Quality of life of patients after low anterior, intersphincteric, and abdominoperineal resection for rectal cancer--a matched-pair analysis

Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.

RESULTS

A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.

CONCLUSIONS

Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.

Effect of laparoscopic versus open surgery on postoperative wound complications in patients with low rectal cancer: A meta-analysis

This meta-analysis was conducted to evaluate the effect of microinvasive and open operations on postoperative wound complications in low rectal carcinoma patients. Research on limited English has been conducted systematically in PubMed, Embase, Cochrane Library and Web of Science. The date up to the search was in August 2023. Following review of the classification and exclusion criteria for this research and the evaluation of its quality in the literature, there were a total of 266 related papers, which were reviewed for inclusion in the period from 2004 to 2017. A total of 1774 cases of low rectal cancer were enrolled. Of these 913 cases, the laparoscopic operation was performed on 913 cases, while 861 cases were operated on low rectal carcinoma. The overall sample was between 10 and 482. Five trials described the efficacy of laparoscopy have lower risk than open on postoperative wound infection in patients with low rectal cancer (OR, 0.72;95 % CI, 0.48,1.09 p = 0.12). Three studies results showed that the anastomotic leak was not significantly different between open and laparoscopy (OR, 0.86; 95% CI, 0.58,1.26 p = 0.44). Six surgical trials in low rectal cancer patients reported haemorrhage, and five cases of surgical time were reported, with laparoscopy having fewer bleeding compared with open surgery (MD, -188.89; 95% CI, -341.27, -36.51 p = 0.02). Compared with laparoscopy, the operation time was shorter for the open operation (MD, 33.06; 95% CI, 30.56, 35.57 p < 0.0001). Overall, there is no significant difference between laparoscopy and open surgery in terms of incidence of infection and anastomosis leak. However, the rate of haemorrhage in laparoscopy is lower，and operation time in open surgery is lower.

Patient-Reported Sexual Function, Bladder Function and Quality of Life for Patients with Low Rectal Cancers with or without a Permanent Ostomy

BACKGROUND

Despite the increasing utilization of sphincter and/or organ-preservation treatment strategies, many patients with low-lying rectal cancers require abdominoperineal resection (APR), leading to permanent ostomy. Here, we aimed to characterize overall, sexual-, and bladder-related patient-reported quality of life (QOL) for individuals with low rectal cancers. We additionally aimed to explore potential differences in patient-reported outcomes between patients with and without a permanent ostomy.

METHODS

We distributed a comprehensive survey consisting of various patient-reported outcome measures, including the FACT-G7 survey, ICIQ MLUTS/FLUTS, IIEF-5/FSFI, and a specific questionnaire for ostomy patients. Descriptive statistics and univariate comparisons were used to compared demographics, treatments, and QOL scores between patients with and without a permanent ostomy.

RESULTS

Of the 204 patients contacted, 124 (60.8%) returned completed surveys; 22 (18%) of these had a permanent ostomy at the time of survey completion. There were 25 patients with low rectal tumors (≤5 cm from the anal verge) who did not have an ostomy at the time of survey completion, of whom 13 (52%) were managed with a non-operative approach. FACTG7 scores were numerically lower (median 20.5 vs. 22, p = 0.12) for individuals with an ostomy. Sexual function measures IIEF and FSFI were also lower (worse) for individuals with ostomies, but the results were not significantly different. MLUTS and FLUTS scores were both higher in individuals with ostomies (median 11 vs. 5, p = 0.06 and median 17 vs. 5.5, p = 0.01, respectively), suggesting worse urinary function. Patient-reported ostomy-specific challenges included gastrointestinal concerns (e.g., gas, odor, diarrhea) that may affect social activities and personal relationships.

CONCLUSIONS

Despite a limited sample size, this study provides patient-centered, patient-derived data regarding long-term QOL in validated measures following treatment of low rectal cancers. Ostomies may have multidimensional negative impacts on QOL, and these findings warrant continued investigation in a prospective setting. These results may be used to inform shared decision making for individuals with low rectal cancers in both the settings of organ preservation and permanent ostomy.

Conformal sphincteric resection for ultra-low rectal cancer located below the dentate line: A pilot report

AIM

Sphincter-sparing surgery can be achieved in most cases of low rectal cancer with the development of intersphincteric resection. However, abdominoperineal resection is still inevitable for patients with tumours located below the dentate line. To address this, we have developed a procedure called conformal sphincteric resection (CSR) in which the corresponding part of the subcutaneous portion of the external anal sphincter and the perianal skin on the tumour side is removed to achieve a safe distal resection margin and lateral resection margin while the dentate line and the internal anal sphincter on the tumour-free side are preserved as much as possible, to achieve sphincter preservation without compromising oncological safety and functional acceptability, and to render tumour location no longer a contraindication for sphincter-sparing surgery. This is the first study to describe the concept, indication and surgical procedure of CSR and to report its preliminary surgical, oncological and functional results.

METHODS

This is a retrospective, single-centre, single-arm pilot study conducted at Huashan Hospital, Fudan University. Demographic, clinicopathological, oncological and functional follow-up data were collected from 20 consecutive patients with rectal tumours located below the dentate line who underwent laparoscopic CSR by the same surgical team from June 2018 to March 2022.

RESULTS

The mean distance of the tumour's lower edge from the anal verge was 13.1 ± 6.0 mm. The mean distal resection margin was 10.6 ± 4.3 mm. All circumferential resection margins were negative. There were no instances of perioperative mortality. The complication rate was 25% but all were Clavien-Dindo Grade I. Among the 20 cases, 17 were diagnosed with adenocarcinoma, one with squamous cell carcinoma and two with adenoma featuring high-grade intraepithelial neoplasia. Pathological TNM staging revealed two, seven, five, five and one case(s) in Stages 0, I, II, III and IV, respectively. The median follow-up period was 20 months (interquartile range 22 months), with no withdrawals. The overall and disease-free survival rates were both 95%. The mean Wexner incontinence score and low anterior resection syndrome score recorded 18 months following diverting ileostomy closure were 6.3 ± 3.8 and 27.3 ± 3.6, respectively.

CONCLUSIONS

This study has proposed the CSR procedure for the first time, which is a technically feasible, oncologically safe and functionally acceptable procedure for carefully selected patients with rectal tumours located below the dentate line.

Low anterior resection syndrome and quality of life after intersphincteric resection for rectal cancer: a propensity score-matched study

PURPOSE

Our aim was to perform a propensity score-matched study to compare the long-term functional outcomes and quality of life following intersphincteric resection vs. low anterior resection (LAR) with very low anastomosis.

METHODS

Patients who underwent intersphincteric resection or low anterior resection with low anastomosis (≤ 4 cm from the anal verge) for rectal cancer between January 2017 and June 2020 were retrospectively included. A propensity score-matching process was performed. Functional outcomes and quality of life were assessed using the European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L), EORC-QLQ C30, EORC-QLQ CR29, Low Anterior Resection Syndrome (LARS), Wexner, and International Prostate Symptom Score (IPSS) questionnaires. The primary outcome was the presence of LARS at least 12 months after surgery. The second outcome was the postoperative quality of life of included patients.

RESULTS

After propensity matching, 128 patients were included, including 58 males and 70 females with a median age of 59.5. Patients in the intersphincteric resection group showed a higher incidence of incontinence to flatus (32.8% versus 14.0%, p = 0.043) and stools (42.2% versus 21.9%, p = 0.046), pain/discomfort (25.0% versus 7.8%, p = 0.001), and bowel dysfunction, while the LARS scores (15.0 versus 13.2, p = 0.461) and major LARS rates (26.6% versus 14.1%, p = 0.078) were comparable in both groups.

CONCLUSION

ISR leads to increased bowel incontinence rate and increased anal pain, without affecting the grade of low anterior resection syndrome, fecal urgency, and clustering. LAR might be the preferred sphincteric-preserving approach when negative resection margins and a safe anastomosis are guaranteed. Patients should be fully informed about potential functional impairment after sphincter-preservation procedures.

