Retained Rectal Stump

The use of stapling in the realisation of the pouchanal anastomosis or the insufficient execution of mucosectomy are the main causes of retention of rectal mucosa. In fact, with the double stapling technique, a little stump of rectal mucosa of variable length from 1.5-3 cm, in which the disease persists, is left In Situ. A certain degree of inflammation is commonly found on the biopsies carried out on the residual cuff of the columnar epithelium. However, this only causes symptoms in 2-15% of patients [39-42].

According to the experience of Herbst [38] in a study of 16 PRs with OO, in half of the patients, the functional disturbance was associated with an LEL of the S-pouch, five were associated with a stenosis of the pouch-anal anastomosis, and one was associated with a stenosis associated to an LEL, while two were associated with a long rectal stump. None of the patients had the reservoir reconstructed during a subsequent operation and surgery was successful in 80% of cases. The author concludes that with the use of a mechanical pouch-anal anastomosis, the incidence of a long rectal stump increases because of OO [38].

Lavery of the Cleveland Clinic, in one study focussing on 227 patients with PR, reports the presence of inflammation of the cuff, histologically demonstrated, in 82% of cases. This condition generated a clinical symptomatology in only 14.7% of the patients. The more frequent disturbances during cuf-fitis are bleeding, burning and urgency; moreover, neoplastic transformation of the residual rectal mucosa is possible [39, 40, 43]. Local treatment with steroids can determine remission of symptoms, but often definitive resolution of clinical presentation is possible only with surgical therapy.

Five patients of the series of Dehni [23] received a salvage procedure of the pouch for complications due to a long rectal stump with the presence of severe cuffitis in two cases, difficulty of emptying in two others and development of carcinoma on the stump in one case. Four of these patients demanded a new anastomosis carried out via a transanal approach and one demanded a review via an abdominalperineal approach.

If the retained portion of mucosa is short, a transanal approach can be possible, but in the majority of the cases, a combined abdominoperineal approach, that includes removal of the residual rectum followed by manual mucosectomy and transanal refashioning of the pouch-anal anastomosis is necessary.

Curran [42] reports three cases where there was a necessity to carry out a transanal mucosectomy for resolution of the symptomatology. In one of these cases the removal of the pouch was necessary. Fazio obtained good results associating the advance of the reservoir to a transanal [44].

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