Can Ileal J-Pouch Interposition Replace Coloanal Anastomosis? Insights From a Case Report Study

Can Ileal J-Pouch Interposition Replace Coloanal Anastomosis? 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Insights From a Case Report Study Saeed Derakhshani, Milad Karimian Ghadim, Sara Ashtari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6555367/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Oct, 2025 Read the published version in BMC Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract Background Surgical management of low rectal cancer can be challenging, particularly when postoperative complications such as anastomotic leakage and ischemia arise. This case report highlights the use of an ileal J-pouch interposition as an innovative solution in a patient with compromised colonic length and perfusion. Case presentation: Here, we present the case of a 50-year-old female patient with diabetes who underwent an intersphincteric resection, coloanal anastomosis, and appendicostomy, followed by an Antergrade Colonic Enema (ACE) for T2N0 rectal adenocarcinoma in November 2020. Postoperatively, she developed anastomotic leakage and a rectovaginal fistula due to ischemia, requiring a second surgery. Intraoperatively, the left and transverse colon were ischemic, leaving only the right colon viable, perfused by the ileocolic artery. Due to insufficient length for coloanal anastomosis, an ileal J-pouch was created and anastomosed to the anal canal, with the right colon connected to the pouch. The patient has achieved normal follow-up results and maintains good bowel function with the use of Loperamide and ACE. Conclusions This case underscores the complexities of surgical management in low rectal cancer and the potential use of ileal J-pouch interposition as an effective solution for complications arising from primary surgical efforts. Further long-term studies are warranted to evaluate the sustainability of this approach in similar patient cohorts. ‘Clinical trial number: not applicable.’ Rectal cancer Ileal pouch interposition Coloanal anastomosis Anastomotic leakage appendicostomy Figures Figure 1 Background Rectal cancer, particularly in its lower segment, poses significant surgical challenges in achieving oncologic control while preserving bowel continuity and minimizing postoperative complications [ 1 , 2 ]. Low rectal cancer, defined as a tumor located less than 5 cm from the anal verge, often necessitates complex surgical techniques to ensure adequate resection margins and functional outcomes [ 3 , 4 ]. The standard surgical approach involves low anterior resection with total mesorectal excision (TME) followed by straight coloanal anastomosis [ 5 , 6 ]. However, the excision of the sigmoid colon during surgery reduces stool storage capacity, leading to a cluster of symptoms known as low anterior resection syndrome (LARS) [ 7 , 8 ]. These symptoms, which include increased bowel frequency, urgency, incomplete evacuation, and fecal incontinence, significantly impair patients' quality of life, particularly in those with mid-to-low rectal cancer [ 7 , 8 ]. LARS can profoundly affect social activities, mental well-being, and overall quality of life [ 9 , 10 ]. To address these challenges, alternative surgical techniques such as colonic J-pouch, transverse coloplasty, and side-to-end anastomosis have been developed as alternatives to the standard straight coloanal anastomosis [ 11 , 12 ]. The colonic J-pouch anastomosis was first introduced by Lazorthes et al. [ 13 ] and Parc et al. [ 14 ] in 1986. Studies have shown that a colonic J-pouch measuring 5–8 cm in length provides optimal functional outcomes [ 15 ]. The ileal J-pouch, in particular, has been well-documented in the management of inflammatory bowel disease, demonstrating superior functional outcomes such as improved continence and defecatory function compared to straight ileoanal anastomosis [ 16 – 18 ]. While this technique has been widely used in patients with ulcerative colitis and familial adenomatous polyposis (FAP) undergoing restorative proctocolectomy, its application in rectal cancer surgery is less common and remains understudied [ 19 – 21 ]. Emerging evidence suggests that ileal J-pouch interposition may serve as a viable alternative in select patients undergoing rectal cancer resection or in cases where the colon is unsuitable for anastomosis due to ischemia or insufficient length [ 22 , 23 ]. This innovative approach addresses complications such as anastomotic leakage or ischemia that may arise from primary surgical efforts. By preserving bowel continuity and improving functional outcomes, ileal J-pouch interposition offers potential benefits for patients with compromised colonic perfusion or anatomical limitations. Despite its promising advantages, the use of ileal J-pouch interposition in rectal cancer surgery remains rare. Further research is needed to evaluate its feasibility, functional outcomes, and long-term efficacy in this context. This case report aimed to contribute to the growing