A recently published method may offer a promising alternative to increase the (neo) rectal compliance following low resection. A Swiss group described a new pouch created in an experimental pig model designed by performing a mere longitudinal colotomy of the taenia libera coli followed by a transverse closure. Although the pouch volume of this new pouch was significantly smaller than that obtained with a J-pouch, the frequency of defecation was comparable.
Clinical application of this new method may overcome severe technical problems in obese patients or in patients with a long anal canal in whom the distal resection margin and the anastomosis are situated in the dentate line, and in whom construction of a J-pouch is almost technically impossible.
Although dynamic graciloplasty has provided excellent results in patients who were operated for fecal incontinence due to major sphincter defects, the use of this technique for sphincter restoration following APR is regarded as a compromise.
Despite sufficiently high sphincter pressures created by the transformed gracilis muscle, defecation disorders, including incomplete evacuation and subsequent episodes of incontinence, are the major functional problems following this procedure. Most patients require periodical enemas or irrigation following APR to empty their neorectum sufficiently. Although a satisfying functional result can be achieved in 60% to 75% of patients by this method, an intensive preoperative interview as well as a close follow-up after the procedure are mandatory to avoid disappointment.
A further point of controversy with this method is the selection of patients. The possible risk of recurrence and early death after such an expensive procedure raises a cost-benefit concern, depending mainly on the local financial and insurance situation of the different institutions. As possible solutions for this problem, a one-stage procedure (APR, muscle transposition and implant of stimulation electrodes and pulse generator) or a secondary total anorectal reconstruction (TAR) may be offered.
While the one-stage procedure provides muscle restoration with acceptable continence (with or without irrigation) within approximately eight weeks (thus providing a good quality of life even for patients with a shorter survival), secondary TAR is selectively performed in patients one to two years after APR. The chance of local recurrence is reduced with secondary TAR, and only patients who definitively cannot bear having a permanent colostomy are selected for this procedure. However, although secondary TARs have been performed with satisfying results, it must be emphasised that they is technically more challenging than TARs done synchronously during APR.
Progress in surgical techniques, and in the knowledge of co- lorectal physiology and the nature of rectal cancer, have augmented the therapeutic options, providing almost all rectal cancer patients who are candidates for elective and radical surgery the opportunity to live without a permanent colostomy.
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In a recent study in our department, we demonstrated that in the elective and curative situation, no patient needed a permanent stoma for the treatment of rectal cancer.