A New Sutureless Rectal Pouch is described which avoids the risks and Limitations of the traditional Pouches. mainly shortening of the Colon and Bulky Mesentry.

1. Modified TeniectomyModified Teniectomy.. A New Technique forA New Technique for
Creation of Sutureless Colonic Reservoir.Creation of Sutureless Colonic Reservoir.
(Technical note)(Technical note)
ByBy
Prof. Dr. Ahmed Farag. MDProf. Dr. Ahmed Farag. MD
Professor of G. Surgery- Cairo University.Professor of G. Surgery- Cairo University.

2. IntroductionIntroduction
 Varying degree of bowel dysfunctionVarying degree of bowel dysfunction
occur after restorative surgery subsequentoccur after restorative surgery subsequent
to low anterior resection.to low anterior resection.

3.  Superior results had been reported inSuperior results had been reported in
patients offered colonic J-pouch analpatients offered colonic J-pouch anal
anastomosis as compared to straightanastomosis as compared to straight
Coloanal anastomosis.Coloanal anastomosis.

4.  Several factors have been identifiedSeveral factors have been identified
which may render Colonic J-pouch analwhich may render Colonic J-pouch anal
anastomosis difficult which led theanastomosis difficult which led the
Cleveland clinic group to use theCleveland clinic group to use the
Coloplasty technique to overcome suchColoplasty technique to overcome such
difficulties.difficulties.

5.  Despite superior results using coloplastyDespite superior results using coloplasty
technique as compared to colonic J-pouchtechnique as compared to colonic J-pouch
in construction of colonic reservoir werein construction of colonic reservoir were
reported by different authors,reported by different authors,

6.  a higher leakage rate in coloplastya higher leakage rate in coloplasty
patients was reported in a recent studypatients was reported in a recent study
as compared to leakage rate in theas compared to leakage rate in the
colonic J-pouch patients (7/44, three ofcolonic J-pouch patients (7/44, three of
them were clinically significant Vs. 0/44)them were clinically significant Vs. 0/44)
(Y.H. Ho et al. Ann Surg. 2002, 236: 49-55(Y.H. Ho et al. Ann Surg. 2002, 236: 49-55.).)

7.  Teniectomy had been used by Najafi andTeniectomy had been used by Najafi and
Beattie in order to overcome shortBeattie in order to overcome short
colonic segment which couldn’t broughtcolonic segment which couldn’t brought
up to the neck as an esophagealup to the neck as an esophageal
substitute in a case report on 1964.substitute in a case report on 1964.
 They excised the tenia coli preservingThey excised the tenia coli preserving
the underlying circular muscle layer.the underlying circular muscle layer.

8.  In the present technical report a modification ofIn the present technical report a modification of
the Teniectomy technique had been done bythe Teniectomy technique had been done by
the inclusion of the circular muscle layer withthe inclusion of the circular muscle layer with
the Teniectomy (i.e. short of the submucosa) inthe Teniectomy (i.e. short of the submucosa) in
order to effect widening of the teniectomizedorder to effect widening of the teniectomized
colonic segment for the creation of acolonic segment for the creation of a
sutureless colonic reservoir after low anteriorsutureless colonic reservoir after low anterior
resection.resection.

9. TechniqueTechnique
 The technique was used in 2 patientsThe technique was used in 2 patients
suffering from carcinoma of the lowersuffering from carcinoma of the lower
one third of the rectum.one third of the rectum.

10.  First was 35 years old female with aFirst was 35 years old female with a
history ofhistory of tenismus and bleeding pertenismus and bleeding per
rectum of 6 months durationrectum of 6 months duration

11.  The second patient was 58 years oldThe second patient was 58 years old
female with 2 months duration of bleedingfemale with 2 months duration of bleeding
and mucous per rectum of 2 monthsand mucous per rectum of 2 months
duration.duration.