body of evidence supporting the use of ileal J-pouch interposition as a viable surgical option for managing complex low rectal cancer cases, particularly when traditional reconstruction techniques are not feasible. Case Presentation Patient History A 50-year-old female with a history of diabetes underwent surgery for low rectal cancer on November 30, 2020. The surgical procedure consisted of intersphincteric resection, coloanal anastomosis, and appendicostomy, followed by an Antergrade Colonic Enema (ACE). The initial pathology report confirmed the diagnosis of adenocarcinoma, classified as T2N0. Clinical Course: Post-operatively, the patient experienced complications due to ischemia at the anastomosis site, leading to a leak and the formation of a fistula to the vagina. Consequently, a second surgical intervention was necessitated to address these issues. During the second operation, the left colon and transverse colon were mobilized. However, it was noted that the bowel became ischemic during the procedure. Only the right colon, which had an adequate blood supply (perfusion) from the ileocolic artery, appeared viable. Given that the right colon lacked sufficient length for a coloanal anastomosis, the surgical team opted to create an ileal J-pouch from the ileum. The ileal J-pouch was then anastomosed to the anal canal, while the right colon was anastomosed to the pouch. Postoperative follow-up and Outcomes The patient has been closely monitored through regular colonoscopies, CT scans, and assessments of the carcinoembryonic antigen (CEA) tumor marker, all of which have remained normal to date (Fig. 1: Colonoscopy report of the patient). From a quality-of-life perspective, the patient reports satisfactory outcomes. She has no episodes of fecal incontinence and maintains 1–2 bowel movements per day. She manages her bowel function with a daily intake of 6 tablets of Loperamide and irrigates her colon with one liter of water through the ACE daily. Discussion The surgical management of low rectal cancer involves balancing oncological resection with the preservation of bowel function, especially in patients with comorbidities such as diabetes, which increase the risk of complications like anastomotic leakage and ischemia. This case illustrates the challenges of salvage surgery following a failed coloanal anastomosis. Here, ileal J-pouch interposition effectively addressed the issues of ischemic colonic segments and inadequate length. The patient’s 5-year follow-up demonstrates the procedure’s success, with normalized imaging, stable CEA levels, and functional bowel control (1–2 daily movements managed with Loperamide and ACE). Anastomotic leakage and ischemia occur in 5–20% of rectal cancer surgeries, often necessitating reoperation and worsening outcomes [ 24 – 26 ]. In this case, postoperative ischemia led to a rectovaginal fistula, requiring a second intervention. The surgical team’s adaptation, interposing an ileal J-pouch between the viable right colon (supplied by the ileocolic artery) and anal canal, demonstrates the technique’s versatility in circumventing ischemic tissue. An appendecostomy further minimized anastomotic stress, critical in a diabetic patient with impaired healing. The absence of long-term complications, such as incontinence or recurrence, validates this approach for high-risk cases. Traditional methods like coloanal anastomosis or colonic J-pouches rely on colonic length and perfusion, which may be compromised in complex cases [ 7 , 8 ]. While colonic J-pouches are optimal for reservoir function, they are technically unfeasible in 26.2% of patients due to anatomical constraints (e.g., narrow pelvis, prior resections) [ 22 ]. The ileal J-pouch, though established in inflammatory bowel disease (IBD), remains understudied in rectal cancer [ 19 – 21 ]. This case highlights its utility as a salvage procedure when colonic viability is limited. The ileal pouch takes advantage of the ileum’s vascular reliability and its ability to be configured into a neorectal reservoir, which helps reduce LARS symptoms such as urgency and frequency [ 27 – 29 ]. Functionally, the patient achieved satisfactory outcomes, reporting no episodes of fecal incontinence and maintaining 1–2 bowel movements per day with the aid of Loperamide and ACE. The ACE technique enables the direct delivery of enemas into the colon, facilitating effective bowel management and supporting the patient’s overall quality of life [ 30 , 31 ]. According to our results, we believe that ileal J-pouch interposition can be a good alternative to coloanal anastomosis because it prevents the need to pull down a narrow and potentially ischemic colon into the pelvis, and it may also reduce the incidence of LARS cases. For coloanal anastomosis, surgeons attempt to preserve the marginal arteries of the colon, mobilize the splenic flexure, and cut the inferior mesenteric vein at its base to prevent colon ischemia and reduce tension on the anastomosis line, which is crucial to minimizing anastomotic leakage. However, these