Comparison of the Colonic J-Pouch Versus Side-To-End Anastomosis Following Low Anterior Resection: A Systematic Review and Meta-Analysis

Abstract

Background

The aim of this systematic review and meta-analysis is to evaluate clinical, functional, and anorectal physiology outcomes of the side-to-end vs colonic J-pouch (CJP) anastomosis following anterior resection for rectal cancer.

Methods

A PRISMA-compliant systematic review and meta-analysis was conducted using multiple electronic databases and clinical trial registers and all studies comparing side-to-end vs CJP anastomosis were included. Peri-operative complications, mortality rate, functional bowel, and anorectal outcomes were evaluated.

Results

Eight randomized controlled trials (RCTs) and two observational studies with 1125 patients (side-to-end: n = 557; CJP: n = 568) were included. Of the entire functional bowel outcome parameters analyzed, only the sensation of incomplete bowel evacuation was significant in the CJP group at 6 months [OR: 2.07; 95% CI 1.06 - 4.02, P = .03]. Peri- and post-operative clinical parameters were comparable in both groups (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, anastomotic stricture formation and mortality). Equally, most of the analyzed anorectal physiology parameters (anorectal volume, anal squeeze pressure, maximum anal volume) were not significantly different between the two groups. However, anal resting pressure (mmHg) 2 years post-operatively was noted to be significantly higher in the side-to-end group than that of the CJP configuration [MD: −8.76; 95% CI - 15.91 - 1.61, P = .02].

Discussion

Clinical and functional outcomes following CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to low anterior resection syndrome in the short term but future well-designed; high-quality RCTs with long term follow-up are required.

Keywords

anterior resection colonic J-pouch side-to-end anastomosis rectal cancer

Introduction

Rectal cancer is one of the most common malignancies worldwide. Improvements in the understanding of cancer pathophysiology and surgical technologies have led to a decline in abdominoperineal resections (APR), first described by Miles.¹ Sphincter-preserving approaches, such as low anterior resection and total mesorectal excision (TME) have become increasingly desirable with emphasis on maintaining intestinal continuity, avoiding need for permanent stoma, and preserving anorectal function while maintaining acceptable oncological outcomes as compared with APR.^2,3

TME is considered the “gold standard” in rectal cancer surgery. Its increased use has led to a reduction in circumferential resection margin (CRM) positivity and improved survival rates. However, sphincter-sparing procedures involving partial/total rectal excision and a straight (end-to-end) anastomosis may lead to “low anterior resection syndrome” (LARS) as excision of the recto-sigmoid colon often leads to loss of the rectal reservoir function.^4,5 LARS is characterized by a collection of symptoms (incontinence, stool frequency/urgency, clustering of bowel motions) with profound adverse effects on patients’ quality of life (QoL).⁶

To overcome these, Lazorthes et al⁷ and Parc et al⁸ independently described the construction of a colonic J-pouch (CJP), created through closing and folding of the distal colon followed by anastomosing the base of the J-pouch with the residual rectum or anal canal.

This serves as a neo-rectal reservoir and studies have demonstrated that compared with a straight anastomosis, the CJP provides better QoL scores, superior functional outcomes, and improved anorectal function.^9-13

However, forming the CJP is technically more demanding and stool evacuation problems may persist post-operatively.¹² As a 5-8 cm long colonic segment is considered optimal for CJP construction, anatomical obstacles such as a narrow male pelvis or insufficient colon length means that not all patients are suitable.¹⁴

Therefore, the side-to-end coloanal anastomosis gained attention as this usually requires a shorter colonic segment of 3-5 cm.¹⁵ It offers a smaller reservoir compared with the CJP but retains functional advantages over a straight configuration. This modification may also offer similar functional advantages and benefits as conferred by the CJP¹⁶ but potentially associated with less long-term evacuation difficulties.

Recent meta-analyses have suggested that the CJP and side-to-end anastomosis are comparable in terms of functional outcomes, QoL parameters, and peri-operative outcomes.^5,17 We conducted an updated systematic review and meta-analysis using all available data to evaluate clinical, functional bowel, and anorectal physiology outcomes of the side-to-end vs CJP anastomosis.

