EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
Abu bakr et al
EXTERNAL COLOANAL ANASTOMOSIS IN LOW-LYING RECTAL
CANCER: OUTCOME ANALYSIS
By
Abu bakr, ME; Tohamy AT, MD; Ahmed hatem, MD.
Department of General Surgery, Minia Faculty of Medicine
ABSTRACT:
Background: To evaluate the safety and efficacy of treating low-lying rectal cancer with
resection and primary repair using a pull-through technique with rectal stump eversion
and external coloanal anastomosis with immediate reintroduction into the pelvis.
Methods: All patients undergoing the above technique in the Department of General
Surgery, Minia University Hospitals, between November 2005 and November 2007 were
included.
Results: Twenty two patients underwent coloanal anastomoses with the above technique,
and follow- up was done for all patients. Mean follow-up period was 12.6+4.7 months
(range 1 to 20). Fecal continence was normal or good in 68% (15 of 22) of patients.
Moderate or complete incontinence was present in 14% (3 of 22) of patients. The local
recurrence rate of rectal cancer was 0%. Morbidity occurred in 23% (5 of 22) of patients.
Survival was 86% (19 of 22 patients).
Conclusion: Coloanal anastomosis with this technique provides effective treatment for
low-lying malignant rectal lesions and has an acceptable complication rate.
KEY WORDS:
Rectal lesions
Colorectal cancer
Colonic anastomosis
resection margin, thereby increasing the
application
for
using
coloanal
anastomosis 3,4,5. Cloanal anastomosis is
an appropriate technique for resection of
low-lying rectal lesions (mid and lower
thirds). This technique is reported to be
adequate for the treatment of malignant
lesions
when
compared
with
abdominoperineal resection with the
added benefit of preserving sphincteric
function 6. Several techniques of
coloanal anastomosis have been
described with different functional
results 7. The present study describes a
series of 22 patients who had resection
of low rectal cancer and coloanal
INTRODUCTION:
The incidence of colorectal
cancer has increased 200% from the
1980s to the year 2000 in Korea 1.
Anterior resection, popularized by Dixon
in the 1940s, was the first operation to
allow patients with rectal cancer to avoid
a definitive stoma. While initially
performed only in patients with tumors
of the upper third of the rectum, the
coloanal anastomosis extended the
possibility of sphincter preservation even
to patients with very low rectal cancers 2.
Several groups have attempted partial
excision of the upper part of the internal
sphincter muscle to achieve a tumor-free
121
EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
anastomosis using the technique of rectal
stump eversion, pull-through, and
immediate
introduction
of
this
anastomosis into the pelvis. This
technique was originally described by
Maunsell in 1892 8 and modified by
Weir in 1901 9. The main outcome
measure was the functional results of
this sphincter-preserving technique. The
type of procedure for restoration of
bowel continuity is defined by the
anatomical site of anastomosis rather
than the position of the cancer. The term
“high” anterior resection refers to a
colorectal anastomosis performed at the
level of between the sacral promontory
and the anterior peritoneal reflection.
The level of the anastomosis is normally
measured to be about 8 to 16 cm from
the anal verge. The term “low” anterior
resection refers to a colorectal
anastomosis performed at the level distal
to the anterior peritoneal reflection and
proximal to the anorectal junction. This
is normally measured to be about 5 to 8
cm above the anal verge. The term
“ultra-low” or “extended” anterior
resection refers to a colorectal or more
usually, a coloanal anastomosis at the
level of the anorectal junction 10.
Abu bakr et al
The following variables were
included for analysis: diagnosis, stage of
the lesion, adjuvant therapy, distance of
the lesion and of the anastomosis to the
dentate line, use of a covering stoma,
follow-up period, local recurrence,
sphincteric function, mortality, and
associated morbidity (ie, pelvic abscess,
fistulae, stenosis of the anastomosis,
urinary retention). Sphincteric function
was graded according to the following
classification: Normal continence was
defined as no postoperative changes in
continence in the face of normal
previous function; mild incontinence
indicated minor sporadic episodes of
incontinence without interference with
normal activity; moderate incontinence
indicated
frequent
episodes
of
incontinence causing an important
interference with normal activity; and
complete incontinence was loss of
control of sphincteric function.