Scope of Onsite, Portable Prevention Diagnostic Strategies for Alternaria Infections in Medicinal Plants

Medicinal plants are constantly challenged by different biotic inconveniences, which not only cause yield and economic losses but also affect the quality of products derived from them. Among them, Alternaria pathogens are one of the harmful fungal pathogens in medicinal plants across the globe. Therefore, a fast and accurate detection method in the early stage is needed to avoid significant economic losses. Although traditional methods are available to detect Alternaria, they are more time-consuming and costly and need good expertise. Nevertheless, numerous biochemical- and molecular-based techniques are available for the detection of plant diseases, but their efficacy is constrained by differences in their accuracy, specificity, sensitivity, dependability, and speed in addition to being unsuitable for direct on-field studies. Considering the effect of Alternaria on medicinal plants, the development of novel and early detection measures is required to detect causal Alternaria species accurately, sensitively, and rapidly that can be further applied in fields to speed up the advancement process in detection strategies. In this regard, nanotechnology can be employed to develop portable biosensors suitable for early and correct pathogenic disease detection on the field. It also provides an efficient future scope to convert innovative nanoparticle-derived fabricated biomolecules and biosensor approaches in the diagnostics of disease-causing pathogens in important medicinal plants. In this review, we summarize the traditional methods, including immunological and molecular methods, utilized in plant-disease diagnostics. We also brief advanced automobile and efficient sensing technologies for diagnostics. Here we are proposing an idea with a focus on the development of electrochemical and/or colorimetric properties-based nano-biosensors that could be useful in the early detection of Alternaria and other plant pathogens in important medicinal plants. In addition, we discuss challenges faced during the fabrication of biosensors and new capabilities of the technology that provide information regarding disease management strategies.

Quality of Life and Functional Outcomes After Intersphincteric Resection for Ultralow Rectal Cancer: A Prospective Observational Study

BACKGROUND

Intersphincteric resection is the ultimate sphincter-preserving surgical technique for ultralow rectal cancer, but quality-of-life changes after surgery remain unclear. It is also unknown which questionnaire has better associations with functional results for capturing clinical variation in quality of life.

OBJECTIVE

This study aimed to assess change in the quality of life and its correlation with functional outcomes among patients undergoing intersphincteric resection for ultralow rectal cancer.

DESIGN

This was a prospective, observational, single-center study.

SETTINGS

Colorectal surgery referral center.

PATIENTS

Patients with ultralow rectal cancer who underwent intersphincteric resection were included.

MAIN OUTCOME MEASURES

The primary outcomes were quality-of-life and functional results at 3 to 6, 12, and 24 months after ileostomy closure using validated questionnaires. The secondary outcome was the relationship between quality of life and neorectal function.

RESULTS

A total of 102 patients (62.7% men) completed follow-up surveys. Wexner incontinence score and Kirwan's incontinence score significantly improved at 12 months after ileostomy reversal, but such improvement in low anterior resection syndrome score was proved until 24 months later ( p = 0.01). Condition-specific quality-of-life domains improved over time, with significant changes in lifestyle ( p = 0.02) and coping/behavior ( p = 0.01), as well as the summary score of Fecal Incontinence Quality of Life ( p = 0.02) and visual analog scale score ( p < 0.001). Among health-related quality-of-life domains, the subscale scores did not differ significantly. The functional systems scores were significantly correlated with all the domains of condition-specific quality-of-life but only a few health-related quality-of-life domains. Only weak to moderate associations with the functional outcomes were observed for both quality-of-life questionnaires.

LIMITATIONS

Single-center data and limited sample size.

CONCLUSIONS

Although low anterior resection syndrome persists for years after intersphincteric resection, condition-specific quality of life and functional outcomes improve over time. Compared to health-related quality-of-life questionnaires, condition-specific quality-of-life instruments might be preferable to evaluate changes in quality-of-life after surgery. See Video Abstract at http://links.lww.com/DCR/C130 .

CALIDAD DE VIDA Y RESULTADOS FUNCIONALES DESPUS DE UNA RESECCIN INTERESFINTRICA EN CASO DE CNCER RECTAL ULTRABAJO ESTUDIO PROSPECTIVO OBSERVACIONAL

ANTECEDENTES:La resección inter-esfintérica es la última técnica quirúrgica conservadora de esfínteres en casos de cáncer rectal ultrabajo, pero los cambios en la calidad de vida después de la cirugía siguen sin estar claros. Se desconoce también, qué tipo de cuestionario tiene mejor asociación con los resultados funcionales para así captar las variaciones clínicas en la calidad de vida.OBJETIVO:Evaluar el cambio en la calidad de vida y su correlación con los resultados funcionales durante el período postoperatorio en pacientes sometidos a resección interesfintérica por cáncer de recto ultrabajo.DISEÑO:Estudio prospectivo, observacional y de un solo centro.AJUSTES:Centro de referencia de cirugía colorrectal.PACIENTES:Se incluyeron pacientes con cáncer de recto ultra bajo que se sometieron a resección interesfintérica con el cierre de la ileostomía.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la calidad de vida y los resultados funcionales a los 3-6, 12 y 24 meses después del cierre de la ileostomía utilizando cuestionarios validados. El resultado secundario fue la relación entre la calidad de vida y la función del néorecto.RESULTADOS:Un total de 102 pacientes (62,7% hombres) completaron las encuestas de seguimiento. La puntuación de incontinencia de Wexner y la puntuación de incontinencia de Kirwan mejoraron significativamente a los 12 meses después del cierre de la ileostomía, pero dicha mejoría en la puntuación del síndrome de resección anterior baja se demostró solo hasta 24 meses después ( p = 0,01). Las condiciones en el dominio de la calidad de vida específicos mejoraron con el tiempo, con cambios significativos en el estilo de vida ( p = 0,02) y el afrontamiento/comportamiento ( p = 0,01), así como la puntuación general de la calidad de vida y de la incontinencia fecal ( p = 0,02), puntuación de la escala analógica visual ( p < 0,001). Entre los dominios de la calidad de vida relacionada con la salud, las puntuaciones de las sub-escalas no difirieron significativamente. Las puntuaciones de los sistemas funcionales se correlacionaron significativamente con todos los dominios de la calidad de vida específica de la nueva condición, pero solo con pocos dominios de calidad de vida relacionados con la salud. Solo se observaron asociaciones débiles a moderadas con los resultados funcionales para ambos cuestionarios de calidad de vida.LIMITACIONES:Datos de un solo centro y tamaño de muestra limitado.CONCLUSIONES:Aunque el síndrome de resección anterior baja persiste durante años después de la resección interesfintérica, la calidad de vida específica de la nueva condición y los resultados funcionales mejoran con el tiempo. En comparación con los cuestionarios de calidad de vida relacionados con la salud, los instrumentos de calidad de vida específicos de la nueva condición pueden ser preferibles para evaluar los cambios en la calidad de vida después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/C130 . (Traducción-Dr. Xavier Delgadillo ).

Comparison of functional and oncological outcome of conformal sphincter preservation operation, low anterior resection, and abdominoperineal resection in very low rectal cancer: a retrospective comparative cohort study with propensity score matching

PURPOSE

Conformal sphincter preservation operation (CSPO) procedure is a sphincter preservation procedure for preserving the anal canal function for very low rectal cancers. This study investigated the functional and oncological outcome of conformal sphincter preservation operation by comparing with low anterior resection (LAR) and abdominoperineal resection (APR).

METHODS

This is a retrospective comparative study. Patients who received conformal sphincter preservation operation (n = 52), low anterior resection (n = 54), or abdominoperineal resection (n = 69) were included between 2011 and 2016 in a tertiary referral hospital. Propensity score matching was applied to adjust the baseline characteristics which may influence the choice of the surgical procedure.

RESULTS

Twenty-one pairs of conformal sphincter preservation operation vs. low anterior resection and 29 pairs of conformal sphincter preservation operation vs. abdominoperineal resection were selected. The first group had a higher tumor location than the second group. Compared with the low anterior resection group, the conformal sphincter preservation operation group had shorter distal resection margins; however, no significant differences were identified in daily stool frequency, Wexner incontinence score, local recurrence, distant metastasis, overall survival, and disease-free survival between both groups. Compared with the abdominoperineal resection group, the conformal sphincter preservation operation group had shorter operative time and shorter postoperative hospital stay. No significant differences were identified in local recurrence, distant metastasis, overall survival, and disease-free survival.

CONCLUSION

Conformal sphincter preservation operation is oncologically safe compared to APR and LAR, and has similar functional findings to LAR. Studies comparing CSPO with intersphincteric resection should be performed.