maneuvers can cause trauma to the spleen and may extensively compromise the blood supply to the colon. Additionally, methods such as creating a colonic J-pouch, performing coloplasty, or using end-to-side coloanal anastomosis cannot significantly reduce the rate of LARS symptoms, such as fecal frequency and incontinence, in the long term. This limitation may be related to the low compliance of the colon. By using the ileal J-pouch interposition method, there is no need to mobilize the splenic flexure to bring the colon down to the anal canal, and the compliance of the J-pouch is better than that of the colon. The results align with previous studies suggesting that ileal J-pouch interposition can provide good functional outcomes in patients with compromised colonic perfusion or insufficient colonic length [ 19 – 21 , 32 ]. A canine study by Ghahramani et al. [ 22 ], supports these findings, demonstrating a 118.2% increase in neorectal volume with ileal J-pouches versus coloanal anastomosis (20.9%) or coloplasty (21.7%). This reservoir capacity, critical for mitigating LARS, was achieved without compromising anastomotic integrity. However, higher inflammation at the pouch site in canine models warrants long-term monitoring in humans. Hida et al. [ 33 ] further corroborate these results, showing superior stool storage with J-pouches in anastomoses < 4 cm from the anal verge, improving quality of life post-resection. While coloplasty and side-to-end anastomosis yield comparable short-term outcomes [ 7 , 34 ], ileal J-pouches offer a critical alternative when colonic J-pouches are unviable. Limitations and Future Directions While this case illustrates promising outcomes, broader adoption of ileal J-pouch interposition in rectal cancer requires long-term data on pouch durability, functional stability, and oncologic safety. The risk of pouchitis, though rare in non-IBD patients, and the potential for metabolic changes due to ileal resection warrant monitoring. Additionally, standardized criteria for patient selection such as colonic viability thresholds or comorbidity profiles are needed to optimize outcomes. Future studies should compare ileal and colonic pouches in complex rectal cancer cases, assessing quality of life, complication rates, and survival metrics. Conclusion This case report contributes to the growing evidence supporting ileal J-pouch interposition as a salvage strategy in selected patients with low rectal cancer, particularly when conventional methods are compromised by anatomical or vascular limitations. By addressing both functional and oncologic goals, this technique offers a tailored solution for challenging cases. However, multicenter trials and extended follow-up are essential to establish its role in routine practice. As surgical innovation advances, such adaptable approaches will remain critical in managing the intricate balance between cure and quality of life. Abbreviations ACE: Antergrade Colonic Enema TME: Total Mesorectal Excision LARS: Low Anterior Resection Syndrome FAP: Familial Adenomatous Polyposis IBD: Inflammatory Bowel Disease CEA: Carcinoembryonic Antigen Declarations Ethics approval and consent to participate The study was approved by the ethics committee of Kasra General Hospital, Tehran, Iran. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. ‘Clinical trial number: not applicable.’ Consent for publication Informed consent has been obtained from the patient included in this study. Conflicts of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Data availability No/Not applicable (this manuscript does not report data generation or analysis). Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. CRediT authorship contribution statement Saeed Derakhshani : Conceptualization, methodology, data curation, risk of bias, writing - review & editing, writing-original draft.; Milad Karimian Ghadim: Supervisor, methodology, conceptualization, data curation, writing - review & editing; Sara Ashtari: writing - review & editing, writing-original draft. Acknowledgement We wish to thank our colleagues in Kasra General Hospital in Tehran, Iran, for their cooperation and helps. References Troester AM, Gaertner WB. Contemporary management of rectal cancer. Surg Open Sci. 2024;1817-22. https://doi.org/10.1016/j.sopen.2024.01.009 Plummer JM, Leake PA, Albert MR. 