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Goyal A, Mathew A, Joseph P, Kaushal G, Rakesh NR, Dhar P. Reconstructive techniques following low anterior resection for carcinoma of the rectum. Minerva Surg 2024; 79:59-72. [PMID: 38381031 DOI: 10.23736/s2724-5691.23.10115-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied. EVIDENCE ACQUISITION PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023. EVIDENCE SYNTHESIS Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown. CONCLUSIONS In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.
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Affiliation(s)
- Anuj Goyal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Anvin Mathew
- Department of Surgical Gastroenterology, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, India -
| | - Princy Joseph
- National Health Systems and Research Center, New Delhi, India
| | - Gourav Kaushal
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Bathinda, India
| | - Nirjhar R Rakesh
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Rishikesh, India
| | - Puneet Dhar
- Department of Surgical Gastroenterology, Amrita Hospitals, Faridabad, India
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Pan H, Zhao Z, Deng Y, Zheng Z, Huang Y, Chi P, Huang S. Transverse Coloplasty Pouch versus Straight Coloanal Anastomosis Following Intersphincteric Resection for Low Rectal Cancer: the Functional Benefits May Emerge After Two Years. J Gastrointest Surg 2023; 27:2526-2537. [PMID: 37848684 DOI: 10.1007/s11605-022-05565-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/06/2022] [Indexed: 10/19/2023]
Abstract
PURPOSE This study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer. METHODS A single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups. RESULTS A total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A-C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10-0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09-0.84; p = 0.023). CONCLUSION This study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure.
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Affiliation(s)
- Hongfeng Pan
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zeyi Zhao
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yu Deng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Zhifang Zheng
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ying Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Pan Chi
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Shenghui Huang
- Department of Colorectal Surgery, Fujian Medical University Union Hospital, No.29 Xinquan Road, Fuzhou, 350001, Fujian Province, China.
- Training center of minimally invasive surgery, Fujian Medical University Union Hospital, Fuzhou, China.
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Lim SL, Wan Zain WZ, Zahari Z, Zakaria AD, Hashim MNM, Wong MPK, Zakaria Z, Ramely R, Sidek ASM. Risk factors associated with low anterior resection syndrome: a cross-sectional study. Ann Coloproctol 2023; 39:427-434. [PMID: 35655395 PMCID: PMC10626329 DOI: 10.3393/ac.2022.00227.0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Oncological outcomes following rectal cancer surgery have improved significantly over recent decades with lower recurrences and longer overall survival. However, many of the patients experienced low anterior resection syndrome (LARS). This study identified the prevalence and risk factors associated with the development of LARS. METHODS This cross-sectional study involved patients who were diagnosed with rectal cancer and had undergone sphincter-preserving low anterior resection from January 2011 to December 2020. Upon clinic follow-up, patients were asked to complete an interviewed based questionnaire (LARS score) designed to assess bowel dysfunction after rectal cancer surgery. RESULTS Out of 76 patients, 25 patients (32.9%) had major LARS, 10 patients (13.2%) had minor LARS, and 41 patients (53.9%) had no LARS. The height of tumor from anal verge showed an association with the development of major LARS (P=0.039). Those patients with less than 8 cm tumor from anal verge had an increased risk of LARS by 3 times compared to those with 8 cm and above (adjusted odds ratio, 3.11; 95% confidence interval, 1.06-9.13). CONCLUSION Results from our study show that low tumor height was a significant risk factor that has a negative impact on bowel function after surgery. The high prevalence of LARS emphasizes the need for study regarding risk factors and the importance of understanding the pathophysiology of LARS, in order for us to improve patient bowel function and quality of life after rectal cancer surgery.
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Affiliation(s)
- See Liang Lim
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Wan Zainira Wan Zain
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Zalina Zahari
- Faculty of Pharmacy, Universiti Sultan Zainal Abidin (UniSZA), Besut Campus, Besut, Malaysia
| | - Andee Dzulkarnaen Zakaria
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Mohd Nizam Md Hashim
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Michael Pak-Kai Wong
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Rosnelifaizur Ramely
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
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Liu H, Xiong M, Zeng Y, Shi Y, Pei Z, Liao C. Comparison of complications and bowel function among different reconstruction techniques after low anterior resection for rectal cancer: a systematic review and network meta-analysis. World J Surg Oncol 2023; 21:87. [PMID: 36899350 PMCID: PMC9999608 DOI: 10.1186/s12957-023-02977-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Anastomosis for gastrointestinal reconstruction has been contentious after low anterior resection of rectal cancer for the past 30 years. Despite the abundance of randomized controlled trials (RCTs) on colon J-pouch (CJP), straight colorectal anastomosis (SCA), transverse coloplast (TCP), and side-to-end anastomosis (SEA), most studies are small and lack reliable clinical evidence. We conducted a systematic review and network meta-analysis to evaluate the effects of the four anastomoses on postoperative complications, bowel function, and quality of life in rectal cancer. METHODS We assessed the safety and efficacy of CJP, SCA, TCP, and SEA in adult patients with rectal cancer after surgery by searching the Cochrane Library, Embase, and PubMed databases to collect RCTs from the date of establishment to May 20, 2022. Anastomotic leakage and defecation frequency were the main outcome indicators. We pooled data through a random effects model in a Bayesian framework and assessed model inconsistency using the deviance information criterion (DIC) and node-splitting method and inter-study heterogeneity using the I-squared statistics (I2). The interventions were ranked according to the surface under the cumulative ranking curve (SUCRA) to compare each outcome indicator. RESULTS Of the 474 studies initially evaluated, 29 were eligible RCTs comprising 2631 patients. Among the four anastomoses, the SEA group had the lowest incidence of anastomotic leakage, ranking first (SUCRASEA = 0.982), followed by the CJP group (SUCRACJP = 0.628). The defecation frequency in the SEA group was comparable to those in the CJP and TCP groups at 3, 6, 12, and 24 months postoperatively. In comparison, the defecation frequency in the SCA group 12 months after surgery all ranked fourth. No statistically significant differences were found among the four anastomoses in terms of anastomotic stricture, reoperation, postoperative mortality within 30 days, fecal urgency, incomplete defecation, use of antidiarrheal medication, or quality of life. CONCLUSIONS This study demonstrated that SEA had the lowest risk of complications, comparable bowel function, and quality of life compared to the CJP and TCP, but further research is required to determine its long-term consequences. Furthermore, we should be aware that SCA is associated with a high defecation frequency.
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Affiliation(s)
- Huabing Liu
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Ming Xiong
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yu Zeng
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yabo Shi
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Zhihui Pei
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Chuanwen Liao
- Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China.
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Morino M, Nicotera A. Low Anterior Resection Syndrome. ANAL INCONTINENCE 2023:171-178. [DOI: 10.1007/978-3-031-08392-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Varghese C, Wells CI, Bissett IP, O'Grady G, Keane C. The role of colonic motility in low anterior resection syndrome. Front Oncol 2022; 12:975386. [PMID: 36185226 PMCID: PMC9523793 DOI: 10.3389/fonc.2022.975386] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Low anterior resection syndrome (LARS) describes the symptoms and experiences of bowel dysfunction experienced by patients after rectal cancer surgery. LARS is a complex and multifactorial syndrome exacerbated by factors such as low anastomotic height, defunctioning of the colon and neorectum, and radiotherapy. There has recently been growing awareness and understanding regarding the role of colonic motility as a contributing mechanism for LARS. It is well established that rectosigmoid motility serves an important role in coordinating rectal filling and maintaining continence. Resection of the rectosigmoid may therefore contribute to LARS through altered distal colonic and neorectal motility. This review evaluates the role of colonic motility within the broader pathophysiology of LARS and outlines future directions of research needed to enable targeted therapy for specific LARS phenotypes.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of General Surgery, Counties Manukau District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Whangārei Hospital, Whangarei, New Zealand
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Herzberg J, Khadem S, Guraya SY, Strate T, Honarpisheh H. Intraoperative Colonic Irrigation for Low Rectal Resections With Primary Anastomosis: A Fail-Safe Surgical Model. Front Surg 2022; 9:821827. [PMID: 35465417 PMCID: PMC9023858 DOI: 10.3389/fsurg.2022.821827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/22/2022] [Indexed: 11/19/2022] Open
Abstract
Aim Regardless the technological developments in surgery, the anastomotic leakage (AL) rate of low rectal anastomosis remains high. Though various perioperative protocols have been tested to reduce the risk for AL, there is no standard peri-operative management approach in rectal surgery. We aim to assess the short-term outcome of a multidisciplinary approach to reduce the rates of ALs using a fail-safe-model using preoperative and intraoperative colonic irrigation in low rectal resections with primary anastomosis. Methods Between January 2015 and December 2020, 92 patients received low rectal resections for rectal cancer with primary anastomosis and diverting ileostomy. All these patients received pre-operative mechanical bowel preparation (MBP) without antibiotics as well as intraoperative colonic irrigation. The intraoperative colonic irrigation was performed via the efferent loop of the ileostomy. All data were analyzed by SPSS for descriptive and inferential analyses. Results In the study period, 1.987 colorectal surgical procedures were performed. This study reports AL in 3 (3.3%) of 92 recruited patients. Other postoperative complications (Dindo-Clavien I-IV) were reported in 25 patients (27.2%), which occurred mainly due to non-surgical reasons such as renal dysfunction and sepsis. According to the fail-safe model, AL was treated by endoscopic or re-do surgery. The median postoperative length of hospitalization was 8 days (4–45) days. Conclusion This study validates the effectiveness of a multi-disciplinary fail-safe model with a pre-operative MBP and an intraoperative colonic irrigation in reducing AL rates. Intraoperative colonic irrigation is a feasible approach that lowers the AL rates by reducing fecal load and by decontamination of the colon and anastomotic region. Our study does not recommend a pre-operative administration of oral antibiotics for colorectal decontamination.
