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COLONIC J-POUCH-ANAL-ANASTOMOSIS (CPAA) OR COLONIC
ANASTOMOSIS WITH J-POUCH IN RECTOSIGMOID AND RECTAL
CANCER
• History
APR (Miles) gold standard in first half of century in tx of rectosigmoid and rectal
cancers
Dixon (Mayo Clinic, 1930) devised LAR for treatment of favorable tumors of
mid-rectum and became procedure of choice
Until 1970s thought that 5cm distal margin from the tumor-- Williams et al.
(1983) described distal spread of >2cm in less than 2.5% of excised tumors
Studies confirmed 2cm distal margin did not compromise survival – overall
results similar LAR vs. APR
Endoanal stapler – increased technical ability to perform LAR
Historical Concerns about LAR
• Complete incontinence– Lane and Parks (1977) examined patients undergoing complete
rectal excision
Rectum not essential for appreciating impending evacuation/ sphincter inhibitory
reflex
7/9 patients had both internal and external sphincter inhibition
8/9 normal feeling of perianal fullness
Theory- regeneration of intramural network of nerves across anastomosis
• Local recurrence- McAnena et al. (1990)– local recurrence as low as 3.5% for cancers
less then 7cm from anal verge with 14mm distal clearance
preservation of sphincter apparatus is feasible without compromising oncologic
result.
• Techniques for first developed
Coloanal / straight anastomosis- Parks (1972)- rectal excision, endorectal
mucosectomy, coloanal anastomosis
• Anterior resection syndrome- defecatory frequency /urgency, soiling
common sequelae
J-pouch - Lazorthes et al. (1986)- rectal excision, pouch formation, anastamosis-
20 pts after 1 year post- surgery had a median 2.3 BMs/day, 60% had <2/day,
normal continence 60%
Parc et al. (1986) – 30 patients BM after 3months 1.1/day mean, absent urgency,
minor incontinence in 33% resolved after 3 months. Normal sensation for
evacuation 75% of patients, but difficult evacuation was seen in 25%.
Colonic J-pouch vs. Straight Anastomosis
• Kusonoki et al. (1991)- Straight anastomosis group high numb