Methods

This systematic review and meta-analysis was designed, performed, and reported as per the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.^18,19

Data Sources and Search Strategy

An online systematic search was conducted on 01/06/2022 using PubMed, Embase, Scopus, Cochrane Database of Systematic Reviews (CENTRAL), clinical trials.gov, ScienceDirect, and the virtual health library (VHL) by two independent authors. Moreover, the same authors independently evaluated the reference lists of included studies to identify relevant articles. Keywords used in the search are outlined in Supplementary file 1.

Design and Study Selection

Two independent authors screened titles, abstracts, or full texts of the selected articles to identify potentially eligible studies. These were carefully assessed against the eligibility criteria. All single-arm studies, case series, case reports, letters to the editor, and review articles were excluded. Disagreements in this process were resolved by discussion between the authors, consulting an independent author if required.

Data Extraction and Collection

Two authors independently performed data extraction from the selected studies including: study-related data; baseline demographic and clinical information of the study populations; and primary and secondary outcome data. A pre-generated standard Microsoft ® Excel (Microsoft Corporation, Redmond, Washington, USA) file was created, pilot-tested in randomly selected articles and adjusted accordingly. Disagreements at this stage were resolved by discussion and consensus with an independent third author consulted if no agreement could be reached.

Outcome Measures

Intra- and peri-operative outcomes (total operative time, intra-operative blood loss, anastomotic leak rate, return to theater, post-operative urinary tract infection, recto-vaginal fistula formation, anastomotic stricture/stenosis occurrence, and mortality rate) were the measured primary parameters. Secondary outcome measures were stool frequency per day and stool urgency (3, 6, and 12 months), tenesmus (6 months), anal resting pressure (2 years), anal resting pressure volume (6 months), anal squeeze pressure (2 years), and maximum anorectal volume (6 months and 2 years).

Risk of Bias Assessment

The Cochrane risk of bias tool was used to appraise the risk of bias for randomized trials.²⁰ Two investigators independently reviewed all studies and graded the risk as “high,” “low,” or “unclear” in the following categories: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other sources of bias.

The Newcastle–Ottawa Scale (NOS) was used to assess the risk of bias for observational studies.²¹ Studies were considered low, medium, or high-risk if the NOS score was 9, 7/8, ≤6, respectively. Disagreement in this process was resolved through discussion and consulting a third reviewer where required.

Statistical Analysis

Odds ratio (OR) was used as the statistical measure for dichotomous outcomes using the Mantel–Haenszel method. When 25% or more of the included studies reported zero events in both comparison groups, the risk difference (RD) was reported instead of the OR. For continuous outcomes, the mean difference (MD) with 95% confidence interval (CI) was estimated. When mean values were not available for continuous outcomes, data on median and interquartile range (IQR) were extracted and subsequently converted to mean and standard deviation (SD) using the well-practised equation described by Hozo et al.²²

P < .05 was considered statistically significant for all analyses, a 95% CI was used, and random-effects modeling was applied to all outcome analysis.

Between-study heterogeneity was assessed using the I² and χ² statistic. High values of I² and the χ2 statistic signify increasing levels of heterogeneity, with P < .05 or an I² value exceeding 50% indicating significant heterogeneity.¹⁹ To check possible causes of heterogeneity and evaluate the robustness of the results, sensitivity analysis was performed by calculating the risk ratio (RR) or RD for dichotomous variables. Moreover, leave one-out-analysis was conducted to assess the effect of each study individually. All statistical analysis was performed using Review Manager 5.0 (Nordic Cochrane Centre, Cochrane Collaboration).

Results

A total of 655 studies were identified and following review of titles/abstracts and removal of any duplicates, 525 studies were excluded. Full manuscripts of the remaining 130 were assessed, identifying 12 relevant articles^23-34 that were included in our final data synthesis.

PRISMA flow chart is shown in Figure 1.

Figure 1.

PRISMA flow diagram.

Two were cohort studies and eight randomized controlled trials (RCTs) with a total of 1125 patients divided into a side-to-end (n = 557) and CJP (n = 568) group. Two RCTs reporting different outcomes from the same cohort resulted in two separate publications.

Characteristics of the included studies are shown in Tables 1 and 2.

Table 1.

Characteristics of the Included Studies.

