American Surgical Association

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Better Function With A Colonic J-pouch Or A Side-to-end Anastomosis? A Randomized Controlled Trial To Compare The Complications, Functional Outcome And Quality Of Life In Patients With Low Rectal Cancer After A J-pouch Or A Side-to- End Anastomosis
Massarat Zutshi*1, Yann Parc*2, Rhinehard Ruppert*3, Alois Fuerst*4, Werner Hohenberger*5, Susan Galandiuk6, Felix Hemminger*3, Henriette Goldcher*5, Emmanuel Tiret*2, Alexander Heriot*7, Alexandra Aiello*1, Tracy Hull1
1Cleveland Clinic Foundation, Cleveland, OH;2Hospital St. Antoine, Paris, France3Krankenhaus Munchen Neuperlach, Munich, Germany4Caritas-Clinic St. Josef, Regensberg, Germany5Zentrum für klinische Studien, Erlangen, Germany6University of Louisville, Louisville, KY;7Peter MacCallum Cancer Centre, Melbourne, Australia

Aim: To compare prospectively the complications and functional outcome of patients undergoing a JP or SE for treating low rectal cancer at 2-years.
Methods: A multicenter study randomized patients with low rectal cancer to receive either a JP or SE and followed for 12/24 months with SF-12&FACT-C surveys to evaluate quality of life(QOL). Fecal Incontinence Severity Index(FISI) evaluated bowel function. Univariate analysis compared JP/SE groups using Pearson's Chi-square/Fisher's exact test for categorical variables and ANOVA for continuous variables.
Results. (Table)236 patients enrolled, 46 ineligible, died or withdrew consent before surgery. 23(10%) failed randomization(15JP, 8SE) and received a straight anastomosis.The main presenting symptom was rectal bleeding(76%). BMI was similar in both groups. 92(55%) underwent radiotherapy (42JP, 40SE) and 89(54%) underwent preoperative chemotherapy(41JP,48 SE).The overall recurrence rate was 7%(similar in both groups).
Complications: 14/37 were Clavien Dindo Grade 3b,2 were 3a. Pouch necrosis was noted in 2(JP).
QOL: QOL scores using either instrument were similar at 12 and 24 months(p>0.05) in both groups.
Bowel Function: At 12 and 24 months the number of bowel movements/urgency/clustering and FISI scores were similar.
Conclusions: At 1 and 2 years after a JP or SE for low rectal cancer, QOL, bowel function and complications are comparable. Although choosing a particular procedure may depend on surgeon/patient choice or anatomical considerations at the time of surgery, SE functions similar to JP and may be chosen due to the ease of construction.

Table
OverallJ-Pouch(N=80)Side to End(N=87)
FactornStatisticsnStatisticsp-value
Age at surgery60.8±10.48960.8±9.49160.1±10.50.61a
Pre-op BMI27.5±11.69528.7±16.89026.3±4.90.20a
Sex
Female73(30.9)24(25.3)37(38.9)0.04
Complications 0.4
Leak3(8.1)2(10.5)1(6.3)
Fistula4(10.8)1(5.3)3(18.8)
Small bowel obstruction4(10.8)3(15.8)1(6.3)
Hernia3(8.1)1(5.3)2(12.5)
Wound Infection5(13.5)2(10.5)3(18.8)
QOL 12 months
FACT-C total score110.1±16.252109.2±16.957110.8±15.70.61a
FACT-C Total outcome index score67.4±11.15467.2±11.65967.6±10.80.86a
QOL 24 months
FACT-C Fact-G total score90.8±13.86190.3±14.96491.4±12.90.67a
FACT-C Total outcome index score68.0±11.16068.1±11.86467.9±10.40.93a
SF-12 Mental Component Score52.8±7.95552.5±8.36253.0±7.50.76a
SF -12 Physical Component Score48.7±9.25549.1±8.66248.3±9.70.63a
Bowel Function
No. of Bowel Movements in a Day (24 hrs) 3.3±1.9
3 [2, 4]
(1, 12)
563.1±1.7
3 [2, 4]
(1, 10)
593.5±2.0
3 [2, 5]
(0, 11)
0.28a
FISI Total Score14.0±10.55814.8±10.96013.2±10.10.42a
Statistics presented as Mean ± SD, Median [P25, P75], Median (min, max) or N (column %).p-values: a=ANOVA,


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