In the elderly, fear of poor function reduces the indication for AR in favour of abdominoperineal excision or Hartmann's procedure. The analysis of literature data shows that functional outcome after colonic J-pouch reconstruction is similar in patients older and younger than 75, that the bowel function is comparable in both groups and also that continence is good [17,48,63]. These results suggest that the creation of a reservoir is appropriate for elderly patients and, if there are no pre-operative continence problems, it is unjustifiable not to restore bowel continuity.
In spite of these reports, however, the colonic J-pouch did not find widespread use except in specialised colorectal units. Many surgeons are not trained in this technique and prefer a straight colo-anal anastomosis, considering the J-pouch reconstruction a complication of AR operation. The failure rate in performing a planned colic pouch is about 26% . The reasons for failure can be divided into two groups: in the first one (86%) are included all technical or anatomic difficulties linked to pouch construction or anastomosis (pelvis too narrow 43%, bulky anal sphincter 33%, extensive diverticular disease 11% and insufficient length of the colon 7%). The second group (14%) contains the relative failures that can follow the surgeon's decision to keep the operation as quick and as simple as possible and perform a straight anastomosis as a consequence of the case complexity (7%) or of the degree of tumour dissemination (7%) [30, 64]. The improvement of this failure rate is the future aim and should stimulate the development of alternative techniques.
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