Technique:
The abdominal phase begins with
careful dissection of the rectosigmoid
colon and wide mobilization of the
splenic flexure to obtain a tension-free
coloanal anastomosis. A good distal
dissection provides increased mobilezation to the rectal stump. The resection
margins are identified and marked with
stay sutures. The affected segment is
resected between clamps. The rectal
stump is thoroughly irrigated with
distilled water or iodine solution. The
proximal stump is closed with a heavy
tie or umbilical tape. The stay sutures in
the distal rectal stump are then
introduced into the lumen of the open
rectum and pulled through the anus until
the stump is completely everted. The
mobilized left colon is lowered into the
PATIENTS AND METHODS:
The study group included
patients who underwent resection of
low-lying rectal lesions and coloanal
anastomosis using the technique of rectal
stump eversion, pull-through, and
immediate
introduction
of
this
anastomosis into the pelvis. All patients
undergoing this procedure between
November 2005 and November 2007 in
the Department of General Surgery, ElMinia University Hospitals, were
included.
122
EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
Abu bakr et al
Figure (1) external coloanal anastomosis
pelvis and pulled through the everted
rectal stump, being careful to avoid any
rotation of the proximal colon.
Additional colonic resection at the
desired level can then be achieved.
Coloanal anastomosis is constructed
using 2 layers of interrupted 3-0 vicryl
suture fig (1).
the everted rectum and the anastomosis
completed.
RESULTS:
During a 2-year period 22
patients underwent resection of low
rectal cancer and reconstruction with this
technique. Twenty two patients were
included in the study (14 males, 8
females). Mean age was 61.1+12.3 years
(range 35 to 83). Distribution by cancer
stage in the 22 patients was as follows:
stage I, 8 patients (36%); stage II, 3
patients (14%); stage III, 7 patients
(32%); and stage IV, 4 patients (18%).
Hospital stay was 10.4+2.7 days.
Average follow-up period was 12.6+4.7
months (range 1 to 20). Postoperative
degree of fecal continence in the 22
patients was determined by sequential
follow-up evaluation and was as follows:
15 (68%) normal continence, 4 (18%)
mild incontinence, 2 (9%) moderate
incontinence, and 1 (4.5%) complete
After completing the anastomosis
the stay sutures are freed, and the rectum
is placed back into the pelvis. In all the
malignant cases, the intraperitoneal
resection was completed using a total
mesorectal excision. The abdominal
phase ends upon suturing the peritoneum
of the mesentery to the pelvic wall to
seal the pelvis off from the peritoneal
cavity. When a tumor is located very low
in the rectum, the distal stump can be
everted together with the mass, and the
mass resected under direct visualization.
After resection, the previously tied
proximal stump is brought down through
123
EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
incontinence.
The
frequency
of
defecation (bowel movements per day)
at the end of the follow-up period was
less than 1 per day in 3 patients (14%), 1
to 3 per day in 9 patients (41%), 4 to 5
per day in 7 patients (32%), and more
than 5 episodes per day in 3 patients
(14%).
Eight
patients
received
preoperative (n 2) or postoperative (n 6)
adjuvant treatment. Four patients with
cancer stages III (n 3) and IV (n 1)
received preoperative chemotherapy and
radiotherapy. Four other patients
Abu bakr et al
received postoperative adjuvant therapy
as follows: stages II (n 1), III (n 2), and
IV (n 1). Two of these 4 patients
developed mild incontinence (n 1) or an
anastomotic stricture (n 1). There was
not an increased incidence of
incontinence in patients receiving
preoperative chemotherapy and radiotherapy compared with the whole group
of patients. Diagnosis and distance of the
lesion to the dentate line are shown in
Table I.
