AIM: There is some evidence of functional superiority of colonic J-pouch over straight coloanal anastomosis (CAA) in ultralow anterior resection (ULAR) or intersphincteric resection. On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with upper sphincter excision (USE: excision of the upper part of the internal sphincter) for low-lying rectal cancer, we compare functional outcome of colonic J-pouch vs the straight CAA.

METHODS: Fifty patients of one hundred and thirty-three rectal cancer patients in whom lower margin of the tumors were located between 3 and 5 cm from the anal verge received ULAR including USE from September 1998 to January 2002. Patients were randomized for reconstruction using either a straight (n = 26) or a colonic J-pouch anastomosis (n = 24) with a temporary diverting-loop ileostomy. All patients were followed-up prospectively by a standardized questionnaire [Fecal Inco-ntinence Severity Index (FISI) scores and Fecal Incontinence Quality of Life (FIQL) scales].

RESULTS: We found that, compared to straight anastomosis patients, the frequency of defecation was significantly lower in J-pouch anastomosis patients for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in straight patients at both 3 and 12 mo after ileostomy takedown. Furthermore, we found that FISI scores highly correlated with FIQL scales.

CONCLUSION: This study indicates that colonic J-pouch anal anastomosis decreases the severity of fecal incontinence and improves the quality of life for 10 mo after ileostomy takedown in patients undergoing ULAR with USE for low-lying rectal cancer.

The incidence of colorectal cancer has increased 200% from the 1980s to the year 2000 in Korea[1]. Advances in stapling technology have allowed restoration of bowel continuity after resection of low-lying rectal cancers. In some lower rectal cancers, for which the DS technique is not feasible, coloanal anastomosis (CAA) has been used to achieve bowel continuity[2]. However, efforts to preserve the sphincter muscle may compromise the application of a classical CAA. Several groups have attempted partial excision of the upper part of the internal sphincter muscle to achieve a tumor-free resection margin, thereby increasing the application for using CAA[3-6].

A further problem in resection of low-lying rectal cancers is the so-called anterior resection syndrome, which is characterized by functional problems related to defecation. To solve this problem, Lazorthes et al, and Parc et al, designed a J-shaped colonic pouch which reportedly reduced the severity of the syndrome[7,8]. As a result, the colonic J-pouch has been widely used in treatments involving anastomosis following ultralow anterior resection (ULAR) for low-lying rectal cancer.

We reported that the appropriate application of ULAR technique preserves anal sphincters in over 90% of patients with very low-lying rectal cancers, in which the lower margin located 3-5 cm from the anal verge, without increased morbidity or decreased oncologic results[9]. In our hospital, the sphincter preservation rate increased significantly over the 10 years, from 16.4% in Period I (January 1991 to February 1994), to 53.0% in Period II (March 1994 to March 1997), to 86.5% in Period III (April 1997 to December 2000), thanks to the introduction of ULAR with double stapling in March 1994 and ULAR with upper sphincter excision (USE) and CAA in April 1997.

On the assumption that colonic J-pouch anal anastomosis is superior to straight CAA in ULAR with USE, the procedure applied to Period III, we compare functional outcome of colonic J-pouch vs the straight CAA.

Fifty patients were enrolled for this study (24 J-pouch vs 26 nonpouch). Clinicopathologic findings did not differ between patients in J-pouch and nonpouch subgroups. The median follow-up period was 43 mo.

Functional outcomes

Bowel frequency The frequency of defecations was significantly lower in the J-pouch subgroup than in the nonpouch subgroup. This finding was observed for 10 mo after ileostomy takedown (Figure 1).

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Figure 1 Bowel frequency after ileostomy takedown. Probability values: 1-10 mo, P<0.05; after 11 mo, P>0.05.

FISI scores and FIQL scales Statistical analysis showed that FISI scores and FIQL scales in the J-pouch subgroup were significantly better than those in the nonpouch subgroup (Table 2). A linear regression model was used to determine the correlation between FISI scores and FIQL scales. At 3 mo after ileostomy takedown, only the FIQL scales of lifestyle and embarrassment correlated with FISI scores. However, at 12 mo, all four scales highly correlated with FISI scores (P<0.05) (Table 3).