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Cite Share Download PDF Status: Published Journal Publication published 24 Oct, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 04 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviewers agreed at journal 02 Aug, 2025 Reviews received at journal 02 Aug, 2025 Reviews received at journal 29 Jul, 2025 Reviewers agreed at journal 26 Jul, 2025 Reviewers agreed at journal 24 Jul, 2025 Reviewers invited by journal 24 Jul, 2025 Editor invited by journal 14 Jul, 2025 Editor assigned by journal 27 May, 2025 Submission checks completed at journal 27 May, 2025 First submitted to journal 29 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6555367","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":491386126,"identity":"4ae29ce4-90c7-4893-b15d-c518ca01b04b","order_by":0,"name":"Saeed Derakhshani","email":"","orcid":"","institution":"Department of Surgery, School of Medecine, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":false,"prefix":"","firstName":"Saeed","middleName":"","lastName":"Derakhshani","suffix":""},{"id":491386128,"identity":"f0c8f12e-27c4-493f-b645-91fc27532f17","order_by":1,"name":"Milad Karimian Ghadim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYDCCA0CcUMDAOAPMNmBg4GdgYCNCiwGSFskGYrQwQLWAgcEBAlr4bh9g3fDAwE52ZvvZh4duFNjlGd9IfvbgQwWDPL/YAaxaJM8lsN1IMEg2ns2TbnA4xyC52OxGmrnhjDMMhjNnJ2DVYnCGAaSFOXEeQxoDUAtz4rYbCWbSvG1AD97Gq6U+cR7/M5CW+sTNM9K/EaPlcOJsCbAthxM3SOTgt0XyDGMbUMtx45kzwLYcT5xx5k2Z5IwzEjj9wneG+djNHxXVsjPOpzF/zvlTndjfnr5N4kOFjTy/NHYtDAyMDWgCAmCVEjiUYwX8B0hRPQpGwSgYBSMAAABmt2PZaQg+lgAAAABJRU5ErkJggg==","orcid":"","institution":"Department of Surgery, School of Medecine, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":true,"prefix":"","firstName":"Milad","middleName":"Karimian","lastName":"Ghadim","suffix":""},{"id":491386129,"identity":"edf7fdcd-34cb-4915-a72b-36491aecd84f","order_by":2,"name":"Sara Ashtari","email":"","orcid":"","institution":"Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Ashtari","suffix":""}],"badges":[],"createdAt":"2025-04-29 10:23:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6555367/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6555367/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03258-0","type":"published","date":"2025-10-24T16:16:26+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87826058,"identity":"05e19e82-e2bf-4367-9485-933ccb2cb752","added_by":"auto","created_at":"2025-07-29 11:50:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4079341,"visible":true,"origin":"","legend":"\u003cp\u003eColonoscopy report of the patient\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6555367/v1/f2fafcfbd4eea444a56882d7.png"},{"id":94490173,"identity":"606df8ee-92f6-426c-89d5-8a86d3ae1697","added_by":"auto","created_at":"2025-10-27 17:08:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6592245,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6555367/v1/6d971f88-05ba-42b3-adfd-7c96e085eb8c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Can Ileal J-Pouch Interposition Replace Coloanal Anastomosis? Insights From a Case Report Study","fulltext":[{"header":"Background","content":"\u003cp\u003eRectal cancer, particularly in its lower segment, poses significant surgical challenges in achieving oncologic control while preserving bowel continuity and minimizing postoperative complications [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Low rectal cancer, defined as a tumor located less than 5 cm from the anal verge, often necessitates complex surgical techniques to ensure adequate resection margins and functional outcomes [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The standard surgical approach involves low anterior resection with total mesorectal excision (TME) followed by straight coloanal anastomosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the excision of the sigmoid colon during surgery reduces stool storage capacity, leading to a cluster of symptoms known as low anterior resection syndrome (LARS) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These symptoms, which include increased bowel frequency, urgency, incomplete evacuation, and fecal incontinence, significantly impair patients' quality of life, particularly in those with mid-to-low rectal cancer [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. LARS can profoundly affect social activities, mental well-being, and overall quality of life [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. To address these challenges, alternative surgical techniques such as colonic J-pouch, transverse coloplasty, and side-to-end anastomosis have been developed as alternatives to the standard straight coloanal anastomosis [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe colonic J-pouch anastomosis was first introduced by Lazorthes et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] and Parc et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] in 1986. Studies have shown that a colonic J-pouch measuring 5\u0026ndash;8 cm in length provides optimal functional outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The ileal J-pouch, in particular, has been well-documented in the management of inflammatory bowel disease, demonstrating superior functional outcomes such as improved continence and defecatory function compared to straight ileoanal anastomosis [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While this technique has been widely used in patients with ulcerative colitis and familial adenomatous polyposis (FAP) undergoing restorative proctocolectomy, its application in rectal cancer surgery is less common and remains understudied [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Emerging evidence suggests that ileal J-pouch interposition may serve as a viable alternative in select patients undergoing rectal cancer resection or in cases where the colon is unsuitable for anastomosis due to ischemia or insufficient length [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This innovative approach addresses complications such as anastomotic leakage or ischemia that may arise from primary surgical efforts. By preserving bowel continuity and improving functional outcomes, ileal J-pouch interposition offers potential benefits for patients with compromised colonic perfusion or anatomical limitations.