Author/Year	Country	Type of Study	Population (n)	Indication for Operation	Part of Bowel Used for J-Pouch Reconstruction	Inclusion Criteria	Exclusion Criteria
Huber et al (1999)	Germany	RCT	Total: n = 59 SE: 30 JP: 29	Rectal cancer	Descending colon	1. Patients with rectal cancer undergoing low anterior resection	1. Intersphincteric excision
Machado et al (2003)	Sweden	RCT	Total: n = 100 SE: 50 JP: 50	Rectal cancer	NR	1. Rectal cancer (tumor level ≤15 cm from anal verge) with no metastases on imaging 2. Low anterior resection considered feasible	NR
Machado et al (2005)	Sweden	RCT	Total: n = 71 SE: 35 JP: 36	Rectal cancer	NR	NR	NR
Jiang et al (2005)	Taiwan	RCT	Total: n = 48 SE: 24 JP: 24	Rectal cancer	Descending colon	1. Middle to low rectal tumor (≤10 cm from the anal verge as measured by rigid sigmoidoscopy) 2. Local curative resection 3. Normal continence pre-operatively 4. Sphincter preservation possible	1. Emergent cases
Tsunoda et al. (2008)	Japan	Cohort study	Total: n = 49 SE: 17 JP: 19	Rectal cancer	NR	1. Patients with cancer in middle and lower third of rectum (≤10 cm from anal verge as measured via colonoscopy) undergoing anterior resection	NR
Doeksen et al (2011)	Netherlands	RCT	Total: n = 107 (100 had procedure) SE: 52 (47 had procedure) JP: 55 (43 had procedure)	Rectal cancer	Descending colon/sigmoid colon	1. Histology proven rectal cancer located in the middle or distal part of rectum (≤10 cm from anal verge) 2. WHO performance status of ≤2	1. cT1 or cT4 tumors 2. Distant metastases 3. Previous colonic resection/anorectal surgery or chemo-radiotherapy 4. Pre-existing faecal incontinence of grades III or IV according to Parks 5. Life expectancy of <1 year
Markovic et al (2015)	Serbia	Cohort study	Total: n = 80 SE: 40 JP: 40	Rectal cancer	Sigmoid colon	1. Patients with middle and lower third rectal cancer	NR
Okkabaz et al (2017)	Turkey	RCT	Total: n = 74 (41 analyzed) SE: 37 (23 analyzed) JP: 37 (18 analyzed)	Rectal cancer	NR	1. All consecutive rectal cancer patients, with tumors up to 12 cm from the dentate line as observed with a rigid rectosigmoidoscope	1. Patient refusal 2. Pregnancy 3. Previous radiation therapy to pelvis 4. Cancer other than adenocarcinoma 5. Planned local excision or AP resection before surgery
Marti et al (2018)	Switzerland	RCT	Total: n = 224 (158 had procedure and analyzed) SE: 112 (63 analyzed) JP: 112 (111 had procedure, 95 analyzed)	Rectal cancer	NR	1. Histologically proven rectal adenocarcinoma, or rectal adenoma with or without neo-adjuvant therapy requiring TME 2. Age ≥18 years 3. Clinically normal function of sphincter muscles with no history of frequent faecal incontinence 4. Pre-treatment staging of any TNM or adenoma 5. Expected R0-resection 6. Completed baseline interview on evacuation and incontinence	1. Rectal cancer surgery other than local excision in previous 2 months 2. Planned adjuvant post-op radiotherapy 3. IBD 4. Contraindication for any of the surgical techniques 5. BMI >35 6. Psychiatric, addictive or any disorder prohibiting informed consent 7. Inability to read and understand languages on questionnaires and during interview
Rasulov et al (2018)	Russia	RCT	Total: n = 90 SE: 30 JP: 22	Rectal adenoma or rectal adenocarcinoma	NR	1. Patients <75 years of age with tumor 5 10 cm from the ano-cutaneous line 2. MR stage T1sm3–T4a	1. Severe concomitant diseases 2. 2nd-3rd degree anal incontinence 3. Injuries/operations on the anal canal 4. History of mental illness 5. ECOG status ≤2
Ribi et al (2019)	Switzerland	RCT	Total: n = 224 (223 had procedure) SE: 112 (111 had procedure) JP: 112	Rectal cancer	Descending colon	1. Histology proven rectal adenocarcinoma or adenoma +/− neo-adjuvant therapy who had TME 2. ≥18 years of age 3. Clinically normal function of sphincter muscle 4. Expected R0 resection	1. Psychiatric or any disorder that could interfere with assessment or inability to read any of three languages available on questionnaire 2. Adjuvant pelvic radiotherapy
Parc et al (2019)	USA	RCT	Total: n = 238 (167 analyzed) SE: 116 (87 analyzed) JP: 122 (80 analyzed)	Rectal cancer	Descending colon	1. Patients with low rectal cancer	1. Metastatic disease 2. Radiation to the pelvis for other cancers 3. History of synchronous or metachronous cancers 4. Previous right colectomy 5. IBD 6. Dementia 7. Inability to comprehend or fill out questionnaires 8. Pregnancy

