des anastomoses basses Résultat fonctionnel des anastomoses basses Pr Yann Parc Hôpital Saint-Antoine, APHP Paris Mr President, dear colleagues, I would like to thank the european society of coloproctology to give me with the opportunity to discuss with you about reconstructive procedures after total mesorectum excision.

Si moigon rectal de plus de 4cm Résultat ACR supérieure à celui d’une ACA avec réservoir Our team has tried to answer to this question in a retrospective analysis in 1998. In this study, we observe that the functional result of patients who had a colorectal anastomosis while the rectal stump left was superior to 4 cm had a better functional results than patients who had a coloanal anasotmosis with a J-pouch. With this findings, we consider that if the rectal stump will measure less than 4 cm of lenght, it is better to do a total mesorectum excision and to perform a coloanal anastomosis on a J-pouch or a reconstruction equivalent or bette than a J pouch. Otherwise a colorectal anastomosis is a better choice in regards of the functional results.

Résultat des anastomoses coloanale directe 81 patients Suivi Médian 4,3 years No. of patients (%) Fecal Continence/Incontinence Complete 41 (51) Incontinent of gas 17 (21) Minor leak 19 (23) Significant leak 4 (5) Urgency 15 (19) Multiple evacuations 26 (32) Functional results of straight coloanal anastomosis is known to be not as good as we would likesince a long time. Here are presented the about 5 five years functional results. In this study, Paty et al observed fragmentation in a third of their patients while only 50% of the patients were fully continent. Eventhough, fecal continence was quiet good, fragmentation is a very disturbing symptoms. Patients are unable to get far from the toilet once an evacuation has started. The impact on social life can therefore to be tremndous, patients refusing to be expose to the necessity to interrupt their occupation with friends or during working hours frequently over one or two hours. PB Paty et al Am J Surg1994; 167: 90-5

difficulté à évacuer : 25% 20 patients IN 1986, two french team, the team of Franck Lazorthes and Saint-Antoine’s team presented their results with coloanal anastomosis ans colonic J pouch. The size of the pouch was already a matter of discussion as with a 8 cm long reservoir difficulty with evacuation was observed by our team and that these difficulties evoked early by Franck Lazorthes leads his team to try several pouch size. 31 patients Réservoir en J de 8 cm difficulté à évacuer : 25% 20 patients soit réservoir en J de 6cm ou de 12cm

Anastomose Coloanale avec réservoir en J Bénéfice démontré dans au moins : 9 études randomisées 1 méta-analyse Bénéfice immédiat Et qui persiste dans le temps Since, these two publications, 9 randomised control trialls has been at least published. All had shown a statisticaly significant benefit for colonic J pouch. This benefit is observed immediatly after surgery but alos persist over time, eventhough the functional results of a straight colonal anastomosis improve with time. Halböök et al. Ann Surg 1996; 224: 58-65 Heriot et al Br J Surg 2006; 93: 19-32 Harris et al. Br J Surg 2001; 88: 1623-7

6 cm : difficultés à évacuer (25%) Le réservoir en J Taille optimale : 5-6cm 6 cm : difficultés à évacuer (25%) < 6 cm : perte de la fonction réservoir sigmoïde = côlon descendant ( si pas de diverticule) Several other studies have been conducted to determine how to improve the results of the J Pouch. The optimal size seems to be around 5 and 6 cm. Shorter reservoir are likely to give results equivalent to straight coloanal anastomosis and longer pouch to be associated with more frequent evacuation problems. Moreover, the descending colon seems to be more appropriate to use than the sigmoid colon. Hida JI et al. Dis Colon Rectum 1996; 39: 986-91 Lazorthes F et al. Dis Colon Rectum 1997; 40: 1409-13 Heah SM et al. Dis Colon Rectum 2002; 45: 322-8

Autre réservoir la coloplastie transverse In 1997, Z’graggen reported an alternative technique with the transverse coloplasty. The pouch constructed like an Henle stricturoplasty with a 8 cm long longitudinal incision began 4 cm above the distal margin. Colotomie longitudinale de 8 cm à 4 cm de la section distale Fermeture transverse Résultat final Z’graggen et al. Gastroenterology 1997, 112: A1487

Réservoir en J ou Coloplastie transverse Morbidité > aprés coloplastie (désunion: 0 vs 16%) 1 identique 2,3 Fonction et qualité de vie identique Puissance ? The simplicity of this technique makes it very intersting and 3 randomised controled study were rapidly conducted. Morbidity was found to be increased in one of these study while in the 2 others no difference in term of morbidity was found when compared to colonic J pouch. Fnuctional results and quality of life were considered to be equivalent. But the sample sizes of these studies were much to small to consider that absence of significant difference signifies equivalence. Ho et al. Ann Surg 2002; 236: 49-55 Furst et al. Dis Colon Rectum 2003; 46: 1161-6 Pimentel et al. Colorectal Dis 2003; 5: 465-70

364 patients randomisés en per-opératoire : coloplastie ou anastomose directe si J impossible coloplastie ou réservoir en J si J possible The Cleveland Clinic directed then a mulcenter international controled study to compare J-Pouch to coloplasty and Coloplasty to straight colonal anastomosis with the aim to include more than three hundred patients and to overcome the problem of sample size. Ann Surg 2007; 246: 481-90

Nombre de patients et groupes Patients were randomised once the rectal cancer has been removed and that a colonal anastomosis was jugded possible. If a J-pouch was considered possible the patients was randomised between a J-pouch or a coloplasty. If a J-pouch was jugded impossible the patient was randomised between a coloplasty and a straight coloanal anastomosis. The patients were then evaluated for sexual, urinary and digestive functional results over two years. 297 patients results were available after 2 years of follow-up. 297 patients évalués à 24 mois