\u003c/p\u003e\u003cp\u003eDespite its promising advantages, the use of ileal J-pouch interposition in rectal cancer surgery remains rare. Further research is needed to evaluate its feasibility, functional outcomes, and long-term efficacy in this context. This case report aimed to contribute to the growing body of evidence supporting the use of ileal J-pouch interposition as a viable surgical option for managing complex low rectal cancer cases, particularly when traditional reconstruction techniques are not feasible.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatient History\u003c/h2\u003e\u003cp\u003eA 50-year-old female with a history of diabetes underwent surgery for low rectal cancer on November 30, 2020. The surgical procedure consisted of intersphincteric resection, coloanal anastomosis, and appendicostomy, followed by an Antergrade Colonic Enema (ACE). The initial pathology report confirmed the diagnosis of adenocarcinoma, classified as T2N0.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinical Course:\u003c/h3\u003e\n\u003cp\u003ePost-operatively, the patient experienced complications due to ischemia at the anastomosis site, leading to a leak and the formation of a fistula to the vagina. Consequently, a second surgical intervention was necessitated to address these issues.\u003c/p\u003e\u003cp\u003eDuring the second operation, the left colon and transverse colon were mobilized. However, it was noted that the bowel became ischemic during the procedure. Only the right colon, which had an adequate blood supply (perfusion) from the ileocolic artery, appeared viable. Given that the right colon lacked sufficient length for a coloanal anastomosis, the surgical team opted to create an ileal J-pouch from the ileum. The ileal J-pouch was then anastomosed to the anal canal, while the right colon was anastomosed to the pouch.\u003c/p\u003e\n\u003ch3\u003ePostoperative follow-up and Outcomes\u003c/h3\u003e\n\u003cp\u003eThe patient has been closely monitored through regular colonoscopies, CT scans, and assessments of the carcinoembryonic antigen (CEA) tumor marker, all of which have remained normal to date (Fig.\u0026nbsp;1: Colonoscopy report of the patient). From a quality-of-life perspective, the patient reports satisfactory outcomes. She has no episodes of fecal incontinence and maintains 1\u0026ndash;2 bowel movements per day. She manages her bowel function with a daily intake of 6 tablets of Loperamide and irrigates her colon with one liter of water through the ACE daily.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe surgical management of low rectal cancer involves balancing oncological resection with the preservation of bowel function, especially in patients with comorbidities such as diabetes, which increase the risk of complications like anastomotic leakage and ischemia. This case illustrates the challenges of salvage surgery following a failed coloanal anastomosis. Here, ileal J-pouch interposition effectively addressed the issues of ischemic colonic segments and inadequate length. The patient\u0026rsquo;s 5-year follow-up demonstrates the procedure\u0026rsquo;s success, with normalized imaging, stable CEA levels, and functional bowel control (1\u0026ndash;2 daily movements managed with Loperamide and ACE).\u003c/p\u003e\u003cp\u003eAnastomotic leakage and ischemia occur in 5\u0026ndash;20% of rectal cancer surgeries, often necessitating reoperation and worsening outcomes [\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In this case, postoperative ischemia led to a rectovaginal fistula, requiring a second intervention. The surgical team\u0026rsquo;s adaptation, interposing an ileal J-pouch between the viable right colon (supplied by the ileocolic artery) and anal canal, demonstrates the technique\u0026rsquo;s versatility in circumventing ischemic tissue. An appendecostomy further minimized anastomotic stress, critical in a diabetic patient with impaired healing. The absence of long-term complications, such as incontinence or recurrence, validates this approach for high-risk cases.