2. • Treatment of rectal cancer has evolved over last two
decades.
• Newer techniques such as transanal total mesorectal
excision are gaining popularity among surgeons.
• Quality of life outcomes are as important as
recurrence free survival.
3. • J pouch:
• Introduced in 1986 by Lazorthes and Parc et
al.
• Optimum size of pouch has been determined
as 5 -9 cm.
4. • In 2007, it was reported that J pouch was
superior to a straight anastomosis in terms of
quality of life and bowel function.
• Disadvantage:unable to be utilised in a narrow
pelvis or bulky mesentry due to placement in
pelvis
• Difficulty in evacuation
5. • Side to end anastomosis:
• Became popular in last decade
• Baker anastomosis
• Had ease of placement in narrow pelvis.
• Has no formal pouch , 1 staple line and
anastomosis.
• optimum length :3 cm with a better outcome
6. Aim
• Hypothesis: that quality of life and functional
outcome after JP and SE are similar.
• Aim:
To Compare the QOL , bowel and sexual function in
patients who received JP or SE for a low rectal
cancer in the setting of a multicenter randomized
control trial.
7. Methods
• Multicentre, prospective, randomised control trial.
• Men and women:18- 80 years with non metastatic low
rectal cancer.
• Exclusion:
metastatic disease
radiation to pelvis
history of metachronous/synchronous
cancer
history of rt colectomy, inflammatory bowel
disease
8. • Technique
• JP was created by making a colotomy in distal
descending colon where the curved portion of J
was situated and a linear stapler was inserted and
fired to make the pouch of 5 to 8 cm in length.
• Open arm of pouch was stapled
• A purse string suture was placed around
colotomy at curved portion of J and anastomosis
with circular stapler was carried on.
9. • Side to end anastomosis
• Done using distal end of descending colonfor
colo rectal anastomosis situated 3-5 cm the
open end.
• Open end of SE was stapled.
• Colotomy was made at anti-mesentric border .
• Anastomosis was either stapled or hand sewn.
• All patients underwent loop ileostomy .
12. • Both the groups matched in age, BMI.
• No difference in operating time in either group.
• Majority of anastomosis were stapled in both the
groups.72% in JP and 76% in SE.
• Estimated blood loss was similar in both groups.260
ml
• Quality of life was similar in both the groups. Post-op
at 6,12,24 months when measured there was no
change in scores.
13. • Intra-operative complications: 4
J Pouch Side To end
anastomosis
Incomplete doughnuts 1 0
Ureteric injury 0 1
Splenic injury 1 1
14.
15. • Bowel function:
• FISI score was used to define bowel function.
• Pre-operatively FISI was similar in both
groups.
• At 6 months , almost doubled in SE group.
• At 12 months, both groups had slight
improvement.
16.
17. Discussion
• This study had low complication rate and
quality of life was similar in both groups.
• Bowel function was affected equally in short
term and gradually improved.
• Both JP and SE can have anastomotic
complications.
• In literature, SE have reported to have lesser
chance of anastomotic stricture
18. Leak rate
• This study had leak rate of 2.5% in JP and 1.1%
in SE group.
• Machado et al reported a leak rate of8% in JP
and 10% in SE .
• Brisinda et al leak rate of 16.8%, which was
much higher in the SA group 29.2% versus 5%
in the SE group
• TME resulted in a higher leak rate than a
partial mesorectal excision.
19. • Stoma closure is delayed when patients
undergo chemotherapy.
• Okkabaz et al in a randomized controlled trial
reported that :
–A delayed stoma closure due to
chemotherapy in this study occurred in
about 24% and was due to complications in
7%
20. Bowel dysfunction
• Bowel dysfunction contributes to poor QOL
after surgery for low rectal cancer.
• Low rectal cancers have been associated with
agreater prevalence of bowel dysfunction
especially if associated with radiotherapy.
• Other factors that have been reported to
influence bowel dysfunction are
– preservation of the pelvic nerves
– choosing a partial mesorectal excision over a TME
21. Other factors
• Many of the negative factors associated with
bowel dysfunction are termed ‘‘low anterior
resection syndrome.’’
• The most common symptom that impacts
patients is clustering.
• In addition fecal incontinence and urgency
have also been shown to negatively impact
QOL
22. • A meta-analysis has reported that a
neoreservoir such as the JP, SE, or coloplasty
pouch has a better outcome regarding bowel
dysfunction than a SA.
• The JP however has been shown to be have
better bowel function when compared with a
coloplasty pouch or a straight colo-anal
anastomosis in trials.
23. Sexual dysfuncytion
• No studies have reported superior sexual
function.
• Sexualfunction after rectal cancer sphincter-
saving surgery is dependent onnerve injury after
a pelvic dissection and preoperative radiation.
• Poor sexual outcomes have been reported in
long-term survivors who havea stoma.
• However, with recent technical advances, the
TATME approach appears to have better
outcomes regarding erectile dysfunction than a
straight laparoscopic approach.
24. • In this study, prospective evaluation of sexual
outcomes found decreased scores from
baseline over time but similar at all time-
points in men.
• In contrast, women reported improved sexual
function compared with baseline.
25. JP vs SE
• SE may have more appeal, as it is easier to
construct and perform the anastomosis
• It may also be easier to place the SE in a
narrow pelvis or particularly in patients who
have a bulky mesocolon.
• This study does not give a clear picture to
answer this question.
26. CONCLUSION
• This study has demonstrated similar results
when comparing complications, physical,
emotional, bowel, and sexual function related
to QOL between the JP and SE .
• There still exists a theoretical possibility that
the SE may be easier to construct and fit
easier into a narrow pelvis
• Hence,surgeons may consider using the SE
due to itsease of construction.
27. Strenghts
• It is a Multi-centric randomized controlled
trial
• Conducted on patients it diverse genetic
variability.
• Data were systematically and extensively
collected including functional outcome
assessment at multiple time points
•
28. Limitations
• Failure to randomize even in the SE group,
especially when threshold to convert to a SA
may be low.
• Follow-up period in this study was 2 years
instead of standard 5 years period.
• Varying Chemotherapy and Radiotherapy
protocols due to multi-centric nature of the
trial.