12.  Both of them proved to have grade 2Both of them proved to have grade 2
adenocarcinoma of the rectum 4 and 5 cmadenocarcinoma of the rectum 4 and 5 cm
from the anal verge respectively with nofrom the anal verge respectively with no
evidence of distant metastases.evidence of distant metastases.

13.  Both of those patients underwent aBoth of those patients underwent a
Sandwich technique of combined pre- andSandwich technique of combined pre- and
postoperative radio-chemotherapy givenpostoperative radio-chemotherapy given
as recommended by other authors .as recommended by other authors .

14. The technique involved total mesorectalThe technique involved total mesorectal
excision technique which was describedexcision technique which was described
by Heald at al . In both cases the upper 2by Heald at al . In both cases the upper 2
cm of the anal canal were excised in ordercm of the anal canal were excised in order
to achieve an adequate 2 cm distal safetyto achieve an adequate 2 cm distal safety
margin and was combined with transanalmargin and was combined with transanal
mucosectomy down to the dentate line.mucosectomy down to the dentate line.

15. BothBoth patients had short mesentery whichpatients had short mesentery which
rendered the creation of colonic Jrendered the creation of colonic J--pouchpouch
difficult and at the time of operating on thedifficult and at the time of operating on the
first patient coloplasty techniquefirst patient coloplasty technique was notwas not
published yet on February 2000published yet on February 2000..
The second patient was operatedThe second patient was operated upon 2upon 2
years lateryears later..

17. The integrity of the mucosa was confirmedThe integrity of the mucosa was confirmed
before the Coloanal anastomosisbefore the Coloanal anastomosis byby
visually inspecting the mucosa fromvisually inspecting the mucosa from
outside during gentle fingeroutside during gentle finger palpation frompalpation from
inside of the teniectomized segment andinside of the teniectomized segment and
by injecting a 100 ccby injecting a 100 cc of Methlylene Blueof Methlylene Blue
colored saline injected in the pouch aftercolored saline injected in the pouch after
the completionthe completion of the straight Coloanalof the straight Coloanal
anastomosisanastomosis..

18. The creation of a sutureless colonic pouchThe creation of a sutureless colonic pouch
was done using the doublewas done using the double TeniectomyTeniectomy
technique by removing both the antitechnique by removing both the anti--
mesentericmesenteric tenia colitenia coli which was followedwhich was followed
by the creation of a protective transverseby the creation of a protective transverse
looploop colostomy in the first patient but notcolostomy in the first patient but not
in the second patientin the second patient..

19.  Defecography was done in order toDefecography was done in order to
assess the integrity of the colonic pouchassess the integrity of the colonic pouch
and the pouchand the pouch--anal segment 3 and 6anal segment 3 and 6
months postoperatively in both patientsmonths postoperatively in both patients..
 Further defecographic studies wereFurther defecographic studies were
done just before closure of thedone just before closure of the colostomycolostomy
and 3 and 6 months after closure of theand 3 and 6 months after closure of the
colostomy in the firstcolostomy in the first patientpatient..

22.  P.O. Anal Incontinence Score was 3 & 4P.O. Anal Incontinence Score was 3 & 4
respectively without medication (Pesctorirespectively without medication (Pesctori
Score).Score).
 Rectal compliance was 4.2 & 4.9Rectal compliance was 4.2 & 4.9
respectively as compared to 2.2, 1.9 andrespectively as compared to 2.2, 1.9 and
2.4 for another 3 patients who had direct2.4 for another 3 patients who had direct
colo-anal anastomosis.colo-anal anastomosis.

23. DiscussionDiscussion
The creation of a colonic pouch is a widelyThe creation of a colonic pouch is a widely
accepted and practiced techniqueaccepted and practiced technique toto
improve the function after Coloanalimprove the function after Coloanal
anastomosis.anastomosis.