\u003c/p\u003e\u003cp\u003eTraditional methods like coloanal anastomosis or colonic J-pouches rely on colonic length and perfusion, which may be compromised in complex cases [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. While colonic J-pouches are optimal for reservoir function, they are technically unfeasible in 26.2% of patients due to anatomical constraints (e.g., narrow pelvis, prior resections) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The ileal J-pouch, though established in inflammatory bowel disease (IBD), remains understudied in rectal cancer [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This case highlights its utility as a salvage procedure when colonic viability is limited. The ileal pouch takes advantage of the ileum\u0026rsquo;s vascular reliability and its ability to be configured into a neorectal reservoir, which helps reduce LARS symptoms such as urgency and frequency [\u003cspan additionalcitationids=\"CR28\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Functionally, the patient achieved satisfactory outcomes, reporting no episodes of fecal incontinence and maintaining 1\u0026ndash;2 bowel movements per day with the aid of Loperamide and ACE. The ACE technique enables the direct delivery of enemas into the colon, facilitating effective bowel management and supporting the patient\u0026rsquo;s overall quality of life [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAccording to our results, we believe that ileal J-pouch interposition can be a good alternative to coloanal anastomosis because it prevents the need to pull down a narrow and potentially ischemic colon into the pelvis, and it may also reduce the incidence of LARS cases. For coloanal anastomosis, surgeons attempt to preserve the marginal arteries of the colon, mobilize the splenic flexure, and cut the inferior mesenteric vein at its base to prevent colon ischemia and reduce tension on the anastomosis line, which is crucial to minimizing anastomotic leakage. However, these maneuvers can cause trauma to the spleen and may extensively compromise the blood supply to the colon. Additionally, methods such as creating a colonic J-pouch, performing coloplasty, or using end-to-side coloanal anastomosis cannot significantly reduce the rate of LARS symptoms, such as fecal frequency and incontinence, in the long term. This limitation may be related to the low compliance of the colon. By using the ileal J-pouch interposition method, there is no need to mobilize the splenic flexure to bring the colon down to the anal canal, and the compliance of the J-pouch is better than that of the colon.\u003c/p\u003e\u003cp\u003eThe results align with previous studies suggesting that ileal J-pouch interposition can provide good functional outcomes in patients with compromised colonic perfusion or insufficient colonic length [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. A canine study by Ghahramani et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], supports these findings, demonstrating a 118.2% increase in neorectal volume with ileal J-pouches versus coloanal anastomosis (20.9%) or coloplasty (21.7%). This reservoir capacity, critical for mitigating LARS, was achieved without compromising anastomotic integrity. However, higher inflammation at the pouch site in canine models warrants long-term monitoring in humans. Hida et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] further corroborate these results, showing superior stool storage with J-pouches in anastomoses\u0026thinsp;\u0026lt;\u0026thinsp;4 cm from the anal verge, improving quality of life post-resection. While coloplasty and side-to-end anastomosis yield comparable short-term outcomes [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], ileal J-pouches offer a critical alternative when colonic J-pouches are unviable.\u003c/p\u003e"},{"header":"Limitations and Future Directions","content":"\u003cp\u003eWhile this case illustrates promising outcomes, broader adoption of ileal J-pouch interposition in rectal cancer requires long-term data on pouch durability, functional stability, and oncologic safety. The risk of pouchitis, though rare in non-IBD patients, and the potential for metabolic changes due to ileal resection warrant monitoring. Additionally, standardized criteria for patient selection such as colonic viability thresholds or comorbidity profiles are needed to optimize outcomes. Future studies should compare ileal and colonic pouches in complex rectal cancer cases, assessing quality of life, complication rates, and survival metrics.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case report contributes to the growing evidence supporting ileal J-pouch interposition as a salvage strategy in selected patients with low rectal cancer, particularly when conventional methods are compromised by anatomical or vascular limitations. By addressing both functional and oncologic goals, this technique offers a tailored solution for challenging cases. However, multicenter trials and extended follow-up are essential to establish its role in routine practice. As surgical innovation advances, such adaptable approaches will remain critical in managing the intricate balance between cure and quality of life.