Introduction

Carcinoma of the upper third of the rectum is almost invariably treated with resection and end-to-end anastomosis (high anterior resection). The operation is followed by an excellent functional result. In the last few decades an increasing number of sphincter-saving procedures in rectal cancer cases have been performed. Anterior resection, popularised by Dixon in the 1940s, was the first operation to enable patients with rectal cancer to avoid a definitive stoma. The transanal colo-anal anastomosis extended the possibility of sphincter preservation to patients with very low rectal cancers as well. However, during the last few years there has been a striking change in attitude in favour of an increased use of sphincter-saving operations. The reasons for this altered approach is partly that a safety margin of 4 cm or more distal to the growth is no longer always considered necessary. Technical advances facilitating the construction of reliable anastomoses in the deep pelvis had an

Fig. 1. Schematic illustration of a low anterior resection with a stapled recto-anal anastomosis

important role. After low anterior resection (LAR) such an anastomosis can now be accomplished by a stapling device, permitting automatic suturing in the deep pelvis (Fig. 1). Besides an abdominosacral resection or an abdominotransphincteric resection, the abdominotransanal resection with a hand-sutured colo-anal anastomosis, used mainly by a few experts, is a further possibility for very low tumours [1] (Fig. 2). An important question is if the change in policy might adversely affect the ultimate cure of the disease, a question that has still not been definitively answered. Another question is whether the functional results are acceptable after this type of surgery.

Anorectal function deteriorates following low col-orectal/colo-anal anastomoses and stabilisation of functional results may require 1-3 years in the majority of patients [1-3]. During this period, frequency and fragmentation of stools, the feeling of incomplete evacuation, tenesmus and urgency are common complaints. Faecal continence may account for 13-80% of cases [4, 5]. Usually, in these cases,

Fig. 2. Schematic illustration representing a proctectomy and reconstruction of bowel continuity with a hand sutured colo-anal anastomosis

Fig. 2. Schematic illustration representing a proctectomy and reconstruction of bowel continuity with a hand sutured colo-anal anastomosis

Fig. 3. Manovolumetry performed according to a previously described method [34] allows the investigation of the neorectum volume. Volume and contractility are recorded during the graded isobaric distension of a flaccid plastic bag placed within the neo-rectum. Volumes are defined as the peak volume reached during a distension of 40 cm H2O, which is maintained for 60 s. Resting and maximal squeeze pressures are recorded by means of cylindrical water-filled cuff

alterations of continence are limited to impaired control of flatus, soiling, occasional loss of liquid and sometimes, solid stools.

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