Pouchanlage und andere Maßnahmen zur Verbesserung der Kontinenz nach tiefer anteriorer Rektumresektion mit TME

Zusammenfassung

75-95 % der Rektumkarzinome können ohne Einbuße an onkologischer Qualität sphinktererhaltend operiert werden. Allerdings treten bei etwa 50 % der Patienten nach subtotaler oder totaler Rektumresektion Kontinenzstörungen auf, auch als anteriores Resektionssyndrom bezeichnet, wenn die Kontinuität mit einer direkten kolorektalen oder koloanalen Anastomose wiederhergestellt wird. Gegenüber der direkten Anastomose verbessert der Kolonpouch durch seine Reservoirfunktion die Kontinenz. Die Verbesserung verschiedener Kontinenzparameter ist evidenzbasiert, sodass der Kolonpouch nach tiefer anteriorer Resektion mit totaler mesorektaler Exzision regelhaft angelegt werden sollte. Hinsichtlich der Funktion und der Komplikationsrate sind der Kolon-J-Pouch, das am besten untersuchte Verfahren, und die Koloplastie gleichwertige Alternativen. Dabei hat sich eine Länge des J-Pouches von 5-6 cm als funktionell am günstigsten erwiesen. Die Seit-zu-End-Anastomose scheint nach den vorliegenden Daten jedoch gleichwertig zu sein. Der Ileozökalpouch ist dagegen wegen des hohen operativen Aufwandes und der schlechteren Funktion nur ein Ausweichverfahren. Der temporäre Verlust des rektoinhibitorischen Reflexes sowie Funktionsstörungen des Sphinkters durch das Dehnungstrauma und durch Verletzungen der autonomen Nerven tragen ebenfalls zum anterioren Resektionssyndrom bei. Die intersphinktere Resektion aggraviert das Syndrom durch den Verlust der Transitionalzone, des Hämorrhoidalplexus und des kranialen Teils des internen Sphinkters. Neben der Pouchanlage kann die Kontinenz mit zwei operationstechnischen Maßnahmen verbessert werden: Das Dehnungstrauma kann bei der Anlage des Kolon-J-Pouches durch die inverse Double-stapling-Technik vermieden werden. Die Darstellung der autonomen Nerven verhindert ihre Läsion und damit eine weitere Funktionsstörung des internen Sphinkters.

Abstract

In 75 to 90 % of patients with rectal cancer, a sphincter-preserving resection can be performed without violating oncological principles. However, almost 50 % of the patients suffer from an anterior resection syndrome after total or subtotal rectal resection with a straight colorectal or coloanal anastomosis. This syndrome describes the characteristic complaints of minor or major incontinence. The anastomosis with the colonic pouch has been proved to result in better continence in the short- and long-terms compared to the straight anastomosis. Based on grade 1 evidence, the colonic pouch should be recommended as a standard procedure after low anterior resection with total mesorectal excision (TME). Both the colonic J pouch of 6-cm length and the coloplasty have been shown to be of equal value in respect to function and morbidity. With regard to the complicated procedure and the poorer functional outcome, the ileocecal pouch should only be applied in cases without the option of an alternative pouch design. The temporary loss of the rectoanal inhibitory reflex, the sphincter lesion caused by the instrumental dilatation in stapling or peranal hand-sutured anastomosis and the disturbed function of the internal sphincter due to the autonomous nerve damage additionally contribute to the anterior resection syndrome. In the intersphincteric resection, the loss of the transitional zone and the hemorrhoidal cushion as well as the removal of the upper part of the internal sphincter aggravate the incontinence. For better continence, two operative procedures should be recommended: By applying the inverse double stapling technique in anastomizing the colonic J pouch, the sphincter lesion as a consequence of the dilatation can be avoided. The nerve-sparing mesorectal excision helps to preserve the function of the internal sphincter.

Schlüsselwörter

Rektumkarzinom - anteriores Resektionssyndrom - Kolonpouch

Key words

rectal cancer - anterior resection syndrome - colon pouch

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