Do we need a pouch after intersphincteric resection?
In the early years of sphincter saving surgery for rectal cancer, an anorectal remnant of at least 6 cmseemed to be necessary for a satisfactory continence. Especially the sensory function of the lower rectum was assumed to be essential for a good postope
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Introduction In the early years of sphincter saving surgery for rectal cancer, an anorectal remnant of at least 6 cm seemed to be necessary for a satisfactory continence. Especially the sensory function of the lower rectum was assumed to be essential for a good postoperative function [1]. Gaston [2] has shown that after extensive resection of the rectum the rectoanal reflex was absent and continence was impaired. He showed on patients with rectal anastomoses in various levels that a minimum of 7 cm of rectal stump was necessary to elicit the rectoanal reflex, demonstrating an intact afferent and efferent nerve supply. His work showed very clearly that the lower rectum is an integral part of the sphincter mechanism. Although further clinical experience with different kinds of sphincter saving procedures did not confirm that a small rectal stump leads to incontinence, the important interaction between the lower rectum, the anal canal and the sphincter muscles is still valid. Parks [3] reported 1982 his experience on 76 patients with coloanal anastomosis. Only one was incontinent out of 70 evaluable patients, the others were continent, but 30 had irregularities with 3 to 4 defaecations per day. The rectoanal reflex was absent in all cases [3]. With increasing experience with low rectal anastomoses, in particular after the widespread use of circular staplers, defaecation disorders, called the “anterior resection syndrome” were observed. This phenomenon was characterized by a high frequency of bowel movements, fractionated defaecations and urgency. Despite earlier observations incontinence was not the dominating problem. The assumption was an insufficient capacity of the neorectum. The awareness of these problems after anterior resection resulted in a study showing that patients with a permanent stoma after abdominoperineal resection had a better quality of life than patients after anterior resection [4, 5]. This was not confirmed by other studies. In 1986 Lazorthes and Parc published their experience with the construction of a colonic pouch for establishing a reservoir after rectal excision [6, 7]. They used a J-shaped
reservoir which was anastomosed to the anal canal. The complication rate was low and the postoperative function was good with 1–2 stools per day and no incontinence. Parc reported, that 25% of the patients had problems with evacuation, requiring enemas. In the following years a colonic J-pouch was used by many surgeons for reconstruction after anterior resection and ultralow resections as well. It became nearly a dogma to use a pouch. Numerous studies showed a functional advantage of the J-pouch over a straight colorectal or coloanal anastomosis. Most randomized studies found a better postoperative bowel function after a pouch. Although the data showed a reduced frequency of bowel movements in the first months after rectal surgery, it was not clear which criteria were necessary to justify a pouch construction. Many studies recommended a pouch after anterior resection, some after coloanal anastomosis. Parameter
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