Modified TeniectomyModified Teniectomy. . A New Technique for A New Technique for Creation of Sutureless Colonic Reservoir.Creation of Sutureless Colonic Reservoir.

(Technical note)(Technical note)

ByBy

Prof. Dr. Ahmed Farag. MDProf. Dr. Ahmed Farag. MDProfessor of G. Surgery- Cairo University.Professor of G. Surgery- Cairo University.

IntroductionIntroduction

Varying degree of bowel dysfunction Varying degree of bowel dysfunction occur after restorative surgery subsequent occur after restorative surgery subsequent

to low anterior resection. to low anterior resection.

Superior results had been reported in Superior results had been reported in

patients offered colonic J-pouch anal patients offered colonic J-pouch anal anastomosis as compared to straight anastomosis as compared to straight

Coloanal anastomosis.Coloanal anastomosis.

Several factors have been identified Several factors have been identified which may render Colonic J-pouch anal which may render Colonic J-pouch anal

anastomosis difficult which led the anastomosis difficult which led the Cleveland clinic group to use the Cleveland clinic group to use the

Coloplasty technique to overcome such Coloplasty technique to overcome such difficulties.difficulties.

Despite superior results using coloplasty Despite superior results using coloplasty technique as compared to colonic J-pouch technique as compared to colonic J-pouch

in construction of colonic reservoir were in construction of colonic reservoir were reported by different authors, reported by different authors,

a higher leakage rate in coloplasty a higher leakage rate in coloplasty patients was reported in a recent study patients was reported in a recent study

as compared to leakage rate in the as compared to leakage rate in the colonic J-pouch patients (7/44, three of colonic J-pouch patients (7/44, three of them were clinically significant Vs. 0/44)them were clinically significant Vs. 0/44)

(Y.H. Ho et al. Ann Surg. 2002, 236: 49-55(Y.H. Ho et al. Ann Surg. 2002, 236: 49-55.) .)

Teniectomy had been used by Najafi and Teniectomy had been used by Najafi and Beattie in order to overcome short Beattie in order to overcome short colonic segment which couldn’t brought colonic segment which couldn’t brought up to the neck as an esophageal up to the neck as an esophageal substitute in a case report on 1964.substitute in a case report on 1964.

They excised the tenia coli preserving They excised the tenia coli preserving the underlying circular muscle layer. the underlying circular muscle layer.

In the present technical report a modification of In the present technical report a modification of the Teniectomy technique had been done by the Teniectomy technique had been done by the inclusion of the circular muscle layer with the inclusion of the circular muscle layer with the Teniectomy (i.e. short of the submucosa) in the Teniectomy (i.e. short of the submucosa) in order to effect widening of the teniectomized order to effect widening of the teniectomized colonic segment for the creation of a colonic segment for the creation of a sutureless colonic reservoir after low anterior sutureless colonic reservoir after low anterior resection.resection.

TechniqueTechnique

The technique was used in 2 patients The technique was used in 2 patients suffering from carcinoma of the lowersuffering from carcinoma of the lower

one third of the rectum. one third of the rectum.

First was 35 years old female with a First was 35 years old female with a history ofhistory of tenismus and bleeding per tenismus and bleeding per

rectum of 6 months durationrectum of 6 months duration

The second patient was 58 years old The second patient was 58 years old female with 2 months duration of bleeding female with 2 months duration of bleeding

and mucous per rectum of 2 months and mucous per rectum of 2 months duration. duration.

Both of them proved to have grade 2 Both of them proved to have grade 2 adenocarcinoma of the rectum 4 and 5 cm adenocarcinoma of the rectum 4 and 5 cm

from the anal verge respectively with no from the anal verge respectively with no evidence of distant metastases. evidence of distant metastases.

Both of those patients underwent a Both of those patients underwent a Sandwich technique of combined pre- and Sandwich technique of combined pre- and postoperative radio-chemotherapy given postoperative radio-chemotherapy given

as recommended by other authors .as recommended by other authors .

The technique involved total mesorectal The technique involved total mesorectal excision technique which was described excision technique which was described

by Heald at al . In both cases the upper 2 by Heald at al . In both cases the upper 2 cm of the anal canal were excised in order cm of the anal canal were excised in order to achieve an adequate 2 cm distal safety to achieve an adequate 2 cm distal safety margin and was combined with transanal margin and was combined with transanal mucosectomy down to the dentate line. mucosectomy down to the dentate line.

BothBoth patients had short mesentery which patients had short mesentery which rendered the creation of colonic Jrendered the creation of colonic J--pouchpouch difficult and at the time of operating on the difficult and at the time of operating on the first patient coloplasty techniquefirst patient coloplasty technique was not was not published yet on February 2000published yet on February 2000. .

The second patient was operatedThe second patient was operated upon 2 upon 2 years lateryears later..

The integrity of the mucosa was confirmed The integrity of the mucosa was confirmed before the Coloanal anastomosisbefore the Coloanal anastomosis by by visually inspecting the mucosa from visually inspecting the mucosa from outside during gentle fingeroutside during gentle finger palpation from palpation from inside of the teniectomized segment and inside of the teniectomized segment and by injecting a 100 ccby injecting a 100 cc of Methlylene Blue of Methlylene Blue colored saline injected in the pouch after colored saline injected in the pouch after the completionthe completion of the straight Coloanal of the straight Coloanal anastomosisanastomosis. .