Table (I): Distance of lesion to dentate line
Distance of lesion to dentate line (cm)
2-4
4-6
6-8
8-10
12-14
14-16
Total
Number of patients
6
10
3
1
1
1
22
One patient had a rectal cancer
within 2 cm of the dentate line. The
lesion measured 1 cm in its major
diameter (T1N0Mx) with a margin free
of disease. One patient had a
rectovaginal fistula, and closed spontaneously upon follow up. Ostomies were
not considered in any patient. Morbidity
occurred in 5 (23%) of 22 patients:
rectovaginal in 1 patient (4.5%), pelvic
abscess in 1 patient (4.5%), anastomotic
fistula in 1 patients (4.5%), stenosis at
the level of the anastomosis in 1 patient
(4.5%) and urinary retention in 1 patients
(4.5%). The patient presented with
stenosis of the coloanal anastomosis
underwent dilatation under local
anesthesia. The patient presented with
anastomotic fistulae was treated
conservatively with complete resolusion
after 2 weeks. The patient with a pelvic
abscess presented with fever and
diarrhea 2 weeks postoperatively. An
abscess was detected by computed
tomography scan and drained through
the
anastomosis,
with
complete
resolution. Urinary retention occurred in
one patient, and both complications
resolved after 1 month. In all cases, the
distal margin was greater than 2 cm.
There was no difference in the distance
from the anastomosis to the dentate line
between patients with normal and
abnormal continence. In one patient with
complete incontinence, rectal manometry was obtained. He had low rectal
pressure before surgery that decreased
postoperatively. At the end of the
follow-up period, 3 patients had died
with the diagnosis of cancer and distant
124
EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
metastasis, but without local recurrence
and with normal continence.
Abu bakr et al
transanal anastomosis with a rectal
pouch was used 16. A defecatory
frequency of 1 to 3 per day occurred in
41% (n 9) of study patients. An
additional 32% (n 7) of patients had 4 to
5 bowel movements per day. A decrease
in the defecatory frequency was
observed with time, more evident after
the first year. This decrease could be due
to the progressive distention of the distal
colon forming a pouch. The high
defecatory frequency observed in some
patients has encouraged some surgeons
to construct a rectal pouch when doing a
coloanal anastomosis 17. Cancer stage
did not affect the decision to perform a
low resection preserving the sphincter,
provided that local control of the disease
with an adequate distal margin of
resection (at least 2 cm) could be
obtained11. The majority of patients with
rectal carcinoma were referred for
possible abdominoperineal resection
(APR). Sixteen (73%) of these patients
had lesions within 6 cm of the dentate
line. A careful evaluation during the
operation indicated that a conservative
procedure was appropriate. In cases of
tumor invading adjacent organs/ pelvic
wall and in cases with annular
infiltrative growth, it is difficult to obtain
an adequate distal margin with
conservative treatment, and APR is the
procedure of choice 16. In 2 male patients
the tumor was located at 12 and 16 cm
from the dentate line (Table II).
DISCUSSION:
Many surgical techniques have
been developed attempting to obtain
good functional results with low
morbidity and adequate control of
malignant rectal disease 11. Coloanal
anastomosis as a two-stage procedure12,
use of a covering stoma 13, use of
different rectal pouches14 transanal
anastomosis13, and rectal stump eversion
with immediate reintroduction of the
anastomosis into the pelvis 15 as in this
study are various options. Although
rectal stump eversion is a standard
technique that has been widely used in
ileoanal and coloanal procedures,
outcome studies with analysis of
functional results are few. The safety of
the technique used in this study for the
treatment of malignant rectal lesions has
been reported 6. Concerns exist about
injury from eversion of the distal stump
to the nerve supply of the sphincter
leading
to
postoperative
fecal
incontinence.
