Omaya A H Nassar1. 1. Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt. Omaya_nassar@hotmail.com
Abstract
BACKGROUND: Innovative techniques created to restore gastrointestinal perineal continuity after abdominoperineal resection in patients with anorectal cancer include pseudocontinent perineal colostomy, in which the colon is pulled to the perineum and wrapped with a sleeve of stretched colon segment to act as a new sphincter. OBJECTIVE: We investigated perineal reconstruction with a modified pseudocontinent perineal colostomy technique. DESIGN: Prospective cohort study. SETTINGS: Tertiary care university hospital in Egypt. PATIENTS: Patients with T2 or T3 anorectal cancer invading the sphincter who underwent Miles abdominoperineal resection and immediate total pelvic reconstruction between 2003 and 2007. INTERVENTION: Reconstruction consisted of a vertical rectus abdominis myocutaneous flap with modified perineal colostomy pulled through the flap to add the high-pressure zone of the flap to that of the colostomy and to create a persistent new anorectal angle. MAIN OUTCOME MEASURES: Early and late complications were recorded. Functional results were evaluated at regular intervals by questionnaire, physical examination, and balloon manometry. Continence was graded according to Kirwan. Satisfaction with continence was assessed by questionnaire. RESULTS: A total of 14 patients (3 women) were included. Tumors were adenocarcinoma (n = 11), squamous-cell carcinoma (n = 2), and melanoma (n = 1). Complete (R0) resection was achieved in all patients without perioperative deaths, major postoperative morbidity, or conversion to permanent iliac colostomy. Early postoperative complications (perineal wound infection, flap dehiscence, and partial perineal stoma necrosis) occurred in the first 4 patients. Late complications occurred in 7 patients, with mucosal prolapse in 3, stomal stricture in 4, and tumor recurrence in 1. Fecal continence progressed consistently with time, and by the end of the first year 8 patients (57%) had complete continence (grade A), 5 (36%) were continent with minor soiling (grade C), and 1 (7%) still had major soiling (grade D). After 6 months, 9 patients (64%) were satisfied with continence; after 1 year, 13 patients (93%) were satisfied. Regular enemas were necessary during the first year to improve soiling, and 8 patients (57%) were not in need after that. At 37 months median follow-up, 8 of 9 evaluable patients (89%) were satisfied with continence (grade A) without regular enemas. LIMITATIONS: This was a preliminary observational study with no control group. CONCLUSIONS: Total orthotopic pelvic reconstruction with autologous tissue transposition to rebuild the principle anorectal continence elements is feasible with minor complications, and is oncologically safe. This new technique offered high continence satisfaction independent of regular enemas and electrical stimulation.
BACKGROUND: Innovative techniques created to restore gastrointestinal perineal continuity after abdominoperineal resection in patients with anorectal cancer include pseudocontinent perineal colostomy, in which the colon is pulled to the perineum and wrapped with a sleeve of stretched colon segment to act as a new sphincter. OBJECTIVE: We investigated perineal reconstruction with a modified pseudocontinent perineal colostomy technique. DESIGN: Prospective cohort study. SETTINGS: Tertiary care university hospital in Egypt. PATIENTS: Patients with T2 or T3 anorectal cancer invading the sphincter who underwent Miles abdominoperineal resection and immediate total pelvic reconstruction between 2003 and 2007. INTERVENTION: Reconstruction consisted of a vertical rectus abdominis myocutaneous flap with modified perineal colostomy pulled through the flap to add the high-pressure zone of the flap to that of the colostomy and to create a persistent new anorectal angle. MAIN OUTCOME MEASURES: Early and late complications were recorded. Functional results were evaluated at regular intervals by questionnaire, physical examination, and balloon manometry. Continence was graded according to Kirwan. Satisfaction with continence was assessed by questionnaire. RESULTS: A total of 14 patients (3 women) were included. Tumors were adenocarcinoma (n = 11), squamous-cell carcinoma (n = 2), and melanoma (n = 1). Complete (R0) resection was achieved in all patients without perioperative deaths, major postoperative morbidity, or conversion to permanent iliac colostomy. Early postoperative complications (perineal wound infection, flap dehiscence, and partial perineal stoma necrosis) occurred in the first 4 patients. Late complications occurred in 7 patients, with mucosal prolapse in 3, stomal stricture in 4, and tumor recurrence in 1. Fecal continence progressed consistently with time, and by the end of the first year 8 patients (57%) had complete continence (grade A), 5 (36%) were continent with minor soiling (grade C), and 1 (7%) still had major soiling (grade D). After 6 months, 9 patients (64%) were satisfied with continence; after 1 year, 13 patients (93%) were satisfied. Regular enemas were necessary during the first year to improve soiling, and 8 patients (57%) were not in need after that. At 37 months median follow-up, 8 of 9 evaluable patients (89%) were satisfied with continence (grade A) without regular enemas. LIMITATIONS: This was a preliminary observational study with no control group. CONCLUSIONS: Total orthotopic pelvic reconstruction with autologous tissue transposition to rebuild the principle anorectal continence elements is feasible with minor complications, and is oncologically safe. This new technique offered high continence satisfaction independent of regular enemas and electrical stimulation.
Authors: Christoph Isbert; Nicolas Schlegel; Joachim Reibetanz; Katica Krajinovic; Karsten Schmidt; Christoph-Thomas Germer; Mia Kim Journal: Int J Colorectal Dis Date: 2015-02-10 Impact factor: 2.571