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Affiliation(s)
- Jonas Herzberg
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
- *Correspondence: Jonas Herzberg
| | - Shahram Khadem
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Salman Yousuf Guraya
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Tim Strate
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
| | - Human Honarpisheh
- Department of Surgery—Krankenhaus Reinbek St. Adolf-Stift, Reinbek, Germany
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Comparison of the colonic J-pouch versus straight (end-to-end) anastomosis following low anterior resection: a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:919-938. [PMID: 35306586 DOI: 10.1007/s00384-022-04130-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 02/04/2023]
Abstract
AIMS To evaluate comparative outcomes of straight (end-to-end) anastomosis versus colonic J-pouch anastomosis following anterior resection. METHODS A systematic search of multiple electronic data sources was conducted, and all studies comparing straight (end-to-end) anastomosis versus J-pouch anastomosis were included. Anastomotic complications, post-operative complications, re-operation, mortality, and functional outcomes were the evaluated outcome parameters. Revman 5.3 was used for data analysis. RESULTS Twenty-seven studies reporting a total number of 3293 patients who underwent straight anastomosis (n = 1581) or J-pouch (n = 1712) were included. Anastomotic leak and re-operation rates were significantly higher in the straight group compared to the J-pouch group [RD 0.03, P = 0.03] and [OR 1.87, P = 0.003], respectively. Stool frequency per 24 h at 6 months and 12 months was lower in the J-pouch group than the straight group [MD 2.13, P = 0.003] and [MD 1.44, P = 0.00001], respectively. In addition, the use of anti-diarrheal medication is lower at 12 months in the J-pouch group [MD 3.85, P = 0.03]. Moreover, the two groups showed comparable results regarding SSI, sepsis, paralytic ileus, anastomotic stricture formation, anastomotic bleeding, and mortality. CONCLUSION J-pouch anastomosis showed lower risk for anastomotic leak and re-operation. Furthermore, better functional outcomes such as stool frequency were achieved using the colonic J-pouch reconstruction over the conventional straight end-to-end anastomosis.
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Trajectory of change of low anterior resection syndrome over time after restorative proctectomy for rectal adenocarcinoma. Tech Coloproctol 2022; 26:195-203. [PMID: 35039911 DOI: 10.1007/s10151-021-02561-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 11/30/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Restorative proctectomy for rectal cancer is associated with a high incidence of low anterior resection syndrome (LARS), but few studies report longitudinal results for bowel function. The aim of our study was to examine the trajectory of change of LARS over the first 18 months after restorative proctectomy for rectal cancer. METHODS A prospective database measuring functional outcomes in rectal cancer patients from a single university-affiliated specialist colorectal referral center from 10/2018 to 03/2020 was queried. Patients were included in this study if they underwent restorative proctectomy for rectal cancer and had at least three assessments in the first 18 months after primary surgery or after closure of proximal diversion. Bowel function was assessed using the LARS score, administered at every surveillance follow-up after restoration of bowel continuity. Latent-class growth curve (trajectory) analysis was used to identify different trajectories of LARS changes over the first 18 months and group patients into these trajectory groups. These groups were then compared to identify predictors for each trajectory. RESULTS A total of 95 patients were included (63 males, mean age. 61.3 ± 12.5 years). Trajectory analysis identified three distinct trajectory groups. Group 1 had stable minimal LARS over time (26%). Group 2 had early LARS scores consistent with the minor LARS category and improved with time (28%). Group 3 had persistently high LARS scores (45%). Neoadjuvant therapy, intersphincteric resection, and proximal diversion were more common in group 3. CONCLUSIONS We identified three main trajectories of change of LARS in the 18 months after restorative proctectomy. These data may be used to better inform patients of their expected postoperative bowel function.
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Park EJ, Baik SH. Functional outcomes after sphincter-preserving surgeries for low-lying rectal cancer: A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Sphincter preservation and organ restoration during rectal cancer surgery avoids permanent stoma creation and diminishes psychosocial damages. However, decreased rectal volumes and sphincter dysfunction—including pelvic nerve damage—results in low anterior resection syndrome, as well as urinary and sexual dysfunction after rectal resection. Bowel habit changes such as fecal incontinence, fecal urgency, frequent bowel movements, clustered stools, and difficulties in bowel emptying can be treated using medications, pelvic floor rehabilitation, sacral neuromodulation, or neorectal reservoir reconstruction. Pelvic nerve damage resulting from superior and inferior hypogastric plexi during sphincter-preserving rectal cancer surgery can induce urologic and sexual dysfunctions. Preoperative voiding difficulty, perioperative blood loss, and autonomic nerve injury are considered independent risk factors for postoperative urinary dysfunction. Retrograde ejaculation and erectile dysfunction, female dyspareunia, and vaginal dryness are manifestations of sexual dysfunction resulting from autonomic nerve injury during rectal cancer surgery. Multifactorial causes for functional outcomes after sphincter- preserving surgeries are considered to improve patient’s quality of life with acceptable oncologic outcomes in the treatment of rectal cancer patients.
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Annicchiarico A, Martellucci J, Solari S, Scheiterle M, Bergamini C, Prosperi P. Low anterior resection syndrome: can it be prevented? Int J Colorectal Dis 2021; 36:2535-2552. [PMID: 34409501 DOI: 10.1007/s00384-021-04008-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 02/04/2023]
Abstract
Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.
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Affiliation(s)
| | | | - Stefano Solari
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | | | - Carlo Bergamini
- Emergency Surgery, Careggi University Hospital, Florence, Italy
| | - Paolo Prosperi
- Emergency Surgery, Careggi University Hospital, Florence, Italy
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12
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Wang Z. Colonic J-pouch versus side-to-end anastomosis for rectal cancer: a systematic review and meta-analysis of randomized controlled trials. BMC Surg 2021; 21:331. [PMID: 34419022 PMCID: PMC8379825 DOI: 10.1186/s12893-021-01313-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 06/29/2021] [Indexed: 02/08/2023] Open
Abstract
Background This study aims to compare colonic J-pouch and side-to-end anastomosis for rectal cancer in terms of surgical and bowel functional outcomes and quality of life (QoL). Methods A systematic literature search was performed in PubMed, Embase and Cochrane. The last search was performed on March 28, 2021. All randomized controlled trials comparing colonic J-pouch with side-to-end anastomosis for rectal cancer were enrolled. The main outcomes were bowel functional outcomes and QoL. The secondary outcomes were surgical outcomes including operative time, postoperative hospital stay, complications, and mortality. Results Nine articles incorporating 7 trials with a total of 696 patients (330 by J-pouch and 366 by side-to-end) were enrolled in this meta-analysis. The bowel functional outcomes were comparable between J-pouch and side-to-end groups in terms of stool frequency, urgency, and incomplete defecation at the short term (< 8 months), medium term (8–18 months), and long term (> 18 months) follow up evaluations. No difference was observed between groups with regards to QoL (SF-36: physical function, social function, and general health perception). Besides, surgical outcomes were also similar in two groups. Conclusion The currently limited evidence suggests that colonic J-pouch and side-to-end anastomosis are comparable in terms of bowel functional outcomes, QoL, and surgical outcomes. Surgeons may choose either of the two techniques for anastomosis. A large sample randomized controlled study comparing colonic J-pouch and side-to-end anastomosis for rectal cancer is warranted.