Nombre de selles par jours au cours du temps pour les 4 groupes On this graph you can see the evolution of the number of daily bowel movements for the 4 groups of patients. For this criteria J pouch was always better than coloplasty and after 2 years of follow-up, the diffrence remained significant while the difference between a coloplasty pouch and a straight coloanal anastomosis was not significant. Réservoir en J-pouch vs coloplastie : 0,03 à 4 mois 0,03 à 12 mois 0,007 à 24 mois Ann Surg 2007; 246: 481-90

Fecal Incontinence Severity Index (FISI) Sur les 24 mois des 4 groupes When FISI scores were compare the then evolution over time noticed and also the same difference J Pouch better than coloplasty but coloplasty and straight coloanal anastomosis no diffirence. Réservoir en J-pouch vs coloplastie : 0,001 à 4 mois 0,04 à 24 mois Ann Surg 2007; 246: 481-90

Scores physique et mental Qualité de vie Scores physique et mental du SF-36 0.09 Quality of life comparison was already disappointing with no diffrence observed. But we should consider that the score use was a general quality of life score and not a score more focused on the possible symptoms observed after rectal resection. Pas de différence significative à 24 mois Mais que dire du SF 36 ?? Ann Surg 2007; 246: 481-90

Fragmentation à 24 mois CP AD p J 10% 21% <0.03 Jamais 7% 16% 0.21 10% 21% <0.03 1-4 / mois 38% 37% 27% 39% >2 par semaine 22% 24% 20% 1 ou >1 par jour 33% 25% Clustering is one or the most important symptom reported after anterior resection and has a big impact on social. In this study, after 2 years of follow-up the difference was still significant in favor of the J-pouch when compared to coloplasty.

Réservoir en J versus coloplastie Conclusion: Réservoir en J versus coloplastie Le réservoir en J est supérieur à la coloplastie et anastomose coloanale directe en terme de résultats fonctionnels : moins de selles d’utilisation de protection meilleure continence. Les résultats de la coloplastie sont similaires à ceux d’une anastomose coloanale directe. With all these findings on functional outcome measurements eventhough no difference in term of quality of life could have been highlighted, it was considered that J-pouch is superior to coloplasty and that coloplasty results not significantly better than those of straight coloanal anastomosis.

« Autre » réservoir : anastomose latéro-terminale At the same time, another alternative to J-pouch was tested; the side-to-end colonal anastomosis. The advantages of this technique is one more time it’s simplicity and a shorter operating time.

Réservoir en J ou anastomose latéro-terminale ? Machado et al reported their results in Annals of Surgery. In this randomised controlled study, Side-to-end coloanal anastomosis was compared to coloanal anasomosis with a J-Pouch. Fifty patients were included in each arms of the study. No difference in term of morbidity was observed. Pas de différence de morbidité Machado M et al. Ann Surg 2003; 238: 214-20

Réservoir en J ou anastomose latéro-terminale ? Comparison of functional results at 6 months and 12 onths were also not significantly different. However, some criterias were almost significantly different and all tended to demonstrated that the functional results observed after a coloanal anastomosis with a J-pouch were better than those observed after a side-to-end coloanal anastomosis. Presque pas de différence de fonction Machado M et al. Ann Surg 2003; 238: 214-20

Réservoir en J ou anastomose latéro-terminale ? A 2 ans The functional results after two years were also not significantly different but urgency still tended to be more frequently observed after side-to-end coloanal anastomosis. Pas de Différence significative Puissance ? Machado et al. Dis Colon Rectum 2005; 48: 29-36

Réservoir en J ou anastomose latéro-terminale ? The first to be published since, included almost the same number of patients one hundred and seven and functional results after one year of follow-up were available in only 52 patients.

Réservoir en J ou anastomose latéro-terminale ? In this study, functional results were significantly better in the group of patients who a coloanal anastomosis and a J-pouch. Incontinence was less frequent and the score used to compare the funtional results was better. At 4 and 12 months.

Réservoir en J ou anastomose latéro-terminale ? Quality of life scores comparison did not highlighted significant differences. And it was propose as conlcusion that as functional outcome were not different eventhought functional outcome were significantly different, that hese findings contribute to the body of evidence showing that J-pouch had no convincing support for its superiority in comparison to side-to-end coloanal anastomsis. A conclusion difficult for me to understand in regards of the analysis of their results. Hopefully, the Celveland Clinic is conducting a second international multicenter study comparing the two techniques with the aim to overcome any samlpe size bias analysis.

Après résection de l’ampoule rectale, il est recommandé de faire CONCLUSION Après résection de l’ampoule rectale, il est recommandé de faire un réservoir en J : Meilleur fonction améliore la qualité de vie Taille optimale : 5-6 cm autres réservoir : coloplastie Anastomose latéro-terminale? Si moignon rectal restant de plus de 4cm Anastomose colorectale. In conlcusion, mister president, at the moment it is demonstrated that after excision of the recal ampulla formation a colonic J-pouch is recommended. It improves function and quality of life. The optimal siez of Jpouch is 5 to 6 cm of lenght. Two alternatives have been proposed since. The Coloplasty pouch technique but the Cleveland Clinic international study has shown that their was almost not difference in terms of function when compared to straight coloanal anastomosis and that J-pouch had significant better functional results. For side-to-end anastomsis, functional results are maybe equivalent as was initially reported but the recent dutch rrepost seems to demonstrate the contrary and larger study results to overcome sample size bias analysis have to be produced to conclude on this matter. Thank you very much for your attention.