Normal
or
good
continence (no interference with normal
activity) was present in 68% of study
patients, indicating that they also had
normal or near-normal sphincteric
function. This incidence compares
favorably with the results obtained by
Cohen et al who found adequate
continence in 78% of their patients when
Table (II): Distance of the anastomosis to the dentate line in patients
Distance (cm)
0
1-2
2-4
4-6
Patient number %
4 (18%)
8 (36%)
7 (32%)
3 (14%)
125
EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
A coloanal anastomosis was
chosen because the presence of a narrow
pelvis and the distal margin requirement
produced a short rectal stump and a
potentially difficult anterior APR
anastomosis 15. No cases of recurrent
local cancer occurred during the period
of follow-up. Adjuvant therapy was
administered as needed 18, and its
preoperative use did not interfere with
the decision to preserve the sphincter. In
these patients with rectal cancer, 50% (n
11) had stage III or IV disease. At the
end of the follow-up period, 3 patients
had died from cancer although none of
them had local recurrence, and adequate
sphincteric function was postoperatively
preserved. Mean hospital stay was
10.4+2.7 days. This hospitalization
compares favorably with that in studies
having similar group of patients in
whom a covering stoma was used and
who had a hospital stay of 24.5 17 and
19.6 days6 including the time required to
close the stoma. A covering stoma was
not used in this study although it was
recommended by others14,19 given the
low risk of leaks to the peritoneal cavity
by such a low pelvic anastomosis. In the
few cases where an anastomotic leak
was detected (n 3, 14%), it presented
with local signs and without symptoms
of peritonitis or rectal stump necrosis (1
pelvic abscess, 1 rectovaginal fistulae, 1
anastomotic fistula). Cutait et al report a
suture leak rate of 31.9% even with the
use of a covering stoma20. One patient
with a pelvic abscess underwent
transanal drainage through the anastomotic line. Based on our results, it is
difficult to recommend the routine use of
a covering stoma as part of this
procedure. Stenosis of the anastomosis
was seen in 1 patient (4.5%). This seems
to be related to the level of the
anastomosis since Cohen et al.,16 report a
Abu bakr et al
stenosis incidence of 25% when
constructing a transanal anastomosis,
and Marcello et al report an 8.7%
incidence for ileoanal anastomosis. In a
patient with a low-lying rectal lesion that
must be resected, the chosen surgical
procedure must offer the best curative
potential with the lowest morbidity.
Often, radical procedures do not result in
increased survival, while having a
significant associated morbidity and
mortality. Williams and Johnston and
others have compared quality of life in 2
groups of patients with rectal carcinoma
located 5–10 cm from the anal verge
treated with either APR or low anterior
resection (LAR) and reported a 25%
incontinence rate in patients treated with
the more conservative LAR as opposed
to 100% incontinence expected with
APR. Eighty-three percent of these
patients returned to normal activity
compared with 40% of those who
underwent APR 21,22. Four of our study
patients had stage IV disease and
underwent the pull-through procedure.
Although an APR may have been as safe
and effective for some of these patients,
particularly the patient in whom a fistula
occurred, 3 of these 4 patients had
normal
postoperative
sphincteric
function and avoided a colostomy and a
perineal wound. Furthermore, all
patients died of distal disease without
local recurrence. The rectovaginal fistula
developed in a patient closed
spontaneously upon follow up. Patients
with low rectal lesions who require
surgery must be carefully evaluated to
preserve sphincteric function when
possible and to avoid an APR if similar
control of the disease can be obtained
with less invasive procedures. In
conclusion, coloanal anastomosis with
rectal stump eversion produces good
functional results and has an acceptable
126
EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008
complication rate. Routine use of a
covering stoma does not seem to be
indicated. When functional results
obtained with this technique are
compared with other procedures, results
do not suggest that the cause of
sphincteric dysfunction is rectal stump
eversion. The incidence of this
complication in techniques where the
rectal stump is not everted 6,19 is similar
to the incidence in this study. Careful
pelvic dissection may be more important
in avoiding sphincteric dysfunction. In
addition, eversion of the rectal stump
may facilitate construction of the
coloanal anastomosis.
Abu bakr et al
very low rectal cancer. Surg Today
2002; 32: 315-321.
6. Parks AG, Percy JP: Resection
and sutured coloanal anastomosis for
rectal carcinoma. Br J Surg. 1982;
69:301–304.
7. Marcello PW, Roberts PL,
Schoetz DJ: Long-term results of the
ileoanal pouch procedure. Arch Surg.
1993; 128:500 –504.