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Affiliation(s)
- Zheng Wang
- Department of Science and Technology, West China Hospital, Sichuan University, Chengdu, China.
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Sun R, Dai Z, Zhang Y, Lu J, Zhang Y, Xiao Y. The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis. Support Care Cancer 2021; 29:7249-7258. [PMID: 34296335 DOI: 10.1007/s00520-021-06326-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/30/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Many patients after sphincter-preserving surgery experienced anorectal functional disturbances which were known as low anterior resection syndrome (LARS). Although many studies investigated LARS, there was inconsistency of their assessment tools and results. The aim of this systematic review was to elucidate the incidence and risk factors of LARS by a validated tool-LARS score. METHODS A systematic literature search in Pubmed, Embase, and Cochrane Library was conducted in April 2020. Studies investigating patients who were evaluated by LARS score 1 year after their sphincter-preserving surgery due to rectal cancer were included. Meta-analysis of incidence was conducted using the double arcsine method. Meta-analysis of each risk factor was conducted using a random effects model. RESULTS A total of 50 studies were included. The pooled incidence of major LARS was 44% (95% CI 40-48%; I2 = 88%; 36 studies). Long course neoadjuvant radiotherapy (OR 2.89, 95% CI 2.06-4.05; I2 = 47%; P < 0.01; 10 studies), total mesorectal excision (TME) (OR 2.13, 95% CI 1.49-3.04; I2 = 53%; P < 0.01; 7 studies), anastomotic leak (OR 1.98, 95% CI 1.34-2.93; I2 = 39%; P < 0.01; 9 studies), and diverting stoma (OR 1.89, 95% CI 1.58-2.27; I2 = 0%; P < 0.01; 13 studies) were associated with increased risk of major LARS. No significant difference was found in major LARS incidence between transanal TME and laparoscopic TME (OR 1.36, 95% CI 0.78-2.40; I2 = 19%; P = 0.28; 4 studies). Pouch reconstruction failed to lower the risk of major LARS in long term (OR 1.43, 95% CI 0.88-2.33; I2 = 70%; P = 0.29; 9 studies). CONCLUSION The incidence of major LARS after sphincter-preserving surgery is relatively high. Neoadjuvant radiotherapy, TME, anastomostic leak, and diverting stoma are major risk factors. No significant differences in postoperative anorectal functions were observed between transanal and laparoscopic TME. Pouch reconstruction was not found to be significantly beneficial to anorectal functions in long term.
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Affiliation(s)
- Rui Sun
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Ziyi Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Yin Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Junyang Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Yuelun Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China.
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Safety and efficacy of side-to-end anastomosis versus colonic J-pouch anastomosis in sphincter-preserving resections: an updated meta-analysis of randomized controlled trials. World J Surg Oncol 2021; 19:130. [PMID: 33882952 PMCID: PMC8061176 DOI: 10.1186/s12957-021-02243-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
Background The application of side-to-end anastomosis (SEA) in sphincter-preserving resection (SPR) is controversial. We performed a meta-analysis to compare the safety and efficacy of SEA with colonic J-pouch (CJP) anastomosis, which had been proven effective in improving postoperative bowel function. Methods The protocol was registered in PROSPERO under number CRD42020206764. PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials databases were searched. The inclusion criteria were randomized controlled trials (RCTs) that evaluated the safety or efficacy of SEA in comparison with CJP anastomosis. The outcomes included the pooled risk ratio (RR) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. All outcomes were calculated with 95% confidence intervals (CI) by STATA software (Stata 14, Stata Corporation, TX, USA). Results A total of 864 patients from 10 RCTs were included in the meta-analysis. Patients undergoing SEA had a higher defecation frequency at 12 months after SPR (WMD = 0.20; 95% CI, 0.14–0.26; P < 0.01) than those undergoing CJP anastomosis with low heterogeneity (I2 = 0%, P = 0.54) and a lower incidence of incomplete defecation at 3 months after surgery (RR = 0.28; 95% CI, 0.09–0.86; P = 0.03). A shorter operating time (WMD = − 17.65; 95% CI, − 23.28 to − 12.02; P < 0.01) was also observed in the SEA group without significant heterogeneity (I2 = 0%, P = 0.54). A higher anorectal resting pressure (WMD = 6.25; 95% CI, 0.17–12.32; P = 0.04) was found in the SEA group but the heterogeneity was high (I2 = 84.5%, P = 0.84). No significant differences were observed between the groups in terms of efficacy outcomes including defecation frequency, the incidence of urgency, incomplete defecation, the use of pads, enema, medications, anorectal squeeze pressure and maximum rectal volume, or safety outcomes including operating time, blood loss, the use of protective stoma, postoperative complications, clinical outcomes, and oncological outcomes. Conclusions The present evidence suggests that SEA is an effective anastomotic strategy to achieve similar postoperative bowel function without increasing the risk of complications compared with CJP anastomosis. The advantages of SEA include a shorter operating time, a lower incidence of incomplete defecation at 3 months after surgery, and better sphincter function. However, close attention should be paid to the long-term defecation frequency after SPR. Supplementary Information The online version contains supplementary material available at 10.1186/s12957-021-02243-0.
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Tajima Y, Hanai T, Katsuno H, Masumori K, Koide Y, Ashida K, Matsuoka H, Hiro J, Endo T, Kamiya T, Chong Y, Maeda K, Uyama I. Robotic low anterior resection for rectal cancer with side-to-end anastomosis in a patient with anal stenosis. World J Surg Oncol 2021; 19:14. [PMID: 33441169 PMCID: PMC7807432 DOI: 10.1186/s12957-021-02121-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/04/2021] [Indexed: 11/15/2022] Open
Abstract
Background Colorectal anastomosis using the double stapling technique (DST) has become a standard procedure. However, DST is difficult to perform in patients with anal stenosis because a circular stapler cannot be inserted into the rectum through the anus. Thus, an alternative procedure is required for colorectal anastomosis. Case presentation A 78-year-old woman presented with bloody stool. Colonoscopy and computed tomography revealed advanced low rectal cancer without lymph node or distant metastasis. We initially planned to perform low anterior resection using a double stapling technique or transanal hand-sewn anastomosis, but this would have been too difficult due to anal stenosis and fibrosis caused by a Milligan-Morgan hemorrhoidectomy performed 20 years earlier. The patient had never experienced defecation problems and declined a stoma. Therefore, we inserted an anvil into the rectal stump and fixed it robotically with a purse-string suture followed by insertion of the shaft of the circular stapler from the sigmoidal side. In this way, side-to-end anastomosis was accomplished laparoscopically. The distance from the anus to the anastomosis was 5 cm. The patient was discharged with no anastomotic leakage. Robotic assistance proved extremely useful for low anterior resection with side-to-end anastomosis. Conclusion Performing side-to-end anastomosis with robotic assistance was extremely useful in this patient with rectal cancer and anal stenosis.
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Affiliation(s)
- Yosuke Tajima
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan.
| | - Tsunekazu Hanai
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Hidetoshi Katsuno
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Koji Masumori
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yoshikazu Koide
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Keigo Ashida
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Hiroshi Matsuoka
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Junichiro Hiro
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Tomoyoshi Endo
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Tadahiro Kamiya
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Yongchol Chong
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Kotaro Maeda
- International Medical Center, Fujita Health University Hospital, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
| | - Ichiro Uyama
- Department of Gastrointestinal Surgery, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192, Japan
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Ganapathi SK, Subbiah R, Rudramurthy S, Kakkilaya H, Ramakrishnan P, Chinnusamy P. Laparoscopic anterior resection: Analysis of technique over 1000 cases. J Minim Access Surg 2021; 17:356-362. [PMID: 33605924 PMCID: PMC8270051 DOI: 10.4103/jmas.jmas_132_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose: Laparoscopic rectal surgery has moved from being experimental to getting established as a mainstream procedure. We aimed at analysing how rectal cancer surgery has evolved at our institute. Methods: A retrospective review of 1000 consecutive patients who underwent laparoscopic anterior resection for rectal adenocarcinoma over a period of 15 years (January 2005 to December 2019) was performed. Technical modifications were made with splenic flexure mobilisation, intersphincteric dissection and anastomotic technique. The data collected included type of surgery, duration of surgery, conversion to open, anastomotic leak, defunctioning stoma and duration of hospital stay. The first 500 and the next 500 cases were compared. Results: The study patients were predominantly males comprising 68% (n = 680). The mean age of the patients was 58.3 years (range: 28–92 years). Majority of the procedures performed were high anterior resection (n = 402) and low anterior resection (LAR) (n = 341) followed by ultra-LAR (ULAR) (n = 208) and ULAR + colo-anal anastomosis (n = 49). A total of 42 patients who were planned for laparoscopic surgery needed conversion to open procedure. Forty-one patients (4.1%) had an anastomotic leak. The mean duration of stay was 5.3 + 2.8 days. The rate of conversion to open procedure had reduced from 5.4% to 3.0%. The rate of defunctioning stoma had reduced by >50% in the recent group. The anastomotic leak rate had reduced from 5.0% to 3.2%. The average duration of stay had reduced from 5.8 days to 4.9 days. Conclusion: This is one of the largest single-centre experiences of laparoscopic anterior resection. We have shown the progressive benefits of an evolving approach to laparoscopic anterior resection.