RCT, randomized controlled trial; SE, side-to-end anastomosis; JP, colonic J-pouch anastomosis; NR, not recorded; WHO, World Health Organization; TME, total mesorectal excision; MR, magnetic resonance imaging; AP, abdominoperineal; IBD, inflammatory bowel disease; BMI, body mass index; ECOG, Eastern Cooperative Oncology Group.

Table 2.

Baseline Characteristics of the Study Population.

Author Year	Age (years) Median (Range)/Mean ± SD		Gender (Male:Female)		BMI Median (Range)/Mean ± SD		Tumor Height Above Anal Verge (cm) Median (Range)/Mean ± SD		Anastomotic Height Above Anal Verge (cm) Median (Range)/Mean ± SD
Author Year	SE	JP	SE	JP	SE	JP	SE	JP	SE	JP
Huber et al (1999)	61.9	62.3	12:18	13:16	NR	NR	NR	NR	4.2 (mean)	3.8 (mean)
Machado et al (2003)	66.5 (40-87)	67 (38-83)	32:18	27:23	NR	NR	10 (4-15)	10 (3-15)	4 (2-5)	4 (2-6)
Machado et al (2005)	66 (50-87)	65 (38-83)	21:14	18:18	NR	NR	10 (4-15)	10 (3-15)	4 (2-5)	4 (2-5)
Jiang et al (2005)	64.9 ± 2.8	62.3 ± 3.3	15:9	12:12	NR	NR	8.6 ±0.3	7.9 ±1.5	5.3 ±0.3	4.8 ±0.2
Tsunoda et al (2008)	62 (29-89)	60 (45-79)	11:6	11:8	NR	NR	middle/lower third rectum (n): 5/12	middle/lower third rectum (n): 3/16	4 (2.5-6)	4 (3-6)
Doeksen et al (2011)	66 (44-79)	66 (33-82)	37:15	36:19	NR	NR	≤10 cm	≤10 cm	NR	NR
Markovic et al (2015)	56.4 (35-79)	55.25 (34-78)	30:10	23:17	NR	NR	NR	NR	2-4	2-4
Okkabaz et al (2017)	59.1 ± 11.9	58.9 ± 13.7	19:9	18:11	NR	NR	6.2 ±3.8	7.9 ±3.8	NR	NR
Marti et al (2018)	67.2 (32.3-88.9)	68.6 (30.9-85.5)	62:33	38:25	24.3 (median)	24.2 (median)	7.0 (1-15)	6 (1-11)	NR	NR
Rasulov et al (2018)	60 (28-71)	57 (30-68)	18:12	6:16	26.5 (mean)	24.9 (mean)	7 (5-10)	7 (5-10)	NR	NR
Ribi et al (2019)	67.2 (32.3-88.9)	68.6 (30.9-85.5)	62:33	38:25	24.3 (median)	24.2 (median)	7 (1-15)	6 (1-11)	NR	NR
Parc et al (2019)	59.6 ± 10.6	60.2 ± 9.7	52:35	59:21	26.2 ± 4.9	28.5 ± 18.3	NR	NR	NR	NR

SD, standard deviation; SE, side-to-end anastomosis; JP, colonic J-pouch anastomosis; BMI, body mass index; NR, not recorded.

Risk of bias assessment for the RCTs and observational studies is shown in Figure 2 and Table 3, respectively.

Figure 2.

Risk of bias assessment of included randomized controlled trials. (A) Risk of bias summary, (B) Risk of bias graph.

Table 3.

Methodological Quality of Observational Studies Assessed using the Newcastle–Ottawa Scale (NOS).

