Subscribe to RSS
DOI: 10.1055/s-2002-33956
© Georg Thieme Verlag Stuttgart · New York
Vulnerabilität von ileocoecalem Interpositionspouch und Colon-J-Pouch gegenüber der postoperativen, adjuvanten Strahlentherapie
Vulnerability of Ileocoecal Interposition Pouch and Colonic J-pouch to Postoperative Adjuvant radiotherapyPublication History
Publication Date:
09 September 2002 (online)
![](https://www.thieme-connect.de/media/zblchir/200209/lookinside/thumbnails/10.1055-s-2002-33956-1.jpg)
Zusammenfassung
Zielsetzung: Die ileocoecale Interposition (ICI) stellt ein Alternativverfahren zum Colon-J-Pouch (CJP) zur Verbesserung des funktionellen Ergebnisses nach totaler Mesorektumexcision (TME) dar. Bisher liegen keine Erkenntnisse über die Folgen einer postoperativen Radiochemotherapie auf die Funktion nach ICI vor, was im Rahmen der vorliegenden Untersuchung überprüft wurde.
Patienten und Methoden: Achtzehn Patienten nach TME und ICI, von denen zehn eine postoperative Strahlentherapie erhielten, wurden bezüglich des funktionellen Ergebnisses, der analen und neorektalen Funktion und strahlenspezifischer Komplikationen mit einem Kollektiv von 15 Patienten mit TME und CJP verglichen, von denen 7 strahlentherapeutisch behandelt wurden.
Ergebnisse: Ohne Strahlentherapie fand sich in beiden Gruppen ein vergleichbares funktionelles Ergebnis mit einer medianen Stuhlfrequenz von 4,25 (2-5) nach ICI und 3 (2-6) nach CJP-Rekonstruktion sowie einem Inkontinenz-Score von 2,8 (0-6) nach ICI beziehungsweise 1,0 (0-2) nach CJP. Nach Strahlentherapie waren sowohl die Stuhlfrequenz mit 7 (2-11) (ICI) beziehungsweise 5 (2,5-11) (CJP) sowie der Inkontinenzscore mit 6 (0-12) (ICI) beziehungsweise 7 (6-17) (CJP) in beiden Gruppen erhöht. Neben einem Abfall des analen Ruhedrucks fanden sich eine Reduktion des maximal tolerierten Füllungsvolumens sowie der Compliance des Neorektums durch die Bestrahlung als Ursache. Vier von 10 Patienten nach ICI und Radiatio entwickelten eine operationspflichtige Obstruktion, die bei 3 Patienten ausschließlich oder führend im ileocoecalen Interponat lokalisiert war. Keiner der CJP Patienten erlitt eine vergleichbare Komplikation.
Diskussion: Die Daten zeigen eine methodenunabhängige, erhebliche Verschlechterung des funktionellen Ergebnisses, sowie eine ausschließlich nach ICI nachweisbare hohe Inzidenz schwer wiegender Komplikationen durch die postoperative Strahlentherapie.
Schlussfolgerung: Die Indikation zur postoperativen Strahlentherapie sollte zurückhaltend gestellt werden, und die ileocoecale Interposition sollte nicht eingesetzt werden, wenn eine postoperative Radiotherapie geplant ist.
Abstract
Aim: The interposition of an ileocoecal segment has been introduced as an alternative procedure to impair the functional outcome following total mesorectal excision (TME). Up to now, there is no information concerning the effect of postoperative radiotherapy on the functional outcome of this method.
Patients and methods: We compared functional outcome, anorectal physiology, and radiation therapy-related morbidity of 18 patients treated with TME und ileocoecal interposition (ICI) of which ten had postoperative radiotherapy, with 15 patients who had TME and colonic J-pouch (CJP) reconstruction of which 7 were subjected to radiotherapy.
Results: Patients with no radiotherapy revealed a satisfying functional result with a similar median frequency of defecation of 4.25 (2-5) and 3 (2-6) and an incontinence-score of 2.8 (0-6) and 1.0 (0-2) after ICI and CJP, respectively. Median stool frequency (7 (2-11) (ICI) and 5 (2.5-11) (CJP)) and incontinence score (6 (0-12) (ICI) and 7 (6-12) (CJP)) were markedly increased in both groups after radiotherapy. Besides a reduced anal resting pressure, a lower compliance and a smaller volume of the neorectum were observed in the irradiated patients. A radiogenic injury which required surgery was seen in 4/10 patients after ICI. In three of these four patients the interposed ileocoecal segment was mainly affected. None of the patients treated with a CJP suffered a similar complication.