Validation of the Vietnamese version of the low anterior resection syndrome score questionnaire

Purpose

The aim of this study was to validate the low anterior resection syndrome (LARS) score questionnaire in the Vietnamese language among Vietnamese patients who underwent sphincter-preserving surgery for rectal cancer.

Methods

The LARS score questionnaire was translated from English into Vietnamese and then back-translated as recommended internationally. From January 2018 to December 2020, 93 patients who underwent sphincter-preserving surgery completed the Vietnamese version of the LARS score questionnaire together with an anchored question assessing the influence of bowel function on quality of life (QoL). To validate test-retest reliability, patients were requested to answer the LARS score questionnaire twice.

Results

Ninety-three patients completed the LARS score questionnaire, of whom 89 responded twice. The patients who responded twice were included in the analysis of test-retest reliability. Fifty-eight patients had a "major" LARS score. The LARS score was able to discriminate between patients who were obese and those who were not (P<0.001) and between the low anterior resection and anterior resection procedures (P<0.001). Age and sex were not associated with higher LARS scores (P=0.975). There was a perfect fit between the QoL category question and the LARS score in 56.2% of cases, and a moderate fit was found in 42.7% of cases, showing reasonable convergent validity. The test-retest reliability of 89 patients showed a high intraclass correlation coefficient.

Conclusion

The Vietnamese version of the LARS score questionnaire is a valid tool for measuring LARS.

The Quality of Life of Patients with Surgically Treated Colorectal Cancer: A Narrative Review

INTRODUCTION

Quality of life is a topic increasingly being addressed by researchers. Due to the increasing incidence of colorectal cancer, this issue is particularly relevant. Despite the increasing number of publications on this topic each year, it still requires further research. The aim of this study was to analyze the available literature from the past 10 years, addressing the topic of QoL in patients with colorectal cancer which has been treated surgically.

MATERIAL AND METHODS

This review is based on 93 articles published between 2012 and 2022. It analyzes the impact of socioeconomic factors, the location and stage of the tumor, stoma and the method of surgical treatment on patients' QoL and sexual functioning.

RESULTS

CRC has a negative impact on patients' financial status, social functioning, pain and physical functioning. Patients with stage II or III cancer have an overall lower QoL than patients with stage I. The more proximally the lesion is located to the sphincters, the greater the negative impact on the QoL. There was a significant difference in favor of laparoscopic surgery compared with open surgery. In patients with a stoma, the QoL is lower compared with patients with preserved gastrointestinal tract continuity. The more time has passed since surgery, the more the presence of a stoma has a negative impact on QoL. Surgery for CRC negatively affects patients' sex lives, especially in younger people and among men.

CONCLUSIONS

This study may contribute to the identification of the factors that affect the QoL of patients with surgically treated colorectal cancer. This will allow even more effective and complete treatment, facilitating patients' return to normal physical, mental and social functioning.

Comparative survival risks in patients undergoing abdominoperineal resection and sphincter-saving operation for rectal cancer: a 10-year cohort analysis using propensity score matching

PURPOSE

Abdominoperineal resection (APR) has been considered to have a higher risk of local recurrence and poorer survival outcome than sphincter-saving operation (SSO) in patients with rectal cancer. This study compared long-term oncologic outcomes and prognostic parameters in propensity score-matched patients who underwent APR and SSO.

METHODS

This study analyzed 958 consecutive patients with lower rectal cancer who underwent preoperative chemoradiotherapy followed by APR or SSO between 2005 and 2015. Propensity score matching analysis was performed to adjust baseline characteristics, including clinical stage, tumor distance from the anal verge, and tumor size.

RESULTS

In the entire cohort, the APR group had larger and lower tumors and showed significantly shorter 5-year disease-free survival (DFS) than the SSO group (64.5% vs. 75.8%, p = 0.01). After propensity score matching, there were no significant between-group differences in local (9.5% vs. 8.0%, p = 0.59) and systemic (27.9% vs. 23.4%, p = 0.3) recurrence rates, and 5-year DFS (67.5% vs. 69.9%, p = 0.49) and overall survival (80.8% vs. 82.9%, p = 0.65) rates. A lower number of lymph nodes retrieved was independently associated with recurrence and survival outcomes in the APR group, whereas poorly differentiated histology was an independent associated parameter in the SSO group. Advanced stage and perineural invasion were identified as independent prognostic parameters in both groups.

CONCLUSIONS

This study indicated that the long-term oncologic outcomes of APR were comparable to those of SSO. Because prognostic parameters associated with oncologic outcomes differed between the respective procedures, correctable parameters could be ameliorated through complete total mesorectal excision and personalized systemic treatment.

Quality of life in a randomized trial comparing two neoadjuvant regimens for locally advanced rectal cancer-INCAGI004

BACKGROUND

Neoadjuvant chemoradiotherapy (neoCRT) followed by surgery is the standard of care for locally advanced rectal cancer (LARC), but the emergence of different drug regimens may result in different response rates. Good clinical response translates into greater sphincter preservation, but quality of life (QOL) may be impaired after treatment due to chemoradiotherapy and surgical side effects.

OBJECTIVE

To prospectively evaluate the impact of clinical response and surgical resection on QOL in a randomized trial comparing two different neoCRT regimens.

METHODS

Stage II and III rectal cancer patients were randomized to receive neoCRT with either capecitabine (group 1) or 5-Fu and leucovorin (group 2) concomitant to long-course radiotherapy. Clinical downstaging was accessed using MRI 6-8 weeks after treatment. EORTCs QLQ-C30 and CR38 were applied before treatment (T0), after neoCRT (T1), after rectal resection (T2), early after adjuvant chemotherapy (T3), and 1 year after the end of treatment or stoma closure (T4). The Wexner scale was used for fecal incontinence evaluation at T4. A C30SummaryScore (Geisinger and cols.) was calculated to compare QOL results.

RESULTS

Thirty-two patients were assigned to group 1 and 31 to group 2. Clinical downstaging occurred in 70.0% of group 1 and 53.3% of group 2 (p = 0.288), and sphincter preservation was 83.3% in group 1 and 80.0% in group 2 (p = 0.111). No significant difference in QOL was detected when comparing the two treatment groups after neoCRT using QLQ-C30. However, the CR38 module detected differences in micturition problems (15.3 points), gastrointestinal problems (15.3 points), defecation problems (11.8 points), and sexual satisfaction (13.3 points) favoring the capecitabine group. C30SummaryScore detected significant improvement comparing T0 to T1 and deterioration comparing T1 to T2 (p = 0.025). The mean Wexner scale score was 9.2, and a high score correlated with symptoms of diarrhea and defecation problems at T4.

CONCLUSIONS

QOL was equivalent between groups after neoCRT except for micturition problems, gastrointestinal problems, defecation problems, and sexual satisfaction favoring the capecitabine arm after. The overall QOL using the C30SummaryScore was improved after neoCRT, but decreased following rectal resection, returning to basal levels at late evaluation. Fecal incontinence was high after sphincter preservation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03428529.

Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life

BACKGROUND

Surgical resection is the mainstay of curative treatment for rectal cancer. Post-operative complications, low anterior resection syndrome (LARS), and the presence of a stoma may influence the quality of life after surgery. This study aimed to gain more insights into the long-term trade-off between stoma and anastomosis.

METHODS

All patients who underwent sphincter-sparing surgical resection for rectal cancer in the Leiden University Medical Center and the Reinier de Graaf Gasthuis between January 2012 and January 2016 were included. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, EQ-5D-5L, and the LARS score. A comparison was made between patients with a stoma and without a stoma after follow-up.

RESULTS

Some 210 patients were included of which 149 returned the questionnaires (70.9%), after a mean follow-up of 3.69 years. Overall quality of life was not significantly different in patients with and without stoma after follow-up using the EORTC-QLQ-C30 (p = 0.15) or EQ-5D-5L (p = 0.28). However, after multivariate analysis, a significant difference was found for the presence of a stoma on global health status (p = 0.01) and physical functioning (p < 0.01). Additionally, there was no difference detected in the quality of life between patients with major LARS or a stoma.

CONCLUSION

This study shows that after correction for possible confounders, a stoma is associated with lower global health status and physical functioning. However, no differences were found in health-related quality of life between patients with major LARS and patients with a stoma. This suggests that the choice between stoma and anastomosis is mainly preferential and that shared decision-making is required.