The creation of a sutureless colonic pouch The creation of a sutureless colonic pouch was done using the doublewas done using the double Teniectomy Teniectomy technique by removing both the antitechnique by removing both the anti--mesentericmesenteric tenia colitenia coli which was followed which was followed by the creation of a protective transverse by the creation of a protective transverse looploop colostomy in the first patient but not colostomy in the first patient but not in the second patientin the second patient..

Defecography was done in order to Defecography was done in order to assess the integrity of the colonic pouchassess the integrity of the colonic pouch and the pouchand the pouch--anal segment 3 and 6 anal segment 3 and 6 months postoperatively in both patientsmonths postoperatively in both patients..

Further defecographic studies were Further defecographic studies were

done just before closure of thedone just before closure of the colostomy colostomy and 3 and 6 months after closure of the and 3 and 6 months after closure of the colostomy in the firstcolostomy in the first patientpatient..

P.O. Anal Incontinence Score was 3 & 4 P.O. Anal Incontinence Score was 3 & 4 respectively without medication (Pesctori respectively without medication (Pesctori Score).Score).

Rectal compliance was 4.2 & 4.9 Rectal compliance was 4.2 & 4.9 respectively as compared to 2.2, 1.9 and respectively as compared to 2.2, 1.9 and 2.4 for another 3 patients who had direct 2.4 for another 3 patients who had direct colo-anal anastomosis.colo-anal anastomosis.

DiscussionDiscussion

The creation of a colonic pouch is a widely The creation of a colonic pouch is a widely accepted and practiced techniqueaccepted and practiced technique to to improve the function after Coloanal improve the function after Coloanal

anastomosis.anastomosis.

Failure of colonic pouch anal anastomosis can Failure of colonic pouch anal anastomosis can take place due to 7 identified factors which may take place due to 7 identified factors which may be technical factors namely: be technical factors namely:

1.1. Narrow pelvis.Narrow pelvis.2.2. Bulky anal sphincter.Bulky anal sphincter.3.3. The need for mucosectomy.The need for mucosectomy.4.4. Diverticulosis.Diverticulosis.5.5. Insufficient colon length.Insufficient colon length.6.6. Pregnancy. Pregnancy. 7.7. Non-technical factors such as complex surgery Non-technical factors such as complex surgery

or the presence of distant metastases. or the presence of distant metastases.

The coloplasty technique a procedure The coloplasty technique a procedure invented by z’Graggen et al in pigs11invented by z’Graggen et al in pigs11 and and applied to humans by the Cleveland Clinic applied to humans by the Cleveland Clinic group offered an alternativegroup offered an alternative with a drop in with a drop in the intraoperative colonic pouch anal the intraoperative colonic pouch anal anastomosis failure rateanastomosis failure rate from 30.7% using from 30.7% using colonic J-pouch to 5.3% using the colonic J-pouch to 5.3% using the coloplasty technique.coloplasty technique.

However a higher leakage rate had been However a higher leakage rate had been recently reported in the coloplasty anal recently reported in the coloplasty anal anastomosis as compared to colonic J-anastomosis as compared to colonic J-pouch anal anastomosis (15.9% vs. 0% pouch anal anastomosis (15.9% vs. 0% leakage rate.leakage rate.

Unlike other techniques, the use of Unlike other techniques, the use of modified teniectomy technique create a modified teniectomy technique create a

sutureless colonic pouch whichsutureless colonic pouch which

theoretically minimizes the postoperative theoretically minimizes the postoperative leakage rate .leakage rate .

It is easy and fast technique (5-8 It is easy and fast technique (5-8 minutes for each Teniectomy) and is easy minutes for each Teniectomy) and is easy

to route into the pelvis as the straight to route into the pelvis as the straight Coloanal anastomosisColoanal anastomosis..

Unlike the other pouch techniques the Unlike the other pouch techniques the Teniectomy technique does notTeniectomy technique does not shorten shorten

the colon on the contrary it leads to the colon on the contrary it leads to elongation of theelongation of the deteniectomized deteniectomized segment as was reported by other segment as was reported by other

authors.authors.

(Najafi H. & Beattie J (1965) and Hovnanian A.P.& (Najafi H. & Beattie J (1965) and Hovnanian A.P.& Prudenico R (1968)Prudenico R (1968) ) )

The use of a 5 cm colonic segment distal The use of a 5 cm colonic segment distal to the sutureless colonic pouch wasto the sutureless colonic pouch was

Used in the present study in order to Used in the present study in order to partially compensate for the excisedpartially compensate for the excised

Proximal 2 cm of the anal canal including Proximal 2 cm of the anal canal including the internal anal sphincterthe internal anal sphincter..

Both patients had a normal Both patients had a normal (unobstructed) postoperative defecation (unobstructed) postoperative defecation

pattern as evidenced by their normal pattern as evidenced by their normal evacuation proctography.evacuation proctography.

Due to the lack of data on the effect of Due to the lack of data on the effect of radiotherapy on the deteniectomized radiotherapy on the deteniectomized

colonic segment, It is advisable to use colonic segment, It is advisable to use those neo-adjuvant protocols which avoids those neo-adjuvant protocols which avoids

postoperative radiotherapy by using postoperative radiotherapy by using preoperative radio-chemotherapy and preoperative radio-chemotherapy and

postoperative chemotherapy. postoperative chemotherapy.

A large controlled study comparing the A large controlled study comparing the colonic Jcolonic J--pouch, coloplasty andpouch, coloplasty and

sutureless pouch techniques after low sutureless pouch techniques after low anterior resections is stronglyanterior resections is strongly

recommendedrecommended. .

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