Discussion: These data indicate that postoperative radiotherapy severely impairs the functional outcome after TME independent of the type of surgery used for reconstruction, and causes a significant morbidity after ICI.
Conclusion: Postoperative radiotherapy following TME should be indicated cautiously, and ICI should not be used if postoperative radiotherapy is intended.
Schlüsselwörter
Totale Mesorektumexcision - Rektumkarzinom - Funktionelles Ergebnis - Strahlentherapie - Strahlenstenose
Key words
Total mesorectal excision - rectal cancer - functional outcome - radiotherapy - bowel obstruction
Literatur
- 1 Aktualisierter Konsensus der CAO/AIO/ARO zur adjuvanten Therapie bei Kolon- und Rektumkarzinomen. Onkologie. 1999; 22 154-156
- 2 Berger A, Tiret E, Parc R, Frileux P, Hannoun L, Nordlinger B, Ratelle R, Simon R. Excision of the rectum with colonic J-pouch-anal anastomosis for adenocarcinoma of the low and mid rectum. World J Surg. 1992; 16 470-472
- 3 Birnbaum E H, Myerson R J, Fry R D, Kodner I J, Fleshman J W. Chronic effects of pelvic radition therapy on anorectal function. Dis Colon Rectum. 1994; 37 909-915
- 4 Cammá C, Giunta M, Pagliaro Fiorica L, Craxi A, Cottone M. Preoperative radiotherapy for resectable rectal cancer. JAMA. 2000; 286 1008-1015
- 5 Carlsen E, Schlichting E, Guldvog I, Johnson E, Heald R J. Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Br J Surg. 1998; 85 526-529
- 6 Cionini L, Marzano S, Boffi L, Cardona G, Ficari F, Fucini C, Tonelli F. Adjuvant postoperative radiotherapy in rectal cancer: 148 cases treated at Florence university with 8 years median follow-up. Radiotherapy and Oncology. 1995; 40 127-135
- 7 Coia L R, Myerson R J, Tepper J E. Late effects of radiation therapy on the gastrointestinal tract. Int J Raditation Oncology Biol Phys. 1995; 31 1213-1236
- 8 Dahlberg M, Pahlman L, Bergström M, Glimelius B. Improved survival in patients with rectal cancer: a population-based register study. Br J Surg. 1998; 85 515-520
- 9 Farouk R, Duthie G S, Bartolo D CC. Recovery of the internal anal sphincter and continence after restorative proctocolectomy. Br J Surg. 1994; 81 1065-1068
- 10 von Flüe M O, Degen L P, Beglinger C, Hellwig J M, Rothenbühler A C, Harder F H. Ileocoecal reservoir reconstruction with physiologicfunction after total mesorectal cancer excision. Ann Surg. 1996; 224 204-212
- 11 Freys S M, Fuchs K-H, Bussen D, Thiede A. Anorektale Durchzugs- und Vektorvolumen-Manometrie. Zentrabl Chir. 1996; 121 652-658
- 12 Hallböök O, Påhlman L, Krog M, Wexner S D, Sjödahl R. Randomized comparison of straight colonic J-pouch anastomosis after low anterior resection. Ann Surg. 1996; 224 58-65
- 13 Hallböök O, Nyström P-O, Sjödahl R. Physiologic characteristics of straight and colonic J-pouch anastomoses after rectal excision for cancer. Dis Colon Rectum. 1997; 40 332-338
- 14 Hida J, Yasutomi M, Fujimoto K, Okuno K, Ieda S, Machidera N, Kubo R, Shindo K, Koh K. Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch: Prospective randomized study for determination of optimum pouch size. Dis Colon Rectum. 1996; 39 986-991
- 15 Heald R J, Ryall R D. Recurrence and survival after total mesorectal excision for rectal cancer. Lancet. 1986; 1 1479-1482
- 16 Heald R J, Smedh R K, Kald A, Sexton R, Moran B J. Abdominoperineal excision of the rectum - an endangered operation. Dis Colon Rectum. 1997; 40 747-751
- 17 Hemingway D, Flett M, McKee R F, Finlay I G. Sphincter function after transanal endoscopic microsurgical excision of rectal tumours. Br J Surg. 1996; 83 51-52