24.  Failure of colonic pouch anal anastomosis canFailure of colonic pouch anal anastomosis can
take place due to 7 identified factors which maytake place due to 7 identified factors which may
be technical factors namely:be technical factors namely:
1.1. Narrow pelvis.Narrow pelvis.
2.2. Bulky anal sphincter.Bulky anal sphincter.
3.3. The need for mucosectomy.The need for mucosectomy.
4.4. Diverticulosis.Diverticulosis.
5.5. Insufficient colon length.Insufficient colon length.
6.6. Pregnancy.Pregnancy.
7.7. Non-technical factors such as complex surgeryNon-technical factors such as complex surgery
or the presence of distant metastases.or the presence of distant metastases.

25.  The coloplasty technique a procedureThe coloplasty technique a procedure
invented by z’Graggen et al in pigs11invented by z’Graggen et al in pigs11 andand
applied to humans by the Cleveland Clinicapplied to humans by the Cleveland Clinic
group offered an alternativegroup offered an alternative with a drop inwith a drop in
the intraoperative colonic pouch analthe intraoperative colonic pouch anal
anastomosis failure rateanastomosis failure rate from 30.7% usingfrom 30.7% using
colonic J-pouch to 5.3% using thecolonic J-pouch to 5.3% using the
coloplasty technique.coloplasty technique.

26.  However a higher leakage rate had beenHowever a higher leakage rate had been
recently reported in the coloplasty analrecently reported in the coloplasty anal
anastomosis as compared to colonic J-anastomosis as compared to colonic J-
pouch anal anastomosis (15.9% vs. 0%pouch anal anastomosis (15.9% vs. 0%
leakage rate.leakage rate.

27.  Unlike other techniques, the use ofUnlike other techniques, the use of
modified teniectomy technique create amodified teniectomy technique create a
sutureless colonic pouch whichsutureless colonic pouch which
theoretically minimizes the postoperativetheoretically minimizes the postoperative
leakage rate .leakage rate .

28.  It is easy and fast technique (5-8It is easy and fast technique (5-8
minutes for each Teniectomy) and is easyminutes for each Teniectomy) and is easy
to route into the pelvis as the straightto route into the pelvis as the straight
Coloanal anastomosisColoanal anastomosis..

29.  Unlike the other pouch techniques theUnlike the other pouch techniques the
Teniectomy technique does notTeniectomy technique does not shortenshorten
the colon on the contrary it leads tothe colon on the contrary it leads to
elongation of theelongation of the deteniectomizeddeteniectomized
segment as was reported by othersegment as was reported by other
authors.authors.
(Najafi H. & Beattie J (1965) and Hovnanian A.P.&(Najafi H. & Beattie J (1965) and Hovnanian A.P.&
Prudenico R (1968)Prudenico R (1968) ))

30.  The use of a 5 cm colonic segment distalThe use of a 5 cm colonic segment distal
to the sutureless colonic pouch wasto the sutureless colonic pouch was
Used in the present study in order toUsed in the present study in order to
partially compensate for the excisedpartially compensate for the excised
Proximal 2 cm of the anal canal includingProximal 2 cm of the anal canal including
the internal anal sphincterthe internal anal sphincter..

31.  Both patients had a normalBoth patients had a normal
(unobstructed) postoperative defecation(unobstructed) postoperative defecation
pattern as evidenced by their normalpattern as evidenced by their normal
evacuation proctography.evacuation proctography.

33.  Due to the lack of data on the effect ofDue to the lack of data on the effect of
radiotherapy on the deteniectomizedradiotherapy on the deteniectomized
colonic segment, It is advisable to usecolonic segment, It is advisable to use
those neo-adjuvant protocols which avoidsthose neo-adjuvant protocols which avoids
postoperative radiotherapy by usingpostoperative radiotherapy by using
preoperative radio-chemotherapy andpreoperative radio-chemotherapy and
postoperative chemotherapy.postoperative chemotherapy.

34.  A large controlled study comparing theA large controlled study comparing the
colonic Jcolonic J--pouch, coloplasty andpouch, coloplasty and
sutureless pouch techniques after lowsutureless pouch techniques after low
anterior resections is stronglyanterior resections is strongly
recommendedrecommended..

35. THANK YOU