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Affiliation(s)
- Senthil Kumar Ganapathi
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Rajapandian Subbiah
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Sathiyamoorthy Rudramurthy
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Harish Kakkilaya
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Parthasarathi Ramakrishnan
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Palanivelu Chinnusamy
- Department of Surgical Gastroenterology, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
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Nocera F, Angehrn F, von Flüe M, Steinemann DC. Optimising functional outcomes in rectal cancer surgery. Langenbecks Arch Surg 2020; 406:233-250. [PMID: 32712705 PMCID: PMC7936967 DOI: 10.1007/s00423-020-01937-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Background By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention. Purpose This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted. Conclusion Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.
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Affiliation(s)
- Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Fiorenzo Angehrn
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
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Abstract
The role of transanal total mesorectal excision (taTME) in minimally invasive proctectomy, especially rectal cancer surgery, is increasing. There has been exponential growth in uptake from the initial in vivo case in 2010 to the present day. Early adopters of taTME are well within the mature portions of their learning curve, but there are a significant number of novice taTME surgeons. We have overviewed the critical aspects of patient selection, operating room set-up, and necessary equipment. In particular, we recommend that a one-team approach is used for the early cases, and ideally with an experienced proctor. The important technical pearls that will aid the novice taTME surgeon were also described.
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Affiliation(s)
| | - Lawrence Lee
- McGill University Health Centre, Montreal, Canada
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19
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The Incidence of Low Anterior Resection Syndrome as Assessed in an International Randomized Controlled Trial (MRC/NIHR ROLARR). Ann Surg 2020; 274:e1223-e1229. [DOI: 10.1097/sla.0000000000003806] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Ribi K, Bernhard J. ASO Author Reflections: What is the Impact of Different Rectal Reconstruction Techniques After Total Mesorectal Excision on Quality of Life? Ann Surg Oncol 2019; 26:772-773. [DOI: 10.1245/s10434-019-07929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Indexed: 11/18/2022]
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21
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Lee KH, Kim JS, Kim JY. Efficacy of biofeedback therapy for objective improvement of pelvic function in low anterior resection syndrome. Ann Surg Treat Res 2019; 97:194-201. [PMID: 31620393 PMCID: PMC6779952 DOI: 10.4174/astr.2019.97.4.194] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/22/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose There is no established treatment of choice for low anterior resection syndrome (LARS). To evaluate the efficacy of biofeedback therapy for objective improvement of pelvic function in LARS, we performed the present study. Methods The primary endpoint was the change of Wexner score. Consenting patients between 20 and 80 years old with major LARS at least 2 months after sphincter preserving proctectomy for rectal cancer were enrolled. After recommendation of biofeedback therapy, patients who accept it were enrolled in the biofeedback group and patients who refuse were enrolled in the control group. Initial and follow-up evaluations were performed and analyzed. Results Fifteen and sixteen patients were evaluated in the control group and the biofeedback group, respectively. There was no statistically significant difference of LARS score between both groups. Decrease in Wexner score and increase in rectal capacity were significantly higher in the biofeedback group (odds ratio [OR], 5.386; 95% confidence interval [CI], 1.194–24.287; P = 0.028 and OR, 1.061; 95% CI, 1.002–1.123; P = 0.042). Conclusion Biofeedback therapy was superior for objective improvement of pelvic function to observation in LARS. It can be considered to induce more rapid improvement of major LARS.
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Affiliation(s)
- Kyung Ha Lee
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
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Feeney G, Sehgal R, Sheehan M, Hogan A, Regan M, Joyce M, Kerin M. Neoadjuvant radiotherapy for rectal cancer management. World J Gastroenterol 2019; 25:4850-4869. [PMID: 31543678 PMCID: PMC6737323 DOI: 10.3748/wjg.v25.i33.4850] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/28/2019] [Accepted: 08/07/2019] [Indexed: 02/06/2023] Open
Abstract
Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.
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Affiliation(s)
- Gerard Feeney
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Rishabh Sehgal
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Margaret Sheehan
- Department of Histopathology, Galway University Hospital, Galway H91 YR71, Ireland
| | - Aisling Hogan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Mark Regan
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Myles Joyce
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
| | - Michael Kerin
- Department of General/Colorectal Surgery, Galway University Hospital, Galway H91 YR71, Ireland
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Shalaby M, Thabet W, Morshed M, Farid M, Sileri P. Preventive strategies for anastomotic leakage after colorectal resections: A review. World J Meta-Anal 2019; 7:389-398. [DOI: 10.13105/wjma.v7.i8.389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/31/2019] [Accepted: 09/03/2019] [Indexed: 02/06/2023] Open
Abstract
Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
- Department of General Surgery UOC C, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome 00133, Italy
| | - Waleed Thabet
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Mosaad Morshed
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Mohamed Farid
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Pierpaolo Sileri
- Department of General Surgery UOC C, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome 00133, Italy
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Cura Pales CG, An S, Cruz JP, Kim K, Kim Y. Postoperative Bowel Function After Anal Sphincter-Preserving Rectal Cancer Surgery: Risks Factors, Diagnostic Modalities, and Management. Ann Coloproctol 2019; 35:160-166. [PMID: 31487762 PMCID: PMC6732333 DOI: 10.3393/ac.2019.08.10] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/10/2019] [Indexed: 02/06/2023] Open
Abstract
Low anterior resection syndrome (LARS) refers to a disturbance of bowel function that commonly manifests within 1 month after rectal cancer surgery. A low level of anastomosis and chemoradiotherapy have been consistently found to be risk factors for developing LARS. Thorough history taking and physical examination with adjunctive procedures are essential when evaluating patients with LARS. Anorectal manometry, fecoflowmetry, and validated questionnaires are important tools for assessing the quality of life of patients with LARS. Conservative management (medical, physiotherapy, transanal irrigation), invasive procedures (neuromodulation), and multimodal therapy are the mainstay of treatment for patients with LARS. A stoma could be considered when other treatment modalities have failed. An initial meticulous surgical procedure for rectal cancer, creation of a neorectal reservoir during anastomosis, and proper exercise of the anal sphincter muscle (Kegel’s maneuver) are essential to combat LARS. Pretreatment counseling is a crucial step for patients who have risk factors for developing LARS.
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Affiliation(s)
- Chris George Cura Pales
- Section of Colon and Rectal Surgery, Department of Surgery, Southern Philippines Medical Center, Davao City, The Philippines
| | - Sanghyun An
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jan Paolo Cruz
- Section of Colorectal Surgery, Department of Surgery, Rizal Medical Center, Pasig City, The Philippines.,Department of Surgery, Clinica Antipolo Hospital and Wellness Center, Antipolo City, The Philippines
| | - Kwangmin Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Department of Surgery, Saidabad Clinic, Dhaka, Bangladesh
| | - Youngwan Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Martellucci J, Sturiale A, Bergamini C, Boni L, Cianchi F, Coratti A, Valeri A. Role of transanal irrigation in the treatment of anterior resection syndrome. Tech Coloproctol 2018; 22:519-527. [PMID: 30083782 DOI: 10.1007/s10151-018-1829-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/23/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center. METHODS Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol. RESULTS Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended. CONCLUSIONS TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life. Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed 6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.
