A pilot study assessing the efficacy of posterior tibial nerve stimulation in the treatment of low anterior resection syndrome

The Role of Percutaneous Tibial Nerve Stimulation (PTNS) in Low Anterior Resection Syndrome (LARS): A Systematic Review and Meta-analysis

PURPOSE

The aim of the present study was to evaluate the pooled efficacy of percutaneous tibial nerve stimulation (PTNS) in patients with low anterior resection syndrome (LARS).

MATERIAL AND METHODS

This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The primary endpoint was the pooled effect size of PTNS in LARS score (LARSS). Secondary endpoints included incontinence (Fecal Incontinence Score-FIC, Obstructive Defecation Syndrome-ODS), sexual functionality and quality of life (QoL) questionnaires, and manometric evaluations. Continuous outcomes were reported as weighted mean difference (WMD), with the corresponding 95% confidence interval (95% CI). Quality evaluation was performed via the National Institutes of Health (NIH) quality assessment tool.

RESULTS

Overall, 5 studies were included. PTNS resulted to reduced LARSS values (WMD: - 5.68, 95%CI: - 7.73, - 3.63, p < 0.001). A similar effect was noted in St Mark's FIC (p < 0.001) and ODS (p = 0.02) score. An improvement in several QoL scales was found. There was no effect in sexual functionality and manometric measurements. Compared to sham, PTNS significantly improved LARSS.

CONCLUSIONS

The application of PTNS in patients with LARS results in an improvement in multiple clinical parameters, including defecation functionality and quality of life. Due to several study limitations, further high quality RCTs are required to delineate the exact efficacy of PTNS.

Systematic review and meta-analysis of randomized clinical trials on the treatment of low anterior resection syndrome

BACKGROUND

We conducted a systematic review of randomized clinical trials on treating low anterior resection syndrome to help inform current practice.

METHODS

This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials involved different treatments for low anterior resection syndrome. The risk of bias 2 tool was used to assess the risk of bias. The main outcomes were improvement in low anterior resection syndrome after treatment assessed by change in low anterior resection syndrome, fecal incontinence scores, and adverse treatment effects.

RESULTS

After an initial screening of 1,286 studies, 7 randomized clinical trials were included. Sample sizes ranged between 12 to 104 patients. Posterior tibial nerve stimulation was the most frequently assessed treatment in 3 randomized clinical trials. The weighted mean difference between posterior tibial nerve stimulation and medical treatment or sham therapy in follow-up low anterior resection syndrome score (-3.31, P = .157) was insignificant. Transanal irrigation reduced major low anterior resection syndrome symptoms by 61.5% compared with 28.6% after posterior tibial nerve stimulation with a significantly lower 6-month follow-up low anterior resection syndrome score. Pelvic floor training achieved better improvement in low anterior resection syndrome than standard care (47.8% vs 21.3%) at 6 months, but this was not maintained at 12 months (40.0% vs 34.9%). Ramosetron was associated with a greater short-term improvement in major low anterior resection syndrome (23% vs 8%) and a lower low anterior resection syndrome score (29.5 vs 34.6) at 4-weeks follow-up than Kegels or Sitz baths. No significant improvement in bowel function was noted after probiotics use as probiotics and placebo had similar follow-up low anterior resection syndrome scores (33.3 vs 36).

CONCLUSION

Transanal irrigation was associated with improvement in low anterior resection syndrome according to 2 trials, and ramosetron showed promising short-term results in one trial. Posterior tibial nerve stimulation had a marginal benefit compared with standard care. In contrast, pelvic floor training was associated with short-term symptomatic improvement, and probiotics showed no tangible improvement in low anterior resection syndrome symptoms. Firm conclusions cannot be drawn due to the small number of trials published.

Management of treatment-related sequelae following colorectal cancer

AIM

Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment.

METHOD

A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included.

RESULTS

Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units.

CONCLUSION

Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.

Efficacy of Tibial Nerve Stimulation on Fecal Incontinence in Patients With Low Anterior Resection Syndrome Following Surgery for Colorectal Cancer

OBJECTIVE

To systematically review the available literature on the efficacy of tibial nerve stimulation on faecal incontinence and quality of life in adult patients with low anterior resection syndrome following surgery for colorectal cancer.

METHODS

A primary search of electronic databases was conducted adopting a combination of search terms related to the following areas of interest: "efficacy", "tibial nerve stimulation" and "low anterior resection syndrome". A secondary search of the grey literature was performed in addition to checking the reference list of included studies and review papers. The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A descriptive analysis was used to integrate the review findings.