FISI score
		Nonpouch	J-pouch	P	1-β2
3	mo	38.9	31.2	0.017	0.7677
12	mo	27.7	18.6	0.032	0.7747
FIQL scales
		Nonpouch	J-pouch	P	1-β2
3	mo	(n = 22)	(n = 21)
	Lifestyle	1.96	2.61	0.011	0.8223
	Coping	1.74	2.41	0.004	0.8961
	Depression	2.24	2.91	0.016	0.7786
	Embarrassment	2.05	2.73	0.018	0.7717
12	mo	(n = 22)	(n = 19)
	Lifestyle	2.67	3.37	0.015	0.8312
	Coping	2.59	3.18	0.040	0.7011
	Depression	2.83	3.64	0.004	0.9154
	Embarrassment	2.98	3.23	0.267	0.2663

²1-β: power calculation.

Spearman’s rho	FISI (3 mo)	FISI (12 mo)
FIQL (3 mo)
Lifestyle	-0.420a
Coping	-0.311
Depression	-0.254
Embarrassment	-0.383a
FIQL (12 mo)
Lifestyle		-0.484b
Coping		-0.413b
Depression		-0.563b
Embarrassment		-0.396a

^aP<0.05,

^bP<0.01.

The techniques of ULAR[12] and intersphincteric resection[3,6] are now more widely applied in the treatment of low-lying rectal cancer, due to safety for a distal resection margin of 1cm[13].

The distal resection margin of present study was about 0.7-0.8 cm. In general, no less than 1-cm margin was accepted. In patients with very low-lying rectal cancer, we accepted the margin of less than 10 mm by assistance of pathologic findings. If the margin was tumor-positive on frozen section, the cases underwent APR and were excluded from the present study. Four cases with tumor-positive distal margin underwent APR. We previously reported that the appropriate application of ULAR technique preserves anal sphincters in over 90% of patients with very low-lying rectal cancers, located 3-5 cm from the anal verge, without increased morbidity or decreased oncologic results[9,14].

Despite conservation of the anus, some functional problems involving frequency, urgency and incontinence are inevitable after sphincter-preserving operations for very low-lying rectal cancers[2]. These problems gradually improves over time[15], but in about 30% of patients the problems continues beyond a year[16], and these functional problems become the main issue in postoperative quality of life. Lazorthes et al, and Parc et al, reported that the defecation frequency could be reduced by using a colonic J-pouch[7,8]. A subsequent randomized study concluded that an anastomosis using a colonic J-pouch after resection for rectal cancer could reduce the frequency of defecations and laxative use[17]. The results from the present study demonstrate that a colonic J-pouch significantly reduces the defecation frequency during 10 mo after ileostomy takedown.

The effect of the colonic J-pouch on frequency disappears after a long follow-up[18]. Our results show that the difference between the two groups was no longer apparent after 10 mo. However, because most patients undergoing such procedures have cancer and many will have a limited longevity, quality of this limited life span becomes paramount for the affected patient[19].

It has been suggested that functional improvement when using the colonic J-pouch is attributable to the capacity of the neorectum. Recently, Furst et al[20], presented the alternative possibility that bowel function is improved by reduced bowel motility. One further advantage claimed for the colonic J-pouch is that it reduces anastomotic leakage[17,18,21,22]. Proposed mechanisms for this were better blood supply to the anastomosis site[23] and reduced ‘dead space’ in the pelvic cavity due to the J-pouch[24]. In contrast to these advantages, inefficient evacuation has been a concern with the colonic J-pouch. Parc et al[8], reported that 25% of patients with colonic J-pouches needed medication for evacuation. This problem appeared to be related to the size of the pouch. Hida et al[25], appeared to have solved this problem by using a smaller, 5-6 cm pouch and this size is currently recommended in general. A randomized, isotope-based study revealed improved fluid retention in small colonic pouches[26]. The size of the pouch in the present study was 5-6 cm, and although two patients did complain of defecation difficulty (1/24 pouch group, 4.2%), their symptoms were mild and relieved by medication.

In conclusions, following ULAR with USE, the frequency of defecation was significantly lower in patients with colonic J-pouch for 10 mo after ileostomy takedown. The FISI scores and FIQL scales were significantly better in J-pouch patients than in nonpouch patients. On the basis of these findings, we recommend CAA using a colonic J-pouch in patients with rectal cancer located 3-5 cm from the anal verge undergoing ULAR with USE.