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Affiliation(s)
- J Martellucci
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy.
| | - A Sturiale
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy
| | - C Bergamini
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy
| | - L Boni
- Clinical Trial Center, Careggi University Hospital, Florence, Italy
| | - F Cianchi
- General and Endocrine Surgery, Careggi University Hospital, Florence, Italy
| | - A Coratti
- Oncologic and Robotic Surgery, Careggi University Hospital, Florence, Italy
| | - A Valeri
- General Emergency and Minimally Invasive Surgery, Careggi University Hospital, largo Brambilla 3, 50134, Florence, Italy
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Qin Q, Wang L. Neoadjuvant therapy and subsequent treatment in rectal cancer: balance between oncological and functional outcomes. JOURNAL OF THE ANUS RECTUM AND COLON 2018; 2:47-58. [PMID: 31583321 PMCID: PMC6768820 DOI: 10.23922/jarc.2017-049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 02/09/2018] [Indexed: 12/21/2022]
Abstract
Current practice of neoadjuvant therapy and total mesorectal excision (TME) in rectal cancer bears the weakness in systemic disease control and long-term functional outcomes. With increasing concerns of the balance between cure and quality of life, new strategies are developed to better oncological outcomes at least cost of function damage. Attractive options to adjust neoadjuvant modality include escalation of radiotherapy, intensification of chemotherapy, and chemoradiotherapy with consolidation or full-course chemotherapy. Subsequently, organ-preserving strategies have gained the popularity. Surgical or nonsurgical approaches that spare the rectum are used as possible alternatives for radical surgery, though high-quality TME remains the last resort to offer reliable local disease control. This review discusses new strategies of neoadjuvant therapy and subsequent management, with a specific focus on the balance between oncological and functional outcomes.
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Affiliation(s)
- Qiyuan Qin
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, Sun Yat-sen University, Guangzhou, Guangdong, China
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Sturiale A, Martellucci J, Zurli L, Vaccaro C, Brusciano L, Limongelli P, Docimo L, Valeri A. Long-term functional follow-up after anterior rectal resection for cancer. Int J Colorectal Dis 2017; 32:83-88. [PMID: 27695976 DOI: 10.1007/s00384-016-2659-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. METHOD Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. RESULTS A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. CONCLUSIONS Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.
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Affiliation(s)
- Alessandro Sturiale
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy.
| | - Jacopo Martellucci
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Letizia Zurli
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Carla Vaccaro
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Luigi Brusciano
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Paolo Limongelli
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Ludovico Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Andrea Valeri
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
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Rybakov EG, Pikunov DY, Fomenko OY, Chernyshov SV, Shelygin YA. Side-to-end vs. straight stapled colorectal anastomosis after low anterior resection: results of randomized clinical trial. Int J Colorectal Dis 2016; 31:1419-26. [PMID: 27240822 DOI: 10.1007/s00384-016-2608-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2016] [Indexed: 02/04/2023]
Abstract
AIM The aim of this study is to compare surgical, functional, physiologic outcomes and QOL after low anterior resection (LAR) with andside-to-end or straight colorectal anastomosis. METHOD Between 2012 and 2015, 86 patients with mid and low rectal tumors were enrolled into randomized trial. Wexner score, number of defecations, use of antidiarrheal medicine or laxatives, enemas, pads, episodes of nocturnal incontinence, and urgency were recorded. The Fecal Incontinence Quality of Life (FIQL) scale was used for assessment of QOL. Anal manometry and volumetric examination were performed. RESULTS Six patients were excluded from the study. There was no mortality. The morbidity rate was 6 (14.6 %) for side-to-end vs. 8 (20.0 %) for straight anastomosis (p = 0.57). The median Wexner score was 5 vs. 6 (p = 0.033), 4 vs. 5 (p = 0.006), and 2 vs. 3 (p = 0.1) at 1, 3, and 6 months after stoma reversal, respectively. Side-to-end anastomosis resulted in a fewer mean numbers of bowel movements per day at the same check points of follow-up: 5.8 ± 0.14 vs. 6.4 ± 0.15 (p = 0.006), 3.7 ± 0.1 vs. 4.2 ± 0.1 (p = 0.003), and 2.5 ± 0.1 vs. 3.0 ± 0.10 (p = 0.0002), correspondingly. Maximal tolerated volume was higher for side-to-end anastomosis at 3 and 6 months of follow-up: 152.0 vs. 137.8 cm(3) (p = 0.002) and 180.5 vs. 167.0 cm(3) (p = 0.006), respectively. Better FIQL score was found at 1 and 3 months in the side-to-end group. CONCLUSION Better functional outcomes and QOL were observed in a short period after stoma closure, but at 6 months of follow-up, the only benefit of side-to-end anastomosis was a lower number of bowel movements.
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Affiliation(s)
- E G Rybakov
- Department of Oncoproctology, State Scientific Centre of Coloproctology, Saliama Adila 2, Moscow, Russia, 123423.
| | - D Yu Pikunov
- Department of Oncoproctology, State Scientific Centre of Coloproctology, Saliama Adila 2, Moscow, Russia, 123423
| | - O Yu Fomenko
- Laboratory of clinical pathophysiology State Scientific Centre of Coloproctology, Moscow, Russia
| | - S V Chernyshov
- Department of Oncoproctology, State Scientific Centre of Coloproctology, Saliama Adila 2, Moscow, Russia, 123423
| | - Yu A Shelygin
- Director of State Scientific Centre of Coloproctology, Moscow, Russia
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Kye BH, Kim HJ, Kim G, Yoo RN, Cho HM. The Effect of Biofeedback Therapy on Anorectal Function After the Reversal of Temporary Stoma When Administered During the Temporary Stoma Period in Rectal Cancer Patients With Sphincter-Saving Surgery: The Interim Report of a Prospective Randomized Controlled Trial. Medicine (Baltimore) 2016; 95:e3611. [PMID: 27149496 PMCID: PMC4863813 DOI: 10.1097/md.0000000000003611] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We evaluated the effect of biofeedback therapy (BFT) on anorectal function after stoma closure when administered during the interval of temporary stoma after sphincter-preserving surgery for rectal cancer.Impaired anorectal function is common after lower anterior resections, though no specific treatment options are currently available to prevent this adverse outcome.Fifty-six patients who underwent neoadjuvant chemoradiation therapy after sphincter-preserving surgery with temporary stoma were randomized into 2 groups: group 1 (received BFT during the temporary stoma period) and group 2 (did not receive BFT). To evaluate anorectal function, anorectal manometry was performed in all patients and subjective symptoms were evaluated using the Cleveland Clinic Incontinence Score. The present study is a report at 6 months after rectal resection.Forty-seven patients, including 21 in group 1 and 26 in group 2, were evaluated by anorectal manometry. Twelve patients (57.1%) in group 1 and 13 patients (50%) in group 2 were scored above 9 points of Cleveland Clinic Incontinence Score, which is the reference value for fecal incontinence (P = 0.770). With time, there was a significant difference (P = 0.002) in the change of mean resting pressure according to time sequence between the BFT and control groups.BFT during the temporary stoma interval had no effect on preventing anorectal dysfunction after temporary stoma reversal at 6 months after rectal resection. However, BFT might be helpful for maintaining resting anal sphincter tone (NCT01661829).
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Affiliation(s)
- Bong-Hyeon Kye
- From the Department of Surgery, St Vincent's Hospital, The Catholic University of Korea, Korea
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30
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Experience of colonic J pouch reconstruction following anterior resection. Eur Surg 2015. [DOI: 10.1007/s10353-015-0345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Maggiori L, Blanche J, Harnoy Y, Ferron M, Panis Y. Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula. Int J Colorectal Dis 2015; 30:543-8. [PMID: 25586206 DOI: 10.1007/s00384-014-2119-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2014] [Indexed: 02/07/2023]
Abstract
PURPOSE Redo-surgery with new colorectal (CRA) or coloanal (CAA) anastomosis for failed previous CRA or CAA is exposed to failure and recurrent leakage, especially in case of rectovaginal fistula (RVF) or chronic pelvic sepsis (CPS). In these two situations, transanal colonic pull-through and delayed coloanal anastomosis (DCAA) could be an alternative to avoid definitive stoma. This study aimed to assess results of such redo-surgery with DCAA for failed CRA or CAA with CPS and/or RVF. METHODS All patients who underwent DCAA for failed CRA or CAA with CPS and/or RVF were reviewed. Success was defined as a patient without any stoma at the end of follow-up. Long-term functional results were assessed using the low anterior resection syndrome (LARS) score. RESULTS 24 DCAA were performed after failed CRA or CAA with CPS (n = 15) or RVF (n = 9). Sixteen (67%) patients had a diverting stoma at the time (n = 5) or performed during DCAA (n = 11). After a mean follow-up of 29 ± 19 months, success rate was 79% (19/24): 5 patients had a permanent stoma because of recurrent sepsis (n = 2), anastomotic stricture (n = 1), or poor functional outcomes (n = 2). Functional outcomes were satisfactory (no or minor LARS) in 82% of the successful patients. CONCLUSION In case of failed CRA or CAA with CPS or RVF, DCAA was associated with a 79% success rate. It could therefore be proposed as an alternative to standard redo-CRA or CAA when the risk of recurrent sepsis and failure with subsequent definitive stoma is thought to be high.
