To the Editor:

We read the article "Perceptions of Phantom Rectum Syndrome and Health-Related Quality of Life in Patients Following Abdominoperineal Resection (APR) for Rectal Cancer" written by J. Fingren and colleagues,1 which focused on phantom rectum syndrome and health-related quality of life after APR with creation of an abdominal ostomy with great interest. The authors succeeded in describing the unknown impact of such underestimated syndrome on daily living and health-related quality of life.

Indeed, defining this syndrome can help assessing its real prevalence and even prevent its consequences on health-related quality of life. However, we suggest a surgical solution to minimize the prevalence and consequences of this syndrome. 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.2 We advocate placing a graft of smooth colonic muscle around the lowered colon.3 This technique allows preservation of body image and ensures a neonatural orifice stools delivery and no need for regular ostomy pouching systems.2-4 Moreover, it is reported to be associated with good functional results and high satisfaction rate among patients.5-7 The only condition of using this technique is the accomplishment of regular colonic irrigations (every 24-72 hours) that helps emptying the residual colon.2-6

We agree that major problems of APR are perineal complications and wound healing that may explain the occurrence of this syndrome.1 By filling the pelvic space and bringing a well-vascularized tissue to an irradiated area, PCPC helps decrease healing time and reduce perineal complications.8,9 As Fingren and associates describe in their article, there are 2 kinds of phantom rectum syndrome: painful or nonpainful.1

Concerning nonpainful symptoms, PCPC can be helpful to reduce or eliminate these symptoms such as phantom flatus and/or feces. Indeed, PCPC is associated to real bowel movements and sensation of need to defecation stools' arrival sensation in our experience.7

Otherwise, authors reported that painful symptoms were frequently responsible for worries and concerns for both local recurrence and bowel perforation in 29% of the patients.1 Indeed, after APR with abdominal colostomy, the pelvis is no longer accessible to direct clinical or endoscopic examination and radiologic diagnosis of local recurrences is challenging. In contrast, a perineal colostomy ensures a total accessibility to pelvis clinical and instrumental examination allowing quick and efficient diagnosis of local recurrence.2-6 Furthermore, this easy and accessible examination can reduce the worries and fears about potential recurrences for not only patients with painful phantom rectum syndrome but also their physicians.7

Abdominal colostomy after APR is associated with more severely impaired health-related quality of life as compared to sphincter-preserving procedures.10 All efforts have been done to reduce the rate of APR in the last 2 decades in favor of more radical sphincter preserving procedures such as interspheric resections. But when APR is the only option, PCPC allows preservation of body image and its quality of life is often comparable to sphincter-preserving surgeries after rectal resections.11 Pocard and colleagues12 compared health-related quality of life between PCPC and coloanal anastomosis and found similar results between the 2 techniques. These results suggest that PCPC has comparable results as sphincter-preserving procedures and that it could be the answer to reduce many disadvantages associated to APR.

In conclusion, we strongly believe that, by using PCPC as a reconstruction procedure after APR instead of perineal primary closure, we will be able to reduce phantom rectum syndrome and improve the health-related quality of life of patients undergoing abdominoperineal resections.

Amine Souadka, MD

University Mohammed Vth Souissi and

Surgical Department A,

Ibn Sina Hospital, Rabat, Morocco

Mohammed Anass Majbar, MD

University Mohammed Vth Souissi;

Surgical Department A, Ibn Sina Hospital and

Medical Center of Clinical Trials and Epidemiological

Study (CRECET), Rabat, Morocco

References