RESULTS

Five distinct studies involving 116 patients met the inclusion criteria for the review. The included studies suggest that tibial nerve stimulation may have a positive effect on faecal incontinence and quality of life in some patients with low anterior resection syndrome and might be considered as an additional treatment option.

CONCLUSION

There were a limited number of studies and a great degree of heterogeneity of evidence due to differences in participants' baseline characteristics, dropout rates, and follow-up periods. Further research adopting validated, consistent, and complex outcome assessment methods is recommended to determine the efficacy of tibial nerve stimulation for treatment of patients with low anterior resection syndrome.

The Role of Traditional Acupuncture in Low Anterior Resection Syndrome Treatment: A Pilot Study

BACKGROUND

There is limited evidence on the efficacy of acupuncture in bowel dysfunction treatment.

OBJECTIVE

The aim of this pilot study was to investigate the potential value of acupuncture in the treatment of low anterior resection syndrome.

DESIGN

This was an open-design pilot study.

SETTINGS

This was a single-center study.

PATIENTS

Nine (5 female) patients with major low anterior resection syndrome were included.

INTERVENTIONS

All patients underwent acupuncture by a trained specialist once a week for 10 weeks.

MAIN OUTCOME MEASURES

Bowel function was assessed by using the low anterior resection syndrome score and the Memorial Sloan-Kettering Cancer Center bowel function instrument before the procedure, just after finishing the course of acupuncture, and 6 months after the treatment.

RESULTS

The average age was 56.44 (50-65; SD ±5.4). Median age was 56 years. At the end of the procedure, all patients reported significant improvement in low anterior resection syndrome symptoms: the average low anterior resection syndrome score before acupuncture was 39 (±2.7), after acupuncture it was 30.3 (±10.6), and 6 months after acupuncture it was 7.22 (±10.244; p < 0.000). The average Memorial Sloan-Kettering Cancer Center bowel function instrument score before acupuncture was 55.33 (±11.55), after the procedure it was 60 (±14.97), and 6 months later it was 70.22 (±12.2; p < 0.000).

LIMITATIONS

The small sample size and the fact that this is a single-center nonblinded study are limitations of this work.

CONCLUSIONS

Acupuncture may be effective in low anterior resection syndrome treatment and needs further evaluation. The procedure is safe and feasible. See Video Abstract at http://links.lww.com/DCR/B700.

REGISTRATION

ClinicalTrials.gov: NCT03916549.

EL PAPEL DE LA ACUPUNTURA TRADICIONAL EN EL TRATAMIENTO DEL SNDROME DE RESECCIN ANTERIOR BAJA UN ESTUDIO PILOTO

ANTECEDENTES:Existe evidencia limitada sobre la eficacia de la acupuntura para el tratamiento de la disfunción intestinal.OBJETIVO:El objetivo de este estudio piloto fue investigar el valor potencial de la acupuntura en el tratamiento del síndrome de resección anterior baja.DISEÑO:Este fue un estudio piloto de diseño abiertoAJUSTES:Este fue un estudio en un solo centroPACIENTES:Fueron incluidos nueve pacientes con síndrome de resección anterior baja (muy sintomáticos), cinco de ellos eran mujeresINTERVENCIONES:Todos los pacientes fueron tratados con acupuntura, una vez a la semana durante diez semanas por un especialista capacitado.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal fue evaluada, antes del procedimiento, justo al finalizar el ciclo de acupuntura y a los seis meses, utilizando la puntuación (score) para el síndrome de resección anterior baja y el instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center.RESULTADOS:La edad media fue 56,44 (50 - 65) (DE ± 5,4). Edad mediana 56 años. Al final del procedimiento, todos los pacientes manifestaron una mejoría significativa de los síntomas del síndrome de resección anterior baja: La puntuación promedio del síndrome de resección anterior baja antes de la acupuntura fue 39 (± 2,7), después de - 30,3 (± 10,6) y 6 meses después de 7,22 (± 10,244) (p <0,000). El puntaje promedio del instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center antes de la acupuntura fue 55.33 (± 11.55), después del procedimiento 60 (± 14.97) y 6 meses después 70.22 (± 12.2) (p <0,000).LIMITACIONES:Tamaño de muestra pequeño, estudio no cegado en un solo centro.CONCLUSIONES:La acupuntura puede ser eficaz en el tratamiento del síndrome de resección anterior baja, pero es necesario continuar evaluando su utilidad. El procedimiento es seguro y factible. Consulte Video Resumen en http://links.lww.com/DCR/B700.

Percutaneous tibial nerve stimulation in patients with severe low anterior resection syndrome: randomized clinical trial

BACKGROUND

Treatment of low anterior resection syndrome (LARS) is challenging. Percutaneous tibial nerve stimulation (PTNS) can improve select bowel disorders. An RCT was conducted to assess the efficacy of PTNS compared with sham stimulation in patients with severe LARS.

