans, les patients ayant une anastomose STRAIGHT ont des résultats similaires. Néanmoins, cet avantage fonctionnel inhérent à l’utilisation de l’anastomose avec réservoir en J ne demande qu’un minime effort de plus et l’intervention se complique peu.
Resumen
Existen pocos trabajos que valoren los resultados funcionales tardíos de la bolsa en J de colon (POUCH) con la anastomosis termino-terminal colorrectal, tras resecciones anteriores, muy bajas, de recto. En este estudio controlado y randomizado, se comparan, tras un seguimiento de 2 años, los resultados funcionales, la manometría anal y la barestesia rectal en dos grupos de pacientes tratados quirúrgicamente, con una de las dos técnicas mencionadas. La población estudiada comprende 42 pacientes; 19 tratados mediante anastomosis directa (grupo STRAIGHT) de los que 17 fueron hombres con una edad media de 62.1 (SEM: 2.3) años; el otro grupo (POUCH) comprende 16 pacientes de los que 11 fueron hombres con edad media de 61.3 (3.2) años. 4 enfermos murieron como consecuencia de diseminación metastásica y 2 emigraron. No se registró morbilidad quirúrgica alguna, ni recidivas locales. A los 6 meses, los enfermos del grupo POUCH presentaban un número significativamente menor de deposiciones [32.9 (2.8) vs. 49 (1.4)] por semana (p<0.05). y al ventosear dejan escapar menos materia fecal (38% vs 73.7%; p<0.05). A los 2 años, los pacientes de ambos grupos mejoraron sin que existieran diferencias ni en el número de deposiciones [7.3 (0.4) vs. 8 (0.2)], ni al mancharse al ventosear (38% vs. 53%). Los problemas de defecación fueron mÍnimos en ambos grupos. Las presiones anales al intento de defecar mejoraron significativamente en ambos grupos, a partir de los 2 años de la intervención (p<0.05). El volumen máximo tolerable y la “compliance” rectal fue igual en los dos grupos. La sensibilidad rectal, detectada mediante un programa fásico barestésico, mejora a los 6 meses y se recupera a los 2 años de la operación, lo que sugiere que en la recuperacion postoperatoria, los nervios simpáticos aferentes no resecados, desempeñar un importante papel en la recuperación funcional. Conclusión: el número de defecaciones y la incontinencia son menores en el grupo POUCH, hasta que transcurren 6 meses de la operación, pero tras un période de adaptación de 2 años, los resultados en el grupo POUCH y en el grupo STRAIGHT son semejantes. A pesar de ello la recuperción funcional es más rápida con la bolsa en J de colon (POUCH) y este mayor confort para los enfermos se puede alcanzar con un minimo esfuerzo añadido y sin complicaciones.
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Ho, YH., Seow-Choen, F. & Tan, M. Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: Randomized controlled trial. World J. Surg. 25, 876–881 (2001). https://doi.org/10.1007/s00268-001-0044-1
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DOI: https://doi.org/10.1007/s00268-001-0044-1