Quality of life in restorative versus non-restorative resections for rectal cancer: systematic review

Background

Low rectal cancers could be treated using restorative (anterior resection, AR) or non-restorative procedures with an end/permanent stoma (Hartmann’s, HE; or abdominoperineal excision, APE). Although the surgical choice is determined by tumour and patient factors, quality of life (QoL) will also influence the patient's future beyond cancer. This systematic review of the literature compared postoperative QoL between the restorative and non-restorative techniques using validated measurement tools.

Methods

The review was registered on PROSPERO (CRD42020131492). Embase and MEDLINE, along with grey literature and trials websites, were searched comprehensively for papers published since 2012. Inclusion criteria were original research in an adult population with rectal cancer that reported QoL using a validated tool, including the European Organization for Research and Treatment of Cancer QLQ-CR30, QLQ-CR29, and QLQ-CR38. Studies were included if they compared AR with APE (or HE), independent of study design. Risk of bias was assessed using the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool. Outcomes of interest were: QoL, pain, gastrointestinal (GI) symptoms (stool frequency, flatulence, diarrhoea and constipation), and body image.

Results

Nineteen studies met the inclusion criteria with a total of 6453 patients; all papers were observational and just four included preoperative evaluations. There was no identifiable difference in global QoL and pain between the two surgical techniques. Reported results regarding GI symptoms and body image documented similar findings. The ROBINS-I tool highlighted a significant risk of bias across the studies.

Conclusion

Currently, it is not possible to draw a firm conclusion on postoperative QoL, pain, GI symptoms, and body image following restorative or non-restorative surgery. The included studies were generally of poor quality, lacked preoperative evaluations, and showed considerable bias in the data.

Impact of dose-escalated chemoradiation on quality of life in patients with locally advanced rectal cancer: two year follow-up of the randomized RECTAL-BOOST trial

BACKGROUND

Dose-escalated chemoradiation (CRT) for locally advanced rectal cancer (LARC) did not result in higher complete response rates, but initiated more tumor regression in the randomized XXXXX trial (Clinicaltrials.gov XXXXX). This study compared patient reported outcomes (PROs) between patients who received dose-escalated CRT (5 × 3Gy boost + CRT) or standard CRT for two years following randomization.

METHODS

Patients with LARC, participating in the XXXXX trial, filled out EORTC QLQ-C30 and CR29 questionnaires on quality of life (QoL) and symptoms at baseline, 3, 6, 12, 18 and 24 months following start of treatment. Between-group differences in functional QoL domains were estimated using a linear mixed-effects model and expressed as effect size (ES). Symptom scores were compared using Mann-Whitney U test.

RESULTS

Patients treated with dose-escalated CRT (boost group, n=51) experienced a significantly stronger decline in global health at 3 and 6 months (ES -0,4 and ES -0,4), physical functioning at 6 months (ES -1,1), role functioning at 3 and 6 months (ES -0,8 and ES -0,6) and social functioning at 6 months (ES -0,6) compared to patients treated with standard CRT (control group, n=64). The boost group reported significantly more fatigue at 3 and 6 months (83% vs. 66% resp. 89% vs. 76%), pain at 3 and 6 months (67% vs. 36% resp. 80% vs. 44%) and diarrhea at 3 months (45% vs. 29%) compared to the control group. From 12 months onwards, QoL and symptoms were similar between groups, apart from more blood/mucus in stool in the boost group.

CONCLUSION

In patients with LARC, dose-escalated CRT resulted in a transient deterioration in global health, physical, role, and social functioning and more pain, fatigue and diarrhea at 3 and 6 months following start of treatment compared to standard CRT. From 12 months onwards, the impact of dose-escalated CRT on QoL largely resolved.

Cost Effectiveness of Watch and Wait Versus Resection in Rectal Cancer Patients with Complete Clinical Response to Neoadjuvant Chemoradiation

BACKGROUND

Watch and wait (WW) protocols have gained increasing popularity for patients diagnosed with locally advanced rectal cancer and presumed complete clinical response after neoadjuvant chemoradiation. While studies have demonstrated comparable survival and recurrence rates between WW and radical surgery, the decision to undergo surgery has significant effects on patient quality of life. We sought to conduct a cost-effectiveness analysis comparing WW with abdominoperineal resection (APR) and low anterior resection (LAR) among patients with stage II/III rectal cancer.

METHODS

In this comparative-effectiveness study, we built Markov microsimulation models to simulate disease progression, death, costs, and quality-adjusted life-years (QALYs) for WW or APR/LAR. We assessed cost effectiveness using the incremental cost-effectiveness ratio (ICER), with ICERs under $100,000/QALY considered cost effective. Probabilities of disease progression, death, and health utilities were extracted from published, peer-reviewed literature. We assessed costs from the payer perspective.

RESULTS

WW dominated both LAR and APR at a willingness to pay (WTP) threshold of $100,000. Our model was most sensitive to rates of distant recurrence and regrowth after WW. Probabilistic sensitivity analysis demonstrated that WW was the dominant strategy over both APR and LAR over 100% of iterations across a range of WTP thresholds from $0-250,000.

CONCLUSIONS

Our study suggests WW could reduce overall costs and increase effectiveness compared with either LAR or APR. Additional clinical research is needed to confirm the clinical efficacy and cost effectiveness of WW compared with surgery in rectal cancer.

Circulating Hybrid Cells: A Novel Liquid Biomarker of Treatment Response in Gastrointestinal Cancers

BACKGROUND

Real-time monitoring of treatment response with a liquid biomarker has potential to inform treatment decisions for patients with rectal adenocarcinoma (RAC), esophageal adenocarcinoma (EAC), and colorectal liver metastasis (CRLM). Circulating hybrid cells (CHCs), which have both immune and tumor cell phenotypes, are detectable in the peripheral blood of patients with gastrointestinal cancers, but their potential as an indicator of treatment response is unexplored.

METHODS

Peripheral blood specimens were collected from RAC and EAC patients after neoadjuvant therapy (NAT) or longitudinally during therapy and evaluated for CHC levels by immunostaining. Receiver operating characteristics (ROCs) and the Kaplan-Meier method were used to analyze the CHC level as a predictor of pathologic response to NAT and disease-specific survival (DSS), respectively.

RESULTS

Patients with RAC (n = 23) and EAC (n = 34) were sampled on the day of resection, and 11 patients (32%) demonstrated a pathologic complete response (pCR) to NAT. On ROC analysis, CHC levels successfully discriminated pCR from non-pCR with an area under the curve of 0.82 (95% confidence interval [CI], 0.71-0.92; P < 0.001). Additionally, CHC levels in the EAC patients correlated with residual nodal involvement (P = 0.026) and 1-year DSS (P = 0.029). The patients with RAC who were followed longitudinally during NAT (n = 2) and hepatic arterial infusion therapy for CRLM (n = 2) had CHC levels that decreased with therapy response and increased before clinical evidence of disease progression.

CONCLUSION

Circulating hybrid cells are a novel blood-based biomarker with potential for monitoring treatment response and disease progression to help guide decisions for further systemic therapy, definitive resection, and post-therapy surveillance. Additional validation studies of CHCs are warranted.

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients’ quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.

Retrospective study of the functional and oncological outcomes of conformal sphincter preservation operation in the treatment of very low rectal cancer

BACKGROUND

Conformal sphincter preservation operation (CSPO) is a new surgical procedure for very low rectal cancers (within 4-5 cm from the anal verge). CSPO preserves more of the dentate line and distal rectal wall and also avoids injuring nerves in the intersphincteric space, resulting in satisfactory anal function after resection. The aim of this study was to analyze the short-term surgical results and long-term oncological and functional outcomes of CSPO.

METHODS

Consecutive patients with very low rectal cancer, who had CSPO between January 2011 and October 2018 at Changhai Hospital, Shanghai were included. Patient demographics, clinicopathological features, oncological outcomes and anal function were analyzed.