METHOD

This was a multicentre, double-blind RCT. Patients with major LARS score were allocated to receive PTNS or sham therapy (needle placement simulation without nerve stimulation). The study included 16 sessions of 30 min once a week for 12 consecutive weeks, followed by four additional sessions once a fortnight for the following 4 weeks. The primary endpoint was efficacy of PTNS defined by the LARS score 12 months after treatment. Secondary endpoints included faecal incontinence, quality of life (QoL), and sexual function.

RESULTS

Between September 2016 and July 2018, 46 eligible patients were assigned randomly in a 1 : 1 ratio to PTNS or sham therapy. Baseline characteristics were similar. LARS scores were reduced in both groups, but only patients who received PTNS maintained the effect in the long term (mean(s.d.) score 36.4(3.9) at baseline versus 30.7(11.5) at 12 months; P = 0.018; effect size -5.4, 95 per cent c.i. -9.8 to -1.0), with a mean reduction of 15.7 per cent at 12-month follow-up. The faecal incontinence score was improved after 12 months in the PTNS group (mean(s.d.) score 15.4(5.2) at baseline versus 12.5(6.4) at 12 months; P = 0.018). No major changes in QoL and sexual function were observed in either group. There was no therapy-associated morbidity. Three patients discontinued the study, but none owing to study-related issues.

CONCLUSION

PTNS has positive effects in some patients with major LARS, especially in those with faecal incontinence. Registration number: NCT02517853 (http://www.clinicaltrials.gov).

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence

INTRODUCTION

The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation.

METHODS

Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry.

RESULTS

32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (±5.39) to 7.71 (±4.57) P < .005], the number of episodes of passive incontinence [8.78 (±9.64) to 4.11 (±7.11) P = .025], the total number of incontinence episodes [16.11 (±16.03) to 7.78 (±11.34) P = .009] and the number of days with fecal soiling [6.89 (±5.53) to 2.56 (±4.13) P = .002] and with an increase in the length of the manometric anal canal at rest [4.55 (±0.596) to 4.95 (±0.213) P = .004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 P < .005) and the number of days with soiling (r = -0.650 P = .022).

CONCLUSIONS

The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

Management guidelines for low anterior resection syndrome - the MANUEL project

AIM

Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS.

METHOD

The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project.

RESULTS

The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts.

CONCLUSIONS

The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.

Randomized Pilot Trial of Percutaneous Posterior Tibial Nerve Stimulation Versus Medical Therapy for the Treatment of Low Anterior Resection Syndrome: One-Year Follow-up

BACKGROUND

Low anterior resection syndrome is significantly associated with a deterioration in the quality of life, and its medical treatment is usually ineffective.

OBJECTIVE

The aim of the present study was to establish the efficacy of percutaneous tibial nerve stimulation in treating this syndrome.

DESIGN

This is a randomized pilot trial with 1-year follow-up.

SETTINGS

The study was conducted in a specialized colorectal unit of a tertiary hospital.

PATIENTS

Patients who underwent neoadjuvant chemoradiotherapy and low anterior rectal resection for cancer with low anterior resection syndrome score ≥21 and ileostomy closed at least 18 months earlier were included.

INTERVENTIONS

Patients were randomly assigned to receive either percutaneous tibial nerve stimulation plus medical treatment (arm A, n = 6) or medical treatment (arm B, n = 6). Low anterior resection syndrome was assessed using symptom severity and disease-specific quality-of-life scores at baseline, at the end of treatment, and at 1-year follow-up.

MAIN OUTCOME MEASURES

The primary outcome was a clinical response, defined as a reduction of the low anterior resection syndrome score.

RESULTS

Only in group A low anterior resection syndrome score, fecal incontinence severity index, and obstructed defecation syndrome score improved significantly with treatment (35.8 ± 2.5 vs 29.0 ± 3.8 (p = 0.03); 36.8 ± 4.3 vs 18.5 ± 8.0 (p = 0.02); 10.3 ± 3.9 vs 8.0 ± 4.9 (p = 0.009)) and changes were observed in all domains of quality-of-life instruments. In both groups the symptom severity and quality-of-life scores at 1-year follow-up did not differ significantly from those recorded at the end of treatment.

LIMITATIONS

The study had a small number of patients and it was underpowered to detect the within-group effect.