Study and year	Representativeness of the Exposed Cohort	Selection of the Non-exposed Cohort	Ascertainment of Exposure	Demonstration that Outcome of Interest was Not Present at Start of Study	Comparability of Cohorts Based on the Design or Analysis Controlled for Confounders	Assessment of Outcome	Was Follow-Up Long Enough for Outcomes to Occur	Adequacy of Follow-up of Cohorts	Total Score
Tsunoda et al (2008)	*		*	*		*	*	*	6
Markovic et al (2015)	*		*	*		*	*	*	6

Outcomes

Primary Outcomes

Total operative time (minutes)

Operative time was reported in five studies^{24,28,30,31,34} (n = 408) with no significant difference between the side-to-end and CJP group [MD: −5.65; 95% CI -33.47, 22.17, P = .69]. The between-study heterogeneity was high (I² = 87%, P < .00001).

Intra-Operative Blood Loss (mL)

Intra-operative blood loss was reported in four studies^24,28,30,34 (n = 257) with no significant difference between the two groups [MD: 6.82; 95% CI -100.14, 113.78, P = .90]. The between-study heterogeneity was high (I² = 84%, P = .0004).

Anastomotic Leak Rate

Six studies^{24,26,27,30-32} with 519 patients reported on post-procedure anastomotic leak with rates of 11.7% (CJP group) and 7.3% (side-to-end group), respectively. No significant difference was seen [OR: 1.35; 95% CI .7, 2.62, P = .37] and the level of heterogeneity detected between the included studies was low (I² = 2%, P = .41).

Return to Theater

Two studies^24,30 (n = 157) reported on return to theater with 10.1% and 10.3% in the CJP and side-to-end group, respectively. The results were not statistically significant [OR: 1.14; 95% CI .22, 5.94, P = .88]. Cochran Q test revealed a moderate level of between-study heterogeneity (I² = 30%, P = .23).

Post-Operative Urinary Tract Infection

Urinary tract infection (UTI) was reported in three studies^24,27,28 (n = 255) with a higher rate in the CJP group (6.9%) compared with the side-to-end group (3.9%). However, there was no significant difference [OR: 1.61; 95% CI .52, 5.01, P = .41] and a low level of heterogeneity existed between the studies (I² = 0%, P = .49).

Recto-Vaginal Fistula Formation

Three studies^26,28,31 reported on the incidence of post-operative recto-vaginal fistula formation with no significant difference between the groups [OR: 1.05; 95% CI .21, 5.32, P = .95]. No significant between-study heterogeneity was detected (I² = 0%, P = .42).

Anastomotic Stricture/Stenosis Occurrence

Anastomotic stricture or stenosis was reported in four studies^24,28,30,31 (n = 312) with rates of 3.5% (CJP group) and 2.7% (side-to-end group), respectively. No significant difference was observed [OR: 1.12; 95% CI .31, 4.02, P = .41] and the Cochran Q test revealed a low level of between‐study heterogeneity (I² = 0%, P = .43).

Mortality Rate

Four studies^24,27,28,30 (n = 312) reported on mortality rate, estimated as 1.9% (CJP) and 1.3% (side-to-end group) with no significant difference between them [OR: 1.19; 95% CI .21, 6.82, P = .84]. A low level of between-study heterogeneity was observed (I² = 0%, P = .47).

Functional Bowel Outcomes

Stool frequency and urgency (3, 6 and 12 months)

Post-operative stool frequency over a 24-hour period and stool urgency were evaluated at 3, 6, and 12 months. Varying number of studies reported on these outcomes at different time intervals. No significant difference was detected for either of these outcomes between the two groups at the various time intervals (Figure 3).

Figure 3.

Forest plots of comparison of (1) total operative time (minutes), (2) intra-operative blood loss (mL), (3) anastomotic leak rate, (4) return to theater, (5) post-operative urinary tract infection, (6) recto-vaginal fistula formation, (7) anastomotic stricture/stenosis occurrence, (8) mortality rate, (9) stool frequency per day (3 months), (10) stool frequency per day (6 months), (11) stool frequency per day (12 months), (12) stool urgency (3 months), (13) stool urgency (6 months), (14) stool urgency (12 months), (15) tenesmus, (16) anal resting pressure (mmHg) at 2 years, (17) resting pressure volume (mL) at 6 months, (18) anal squeeze pressure (mmHg) at 2 years, (19) maximum anorectal volume (mL) at 6 months, and (20) maximum anorectal volume (mL) at 2 years. The solid squares denote the odds ratio or mean difference. The horizontal lines represent the 95% confidence intervals (CIs), and the diamond denotes the pooled effect size. CJP, colonic J-pouch; M–H, Mantel–Haenszel test.