8. Maunsell HW: A new method
of excising the two upper portions of the
rectum and the lower segment of the
sigmoid flexure of the colon. Lancet.
1892; 473– 476.
9. Weir RF: An improved method
of treating high-seated cancers of the
rectum. JAMA. 1901; 37:801– 803.
10. Yik-Hong Ho: Techniques for
restoring bowel continuity and function
after rectal cancer surgery. World J
Gastroenterol 2006; 12(39): 6252-6260.
11. Williams NS, Dixon MF,
Johnston D: Reappraisal of the 5centimeter rule of distal excision for
carcinoma of the rectum: a study of
distal intramural spread and of patient’s
survival. Br J Surg. 1983; 70:150-54.
12. Paty PB, Enker WE, Cohen
AM: Treatment of rectal cancer by low
anterior
resection
with
coloanal
anastomosis. Ann Surg. 1994; 219:365–
373.
13. Castrini G, Pappalardo G,
Mobarhan S: A new technique for
ileoanal and coloanal anastomosis.
Surgery. 1985; 97:111–116.
14. Melville DM, Ritchie JK,
Nicholls RJ, Hawley PR: Surgery for
ulcerative colitis in the era of the pouch:
St. Mark’s hospital experience. Gut.
1994; 35:1076 –1080.
15. Schraut
WH:
Sphincterpreserving colorectal resections. In:
Reconstructive
Surgery
of
the
REFERENCES:
1. Shin HR, Jung KW, Won YJ,
Park JG: 2002 Annual report of the
Korea Central Cancer Registry: Based
on registered data from 139 Hospitals.
Cancer Res Treat 2004; 36: 103-114
2. McNamara DA, Parc R:
Methods and Results of SphincterPreserving Surgery for Rectal Cancer.
Cancer Control 2003; 10, 3.
3. Rullier E, Zerbib F, Laurent C,
Bonnel C, Caudry M, Saric J, Parneix
M: Intersphincteric resection with
excision of internal anal sphincter for
conservative treatment of very low rectal
cancer. Dis Colon Rectum 1999; 42:
1168-1175.
4. Willis S, Kasperk R, Braun J,
Schumpelick V: Comparison of colonic
J-pouch reconstruction and straight
coloanal anastomosis after intersphincteric rectal resection. Langenbeck Arch
Surg 2001; 386: 193-199.
5. Takase Y, Oya M, Komatsu J:
Clinical and functional comparison
between stapled colonic J-pouch low
rectal anastomosis
and
hand-sewn
colonic J-pouch anal anastomosis for
127
‫‪Abu bakr et al‬‬
‫‪EL-MINIA MED., BULL., VOL. 19, NO. 1, JAN., 2008‬‬
‫‪Gastrointestinal‬‬
‫‪Tract.‬‬
‫‪Bodmin,‬‬
‫‪Cornwall: Butterworth; 1985; 167–210.‬‬
‫‪16. Cohen AM, Enker WE, Minsky‬‬
‫‪BD:‬‬
‫‪Proctectomy‬‬
‫‪and‬‬
‫‪coloanal‬‬
‫‪reconstruction for rectal cancer. Dis‬‬
‫‪Colon Rectum. 1990; 33:40–43.‬‬
‫‪17. Berger A, Tiret E, Parc R:‬‬
‫‪Excision of the rectum with colonic J‬‬