RESULTS

A total of 102 patients (67 men) with a mean age of 56.9 ± 10.8 years were included. The median distance of the tumor from the anal verge was 3 (IQR, 3-4) cm. Thirty-five patients received neoadjuvant chemoradiation (nCRT). The median distal resection margin (DRM) was 0.5 (IQR, 0.3-0.8) cm. One patient had a positive DRM. All circumferential margins were negative. There was no perioperative mortality. The postoperative complication rate was 19.6%. The median duration of follow-up was 28 (IQR, 12-45.5) months. The local recurrence rate was 2% and distant metastasis rate was 10.8%. The 3-year overall survival and disease-free survival rates were 100% and 83.9%, respectively. The mean Wexner incontinence and low anterior resection syndrome scores 12 months after ileostomy reversal were 5.9 ± 4.3, and 29.2 ± 6.9, respectively.

CONCLUSIONS

For patients with very low rectal cancers, fecal continence can be preserved with CSPO without compromising oncological results.

Protocol for a single-arm confirmatory trial of adjuvant chemoradiation for patients with high-risk rectal submucosal invasive cancer after local resection: Japan Clinical Oncology Group Study JCOG1612 (RESCUE study)

INTRODUCTION

Intestinal resection with lymph node dissection is the current standard treatment for high-risk lower rectal submucosal invasive cancer after local resection; however, surgery affects patients' quality of life due to stoma placement or impaired anal sphincter function. A recent study demonstrated that adjuvant chemoradiation yields promising results.

METHODS AND ANALYSIS

This study aims to confirm the non-inferiority of adjuvant chemoradiation, consisting of capecitabine and concurrent radiotherapy (45 Gy in 25 fractions), measured by 5-year relapse-free survival (RFS), over standard surgery in patients with high-risk lower rectal submucosal invasive cancer after local resection. The primary endpoint is 5 year RFS. The secondary endpoints are 10 years RFS, 5-year and 10-year overall survival, 5-year and 10-year local RFS, 5-year and 10-year proportion of anus-preservation without stoma, Wexner score, low anterior resection syndrome score, adverse events and serious adverse events. During the 5-year trial period, 210 patients will be accrued from 65 Japanese institutions.

ETHICS AND DISSEMINATION

The National Cancer Center Hospital East Certified Review Board approved this study protocol in October 2018. The study is conducted in accordance with the precepts established in the Declaration of Helsinki and Clinical Trials Act. Written informed consent will be obtained from all eligible patients prior to registration. The primary results of this study will be published in an English article. In addition, the main results will be published on the websites of Japan Clinical Oncology Group (www.jcog.jp) and jRCT (https://jrct.niph.go.jp/). As to data curation, it has not been prepared yet.

TRIAL REGISTRATION NUMBER

jRCT1031180076.

A controlled study on the efficacy and quality of life of laparoscopic intersphincteric resection (ISR) and extralevator abdominoperineal resection (ELAPE) in the treatment of extremely low rectal cancer

BACKGROUND

The aim of this study is to compare the postoperative quality of life (QoL) and survival outcomes in lower rectal cancer (LRC) patients who undergo either laparoscopic- intersphincteric resection or extralevator abdominoperineal excision (L-ELAPE) after long-course neoadjuvant chemoradiation therapy (nCRT).

METHODS

This prospective, single-center, non-randomized, controlled, non-blinded, phase I/II clinical trial is designed to enroll 159 eligible LRC patients who achieved favorable response to long-course nCRT (2 × 25 Gy). After informed consent, the patients will be assigned into the laparoscopic intersphincteric resection group or L-ELAPE group according to their own will. Standard radical laparoscopic surgeries will be performed for every participant. Then every participant will be followed up for 3 years. The primary outcomes are scores of QoL questionnaire-core 30, QoL questionnaire-colorectum 29, Wexner incontinence score, International Prostate Symptom Score (for male), International Index of Erectile Function-5 (for male) and Female Sexual Function Index (for female). The secondary outcomes consist of incomplete circumferential resection margin rate, 3-year local recurrence, 3-year disease-free survival, 3-year overall survival and other surgical outcomes.

DISCUSSION

This is the first prospective clinical controlled trial to assess postoperative QoL and efficacy for LRC patients after favorable long-course nCRT. The result is expected to provide new evidence for a more detailed individualized treatment guideline for LRC.

TRIAL REGISTRATION

This trial was registered at Chinese Clinical Trial Registry (ChiCTR1800017512; ChiCTR.org) on August 2, 2018.

Intersphincteric Resection Versus Abdominoperineal Resection for Low Rectal Cancer: A Meta-Analysis

Background. Abdominoperineal resection (APR) has been the standard surgery for ultra-low rectal cancer for a century. In recent years, intersphincteric resection (ISR) has been increasingly used to avoid the permanent colostomy. Up to now, there is no relevant meta-analysis comparing the clinical efficacy of ISR and APR. This meta-analysis aimed to compare the outcomes of these 2 procedures. Methods. A comprehensive search of online databases was performed on PubMed, EMBASE, and the Cochrane Library to obtain comparative studies of ISR and APR. Then the data from studies that met the inclusion criteria were extracted and analyzed. Results. A total of 12 studies covering 2438 patients were included. No significant differences were found between ISR and APR in gender, body mass index, distance from tumor to anal edge, operative time, and blood loss. In addition, hospital stay (weighted mean differences = -2.98 days; 95% confidence interval [CI] = -3.54 to -2.43; P < .00001) and postoperative morbidity (odds ratio [OR] = 0.76; 95% CI = 0.59 to 0.99; P = .04) were significantly lower in ISR group compared with APR group. However, patients who underwent ISR showed lower pathological T-stage (T3T4%, OR = 0.49; 95% CI = 0.28 to 0.86; P = .01) and lymph node metastasis rate (OR = 0.77; 95% CI = 0.59 to 1.01; P = .06) compared with those who underwent APR. Moreover, oncological outcomes were similar between the 2 groups. Conclusion. ISR may provide a safe alternative to APR, with shorter hospital stays, lower postoperative morbidity, and similar oncological outcomes. Well-designed randomized controlled trials are needed to confirm and update the findings of this analysis.

Advanced design, simulation, and dosimetry of a novel rectal applicator for contact brachytherapy with a conventional HDR 192Ir source

PURPOSE

Dose escalation yields higher complete response to rectal tumors, which may enable the omission of surgery. Dose escalation using 50 kVp contact x-ray brachytherapy (CXB) allow the treatment of a selective volume, resulting in low toxicity and organs-at-risk preservation. However, the use of CXB devices is limited because of its high cost and lack of treatment planning tools. Hence, the MAASTRO applicator (for HDR ¹⁹²Ir sources) was developed and characterized by measurements and Monte Carlo simulations to be a cost-effective alternative to CXB devices.

METHODS AND MATERIALS

A cylindrical applicator with lateral shielding was designed to be used with a rectoscope using its tip as treatment surface. Both the applicator and the rectoscope have a slanted edge to potentially allow easier placement against tumors. The applicator design was achieved by Monte Carlo modeling and validated experimentally with film dosimetry, using the Papillon 50 (P50) device as reference.

RESULTS

The applicator delivers CXB doses in less than 9 min using a 20375 U source for a treatment area of approximately 20 × 20 mm² at 2 mm depth. Normalized at 2 mm, the dose falloff for depths of 0 mm, 5 mm, and 10 mm are 130%, 70%, and 43% for the P50 and 140%, 67%, and 38% for the MAASTRO applicator, respectively.

CONCLUSIONS

The MAASTRO applicator was designed to use HDR ¹⁹²Ir sources to deliver a dose distribution similar to those of CXB devices. The applicator may provide a cost-effective solution for endoluminal boosting with clinical treatment planning system integration.

Validation of Korean Version of Low Anterior Resection Syndrome Score Questionnaire

Purpose

Patients who undergo radical surgery for rectal cancer often experience low anterior resection syndrome (LARS). Symptoms of this syndrome include frequent bowel movements, gas incontinence, fecal incontinence, fragmentation, and urgency. The aim of this study was to investigate the convergent validity, discriminative validity, and reliability of the Korean version of the LARS score questionnaire.

Methods

The English LARS score questionnaire was translated into Korean using the forward-and-back translation method. A total of 146 patients who underwent radical surgery for rectal cancer answered the Korean version of the LARS score questionnaire including an anchor question assessing the impact of bowel function. Participants answered the questionnaire once more after 2 weeks.