Tenesmus (6 months)

Tenesmus 6 months post procedure was reported in three studies^24,26,28 (n = 70) with 42.7% in the CJP group and 29.3% in the side-to-end group. This was significantly higher in the CJP group [OR: 2.07; 95% CI 1.06, 4.02, P = .03] with no significant heterogeneity detected between studies (I² = 0%, P = .91).

Anal resting pressure (2 years)

Anal resting pressure (mmHg) 2 years post-operatively was reported by two studies^25,28 (n = 119) and was significantly higher in the side-to-end group compared with the CJP configuration [MD: −8.76; 95% CI -15.91, −1.61, P = .02]. Cochran Q test revealed significant between-study heterogeneity (I² = 90%, P = .002).

Other Functional Bowel Outcomes

Other functional bowel outcomes that were evaluated included resting pressure volume (mL) at 6 months,^26,28 anal squeeze pressure (mmHg) at 2 years,^25,28 maximum anorectal volume (mL) at 6 months,^26,28 and 2 years,^25,28 respectively (Figure 3).

These outcomes were reported in two studies and no significant difference was observed between the groups. Cochran Q test revealed significant between-study heterogeneity.

Sub-Group Analysis

Sub-group analysis was performed for the following outcomes: stool frequency (3, 6, and 12 months post-operatively), stool urgency (3, 6 and 12 months post-operatively) and anastomotic leak rate. Conducting sub-group analysis separately for RCTs and observational studies resulted in no change in the direction of the corresponding forest plots (Figure 4).

Figure 4.

Sub-group analysis forest plots of comparison of (1) stool frequency per day (3 months), (2) stool frequency per day (6 months), (3) stool frequency per day (12 months), (4) stool urgency (3 months), (5) stool urgency (6 months), (6) stool urgency (12 months), and (7) anastomotic leak rate. The solid squares denote the odds ratio or mean difference. The horizontal lines represent the 95% confidence intervals (CIs), and the diamond denotes the pooled effect size. M–H, Mantel–Haenszel test.

Outcome Synthesis

Outcomes are summarized in Figures 3 and 4.

Discussion

Our recent comparative review of outcomes following straight (end-to-end) vs CJP anastomosis after low anterior resections found that the J-pouch was associated with a lower risk for anastomotic leak and re-operation.³⁵ Furthermore, better functional outcomes such as stool frequency were achieved using the CJP reconstruction over the straight anastomosis.³⁵ However, not all patients are considered suitable anatomically for creation of a J-pouch. A modified technique such as a side-to-end configuration may help to address/overcome these challenges while maintaining functional advantages over the end-to-end anastomosis.

Two recent meta-analyses of RCTs have suggested that the CJP and side-to-end anastomosis are comparable in terms of functional outcomes, QoL parameters, and peri-operative outcomes.^5,17 We conducted an updated review and meta-analysis to include all study types to evaluate clinical, functional, and anorectal physiology outcomes between these two surgical procedures.

The review by Wang⁵ included seven trials and 696 patients, whilst Hou et al¹⁷ had 864 patients from ten publications. We add to the existing knowledge base by including results from additional observational studies with a total of 1125 patients.

We found comparable peri- and post-operative clinical outcomes between the two surgical approaches. Of the functional bowel outcomes analyzed, only the sensation of incomplete bowel evacuation (tenesmus) was found to be significantly higher in the CJP group at 6 months. Most of the analyzed anorectal physiology parameters were not significantly different between the two groups. However, anal resting pressure 2 years post-operatively was noted to be significantly higher in the side-to-end group compared with the CJP configuration.

Recent surgical advances have resulted in improved clinical and oncological outcomes with emphasis now on improving QoL parameters and post-operative bowel function. These functional outcomes may be improved with the creation of reservoirs after low anterior resection for rectal cancer.³⁶ 1 such reconfiguration strategy is the side-to-end bowel anastomosis. It may be useful in cases where CJP creation proves difficult due to anatomical limitations and has comparable surgical outcomes. Prospective randomized trials have suggested that a CJP may not be achievable in a quarter of cases of distal rectal cancer surgery.^37,38 Moreover, the side-to-end anastomosis is associated with a reduced sensation of incomplete stool evacuation and a higher anal resting pressure long term.