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACE: Antergrade Colonic Enema\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTME: Total Mesorectal Excision\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLARS: Low Anterior Resection Syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFAP: Familial Adenomatous Polyposis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIBD: Inflammatory Bowel Disease\u003c/p\u003e\n\u003cp\u003eCEA: Carcinoembryonic Antigen\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the ethics committee of Kasra General Hospital, Tehran, Iran. Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. \u0026lsquo;Clinical trial number: not applicable.\u0026rsquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent has been obtained from the patient included in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;No/Not applicable (this manuscript does not report data generation or analysis).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCRediT authorship contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSaeed Derakhshani\u003c/strong\u003e: Conceptualization, methodology, data curation, risk of bias, writing - review \u0026amp; editing, writing-original draft.; \u003cstrong\u003eMilad Karimian Ghadim:\u003c/strong\u003e Supervisor, methodology, conceptualization, data curation, writing - review \u0026amp; editing; \u003cstrong\u003eSara Ashtari:\u0026nbsp;\u003c/strong\u003ewriting - review \u0026amp; editing, writing-original draft.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to thank our colleagues in Kasra General Hospital in Tehran, Iran, for their cooperation and helps. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTroester AM, Gaertner WB. 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Ileal neoappendicostomy for antegrade colonic enema (ACE) in the treatment of fecal incontinence and chronic constipation: a systematic review. Tech Coloproctol. 2021;25(8):915-21. https://doi.org/10.1007/s10151-021-02434-7\u003c/li\u003e\n\u003cli\u003eDeacy D, Quinn F. The antegrade continence enema procedure in the setting of acute appendicitis. Urol Ann. 2020;12(3):289-90. https://doi.org/10.4103/ua.Ua_174_18\u003c/li\u003e\n\u003cli\u003eHida J, Yoshifuji T, Matsuzaki T, Hattori T, Ueda K, Ishimaru E, et al. Long-term functional changes after low anterior resection for rectal cancer compared between a colonic J-pouch and a straight anastomosis. Hepatogastroenterology. 2007;54(74):407-13. \u003c/li\u003e\n\u003cli\u003eHida J, Yoshifuji T, Okuno K, Matsuzaki T, Uchida T, Ishimaru E, et al. Long-term functional outcome of colonic J-pouch reconstruction after low anterior resection for rectal cancer. Surg Today. 2006;36(5):441-9. https://doi.org/10.1007/s00595-005-3165-6\u003c/li\u003e\n\u003cli\u003eBiondo S, Frago R, Codina Cazador A, Farres R, Olivet F, Golda T, et al. Long-term functional results from a randomized clinical study of transverse coloplasty compared with colon J-pouch after low anterior resection for rectal cancer. Surgery. 2013;153(3):383-92. https://doi.org/10.1016/j.surg.2012.08.012\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rectal cancer, Ileal pouch interposition, Coloanal anastomosis, Anastomotic leakage, appendicostomy","lastPublishedDoi":"10.21203/rs.3.rs-6555367/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6555367/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSurgical management of low rectal cancer can be challenging, particularly when postoperative complications such as anastomotic leakage and ischemia arise. This case report highlights the use of an ileal J-pouch interposition as an innovative solution in a patient with compromised colonic length and perfusion.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHere, we present the case of a 50-year-old female patient with diabetes who underwent an intersphincteric resection, coloanal anastomosis, and appendicostomy, followed by an Antergrade Colonic Enema (ACE) for T2N0 rectal adenocarcinoma in November 2020. Postoperatively, she developed anastomotic leakage and a rectovaginal fistula due to ischemia, requiring a second surgery. Intraoperatively, the left and transverse colon were ischemic, leaving only the right colon viable, perfused by the ileocolic artery. Due to insufficient length for coloanal anastomosis, an ileal J-pouch was created and anastomosed to the anal canal, with the right colon connected to the pouch. The patient has achieved normal follow-up results and maintains good bowel function with the use of Loperamide and ACE.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case underscores the complexities of surgical management in low rectal cancer and the potential use of ileal J-pouch interposition as an effective solution for complications arising from primary surgical efforts. Further long-term studies are warranted to evaluate the sustainability of this approach in similar patient cohorts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e‘Clinical trial number: not applicable.’\u003c/strong\u003e\u003c/p\u003e","manuscriptTitle":"Can Ileal J-Pouch Interposition Replace Coloanal Anastomosis? 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