Results

The Korean LARS score questionnaire showed high convergent validity in terms of high correlation between the LARS score and quality of life (perfect fit 55.5% vs. moderate fit 37.6% vs. no fit 6.8%, respectively; P < 0.001). The LARS score also showed good discriminative validity between groups of patients differing by sex (29 for males vs. 25 for females; P = 0.014), tumor level (29 for ≤8 cm vs. 24 for >8 cm; P = 0.021), and radiotherapy (32 for yes vs. 24 for no; P = 0.001). The LARS score also demonstrated high reliability at test-retest with no difference between scores at the first and second tests (intraclass correlation coefficient: Q1 = 0.932; Q2 = 0.909, Q3 = 0.944, Q4 = 0.931, and Q5 = 0.942; P < 0.001, respectively).

Conclusion

The Korean version of the LARS score questionnaire has proven to be a valid and reliable tool for measuring LARS in Korean patients with rectal cancer.

Is my life going to change?-a review of quality of life after rectal resection

Rectal resection is a common practice for colorectal surgeons. The causes of this procedure are varied. The most frequent is cancer, but also inflammatory bowel disease, endometriosis, and rectovaginal or rectourethral fistulas. The loss of the normal rectal reservoir function, urinary problems, sexual dysfunction or pelvic pain are frequently reported in patients after rectal surgery and these disorders markedly affect the overall quality of life (QoL). In the last decades, rectal surgery has radically changed, with the development of surgical techniques, and it has progressed from abdominoperineal resection (APR) with a permanent colostomy to sphincter-saving procedures. Nowadays, the use of sphincter-preserving surgery has increased, but all these surgical techniques can have important sequels that modify the QoL of the patients. Historically, surgical outcomes, such as complications, survival and recurrences, have been widely studied by surgeons. In the present day, surgical outcomes have improved, rectal cancer recurrence rate has decreased and survival has increased. For these reasons, it has begun to gain importance in aspects of the QoL of patients, such as body image, fecal continence and sexuality or urinary function. Therefore, physicians should know the influence of different techniques and approaches on functional outcomes and QoL, to be able to inform patients of the treatment benefits and risk of postoperative dysfunctions. The aim of our study is to review the current literature to determine to what degree the QoL of patients who underwent a rectal resection decreases, which domains are the most affected and, in addition, to establish the influence of different surgical techniques and approaches on functional outcomes.

Factors influencing changing bowel habits in patients undergoing sphincter-saving surgery for rectal cancer

A research survey research was conducted to identify factors affecting changes in bowel habits of rectal cancer patients undergoing sphincter-saving surgery and to provide basic information useful in nursing interventions supporting treatment for rectal cancer patients. The subjects were rectal cancer patients who had undergone sphincter-saving surgery over 2 years ago. The final analysis included 107 patients who had made outpatient visits to the colorectal surgery from 12th to 31st May, 2014. Collected data were processed with SPSS Version 21.0. Changes in bowel habits in the subjects were observed: frequent bowel movement in 74 patients (69.2%) and faecal incontinence in 48 (44.9%). Most of the patients used self-care to improve their bowel function including dietary modification (78.5%), regular exercise (72.0%) and pelvic floor exercise (34.6%). Frequent defecation was associated with adjuvant chemoradiation therapy (P < 0.001) and faecal incontinence was associated with age of ≥65 years (P = 0.019) and a group who underwent adjuvant radiation therapy (P < 0.001). It is necessary to give sufficient information about possible postoperative changes in bowel habits to patients with the risk factors before surgery.

Long-term Outcomes After Surgery Involving the Pelvic Floor in Rectal Cancer: Physical Activity, Quality of Life, and Health Status

PURPOSE

This study has aimed to evaluate the effects of surgery on physical activity (PA), quality of life (QoL), and disease-specific health status, by analyzing the differences between sphincter-preserving surgery (low anterior resection (LAR)) and abdominoperineal resection (APR) among rectal cancer survivors.

METHODS

Individuals who were diagnosed with rectal cancer and who underwent an APR or a LAR between 2000 and 2009 were included. The different questionnaires on QoL, disease-specific health status, and physical activity began their surveys in 2010. Differences in QoL, health status, and physical activity were analyzed between the APR group and the LAR group.

RESULTS

The study included 905 rectal cancer survivors (LAR, 632; APR, 273). Besides a higher rate of radiotherapy treatment in the APR group (94% vs. 75%, p < 0.001), there were no differences in clinical characteristics or in comorbid conditions between the LAR group and APR group. No significant differences were found in PA level between the patients who had undergone an APR vs. a LAR. Regarding QoL, APR patients did report a worse physical (p = 0.009) and role functioning (p = 0.03), as well as a worse body image (p = 0.001), compared to patients who had undergone a LAR. However, they reported fewer constipation (p = 0.02) and gastrointestinal problems (p = 0.009). Finally, compared to patients who had undergone a LAR with a permanent ostomy, APR patients reported a better body image (p = 0.048) and less stoma-related problems (p = 0.001).

CONCLUSIONS

This study showed no differences in PA level among the patients who had undergone an APR versus a LAR. With respect to their QoL, their physical and role functioning seemed to be worse in the APR patients. However, these differences in outcomes resolved when comparing the APR group with patients after a LAR with a permanent ostomy.

Etiology and management of low anterior resection syndrome based on the normal defecation mechanism

Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.

Does external beam radiation therapy to the pelvis portend worse ileal pouch outcomes? An international multi-institution collaborative study

AIM

Short-term morbidity and long-term functional outcome of patients with an ileal pouch-anal anastomosis (IPAA) exposed to pelvic external beam radiation therapy (EBRT) remains unknown. We report the largest series to date regarding the effects of pelvic EBRT on: (i) 30-day postoperative outcomes; and (ii) long-term functional outcome following IPAA.

METHOD

A retrospective chart review was conducted of patients who received EBRT before or after IPAA between 1980 and 2017 across three international inflammatory bowel disease referral centres.

RESULTS

Nineteen patients were included. Indications for EBRT were rectal adenocarcinoma (n = 13), prostate adenocarcinoma (n = 4) or anal squamous cell carcinoma (ASCC) (n = 2). EBRT was given prior to IPAA in 12 (63%) patients and after IPAA in seven (37%). In EBRT before IPAA, patients had a median of 5 (range: 4-8) daytime bowel movements, 1 (range: 0-5) night-time bowel movement, no daytime incontinence, and only one patient used pads at a median follow up of 25 (range: 11-163) months; one patient underwent pouch excision 15 months after IPAA. In EBRT after IPAA, patients reported a median of 8 (range: 5-10) daytime and 2 (range: 0-5) night-time bowel movements, 80% had either daytime or night-time incontinence and 80% used pads at a median follow up of 90 (range: 25-315) months.

CONCLUSION

Pelvic EBRT administered prior to IPAA is associated with acceptable long-term function outcome. However, when pelvic EBRT is given to an IPAA in situ, most patients experience poor long-term pouch function without pouch failure.

A quest for sphincter-saving surgery in ultralow rectal tumours-a single-centre cohort study

INTRODUCTION

Despite the progress in the treatment of colorectal cancer, there is still no optimal strategy for tumours located adjacent to the anal sphincter. This study aims to evaluate oncological and functional results of surgery for rectal cancer in unfavourable locations in proximity to anal sphincters.

MATERIALS AND METHODS

Patients with rectal cancer, which was either initially infiltrating the anal sphincter or located in the close proximity of the sphincter, were included in the study. Patients were submitted to extralevator abdominoperineal resection (APR), intersphincteric resection, or transanal total mesorectal excision (TaTME). Primary outcomes were perioperative data: operative time, blood loss, complications, length of stay (LOS), and 30-day mortality. Secondary outcomes were pathological quality of the specimens and functional outcome 6 months after defunctioning ileostomy closure.

RESULTS

Among patients with cancer adjacent to the anal sphincter, 13 (25%) underwent APR, 14 (27%) patients were submitted to intersphincteric resection, and 25 (48%) patients were treated with the TaTME approach. Operative time was 240 (210-270 IQR) for APR, 212.5 (170-260 IQR) for intersphincteric resection, and 270 (240-330 IQR) for TaTME (p = 0.018). Perioperative morbidity was 31% for APR, 36% for intersphincteric resections, and 12% for the TaTME group (p = 0.181). Complete mesorectal excision was achieved in 92% of specimens in the TaTME group, 93% in intersphincteric resections, and 78% in the APR group (p = 0.72). Median circumferential resection margin in APR was 6 mm (4-7 IQR), in intersphincteric resections 7.5 mm (2.5-10 IQR), and in the TaTME group 4 mm (2.8-8 IQR). All patients after intersphincteric resections developed major low anterior resection syndrome (LARS). Four patients in the TaTME group developed minor LARS, and 21 had major LARS.