‫‪pouch-anal anastomosis for adenocar‬‬‫‪cinoma of the low and mid rectum.‬‬
‫‪World J Surg. 1992; 16:470–477‬‬
‫‪18. Adjuvant therapy for patients‬‬
‫‪with colon and rectal cancer: NIH‬‬
‫;‪consensus conference. JAMA. 1990‬‬
‫‪264:1444 –1450.‬‬
‫‪19. Kirwan WO, Turnbull RB,‬‬
‫‪Fazio VW, Weakly FL: Pullthrough‬‬
‫‪operation with delayed anastomosis for‬‬
‫–‪rectal cancer. Br J Surg. 1978; 65:695‬‬
‫‪689.‬‬
‫‪20. Cutait DE, Cutait R, Ioshimoto‬‬
‫‪M: Abdominoperineal endoanal pull‬‬‫‪through resection. Dis Colon Rectum.‬‬
‫‪1985; 28:294– 299.‬‬
‫‪21. Williams NS, Johnston D: The‬‬
‫‪quality of life after rectal excision for‬‬
‫;‪low rectal cancer. Br J Surg. 1983‬‬
‫‪70:460–462.‬‬
‫‪22. DeSilva HJ, DeAngelis CP,‬‬
‫‪Soper N: Clinical and functional‬‬
‫‪outcome after restorative proctocol‬‬‫‪ectomy. Br J Surg. 1991; 78:1039 –1044.‬‬
‫دراسة تحليلة لنتائج التوصيل القولوني الشرجى الخارجى فى حاالت‬
‫االورام الخبيثة القريبة من نهاية المستقيم‬
‫ابو بكر محي الدين ‪ ,‬تهامى عبدهللا تهامى ‪ ,‬احمد حاتم‬
‫قسم الجراحة العامة ‪ ,‬كلية الطب جامعة المنيا‬
‫تهددددده لددددد ه ددددد تقدددددما وكدددددمع لجةم ددددد ك م ددددد الل ا خبمثددددد ق مبددددد كدددددع‬
‫دددددد‬
‫كددددددع خدددددد ع ت دددددد‬
‫نهممدددددد ك ددددددتقما بمال ت صددددددمع ل ددددددت كمع تصدددددد مت خددددددم‬
‫بدددددمع قل دددددلع ل ددددد ‪ ,‬ل ددددد ب ددددد و قل دددددلع خم مدددددم‬
‫وعدددددمهو تلصدددددمع ( تةدددددم‬
‫كمدددددر ك دددددد لعدددددههلا‬
‫دددددل‬
‫ثدددددا وعدددددمهو ةل مددددد ددددد‬
‫ثدددددا تلصدددددم ث بم ددددد‬
‫دددددد مكدددددد دددددد ج مدددددد عددددددو مك دددددد كنمددددددم دددددد ةتدددددد و كددددددع‬
‫‪ 22‬هخ ددددددل ج ددددددا‬
‫دددددددمبق تا دددددد ع كتمب ددددددد‬
‫مددددددا هدددددددا ك مدددددد‬
‫نددددددل كب ‪ 2005‬دددددد ندددددددل كب ‪2007‬‬
‫كمدددددددددر ك دددددددددد جدددددددددمع كتل دددددددددع تددددددددد و كتمب ددددددددد ‪ 12,6+7,4‬ددددددددده ( ‪20 -1‬‬
‫لجددددمع كددددع نتددددم ا لدددد ب دددد ع ددددت جا دددد عك مدددد بدددد ع جددددمع عبم مددددم دددد عددددهه ‪15‬‬
‫بدددددد ع دددددد عددددددهه ‪ %18( 4‬كددددددع‬
‫(‪ %68‬كدددددد م ‪ ,‬ه دددددد ب ددددددمع كددددددع دددددد‬
‫بدددددد ع ددددد عددددددهه ‪ %9( 2‬كدددددع ك ددددددد ‪,‬‬
‫ك دددددد ‪ ,‬ه دددددد كتل دددددع كددددددع ددددد‬
‫دددددد بدددددد ع ج دددددد دددددد كدددددد م ل دددددده(‪ %4,5‬لل دددددده مدددددددم ع ن ددددددب تجدددددد‬
‫ك ي ل ا خبمث صة‬
‫بددددددمع قل ددددددلع ل‬
‫ن ددددددتخ تذ كددددددع لدددددد ه دددددد ع عددددددمهو تلصددددددمع خددددددم‬
‫الل ا‬
‫م تبددددد ع مقددددد كنددددد ل ا جةم ددددد ددددد عددددد‬
‫ددددد‬
‫ددددد كدددددع خددددد ع ت ددددد‬
‫ل ج مو كع نهمم ك تقما‬
‫خبمث ت تقر‬
‫‪128‬‬