- 18 Ho Y H, Tan M, Seow-Choen F. Prospective randomized controlled study of clinical function and anorectal physiology after low anterior resection: comparison of straight and colonic J pouch anastomoses. Br J Surg. 1996; 83 978-980
- 19 Ho Y H, Tan M, Leong A, Eu K W, Nzam D, Seow-Choen F. Anal pressure impaired by stapler insertion during colorectal anastomosis: a randomized trial. Dis Colon Rectum. 1999; 42 89
- 20 Iwamoto T, Nakahara S, Mibu R, Hotokezaka M, Nakano H, Tanaka M. Effect of radiotherapy on anorectal function in patients with cervical cancer. Dis Colon Rectum. 1997; 40 683-697
- 21 Jorge J MN, Wexner S D, Morgado P J, James K, Nogueras J J, Jagelman D G. Optimization of spincter function after the ileoanal reservoir procedure. Dis Colon Rectum. 1994; 37 419-423
- 22 Junginger T, Hossfeld D K, Sauer R, Hermanek P. Adjuvante Therapie bei Kolon- und Rektumkarzinom. Dt Ärztebl. 1999; 96 A 698-A 700
- 23 Kapiteijn E, Marijnen C AM, Nagtegaal I D, Putter H, Steup W H, Wiggers T, Rutten H JT, Pahlmann L, Glimelius B, van Krieken J HJM, Leer J WH, van de Velde C HL. and the dutch colorectal cancer group . Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med. 2001; 345 638-646
- 24 Kollmorgen C F, Meagher A P, Wolff B G, Pemberton J H, Ilstrup J A. The long-term effect of adjuvant postoperative chemoradiotherapy for rectal carcinoma on bowel function. Ann Surg. 1994; 220 676-682
- 25 Langberg C W, Sauer T, Reitan J B, Hauer-Jensen M. Relationship between intestinal fibrosis and histopathologic and morphometric changes in consequential and late radiation enteropathy. Acta Oncologica. 1996; 35 81-87
- 26 Lehnert Th, Herfarth Ch. Multimodale Therapie des Rektumkarzinoms. Chirurg. 1998; 69 384-392
- 27 Lewis W G, Williamson M ER, Kuzu A, Stephenson B M, Holdsworth P J, Finan P J, Ash D, Johnston D. Potential disadvantage of post-operative radiotherapy after anterior resection for rectal cancer: a pilot study of sphincter function, rectal capacity and clinical outcome. Int J Colorectal Dis. 1995; 10 133-137
- 28 MacFarlane F J, Ryall D R, Heald J R. Mesorectal excision for rectal cancer. Lancet. 1993; 341 457-460
- 29 Miller R, Bartolo D CC, Locke-Edmunds J C, Mortensen N J McC. Prospective study of conservative and operative treatment for faecal incontinence. Br J Surg. 1988; 75 101-105
- 30 Ooi B S, Tjandra J J, Green M D. Morbidities of ajuvant chemotherapy and radiotherapy for resectable rectal cancer. Dis Colon Rectum. 1999; 42 403-418
- 31 Ortiz H, De Miguel M, Armendariz P, Rodriguez J, Chocarro C. Coloanal anastomosis: are functional results better with a pouch?. Dis Colon Rectum. 1995; 38 375-377
- 32 Pappalardo G, Toccaceli S, Dionisio P, Gastrini G, Ravo B. Preoperative and postoperative evaluation by manometric study of the anal sphincter after coloanal anastomosis for carcinoma. Dis Colon Rectum. 1988; 31 119-122
- 33 Pélissier E P, Blum D, Bachour A, Bosset J F. Functional results of coloanal anastomosis with reservoir. Dis Colon Rectum. 1992; 35 843-846
- 34 Romanos J, Stebbing J F, Smilgin Humphreys M M, Takeuchi N, Mortensen N CMcC. Ambulatory manometric examination in patients with a colonic J pouch and in normal controls. Br J Surg. 1996; 83 1744-1746
- 35 Rothenberger D A. Postoperative Chemoradiotherapy for rectal carcinoma adversely affects long-term bowel function. Pesp Colon Rect Surg. 1995; 8 1-2
- 36 Seow-Choen F, Goh H S. Prospective randomized trial comparing J colonic pouch-anal anastomosis and straight coloanal reconstruction. Br J Surg. 1995; 82 608-661
- 37 Varma J S, Smith A N, Busuttil A. Function of the anal sphincters after chronic radiation injury. Gut. 1986; 27 528-533
Dr. A. Rink
Klinik für Allgemeinchirurgie
Klinikum Leverkusen
Postfach 10 04 10
51304 Leverkusen