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Affiliation(s)
- Léon Maggiori
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University Denis Diderot (Paris VII), 100 boulevard du Général Leclerc, 92110, Clichy, France
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Hüttner FJ, Tenckhoff S, Jensen K, Uhlmann L, Kulu Y, Büchler MW, Diener MK, Ulrich A. Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg 2015; 102:735-45. [PMID: 25833333 DOI: 10.1002/bjs.9782] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 12/23/2014] [Accepted: 01/13/2015] [Indexed: 01/27/2023]
Abstract
BACKGROUND Options for reconstruction after low anterior resection (LAR) for rectal cancer include straight or side-to-end coloanal anastomosis (CAA), colonic J pouch and transverse coloplasty. This systematic review compared these techniques in terms of function, surgical outcomes and quality of life. METHODS A systematic literature search (MEDLINE, Embase and the Cochrane Library, from inception of the databases until November 2014) was conducted to identify randomized clinical trials comparing reconstructive techniques after LAR. Random-effects meta-analyses were carried out, and results presented as weighted odds ratios or mean differences with corresponding 95 per cent c.i. A network meta-analysis was conducted for the outcome anastomotic leakage. RESULTS The search yielded 965 results; 21 trials comprising data from 1636 patients were included. Colonic J pouch was associated with lower stool frequency and antidiarrhoeal medication use for up to 1 year after surgery compared with straight CAA. Transverse coloplasty and side-to-end CAA had similar functional outcomes to the colonic J pouch. No superiority was found for any of the techniques in terms of anastomotic leak rate. CONCLUSION Colonic J pouch and side-to-end CAA or transverse coloplasty lead to a better functional outcome than straight CAA for the first year after surgery.
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Affiliation(s)
- F J Hüttner
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany; Study Centre of the German Surgical Society, University of Heidelberg, Heidelberg, Germany
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Weaver KL, Grimm LM, Fleshman JW. Changing the Way We Manage Rectal Cancer-Standardizing TME from Open to Robotic (Including Laparoscopic). Clin Colon Rectal Surg 2015; 28:28-37. [PMID: 25733971 DOI: 10.1055/s-0035-1545067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Standardizing total mesorectal excision (TME) has been a topic of interest since 1979 when Professor Richard J. Heald first described TME and a new approach to rectal cancer. The procedure is optimized only if every one of the relevant factors is tackled with precise attention to detail, so that the preoperative, operative, and postoperative practice is standardized completely. The same concept of TME standardization applies today regardless of technique chosen, that is, open laparoscopic, single-incision laparoscopic surgery, or robotic. This article reviews the relevant operative factors in performing a quality TME, looking at both the oncologic and nononcologic advantages and disadvantages. It supports TME as the standard of care in obtaining a negative circumferential margin for mid and lower-third rectal cancers, and discusses the role of tumor-specific mesorectal excision for upper-third rectal cancers. It discusses the new options and challenges each operative technique holds, and identifies the same standardized principles each must obey to provide the highest quality of oncologic resection. The operative documentation of these critical features from diagnostic workup to pathological reporting is also emphasized.
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Affiliation(s)
- Katrina L Weaver
- Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Leander M Grimm
- Division of Colon and Rectal Surgery, University of South Alabama, Mobile, Alabama
| | - James W Fleshman
- Department of Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
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Knol JJ, D'Hondt M, Souverijns G, Heald B, Vangertruyden G. Transanal endoscopic total mesorectal excision: technical aspects of approaching the mesorectal plane from below--a preliminary report. Tech Coloproctol 2015; 19:221-9. [PMID: 25702172 DOI: 10.1007/s10151-015-1275-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 01/27/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Laparoscopic total mesorectal excision (TME) for low rectal cancer can be technically challenging. This report describes our initial experience with a hybrid laparoscopic and transanal endoscopic technique for TME in low rectal cancer. METHODS Between December 2012 and October 2013, we identified patients with rectal cancer < 5 cm from the anorectal junction (ARJ) who underwent laparoscopic-assisted TME with a transanal minimally invasive surgery (TAMIS) technique. A standardized stepwise approach was used in all patients. Resection specimens were examined for completeness and measurement of margins. Preoperative magnetic resonance imaging (MRI) characteristics and short-term postoperative outcomes were examined. All values are mean ± standard deviation. RESULTS Ten patients (8 males; median age: 60.5 (range 36-70) years) were included. On initial MRI, all tumors were T2 or T3, mean tumor height from the ARJ was 28.9 ± 12.2 mm, mean circumferential resection margin was 5.3 ± 3.1 mm , and the mean angle between the anal canal and the levator ani was 83.9° ± 9.7°. All patients had had preoperative chemoradiotherapy, TME via TAMIS, and distal anastomosis. There were no intraoperative complications, anastomotic leaks, or 30-day mortality. The pathologic quality of all mesorectal specimens was excellent. The distal resection margin was 19.4 ± 10.4 mm, the mean circumferential resection margin was 13.8 ± 5.1 mm, and the median lymph node harvest was 10.5 (range 5-15) nodes. CONCLUSIONS A combined laparoscopic and transanal approach can achieve a safe and oncologically complete TME dissection for low rectal tumors. This approach may improve clinical outcomes in these technically difficult cases, but larger prospective studies are needed.
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Affiliation(s)
- J J Knol
- Department of Abdominal Surgery, Jessa Hospital, Salvatorstraat 20, 3500, Hasselt, Belgium,
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Wells CI, Vather R, Chu MJJ, Robertson JP, Bissett IP. Anterior resection syndrome--a risk factor analysis. J Gastrointest Surg 2015; 19:350-9. [PMID: 25326125 DOI: 10.1007/s11605-014-2679-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 10/08/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Evacuatory dysfunction after distal colorectal resection varies from incontinence to obstructed defaecation and is termed anterior resection syndrome. The aim of this study was to identify risk factors for the development of anterior resection syndrome. METHODS All anterior resections undertaken at Auckland Hospital from 2002 to 2012 were retrospectively evaluated. An assortment of patient and peri-operative variables were recorded. Cases were stratified by the occurrence of anterior resection syndrome symptoms from 1 to 5 years post-operatively. RESULTS A total of 277 patients were identified. Prevalence of anterior resection syndrome decreased progressively from 61 % at 1 year to 43 % at 5 years. Univariate analysis identified anastomotic height, surgeon, pT stage, procedure year and temporary diversion ileostomy as recurring significant correlates (p < 0.05). Logistic regression identified lower anastomotic height (odds ratio (OR) 2.11, 95 % confidence interval (CI) 1.05-4.27; p = 0.04) and obstructive presenting symptoms (OR 6.71, 95 % CI 1.00-44.80; p = 0.05) as independent predictors at 1 and 2 years, respectively. Post-operative chemotherapy was a predictor at 1 year (OR 1.93, 95 % CI 1.04-3.57; p = 0.03). Temporary diverting ileostomy was an independent predictor at 2 (OR 2.49, 95 % CI 1.04-5.95; p = 0.04), 3 (OR 4.17, 95 % CI 1.04-16.78; p = 0.04), 4 (OR 8.05, 95 % CI 1.21-53.6; p = 0.03), and 5 years (OR 49.60, 95 % CI 2.17-1134.71; p = 0.02) after adjusting for anastomotic height. CONCLUSIONS Anastomotic height, post-operative chemotherapy and obstructive presenting symptoms were independent predictors at 1 and 2 years. Temporary diversion ileostomy was an independent predictor for the occurrence of anterior resection syndrome at 2, 3, 4 and 5 years even after correcting for anastomotic height. Prospective assessment is required to facilitate more accurate risk factor analysis.
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Affiliation(s)
- Cameron I Wells
- Department of Surgery, The University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand
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Fazeli MS, Keramati MR. Rectal cancer: a review. Med J Islam Repub Iran 2015; 29:171. [PMID: 26034724 PMCID: PMC4431429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 12/24/2014] [Indexed: 11/22/2022] Open
Abstract
Rectal cancer is the second most common cancer in large intestine. The prevalence and the number of young patients diagnosed with rectal cancer have made it as one of the major health problems in the world. With regard to the improved access to and use of modern screening tools, a number of new cases are diagnosed each year. Considering the location of the rectum and its adjacent organs, management and treatment of rectal tumor is different from tumors located in other parts of the gastrointestinal tract or even the colon. In this article, we will review the current updates on rectal cancer including epidemiology, risk factors, clinical presentations, screening, and staging. Diagnostic methods and latest treatment modalities and approaches will also be discussed in detail.
