We have created a new anus with a new bowel shphincter to avoid colostomy (stoma, ostomy) since 1995. .

Introduction of
‘neoanus with a pudendal nerve anastomosis’ (NAPNA)
after abdominoperineal excision of the rectum 
　　　　　　　　　　　　　　　　　　　　　(Institure of the Stomaless on the Web)

Chapter 1

Comments on rectal cancer for neoanus surgery

Since 1995, we have performed “neo-anus surgery,” which is relatively novel operation that is used to create a neo-anus that can function naturally.  The procedure for rectal cancer is thorough and aimed at affecting a cure.  Compared to the conventional operation, there is no difference in the areas that are resected with neo-anus surgery.  In other words, neo-anus surgery does not reduce the possibility of a patient becoming cured from their rectal cancer.  (This result was reported on June 6, 2003 in the general assembly of the Japan Surgery Association held in Sapporo, Japan.  The details will be made public in the future.) 

In our study, we compared 19 cases that underwent neo-anus surgery through 2002 and 19 cases that underwent operations during the same period involving rectal resections near the anus but leaving it untouched.  Near the resected areas, there were no recurrences by the former operation and five local recurrences associated with the latter operation.  There was a statistical difference (meaning a difference not attributed to chance).

 Then, we sutured the pudendal nerve, which plays an important role in maintaining natural anal function, into the skeletal muscle to create a new anal sphincter and form a neo-anus at the position previously occupied by the original anus.  We disclosed this technique to the public at national and international academic meetings and published descriptions in the academic journals. Currently, this is a technique that only we can perform.

              To treat rectal cancer, it is necessary to resect the cancer together with the adjacent tissue.  A number of reports have clarified the fact that rectal cancer cells may spread to the adjacent tissue invisibly.  In other words, it is not enough to resect only cancer to properly treat the disease.  However, the anus is connected to the rectum, and in cases in which the anus must be resected, a resulting colostomy is inevitably necessary.

              While this term is commonly used, you may wonder what exactly is a colostomy or a stoma?  It is the excised end of the intestine sutured to the abdominal wall in the “open position.”  Namely, a colostomy is an opening of the intestine that is exposed to the abdominal wall and acts as the conduit through which feces exits the body.  Unfortunately, this “exit” is very different from than the original anus in many respects. While a colostomy is similar to the anus in excreting feces, it lacks the conscious controllability of a natural anus and feces come out without conscious awareness. This phenomenon is why it is simply called “a stoma” instead of artificial anus.

              A lot of people who have stomas retain feces in a plastic bag attached to the stoma.  Recently the development of ostomy appliances and skin protectants has been remarkable, and the lives of patients with stomas has dramatically improved.  However, it is still an agonizing process for a patient to live without an anus. Therefore, operational techniques for rectal cancer have developed to leave the anus unresected instead of taking risks of aggravating postoperative function of passing a stool and a possible local recurrence of rectal cancer. In other words, operational techniques and devices have been developed to carry out anastomosis as close to the anus as possible and avoid colostomy. 

Despite such developments, some patients still must have their anuses resected for rectal cancer.  If the surgeon in charge informs you that you may become such a patient, you are likely to lose the anus during surgery. (In the past and even now, surgeons often explain to patients the positive side of their status with reservations.)  If you are one of these patients, the following operation will be one of the techniques that you can choose.

The operative procedure involves creating a neo-anus after the original anus is resected. 

              In the middle 1990s when basic research regarding this area began, the procedure was announced as a “functional perineal colostomy”. Later, because there was an operation that had a similar name but involved a different technique, it became necessary to differentiate the two procedures and this operation was named and published in a peer-reviewed journal as “physiological anorectal reconstruction”.  To be correct, because the neo-anus is created after the pudendal nerve is sutured into the muscle, the operation has been called NAPNA by using the acronyms of “neo-anus with a pudendal nerve anastomosis”.  However, this operation is a technique that accompanies other maneuvers, and the term does not exactly reflect the procedure.  Recently, it has been simply called “neoanus surgery” or “Sato’s operation”.

              Rectal cancer is relatively easy to cure compared to other cancers.  Herein, I present the data from our hospital (Jichi Medical School Hospital).  The graph below reproduces data from a book published in commemoration of the retirement of professor emeritus Kyotaro Kanazawa, former professor of the Department of Surgery, Jichi Medical School, and demonstrates data from 204 rectal cancer cases from 1980 through 1994.

Survival rates of rectal cancer patietns according to the Dukes' classification

 

The details of the graph are as follows.  The uppermost line depicts the survival rate of rectal cancer patients with stage A disease as determined by Dukes’ classification.  Dukes’ A means cancer localized within the bowel wall. The postoperative 10-year survival rate was 90%.  The second line represents the survival rate of patients with Dukes’ B rectal cancer.  Dukes’ B refers to cancer that is over the bowel wall, and its 5-year survival exceeded 80%. The last line depicts the survival rate of patients with Dukes’ C rectal cancer developing to the extent that lymph node metastasis is observed. The five-year survival rate was 50% even in the patients with such advanced rectal cancer. Even the nine-year survival rate was almost 40%.

              As shown here, even far-advanced rectal cancer is relatively curable compared with other cancers. If rectal cancer cannot be cured, why is it necessary to do a large-scale operation with even resecting the anus? Because rectal cancer is relatively easy to cure, it is important to do a necessary and sufficient operation.

              Just because it is relatively curable, the operation must not be taken lightly. If you meet surgeons who choose an operation that would raise the possibility of a recurrence (small resection not based on data) to avoid colostomy, you should not trust them too much. They may perform an operation that would just satisfy your hope to avoid colostomy, resulting in a different turnout from what you expect from treatment. No doubt your hope is to have cancer eliminated completely and avoid colostomy at the same time.

              We have performed an operation to construct neo-anus that would work naturally as the anus. We perform a reliable operation for rectal cancer aiming at a cure. Compared with the techniques that have been employed previously, there is no reduction in size of resection. Nevertheless, we create neo-anus at the position where the original anus used to be with new anal sphincter made of the skeletal muscle into which the pudendal nerve, which plays an important role in maintaining natural anal function, is sutured.

 

 

Index .
Preface. To avoid colostomy or stoma, there is a neoanus surgery.
Chapter 1. comments on rectal cancer for neoanus surgery
Chapter 2. A path to develop a new operation to avoid colostomy (neoanus surgery)
Chapter 3. Outlines of the operation avoiding colostomy
Chapter 4. Life without a stoma
Chapter 5 Miscellaneous with self-introduction
Chapter 6 Bibliography
Link


Correspondence to:
Tomoyuki Sato M.D., Ph.D.
Assistant Professor, Center for Clinical Medicine and Reserch, International University of Health and Welfare
Iguchi, Nishinasuno-machi, Nasu-gun, Tochigi-ken, Japan
Email address: tomosato@iuhw.ac.jp
:Fax: to Dr. Sato +81-287-39-3001

or
Tomoyuki Sato M.D., Ph.D. Department of Surgery, Jichi Medical School
3311-1 Yakushiji, Minamikawachi-machi, Kawachi-gun, Tochigi-ken, 329-0498, Japan
Email address: tomoyuki@jichi,ac.jp
fax: +81-285-44-3234

Link to the Japanese website of the stomaless surgery (Neo-anus)