CONCLUSION

Sphincter-saving rectal resections are a feasible alternative to APR with good clinical, pathological, and oncological outcomes. Intersphincteric resections and TaTME seem to be equal in terms of clinicopathological results. The functional outcome is yet to be investigated.

TRIAL REGISTRATION

The study was retrospectively registered in Thai Clinical Trials Registry (23-07-2018, ID TCTR20180724001 ).

A novel rectal applicator for contact radiotherapy with HDR 192Ir sources

PURPOSE

Dose escalation to rectal tumors leads to higher complete response rates and may thereby enable omission of surgery. Important advantages of endoluminal boosting techniques include the possibility to apply a more selective/localized boost than using external beam radiotherapy. A novel brachytherapy (BT) rectal applicator with lateral shielding was designed to be used with a rectoscope for eye-guided positioning to deliver a dose distribution similar to the one of contact x-ray radiotherapy devices, using commonly available high-dose-rate ¹⁹²Ir BT sources.

METHODS AND MATERIALS

A cylindrical multichannel BT applicator with lateral shielding was designed by Monte Carlo modeling, validated experimentally with film dosimetry and compared with results found in the literature for the Papillon 50 (P50) contact x-ray radiotherapy device regarding rectoscope dimensions, radiation beam shape, dose fall-off, and treatment time.

RESULTS

The multichannel applicator designed is able to deliver 30 Gy under 13 min with a 20350 U (5 Ci) source. The use of multiple channels and lateral shielding provide a uniform circular treatment surface with 22 mm in diameter. The resulting dose fall-off is slightly steeper (maximum difference of 5%) than the one generated by the P50 device with the 22 mm applicator.

CONCLUSIONS

A novel multichannel rectal applicator for contact radiotherapy with high-dose-rate ¹⁹²Ir sources that can be integrated with commercially available treatment planning systems was designed to produce a dose distribution similar to the one obtained by the P50 device.

Late assessment of quality of life in patients with rectal carcinoma: comparison between sphincter preservation and definitive colostomy

PURPOSE

Patients with cancer of the lower and middle rectum who are candidates for curative surgery often have negative opinions on definitive colostomy. The purpose of this study is to compare the quality of life (QoL) of patients who undergo standard treatment for rectal cancer with sphincter preservation or definitive colostomy.

METHODS

A total of 125 patients with adenocarcinoma of the lower or middle rectum who underwent radical surgery with curative intent with a follow-up ≥ 1 year were recruited: 83 patients (group 1) were subjected to low anterior resection and low colorectal or coloanal anastomosis-thus preserving their sphincter-and 42 (group 2) were treated with abdominoperineal resection, followed by terminal definitive colostomy. QoL was assessed with the EORTC QLQ-C30 and QLQ-CR29 questionnaires.

RESULTS

Health and global quality of life were similar between groups; however, patients who underwent definitive colostomy had higher scores on the emotional (p value = 0.016) and cognitive function scales (p value = 0.017). Patients with sphincter preservation presented with more symptoms that were related to stool frequency (p value < 0.001), intestinal constipation (p value = 0.005), fecal incontinence (p value = 0.001), buttock pain (p value = 0.023), and nausea and vomiting (p value = 0.036), whereas patients with permanent colostomy had higher scores for dysuria (p value = 0.033).

CONCLUSION

Although global QoL scores did not differ between groups, patients who underwent definitive colostomy had significantly better functional and symptom scale scores, reflecting greater function with fewer symptoms.

Comparison of Anthropometric Parameters after Ultralow Anterior Resection and Abdominoperineal Resection in Very Low-Lying Rectal Cancers

Background and Aim

Ultralow anterior resection (uLAR) is a sphincter-saving procedure for very low-lying rectal cancers. This procedure, however, has complications related to defecation which can aggravate the patient's quality of life postoperatively. In this study, we compared the anthropometric and nutritional parameters after uLAR and abdominoperineal resection (APR).

Methods

We retrospectively reviewed the data of patients who underwent either uLAR or APR in 2012 for rectal cancers within 3 cm from the anal verge. Data including body weight, body mass index (BMI), levels of total protein, albumin, and hemoglobin and lymphocyte count were analyzed. We compared the changes of these parameters before operations to 3 years after discharge between uLAR and APR groups by ANOVA for repeated measures and Bonferroni comparison method.

Results

After 3 years of discharge, the body weight and BMI of the APR group were fully recovered to the preoperative levels; however, those of the uLAR group did not. The hemoglobin level in the APR group was recovered to the preoperative level within 3 months of discharge; however, that in the uLAR group was recovered after 1 year of discharge.

Conclusions

Recovery of anthropometric and nutritional status of patients was more stable after APR than after uLAR. These findings might indirectly reflect the low anterior syndrome effect of uLAR and help colorectal surgeons in selecting better surgical methods and in better counseling patients with very low-lying rectal cancer.

Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus

Objectives: Intersphincteric resection (ISR) for low-lying rectal cancer (LRC) may induce major problems associated with anorectal function. In this study, we assessed the severity of ISR-induced impairment in anorectal function. Methods: In total, 45 patients followed up regularly ≥2 years after diverting ileostoma closure were eligible. The patients underwent ISR (n=35) or conventional coloanal anastomosis without resection of the internal anal sphincter (IAS) (n=10) for treatment of LRC from January 2000 to December 2011. We retrospectively compared anorectal function [stool frequency, urgency, Wexner incontinence scale (WIS) score, and patient satisfaction with bowel movement habits on a visual analog scale (VAS) score] for ≥2 years after stoma closure between the two groups. Results: The median follow-up period was 4.0 years (range, 2.0-6.5 years). Of the total, 17 (48.6%) patients who underwent ISR had poor anorectal function, including two with complete incontinence. Significant differences were found between the groups in the incidence of urgency (p=0.042), WIS score (p=0.024), and defecation disorder with a WIS score of ≥10 (p=0.034) but not in stool frequency. Based on the VAS score, 45.7% of patients who underwent ISR were dissatisfied with their bowel movement habits (p=0.041). Conclusions: Extensive resection of the IAS has negative short- and long-term effects on anorectal function.

Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: A cross-sectional study

BACKGROUND

The aim of this study was to analyze the quality of life (QoL), low anterior resection syndrome (LARS) and fecal incontinence after surgery for mid to low rectal cancer and its relationship with the type of surgical procedure performed.

METHODS

A cross-sectional cohort survey study of 358 patients operated on for mid to low rectal cancer. Patients were included in three groups: abdominoperineal resection (APR), low mechanical colorectal anastomosis (CRA) and hand-sewn coloanal anastomosis (CAA). The QLQ-C30/CR29 questionnaires, LARS and Vaizey scores were used to study QoL and defecatory dysfunction. Multivariable analysis was used to estimate the prognostic effect of the variables on QoL and LARS scores.

RESULTS

62.6% of the patients answered the survey. The global QoL score was similar among APR, CRA and CAA. Patients' body image perception was significantly worse after APR than after CRA or CAA. LARS score was better in CRA group (p = 0.002). A major LARS was observed in 83.3% of the patients who underwent CAA and in 56.6% of the patients who underwent CRA. No relationship between surgical procedures and the global QoL score was observed. Neoadjuvant radiotherapy (p = 0.048) and CAA (p = 0.005) were associated with a major LARS. The Vaizey score was higher for CAA than for CRA (p = 0.036).

CONCLUSIONS

Though CAA group presents worse LARS and higher faecal incontinence scores respect CRA patients, and APR is related with a worse body image, global QoL was similar in the three groups.

Effect of Neoadjuvant Therapy and Rectal Surgery on Health-related Quality of Life in Patients With Rectal Cancer During the First 2 Years After Diagnosis

INTRODUCTION

Rectal cancer surgery with neoadjuvant therapy is associated with substantial morbidity. The present study describes the course of quality of life (QOL) in rectal cancer patients in the first 2 years after the start of treatment.