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Affiliation(s)
- Mohammad Sadegh Fazeli
- 1 Associate Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Reza Keramati
- 2 Assistant Professor of Surgery, Department of Surgery, Tehran University of Medical Sciences, Tehran, Iran.
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Jones DW, Garrett KA. Anastomotic technique—Does it make a difference? SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Contin P, Kulu Y, Bruckner T, Sturm M, Welsch T, Müller-Stich BP, Huber J, Büchler MW, Ulrich A. Comparative analysis of late functional outcome following preoperative radiation therapy or chemoradiotherapy and surgery or surgery alone in rectal cancer. Int J Colorectal Dis 2014; 29:165-75. [PMID: 24136155 DOI: 10.1007/s00384-013-1780-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2013] [Indexed: 02/04/2023]
Abstract
PURPOSE This study evaluates the anorectal and genitourinary function of patients treated by preoperative short-term radiotherapy (RT) or chemoradiotherapy (CRT) followed by surgery and surgery alone for rectal cancer. METHODS For this study, a total of 613 patients, who were identified from a prospective rectal cancer database, underwent anterior resection of the rectum between October 2001 and December 2007. Standardized questionnaires were used to determine fecal incontinence, urinary, and sexual function. Relevant clinical variables were evaluated using univariate and multivariate analyses. Independent predictors of functional outcome were identified by a binary logistic regression analysis. RESULTS The data of 263 (43 %) patients were available for analysis. On multivariate analysis, neoadjuvant RT (P < 0.01) and low anterior resection (LAR) (P = 0.049) were associated with fecal incontinence. In univariate analysis, fecal incontinence was linked to preoperative neoadjuvant treatment (RT and/or CRT vs. LAR) (P < 0.01). The hazard ratio for developing fecal incontinence was 3.3 (1.6-6.8) for patients who received RT. One hundred twenty-five patients (51.2 %) experienced urinary incontinence following surgery, the majority of whom were female (P < 0.01). On univariate analysis, male sexual function was associated with age (P < 0.01), ASA class (P = 0.01) and LAR (P = 0.01). CONCLUSION Multimodal therapy of low rectal cancer increases the incidence of fecal incontinence and negatively affects sexual function. The potential benefits of RT or CRT need to be balanced against the risk of increased bowel dysfunction when determining the appropriate treatment for individual patients with rectal cancer.
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Affiliation(s)
- Pietro Contin
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
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Si C, Zhang Y, Sun P. Colonic J-pouch versus Baker type for rectal reconstruction after anterior resection of rectal cancer. Scand J Gastroenterol 2013; 48:1428-35. [PMID: 24131322 DOI: 10.3109/00365521.2013.845905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE. There is no consensus regarding reconstruction type after anterior resection for rectal cancer. We conducted a meta-analysis of relevant randomized controlled trials (RCTs) to compare outcomes of colonic J-pouch (CJlP) and side-to-end anastomosis (STEA) after anterior resection of rectal cancer. METHODS. Electronic databases were searched in January 2013, with six RCTs selected for further analysis, for a total of 451 patients (229 CJP, 222STEA). Outcome measures included surgical, physiologic, and functional outcomes, as well as postoperative complications. The odds ratio (OR) was used in the statistical analysis; in other circumstances, qualitative descriptions were performed. RESULTS. As far as surgical outcomes and postoperative complications, there was no difference between groups. While functional outcomes were substantially impaired, this was similar between groups. CJP demonstrated better function in the early postoperative period. No difference was seen between groups with regards to physiologic outcome. CONCLUSION. CJP and STEA are comparable when choosing the type of reconstruction for restoration of bowel continuity in anterior resection for rectal cancer.
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Affiliation(s)
- Chengshuai Si
- Department of General Surgery, Shanghai Huashan Hospital, Fudan University , Shanghai , China
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Coloanal anastomosis or abdominoperineal resection for very low rectal cancer: what will benefit, the surgeon's pride or the patient's quality of life? Int J Colorectal Dis 2013; 28:949-57. [PMID: 23274737 DOI: 10.1007/s00384-012-1629-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 02/07/2023]
Abstract
PURPOSES Sphincter-saving operation with coloanal anastomosis (CAA) has become an established option for very low rectal cancer, but few studies have compared its functional results and quality of life (QoL) with abdominoperineal resection (APR) showing controversial results. PATIENTS AND METHODS Patients treated for low rectal cancer with APR or CAA, disease-free after a median follow-up period of 26.5 (8-84) and 52.5 (12-156) months, respectively, were retrospectively reviewed. General and disease-specific changes in QoL and severity of disease were evaluated by Karnofsky scale, EORTC-C30, EORTC-CR38, SF-36, PGWBI, FIQL, PAC-QoL, ICIQ-SF, Stoma-QoL, AMS, Wexner's score and obstructed defecation syndrome (ODS) score. RESULTS Twenty-six APR patients and 34 CAA patients entered the study. Karnofsky score did not show significant differences. The median Stoma-QoL was 58.2 (45-76.6), indicating a good stoma function in 95% of patients. EORTC-C30, CR38, PGWBI and SF-36 questionnaires did not show significant differences between the two groups except for sexual function (better after CAA, p = 0.01). Eleven patients after APR and eight after CAA had urinary incontinence, and its severity did not differ significantly. Eighteen of 21 CAA patients complained of faecal incontinence [AMS, 80 (15-120); Wexner, 13 (2-19)] with an impact on their QoL [FIQL: lifestyle, 1.75 (0-4); coping/behaviour, 1.3 (0-3.5); depression, 2.1 (0-5.2); embarrassment, 2 (0-4.6)] and 11 complained of obstructed defecation [7.5 (3-16)] with significant consequences on QoL [PAC-QoL, 30.4 (19.2-80.3)]. CONCLUSIONS QoL in patients with permanent stoma and in those after CAA did not differ significantly. APR patients had worse sexual function, while most CAA patients had faecal incontinence and sometime obstructed defecation, with important impact on their QoL.
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A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome. Updates Surg 2013; 65:257-63. [PMID: 23754496 DOI: 10.1007/s13304-013-0220-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/31/2013] [Indexed: 12/15/2022]
Abstract
The aim of this review is to characterize the functional results and "anterior resection syndrome" (ARS) after sphincter-saving surgery for rectal cancer. The purpose of sphincter-saving operations is to save the anal sphincters by avoiding the need for rectal abdomino-perineal resection with a permanent stoma. A variety of alternative techniques have been proposed and, today, ultra-low anterior resections of the rectum are commonplace. Inevitably rectal resections modify anorectal physiology. The backdrop of the functional asset for ultralow anterior resections is related to a small neorectal capacity with high endo-neorectal pressures that act together on a weakened sphincteric mechanism. Sometimes a defecation disorder called ARS may be induced and the patient experiences an extremely low quality of life. Impaired bowel function is usually provoked either by colonic dysmotility, neorectal reservoir dysfunction, anal sphincter damage or by a combination of these factors. Surgical technique defects can contribute to these possible causes: anastomotic ischemia, short length of the descending colon and stretching of neorectal mesentery may play a role. Unfortunately, there is no therapeutic algorithm or gold standard treatment that may be used for ARS. Nevertheless, it is rational to use conservative therapy first and then resort to surgery. Drugs, rehabilitative treatment and sacral neuromodulation may be used; after failure of conservative methods, surgical treatment can be considered.
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Abstract
Colorectal cancer (CRC) is one of the most common malignancies worldwide. Due to a higher incidence of CRC in the western hemisphere a significant amount of research was carried out and majority of the controversies could be resolved as far as management of CRC is concerned. Recently a number of significant advances were made in the field of CRC related to surgery, systemic therapy and radiotherapy. During the last decade we have witnessed introduction of minimally invasive surgery, incorporation of more effective newer chemotherapeutic regimes and targeted therapies and refinements in radiotherapy protocols. The demographics and clinical picture of CRC seems to be different in developing countries and there is paucity of CRC related studies from developing countries. In-order to update the practicing surgeons a review of conventional controversies of CRC surgery was performed and an update on the recent developments in the field of CRC was also presented in this article.
