The document discusses various reconstruction methods after low anterior resection (LAR) for rectal cancer, comparing techniques such as straight coloanal anastomosis, colonic J-pouch, and transverse coloplasty. It highlights the advantages of colonic J-pouch in terms of bowel function and reduced anastomotic leakage, particularly in the first few months post-operation, while encouraging further research on alternatives like transverse coloplasty and side-to-end anastomosis. Recommendations suggest that colonic J-pouch should be preferred due to better clinical outcomes, although more comprehensive studies are needed for other techniques.

1. Methods of Reconstruction after
Low Anterior Resection
Dr. Dhaval O. Mangukiya

2. GOAL of LAR
• Cure Disease locally
• Minimize the risk regarding sphincter loss
– Tumor Size
– Differentiation
– Location
• Preserve Bladder, Bowel and Sexual
dysfunction (Avoid nerve Injury)

3. • Tumor on posterior wall moves up 2-3 cm with
mobilsation
• Risk Factors for sphincter
– Male gender
– Low anterior tumor
– Previous pelvic surgery
– Poorly differentiated tumor
– Diverticulosis or Previous Left colectomy
– Poor resting and squeezing anal pressure

4. Margins
• Distal Mural Margin
– 2 cm without h/o preop chemoradiation
– 1 cm if responded to neoadjuvant treatment
• Mesorectal Margin
– 5 cm distal to the edge of the tumor (TME)
• Lateral Margin
– Depend upon the extent of involvement

6. Reconsrtuction
• Colon Mobilization
– Lifting of left colon from Gerota
– Ligation of IMV at the origin
– Division of transverse mesocolon from pancreas
• Divide ligament of Treitz if compressed by
mobilized colon or mesocolon after
reconstruction

8. Straight Colorectal/Anal Anastomosis
• Double Stapled Technique
• Hand sewn Technique

11. End to Side Colorectal Anastomosis
• Double stapled Technique
• Hand Sewn

13. Stapler Vs Hand Sewn
• 1 cm or more rectal wall remaining above
levator ani after having min 2 cm distal margin
• For less margin hand sewn if difficult to allow
stapler

14. Intersphincteric
Resection

15. Colonic J Pouch Anastomosis
• Hand Sewn
• Circular stapler

18. • Double Staple Technique

19. Transverse Coloplasty

21. End to side ColoAnal Anastomosis
• Double Stapled
– 7 cm distal limb from the site of anastomosis
• Hand Sewn

23. • Meta-analysis of colonic reservoirs versus
straight coloanal anastomosis after anterior
resection
• Heriot A G, Tekkis P P, Constantinides V, Paraskevas P, Nicholls RJ, Darzi A,
Fazio V W
• British Journal of Surgery, 2006;93;19-32

24. • Thirty-five studies (n=2,240) were included: 14
RCTs (n=789), 13 prospective CCTs (n=797)
and 8 retrospective studies (n=654).

25. J-pouch versus CAA (31 studies,
n=1,976)
• J-pouch was associated with a reduction in anastomotic leak
compared with CAA ,but the reduction was not statistically
significant
• No statistically significant differences between J-pouch and CAA for
any of the other adverse post-operative events.
• J-pouch was associated with a significant reduction in the frequency
of defaecation at 6 months
• The reduction was less but remained statistically significant at 1
year (WMD -1.35, 95% CI: -1.92, -0.78, p<0.001) and 2 or more
years (WMD -0.74, 95% CI: -1.31, -0.18, p=0.010).
• J-pouch was associated with a significant reduction in faecal
urgency at 6 months compared with CAA and at 1 year but there
was no significant difference between treatments at 2 or more
years

27. Randomized Comparison of Straight and Colonic J
Pouch Anastomosis After Low Anterior Resection
ANNALS OF SURGERY, 1996;Vol. 224, No. 1, 58-65
Olof Hallbook et al.
Method
One hundred patients with rectal cancer in whom a sphincter-saving
procedure was appropriate were randomized to reconstruction with either
a straight or a colonic J pouch anastomosis.
Conclusion
Reconstruction with a colonic J pouch was associated with a lower
incidence of anastomotic leakage and better clinical bowel function when
compared with the traditional straight anastomosis. Functional superiority
was especially evident during the first 2 months.