PATIENTS AND METHODS

We performed a prospective study within a colorectal cancer cohort including rectal cancer patients who were referred for neoadjuvant chemoradiation or short-course radiotherapy and underwent rectal surgery. QOL was assessed using the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and colorectal cancer questionnaire (EORTC QLQ-CR29) before treatment and after 3, 6, 12, 18, and 24 months. The outcomes were compared with the QOL scores from the Dutch general population and stratified by low anterior resection and abdominoperineal resection. Postoperative bowel dysfunction after low anterior resection was measured using the low anterior resection syndrome score.

RESULTS

Of the 324 patients, 272 (84%) responded to at least 2 questionnaires and were included in the present study. Compared with pretreatment levels, the strongest decline was observed in physical, role, and social functioning at 3 and 6 months after the start of treatment. Global health and cognitive functioning declined to a lesser extend, and emotional functioning gradually improved over the time. Within 24 months, the QOL scores had recovered toward the pretreatment levels in most patients. Compared with the general population, physical, role, social, and cognitive functioning and symptoms of fatigue and insomnia remained significantly worse in patients on longer-term. After low anterior resection, major bowel dysfunction was reported by 44% to 60% of the patients. Increasing urinary incontinence and severe complaints of impotence were observed in patients who had undergone abdominoperineal resection.

CONCLUSION

Rectal cancer treatment is associated with a significant decline in QOL during the first 6 months after the diagnosis. Within 2 years, most patients return toward pretreatment functioning but could still experience poorer functioning and treatment-related symptoms compared with the general population. These findings support shared decision-making and emphasize the need for postoperative supportive care and novel treatment approaches.

Intersphincteric proctectomy for rectal mucocele in a Crohn's patient with anal stenosis. A case report and review of literature

In patients who have undergone a colonic resection with creation of an end colostomy, drainage of mucus secreted by the mucosa of the rectal stump may not be possible if there is an outlet obstruction. With an outlet obstruction, formation of a rectal mucocele occurs. A rectal mucocele is a rare condition which has only been reported sporadically in case reports. We present here the utility of an intersphincteric proctectomy for treatment of a rectal mucocele in a 47 year old male Crohn's patient resulting in negligible post-operative or long-term morbidities.

Functional outcomes with handsewn versus stapled anastomoses in the treatment of ultralow rectal cancer

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann–Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients’ expectations and promote comparable quality of life in the long-term.

Laparoscopic intersphincteric resection versus an open approach for low rectal cancer: a meta-analysis

AIM

The aim of this study was to compare the short-term and mid-term effects of laparoscopic intersphincteric resection with the conventional open approach for patients with low rectal cancer through a meta-analysis.

METHODS

The PubMed, EMBASE, Cochrane, and Ovid databases were searched for eligible studies until March 2017. Operation time, blood loss, circumferential resection margin-positive rate, distal margin length, number of resected lymph nodes, diverting stoma rate, postoperative overall morbidity, anastomotic leakage, and hospital stay were the main short-term effect endpoints. We also examined disease-free survival, overall survival, local recurrence, and post-operational anal function as secondary outcomes to evaluate the mid-term effects of laparoscopic surgery.

RESULTS

Five studies involving 620 patients were included in the analyses. Compared with the open approach, the laparoscopic ISR had less blood loss (weighted mean difference [WMD] = - 214.65 ml, 95% CI [- 370.44, - 196.13], p < 0.01), less postoperative overall morbidity (OR = 0.58, 95% CI [0.40, 0.86], p < 0.01), and shorter duration of hospital stay (WMD = - 5.87 days, 95% CI [- 11.35, - 0.40], p < 0.05); however, the operation time was significantly longer in the laparoscopic group (WMD = 47.34 min, 95% CI [4.10, 90.58], p < 0.05). No other significant differences were observed.

CONCLUSION

Laparoscopic ISR for low rectal cancer offers fewer complications and faster recovery, with similar operation quality and mid-term oncological results than the conventional approach. Although this technique is comparatively more complex than the conventional approach and requires practice, laparoscopic ISR shows great potential as a surgical option and deserves further clinical study.

Functional outcomes after intersphincteric resection for ultralow rectal cancer

Anal function is one of the most important parameters for evaluating the efficacy of intersphincteric resection (ISR) for the treatment of ultralow rectal cancer (< 1 cm from the anal sphincter). Although there have been no results hitherto from randomized controlled trials to verify the clinical benefits of the ultimate sphincter-sparing technique, increasing evidence demonstrates that ISR significantly decreases the rate of permanent stoma and patients could acquire satisfied functional results after surgery. This review discusses the short-term and long-term functional outcomes, risk factors for anal incontinence, and surgical method and approach of ISR.

Effects of chemotherapy on the health-related quality of life of Japanese lower rectal cancer patients after sphincter-saving surgery

We examined the effects of adjuvant chemotherapy on the health-related quality of life (HRQOL) of lower rectal cancer patients receiving sphincter-saving surgery (SSS). In all, 109 patients completed a questionnaire before surgery and 1, 6, and 12 months afterwards. In the chemotherapy group, physical and social functioning scores were significantly lower 12 months after surgery compared with the nonchemotherapy group. These effects of adjuvant chemotherapy suggest that a different clinical approach might more effectively improve physical and social functioning in lower-rectal cancer patients undergoing chemotherapy. Healthcare providers should be alert for adverse events in patients with lower-rectal cancer and promptly address such conditions.

Clinical and functional results of laparoscopic intersphincteric resection for ultralow rectal cancer: is there a distinction between the three types of hand-sewn colo-anal anastomosis?

PURPOSE

The purpose of this study is to compare the clinical and functional outcomes of three types of hand-sewn colo-anal anastomosis (CAA) after laparoscopic intersphincteric resection (Lap-ISR) for patients with ultralow rectal cancer.

METHODS

A total of 79 consecutive patients treated by Lap-ISR for low-lying rectal cancer in an academic medical center from June 2011 to February 2016. According to the distal tumor margin and individualized anal length, the patients underwent three types of hand-sewn CAA including partial-ISR, subtotal-ISR, and total-ISR.

RESULTS

Of the 79 patients, 35.4% required partial-ISR, 43% adopted subtotal-ISR, and 21.5% underwent total-ISR. R0 resection was achieved in 78 patients (98.7%). In addition to distal resection margin, there were no significant differences in clinicopathological parameters and postoperative complications between the three groups. The type of hand-sewn CAA did not influence the 3-year disease-free survival (DFS) or local relapse-free survival (LFS). At 24-months follow-up, in spite of higher incontinence scores in total-ISR group, there were not statistically significant differences in functional outcomes including Wexner score or Kirwan grade between the groups. Nevertheless, patients with chronic anastomotic stricture showed worse anal function than those without the complication.

CONCLUSION

The type of hand-sewn CAA after Lap-ISR may not influence oncological and functional outcomes, but chronic stricture deteriorates continence status.

Anorectal functional outcome following laparoscopic low anterior resection for rectal cancer

Low anterior resection (LAR) with total mesorectal excision has been considered a standard treatment for patients with rectal cancer. However, the functional outcome and life quality of laparoscopic LAR (LLAR) in Chinese patients remain unclear. A cohort of 51 Chinese patients (22 men and 29 women) who had undergone LLAR was included in this study. Anorectal manometry combined with the Wexner scores questionnaire were applied to assess functional outcome preoperatively (1 week) and postoperatively (at 3, 6 and 9 months). The validated Chinese versions of the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires were also used to assess the patients' quality of life at the indicated time points. The results demonstrated that the manometric parameters exhibited a temporary decrease at 3 months postoperatively, but a gradual increase at 6 and 9 months, while the Wexner scores exhibited an opposite trend. Furthermore, patients with high anastomoses had significantly higher manometric parameters, a lower frequency of incontinence and lower Wexner scores compared with those with low anastomoses at 9 months (all P<0.05). For the entire cohort, quality of life at 3 months postoperatively was worse compared with the preoperative level, but returned to normal by 9 months. Patients with high anastomoses exhibited significantly better role, emotional and social function, had a better body image and sexual function, fewer problems with defecation and lower frequency of diarrhea, as well as fewer chemotherapy-related side effects at 6 months postoperatively when compared with the low anastomosis group (all P<0.05). In conclusion, LLAR is generally acceptable for Chinese patients with rectal cancer, particularly for those with middle or high rectal cancer, in terms of functional outcome and quality of life.