Perineal pseudocontinent colostomy is safe and efficient technique for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma

The management of ultra-low rectal cancer less than 2 cm from the dentate line is still challenging. The only two procedures available are an abdominoperineal resection (APR) with definitive iliac colostomy and intersphincteric resection (ISR) with a coloanal anastomosis. However ISR oncological and functional results are still debatable, the reason why APR remains the gold standard technique when both internal and external sphincter are involved.

Perineal pseudocontinent colostomy (PCPC) is a reconstruction technique performed after APR, in which the permanent colostomy is placed in the perineum instead of left low quadrant of the abdomen [1]. In this procedure, a graft of smooth colonic muscle tightly surrounds the lowered colon. This technique was first described by Schmidt [2], for abdominal colostomies, and then applied by Gamagami to the perineum [3]. It was encouraged by the fact that it offers two major advantages: preservation of the body image by invisible perineal placement, improving the quality of life of these patients [4], and a reasonable continence with acceptable functional results [3,5-7]. Since previous studies reported that abdominal colostomy is associated with a negative impact on the quality of life [8-10], especially in Muslim patients [11], this technique could be a very interesting for these patients [12].

The main concern about PCPC in all previous published studies was only its promising functional results [3-7,13-16]. Only Goere and al reported oncological outcomes of PCPC after APR for 19 anal epidermoid carcinoma.

The aim of this study was to evaluate long-term oncologic results and patients satisfaction of PCPC using Schmidt technique in Moroccan patients undergoing APR for managing lower rectal adenocarcinoma.

This study is the largest series of pseudocontinent perineal colostomy for rectal adenocarcinoma in the literature, showing that it is oncologically safe and provides high satisfaction rate.

Local and distant recurrences occurred in respectively 6,8% and 20% of the patients with an overall and disease free and five year survival rate of respectively 74,6% and 60,3%.

These results are comparable to classic APR with primary perineal closure in the literature [18-20], since PCPC is only a pelvic reconstruction after rectal resection respecting the rules of oncologic surgery. Moreover, the main theoretical oncological advantage of this technique is to allow an early diagnosis of pelvic recurrences by rectal examination or by echo-endoscopy [14,21], as the case of our study, all local recurrences were detected by clinical rectal inspection and confirmed by histological findings before starting adequate treatment.

Functional results of CPC are good with a high kirwan score (stage A and B) in 68% of the cases with no need to wear pads and no soiling [7]. More over, 77% of the patients were highly satisfied and none of them regretted the choice of this alternative to abdominal colostomy.

Many authors reported that permanent iliac colostomy could significantly alter patients’ quality of life by affecting negatively physical, sexual, social, and psychological aspects of life [8-10,22]. Cakmak and al demonstrated that social and sexual aspects of life are also affected in spouses of patients with colostomies [22]. Since 80% of patients reported that the reason for their inactive sexual life was their spouse’s abdominal colostomy, which they found repulsive [22]. Kuzu et al. showed that social, physical, sexual, and psychological aspects of life, in addition to religious worship, are severely impaired by sphincter sacrificing surgery in the Islamic population [11]. Indeed, daily praying and fasting were altered, since significantly greater number of Muslim who underwent APR stopped daily praying and did not fast during Ramadan [11]. In Islamic societies, religious rituals are considered as an important factor of social adaptation and improved quality of life.

In our study, we proposed the PCPC technique to our patients believing that it would be more adapted to their economic situation, social and religious specificities of our population. By allowing body image preservation, PCPC makes easy the social reinsertion and avoids the alteration of quality of life due to permanent iliac colostomy, especially in Muslim patients. These reasons could explain the high rate of satisfaction among our patients.

Several techniques of anal sphincter reconstruction and perineal closure have been described: myocutanus flaps as RAM flap to cover a large skin defect; artificial sphincter [23] or nearby skeletal muscles including gracilis, gluteus maximus or adductor longus muscle [24-26], with or without electrical stimulator transposed around the PCPC [27] to increase the continence of the neosphincter; more recently the combination of both RAM flap and PCPC [28] or . However, PCPC remains a simpler technique, easy to learn, that may be performed routinely after every APR in selected patients. It is performed by the same perineal incision, less costly to achieve with no need to apply any other synthetic material.

This study has some limitations, by its retrospective aspect and large period studied, we weren’t able to descibe more details about to pathological assessement, quality of mesorectal excition and lateral margins . Furthermore, our assessement of satisfaction was subjective and the use of QOL questionnary as (EORTC) would be more helpful. Further investigation related to specific impact of PCPC on muslim population should be done by comparing APR combined to abdominal colostomy to those with PCPC compared in two different groups according to their religions.

To our knowledge and by the time of writing this article, this is the largest study of patients who have undergone perineal colostomy for lower rectal adenocarcinoma that assessed the oncological results and subjective satisfaction rate of this technique. It allows good functional results without compromising oncological safety. Based on our data, we recommend the use of PCPC for perineal reconstruction in selected patients after APR for very low rectal adenocarcinoma, especially for Muslim patients.

This study shows that pseudocontinent perineal colostomy is a simple, safe and reliable pelvic reconstruction technique after abdominoperineal resection for lower rectal adenocarcinoma. It provides a high degree of patient satisfaction without compromising oncological results. It is a good option in selected patients especially in the muslim and low-income countries population.