Ist eine kolonpouchanale rekonstruktion beim tief sitzenden rektumkarzinom sinnvoll?

Background and Aim: Sphincter preserving procedures are commonly used in patients with carcinoma of the lower third of the rectum. Surgical technique is standardized including total mesorectal excision and straight coloanal or colopouch anal anastomosis. However, many patients are complaining in functional disorders. Compared to the straight coloanal anastomosis some studies found better functional results for the colonic J-pouch in the first postoperative period, respectively. Therefore, we investigated rectal cancer patients regarding morbidity, mortality, functional outcome and survival in long-term follow-up. Patients and Methods: From January 1993 to August 1998, 587 patients with rectal cancer were resected. In 70 patients a colonic J-pouch procedure was performed additionally. Median age of the patients was 58 years, two thirds of them were men. The median distance of the distal tumor margin to the anal verge was 6 cm. Patients with tumor stage II or III received a postoperative radiochemotherapy. Median follow-up was 4.5 years (range 1.5-7). Results: Nearly all patients favored colonic J-pouch reporting a complete continence for solid stool. Mean stool frequency was 2.3 evacuations per day. Only 20% were incontinent for liquid stool and 50% were incontinent for flatus. The colonic J-pouch was superior regarding to stool frequency, urgency and stool clustering compared to a straight coloanal anastomosis. A local R0-resection was achieved in all cases. One patient died due to fulminated pulmonary embolism (1.5%). Nine pouch specific complications (leakage, fistula, necrosis) were seen (12%). Four J-pouches had to be resected over time. Local tumor recurrence was detected in 10%. 83% of the patients survived more than 4.5 years. In our study pouch construction does not lead to an increased rate of postoperative complications or mortality. Conclusion: We agree with others that the advantages of a colonic J-pouch are evident, even in the early postoperative period and in the long-term follow-up. Therefore, we recommend pouch reconstruction following complete rectal resection. "Luminal extension plasty" (coloplasty-pouch) as a new simplified colonic pouch configuration seems to be attractive, if the construction of a colonic J-pouch is not possible for technical reasons.