29. Similar outcome after colonic pouch and side-to-end
anastomosis in low anterior resection for rectal
cancer: randomized trial
Ann Surg 2003; 238: 214-220
Machado M, Nygren J, Goldman S, Ljungqvist O
Conclusion:
There were no significant differences in operative or
postoperative clinical outcomes in this trial that
included 100 procedures. The ability to evacuate the
bowel within 15 min was significantly better after six
months in the pouch group.

30. Reconstructive Techniques After Rectal
Resection for Rectal Cancer
Carl J Brown1,*, Darlene Fenech2, Robin S
McLeod3
Cochrane Colorectal Cancer Group
DOI: 10.1002/14651858.CD006040.pub2

31. Types of interventions
Randomization to one of at least two of the following coloanal
anastomosis techniques defined as:
1) Straight Coloanal Anastomosis (SCA)- The end of the colon is
anastomosed directly to distal rectum/anus after rectal
resection.
2) Side-to-End Anastomosis (STE) - This is a variation of the
straight coloanal anastomosis in which the anastomosis is
performed on the antimesenteric aspect of the colon just
proximal to the distal staple line.
3) Colonic J pouch (CJP)- A pouch of 5-8cm in size is created in
accordance with description by Lazorthes et al.
4) Transverse Coloplasty (TC) - A longitudinal colotomy is created
approximately 8cm in length and 3-4 cm proximal to distal end
of the colon. This colotomy is then closed transversely, and the
distal end of the colon is anastomosed to the anal complex.

32. Objectives
• Primary objective:
Best functional outcome
• Secondary objective:
To compare techniques in terms of
complications

33. Types of outcome measures
• Primary Outcome
Bowel function was defined by the following outcome measures:
1) Number of bowel movements per day.
2) Urgency, defined as the inability to defer defecation.
3) Fecal Incontinence, as measured by an appropriate fecal incontinence
measurement tool.
4) Incomplete evacuation, defined by the sensation of residual stool after
defecation.
5) Anti-diarrheal medication use, defined as continued dependence on
constipating medications.
• These outcomes were also defined by the time after gastrointestinal (GI)
continuity is restored that they are recorded. Thus, they are reported
under the following three time frames:
1) Early Outcomes: <8 months after GI continuity restored
2) Intermediate Outcomes: 8 to 18 months after GI continuity restored
3) Late Outcomes: >18 months after GI continuity restore

34. Secondary Outcomes
The following complications of the operation
were recorded:
1) Perioperative mortality, defined as death
within 30 days of surgery.
2) Anastomotic leak (subclassifications include
clinical and radiologic)
3) Wound infection
4) Chest infection or Pneumonia

35. DATA COLLECTION
• 16 trials included in this review
– Nine RCTs comparing SCA with CJP
– Four RCTs comparing STE with CJP
– three trials comparing CJP to TCP
• Seven trials were excluded
– Non randomized trials(2)
– Did not report bowel function results (3)
– Clearly overlapped results with already published research (2)
• There were no trials identified that compared all three
reconstructive techniques, nor were there any trials that directly
compared SCA, STE or TCP with one another.

36. Implications for practice
• Colonic J pouch leads to better bowel function
and similar rates of postoperative complications
compared to the straight coloanal anastomosis.
• Persist up to 2 years after gastrointestinal
continuity is reestablished, and thereafter similar
between the two procedures.
• Thus, the colonic J pouch should be the
procedure of choice after proctectomy for rectal
cancer.

37. • Limited literature comparing the transverse
coloplasty procedure to the colonic J pouch,
• Three small randomized trials suggest that
bowel function is similar in patients
reconstructed with either procedure
• Some evidence that the transverse coloplasty
procedure results in more anastomotic
dehiscences
Implications for practice

38. • The side-to-end anastomosis has similar
functional outcomes in three small
randomized trials.
• Further study is necessary before this
technique can be recommended.
• In patients whose anatomy is not amenable to
colonic J pouch reconstruction, the side-to-
end anastomotic technique should be
considered.
Implications for practice

39. Implications for research
• Further evaluation of the transverse coloplasty
and side-to-end anastomotic strategies as
alternatives to the colonic J pouch.
• Standard definitions of frequently used bowel
function outcomes should be established to
facilitate comparisons of anastomotic and
other bowel function interventions between
studies.

40. THANK YOU