Safety and efficacy of side-to-end anastomosis versus colonic J-pouch anastomosis in sphincter-preserving resections: an updated meta-analysis of randomized controlled trials

Abstract

Background The application of side-to-end anastomosis (SEA) in sphincter-preserving resection (SPR) is controversial. We performed a meta-analysis to compare the safety and efficacy of SEA with colonic J-pouch (CJP) anastomosis, which had been proven effective in improving postoperative bowel function. Methods The protocol was registered in PROSPERO under number CRD42020206764. PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials databases were searched. The inclusion criteria were randomized controlled trials (RCTs) that evaluated the safety or efficacy of SEA in comparison with CJP anastomosis. The outcomes included the pooled risk ratio (RR) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. All outcomes were calculated with 95% confidence intervals (CI) by STATA software (Stata 14, Stata Corporation, TX, USA). Results A total of 864 patients from 10 RCTs were included in the meta-analysis. Patients undergoing SEA had a higher defecation frequency at 12 months after SPR (WMD = 0.20; 95% CI, 0.14–0.26; P < 0.01) than those undergoing CJP anastomosis with low heterogeneity (I2 = 0%, P = 0.54) and a lower incidence of incomplete defecation at 3 months after surgery (RR = 0.28; 95% CI, 0.09–0.86; P = 0.03). A shorter operating time (WMD = − 17.65; 95% CI, − 23.28 to − 12.02; P < 0.01) was also observed in the SEA group without significant heterogeneity (I2 = 0%, P = 0.54). A higher anorectal resting pressure (WMD = 6.25; 95% CI, 0.17–12.32; P = 0.04) was found in the SEA group but the heterogeneity was high (I2 = 84.5%, P = 0.84). No significant differences were observed between the groups in terms of efficacy outcomes including defecation frequency, the incidence of urgency, incomplete defecation, the use of pads, enema, medications, anorectal squeeze pressure and maximum rectal volume, or safety outcomes including operating time, blood loss, the use of protective stoma, postoperative complications, clinical outcomes, and oncological outcomes. Conclusions The present evidence suggests that SEA is an effective anastomotic strategy to achieve similar postoperative bowel function without increasing the risk of complications compared with CJP anastomosis. The advantages of SEA include a shorter operating time, a lower incidence of incomplete defecation at 3 months after surgery, and better sphincter function. However, close attention should be paid to the long-term defecation frequency after SPR.

The role of colonic motility in low anterior resection syndrome

“…Functional outcomes have been thoroughly compared after various reconstructive techniques in numerous meta-analyses (90-97). When compared to straight anastomoses, CJP have been shown to be associated with lower stool frequency for up to 12-months, but no longer than 2 years (90, 92, 94,95,97,98). SEA anastomoses have been associated with reduced incomplete defecation compared to CJP (97), but generally the two techniques have equivalent functional outcomes (90, 95,96).…”

“…When compared to straight anastomoses, CJP have been shown to be associated with lower stool frequency for up to 12-months, but no longer than 2 years (90, 92, 94,95,97,98). SEA anastomoses have been associated with reduced incomplete defecation compared to CJP (97), but generally the two techniques have equivalent functional outcomes (90, 95,96). In contrast to the vast literature on functional outcomes, there is sparse investigation of underlying physiological or mechanistic differences between the reconstruction techniques.…”

Coloanal Anastomosis

“…Double-stapled anastomosis is faster and has good functional outcomes. 21 In a double-stapled technique, there is limited benefit of a colonic J-pouch and is functionally similar to a SEA. SEA is a more time-efficient anastomosis and therefore preferred in the double-stapled technique.…”

The Colorectal Anastomosis: A Timeless Challenge

“…The authors concluded that a short limb is preferred but the findings are generally regarded as equivocal. 107,118…”