Patients with cancer located in the lower half of the rectum have been increasingly offered total mesorec-tal excision preserving the sphincteric mechanism; the oncological results in terms of recurrence and survival rates are comparable to those of abdominoperineal excision. In cases of reconstruction with reservoir, functional results improved with respect to conventional straight anastomosis. However, many studies are retrospective, or different in study design and evaluation methods, or are not comparable in technical details of reconstruction (size of reservoirs, level and kind of anastomosis, use or not of defunctioning stoma etc.) and follow-up intervals. Furthermore, the results from manometric studies are not always correlated to the real clinical outcome of the patients and the functional criteria are often not uniformly defined. So, the data from the current literature are not suitable for direct comparison and large randomised controlled studies should be carried out to definitively define the role of reservoirs.
However, evidence supporting colonic J-pouch reconstruction has been now sufficiently accumulated and the conclusions are that a small colonic J-pouch of 5-6 cm should be preferred to the straight anastomosis in all cases of low or ultralow AR. Adequate pre-operative investigation of the anal sphincter should prevent failures and support the surgeon's decision to perform a restorative procedure with reservoir. The improvement with colic J-pouch reconstruction is apparent in the early post-operative period and probably remains superior to straight anastomosis for 1-2 years after surgery. This is important especially in the elderly, who often have impaired sphincter function, and for those with limited life expectancy when it is desirable to achieve optimum results as quickly as possible.
The side-to-end anastomosis and the transverse coloplasty represent a useful alternative to the colonic J-pouch and their preliminary functional results seem to be superior to a straight anastomosis and very similar to those of a small colonic J-pouch, confirming that the principles of their functioning are not related only to the creation of a neorectal reservoir but also to decreased motility.
Side-to-end anastomosis and, mainly, transverse coloplasty give some technical advantages in reservoir reconstruction and anastomosis. Coloplasty probably represents the ideal compromise between straight anastomosis and short J-pouch, designed as a pouch of small volume without an anisoperistaltic segment. Further studies and longer follow up may reveal other features in this technique.
For these reasons, our personal advice, based on published data available at present and our experience and clinical practice in the last few years, are the following:
• A reconstruction with reservoir, either J-pouch or coloplasty, should be used whenever the anastomosis is under 5 cm from the anal verge and also in elderly patients or those with advanced tumour.
• Transverse coloplasty is indicated in cases of a very narrow pelvis, obese patients with fatty mesentery or when the colon available is not long enough to perform a J-pouch.
• This technique should certainly be preferred in cases of transanal handsewn anastomosis because of its configuration, allowing to cross the sphinc-teric complex and perform a comfortable direct anastomosis more easily than a colonic J-pouch or a side-to-end reconstruction.
• Although waiting for more data, we recommend at all times the use of a defunctioning stoma to protect anastomosis in case of reconstruction with coloplasty.
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