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Mehrvarz S, Towliat SM, Mohebbi HA, Derakhshani S, Abavisani M. Comparison of Colonic J-pouch and Straight Coloanal anastomosis after Low Anterior Resection. IRANIAN RED CRESCENT MEDICAL JOURNAL 2013; 15:32-5. [PMID: 23486745 PMCID: PMC3589776 DOI: 10.5812/ircmj.3804] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 06/16/2012] [Accepted: 07/08/2012] [Indexed: 11/16/2022]
Abstract
Background The tendency towards sphincter preserving for low rectal cancers with low anterior resection, has led to the technique of straight coloanal anastomosis (SCAA) or colonic J-pouch anal anastomosis (CPAA). Objectives The aim of our study was to compare functional outcomes, complication rates and quality of life (QoL) after LAR with either a straight or colonic J pouch anastomosis. Patients and Methods In 88 patients with rectal tumors located in lower third, who were candidate for LAR with coloanal anastomosis. They were divided for reconstruction using either SCAA (n= 47) or CPAA (n= 41) from January 2007 to May 2009. Functional results were assessed after closure of temporary loop ileostomy, 6 months postoperatively. Quality of life (QoL) was measured using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30. Results The two groups were matched for gender, age, and preoperative chemotherapy and radiotherapy. There were no significant differences between the SCAA and CPAA groups relative to anastomotic leakage. Among patients with CPAA, the mean of 24 hours bowel movements, daytime bowel movements, incontinence scores, and incidence of urgency were significantly lower than those in the SCAA group. Also, patients with a CPAA had a significantly better quality of life. Conclusions CPAA provided not only better functional results than SCAA, but also improved quality of life, thus may be the better choice.
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Affiliation(s)
- Shaban Mehrvarz
- Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Shaban Mehrvarz, Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, Iran. Tel.: +98-2188033539, Fax: +98-2188033539, E-mail:
| | - Seyed Mohsen Towliat
- Baqiyatallah University of Medical Sciences, Research Center for Gastroenterology and Liver Disease, Tehran, IR Iran
| | - Hassan Ali Mohebbi
- Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | | | - Mahdi Abavisani
- Department of General Surgery, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
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Werner J, Sauer P. Nahtinsuffizienz intestinaler Anastomosen: Endoskopische und laparoskopische Therapieoptionen. Visc Med 2013. [DOI: 10.1159/000348266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen die schwerwiegendste septische Komplikation nach viszeralchirurgischen Eingriffen dar. Neben der chirurgischen Therapie sind zunehmend endoskopische Behandlungsoptionen möglich. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Therapieoptionen von Anastomoseninsuffizienzen sind abhängig von der klinischen Symptomatik, der Art der Anastomose, der Defektgröße, den lokalen Gewebeverhältnissen sowie dem Zeitpunkt der Diagnose. Bei einer Nekrose oder Minderdurchblutung der Viszeralorgane müssen diese operativ reseziert werden. Prinzipiell sind alle operativen Revisionseingriffe auch laparoskopisch durchführbar. Bei erhaltener Gewebeperfusion können die Leckagen lokal übernäht oder endoskopisch verschlossen werden. Die Ergebnisse für die Stenttherapie nach Ösophagus- und Magenresektionen sind für moderne Stents sehr Erfolg versprechend. Im Gegensatz dazu sind die Ergebnisse der endoskopischen Stenttherapie bei Insuffizienz nach kolorektalen Eingriffen enttäuschend; dafür steht hier mit der Schwammtherapie eine vielversprechende endoskopische Alternative zur Verfügung. <b><i>Schlussfolgerung: </i></b>Die aktuellen Daten zeigen, dass neue laparoskopische und endoskopische Optionen zur Therapie von Anastomoseninsuffizienzen bestehen, die jedoch noch in prospektiven und randomisierten Studien evaluiert werden müssen.
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Abstract
Up to 80% of patients with rectal cancer undergo sphincter-preserving surgery. It is widely accepted that up to 90% of such patients will subsequently have a change in bowel habit, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection and reconstruction of the rectum has been termed anterior resection syndrome. Currently, no precise definition or causal mechanisms have been established. This disordered bowel function has a substantial negative effect on quality of life. Previous reviews have mainly focused on different colonic reconstructive configurations and their comparative effects on daily function and quality of life. The present Review explores the potential mechanisms underlying disturbed functions, as well as current, novel, and future treatment options.
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Affiliation(s)
- Catherine L C Bryant
- Academic Surgical Unit, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Davis B, Rivadeneira DE. Complications of colorectal anastomoses: leaks, strictures, and bleeding. Surg Clin North Am 2012. [PMID: 23177066 DOI: 10.1016/j.suc.2012.09.014] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Intestinal anastomosis is an essential part of surgical practice, and with it comes the inherent risk of complications including leaks, strictures, and bleeding, which result in significant morbidity and occasional mortality. Understanding the myriad of risk factors and the strength of the data helps guide a surgeon as to the safety of undertaking an operation in which a primary anastomosis is to be considered. This article reviews the risk factors, management, and outcomes associated with anastomotic complications.
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Affiliation(s)
- Bradley Davis
- Department of Surgery, University of Cincinnati, Cincinnati, OH 45267, USA.
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Ziv Y, Zbar A, Bar-Shavit Y, Igov I. Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations. Tech Coloproctol 2012; 17:151-62. [PMID: 23076289 DOI: 10.1007/s10151-012-0909-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Accepted: 09/20/2012] [Indexed: 02/06/2023]
Abstract
Between 25 and 80% of patients undergoing a low or very low anterior resection will suffer postoperatively, from a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation and incontinence, collectively referred to as the low anterior resection syndrome (LARS). The etiology of LARS is multifactorial with the potential of sphincter injury during anastomosis construction, alterations in anorectal physiology, the development of a pudendal neuropathy, and a lumbar plexopathy with exacerbation of symptoms if there is associated anastomotic sepsis or the use of adjuvant and neoadjuavnt therapies. The symptoms of LARS may be obviated in part by the construction of a neorectal reservoir which may take the form of a colonic J-pouch, a transverse coloplasty, or a side-to-end anastomosis. This review outlines the factors contributing to LARS symptomatology along with the short- and medium-term functional results of comparative trials with the different types of neorectal reconstructions.
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Affiliation(s)
- Y Ziv
- Department of General Surgery B, Assaf Harofeh Medical Center, Zerifin, Israel.
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Doeksen A, Bakx R, Vincent A, van Tets WF, Sprangers MAG, Gerhards MF, Bemelman WA, van Lanschot JJB. J-pouch vs side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision for rectal cancer: a multicentre randomized trial. Colorectal Dis 2012; 14:705-13. [PMID: 21831100 DOI: 10.1111/j.1463-1318.2011.02725.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Comparison of functional and surgical outcome of the J-pouch with the side-to-end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision in rectal cancer patients. METHOD In a multicentre study, patients with a carcinoma of the lower two-thirds of the rectum were randomized to either a J-pouch or a side-to-end reconstruction. Primary outcome was function of the neorectum 1 year after surgery. A functional outcome [COloREctal Functional Outcome (COREFO)] questionnaire, and two quality of life questionnaires (EORTC-QLQ-CR38 and SF-36) were to be completed by all participants preoperatively, and 4 and 12 months postoperatively. Independent data managers recorded surgical outcome. A group size of 30 patients in each group was calculated based on a 15-point difference of the COREFO scale. RESULTS In total, 107 patients were randomized, 55 in the J-pouch group and 52 in the side-to-end anastomosis group. The COREFO incontinence scale at 4 months and the total functional outcome at 4 and 12 months showed better results for the J-pouch group in comparison with the side-to-end anastomosis group. The remaining COREFO scales (frequency, social impact, stool-related aspects and bowel medication), surgical outcome (complications, reoperations, length of hospital stay, readmissions and mortality) and quality of life did not show significant differences between treatment groups. CONCLUSION The overall results of a coloanal J-pouch and a side-to-end anastomosis are comparable, although functional results are slightly better with a J-pouch. The side-to-end anastomosis is technically less demanding and therefore a justified alternative in sphincter-saving surgery.
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Affiliation(s)
- A Doeksen
- Department of Surgery, Academic Medical Center at the University of Amsterdam, Amsterdam, The Netherlands.
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Kwaan MR. Bowel Function After Rectal Cancer Surgery: A Review of the Evidence. SEMINARS IN COLON AND RECTAL SURGERY 2011. [DOI: 10.1053/j.scrs.2011.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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