Coloplasty

In 1997 another simplified pouch technique, the transverse coloplasty pouch, was introduced to offer an easier alternative to colonic J-pouch. It was based on the findings that a very small colon pouch could reduce the early dysfunctions frequently seen after straight anastomosis and the late evacuation problems associated with a large reservoir. With this technique, an 8-10 cm longitudinal incision is made at the antimesenteric side of the colon between the tenia beginning 4-6 cm from the cut end of the mobilised colon. The colotomy is closed in a transverse manner similar to the closure of a Hei-necke-Mikulicz strictureplasty of a small bowel and then an end-to-end stapled or handsewn anastomosis is performed (Figs. 2 and 3) [78, 79].

This technique was first examined in an animal model showing functional results similar to the colic J-pouch reconstruction [80]. The transverse coloplasty pouch was then adapted for use in humans in order to determine results, feasibility and safety of the technique.

From a different published series, patients with coloplasty pouch had less stool frequency, urgency and fragmentation than patients with straight anas

tomosis. Comparing both coloplasty and colonic J-pouch, the few differences in bowel function did not reach a statistical significance between the groups, each showing in fact a similar functional outcome even in the early post-operative period [79-87]. The rate of intraoperative and post-operative complications was comparable in both groups; in contrast, in one report a significantly higher rate of anastomostic leak (15.9% vs. 0%) was evident. All the leaks were at the anterior wall of the colo-anal anastomoses, below the site of coloplasty, although all patients were defunctioned with a loop ileostomy [88].

On the basis of these experiences and our own, we can say about this technique:

• The transverse coloplasty is without doubt technically easier, faster and cheaper than J-pouch reconstruction. It may also be useful when the length of bowel that is needed to reach the anal canal, as well as a narrow pelvis, prohibits the formation of a J-pouch. From the time the technique of coloplasty was adopted, there has been a decrease in the rate of overall pouch construction failure after AR from 26.2% to 5.3%, confirming the feasibility of coloplasty reconstruction [64].

• The transverse coloplasty pouch, compared with a straight colo-anal anastomosis, increases the neo-rectal volume only by 40% (MTV<190 ml in our series) [80]; the reservoir function alone cannot justify the improvements of the results of this procedure, especially in terms of stool frequency (in our series mean of daily bowel movements of 2.6 at three months). It is more likely that motility factors, such as disruption of the colonic propulsion as a result of the colotomy on the antimesenteric surface, play a more important role [81, 83].

• The data of high incidence of anastomotic leaks after coloplasty were thought to be a consequence of a compromised blood supply at the anastomosis site as a result of the colostomy [88]. However, laser Doppler studies conducted on animal models did not show any evidence of relative anasto-motic ischaemia and other clinical studies do not confirm these findings (Table 1) [80].

In short, the data published so far make it apparent

Table 1. Data from coloplasty's series

Literature data

Anastomotic leaks (%)

Defunctioning ileostomy (%)

Neoadjuvant therapy (%)

Z'graggen et al. [79]

7

100

19

Mantyh et al. [81]

5

65

30

Ho et al. [88]

15.9

100

0

Fürst et al. [82]

-

75

15

Pimentel et al. [83]

13.2

100

33

Köninger et al. [84]

20

84

64

Personal experience, 23 cases

4.3

100

87

that transverse coloplasty constitutes a useful alternative to the colonic J-pouch and that its technical simplicity is the main advantage.

However, in order to understand the real role of transverse coloplasty it is essential to have a longer observational interval study after surgical operation than the published series reported so far have. Indeed, it is to be expected that coloplasty, as well as the colonic J-pouch or straight anastomosis, undergo functional changes over time: in fact the phenomenon of "split defecation" in the J-pouch usually appears or worsens 12 months after the operation.

Was this article helpful?

0 0
Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

Get My Free Ebook


Post a comment