This latter outcome is an important finding as the pressure is indicative of the baseline tonicity of the internal and external anal sphincters. Average resting and anal squeeze pressures are generally low in incontinent patients.

Doeksen et al²⁷ reported better functional outcomes (stool frequency and incontinence) in the J-pouch group compared with side-to-end anastomosis at 4- and 12 months post reversal of stoma. However, these outcomes were reported as a summary score on the COloREctal Functional Outcome scale and the advantages were present at baseline. A further study (limited by several biases) also showed a significant reduction in stool frequency in favor of the CJP group up to 36-months post procedure.³⁹

Machado et al^24,25 showed no significant difference in incontinence between the two groups at any time point. Similarly, studies have also suggested no significant differences in faecal urgency^24,26 and anti-diarrheal use between the two groups.^25,28 Overall, in keeping with the literature^4,40 our findings (other than sensation of complete stool evacuation and anal resting pressure) failed to reveal any significant differences in functional endpoints during the early, intermediate, or late post-operative phase.

Doeksen et al²⁷ also compared QoL parameters between the two groups. Using the EORTC QLQ-CR38 and Short Form 36 (SF-36) questionnaires, they found no significant differences at any time points.

The superiority of the CJP in terms of functional outcomes over the end-to-end anastomosis has already been demonstrated. Functional and anorectal physiology outcomes following a side-to-end anastomosis seem to be comparable to J-pouch formation. Therefore, it can be inferred that the side-to-end technique may be advantageous in terms of post-operative bowel function compared to the straight configuration. However, long-term data is lacking to make robust conclusions about the superiority of any of the reconstruction techniques. Additionally, complicating factors such as the use of chemo-radiotherapy need to be considered as they may potentially impact long-term bowel function.⁴¹ Nevertheless, the technically less demanding side-to-end anastomosis (in selected cases) offers a suitable alternative in sphincter-saving surgery.

This meta-analysis is not without its limitations. High levels of heterogeneity existed between the included studies for some of the outcome parameters and sensitivity analysis was unable to reduce this. Moreover, we included a mixture of RCTs and observational data. Two of our RCTs reported different outcomes from the same cohort resulting in two separate publications potentially introducing bias in our analysis. Anorectal physiology was inconsistently reported making it challenging to analyze and interpret these parameters. To ensure universality and standardization amongst authors and researchers the International Anorectal Physiology Working Group (IAPWG) recently released a position paper on its recommendations.⁴²

Other factors such as female sex, advanced age, and parity are associated with a deleterious effect on sphincter and rectal sensory function and these need to be considered when interpreting data.

In this study we did not analyze outcomes such as nocturnal stool incontinence, stool deferment and fragmentation, and differentiation between flatus and faeces. Additionally, the use of anti-diarrheal agents was inconsistently reported and the data insufficient to allow meaningful analysis. These are important elements of bowel dysfunction associated with LARS.

Conclusion

Clinical and functional outcomes from CJP surgery and side-to-end coloanal anastomosis are comparable. Neither technique appears to proffer solution to LARS in the short term but future well-designed, high-quality randomized trials with long term follow-up are required.

Supplemental Material

Supplemental Material - Comparison of the Colonic J-Pouch Versus Side-to-end Anastomosis Following Low Anterior Resection: A Systematic Review and Meta-Analysis

Supplemental Material for Comparison of the Colonic J-Pouch Versus Side-to-end Anastomosis Following Low Anterior Resection: A Systematic Review and Meta-Analysis by Shafquat Zaman, Elizabeth Peterknecht, Pratik Bhattacharya, Adewale A. Ayeni, Helen Gilbody, Adil N. Ahmad, Ali Y.-Y. Mohamedahmed, and Akinfemi Akingboye in The American Surgeon

Footnotes

Author Contributions

Study conceptualization: AYYM, AA & AA

Methodology: SZ, AYYM, AA

Data curation: EP, PB, AA, HG

Formal data analysis: PB, AYYM

Writing of original draft: SZ, EP, PB

Review and editing of manuscript: ANA, AA

Final approval: All authors

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Guarantor

Mr Akinfemi Akingboye

Supplemental Material

Supplemental material for this article is available online.

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