CONCLUSIONS

Percutaneous tibial nerve stimulation could be an effective treatment for low anterior resection syndrome. Additional studies are warranted to investigate clinical effectiveness in low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B371. ESTUDIO PILOTO ALEATORIO DE ESTIMULACIÓN PERCUTÁNEA DEL NERVIO TIBIAL POSTERIOR VERSUS TERAPIA MÉDICA PARA EL TRATAMIENTO DEL SÍNDROME DE RESECCIÓN ANTERIOR BAJA: UN AÑO DE SEGUIMIENTO: El síndrome de resección anterior baja se asocia con un deterioro significativo en la calidad de vida y su tratamiento médico generalmente es ineficaz.El objetivo del presente estudio fue establecer la eficacia de la estimulación percutánea del nervio tibial en el tratamiento de este síndrome.Este es un estudio piloto aleatorio con 1 año de seguimiento.El estudio se realizó en una unidad colorrectal especializada de un hospital terciario.Se incluyeron pacientes que se sometieron a quimiorradioterapia neoadyuvante y resección rectal anterior baja por cáncer con puntaje de síndrome de resección anterior baja ≥ 21 e ileostomía cerrada al menos 18 meses antes.Los pacientes fueron asignados aleatoriamente para recibir estimulación percutánea del nervio tibial + tratamiento médico (brazo A, n = 6) o tratamiento médico (brazo B, n = 6). El síndrome de resección anterior baja se evaluó utilizando puntajes de la gravedad de los síntomas y de calidad de vida específicos de la enfermedad al inicio, al final del tratamiento y al año de seguimiento.El resultado primario fue una respuesta clínica, definida como una reducción de la puntuación del síndrome de resección anterior baja.Solo en el grupo A, el puntaje del síndrome de resección anterior baja, el índice de severidad de incontinencia fecal y el puntaje del síndrome de defecación obstruida mejoraron significativamente con el tratamiento (35.8 ± 2.5 vs 29 ± 3.8, p = 0.03; 36.8 ± 4.3 vs 18.5 ± 8.0, p = 0.02; 10.3 ± 3.9 vs 8.0 ± 4.9, p = 0.009, respectivamente) y se observaron cambios en todos los dominios de los instrumentos de calidad de vida. En ambos grupos, los puntajes de severidad de los síntomas y de calidad de vida al año de seguimiento no difirieron significativamente de los registrados al final del tratamiento.El estudio tuvo un pequeño número de pacientes y no logró suficiente poder para detectar el efecto dentro de grupo.La estimulación percutánea del nervio tibial podría ser un tratamiento efectivo para el síndrome de resección anterior baja. Se requieren estudios adicionales para investigar la efectividad clínica en el síndrome de resección anterior baja. Consulte Video Resumen http://links.lww.com/DCR/B371.

Importance of some technical aspects of the procedure of percutaneous posterior tibial nerve stimulation in patients with fecal incontinence

INTRODUCTION

The results of percutaneous posterior tibial nerve stimulation (PTNS) in the treatment of fecal incontinence (IF) are modest. The aim of the study is to assess the relationship of some technical aspects with the clinical response: location of the nerve, distal response (motor or sensory) and accommodation.

METHODS

Prospective study of patients with FI undergoing PTNS therapy. The clinical response was assessed using the Wexner scale, defecation diary and anorectal manometry.

RESULTS

32 patients were studied. The intensity of localization (proximity to the nerve) was not correlated with clinical or manometric changes. Motor response was associated with a decrease on the Wexner scale [12.12 (± 5.39) to 7.71 (± 4.57) p < 0.005], the number of episodes of passive incontinence [8.78 (± 9.64) to 4.11 (± 7.11) p = 0.025], the total number of incontinence episodes [16.11 (± 16.03) to 7.78 (± 11.34) p = 0.009] and the number of days with faecal soiling [6.89 (± 5.53) to 2.56 (± 4.13) p = 0.002] and with an increase in the length of the manometric anal canal at rest [4.55 (± 0.596) to 4.95 (± 0.213) p = 0.004]. The increase in stimulation (accommodation) was inversely correlated with the decrease in the Wexner scale (r = -0.677 p < 0.005) and the number of days with soiling (r = -0.650 p = 0.022).

CONCLUSIONS

The motor response during PTNS seems to be related to a better clinical response. The accommodation phenomenon could be associated with worse results. The proximity of the electrode to the nerve does not seem to be important as long as a good distal response is achieved.

[Rehabilitation program for patients with low anterior resection syndrome]

Surgical treatment of rectal cancer and sphincter-preserving low anterior resection results to evacuation disorders («low anterior resection syndrome» - LARS). There are no clinical recommendations for the treatment of patients with LARS as well as a rehabilitation program for them.

OBJECTIVE

To develop a rehabilitation program for patients with low anterior resection syndrome.

MATERIAL AND METHODS

The investigation was performed at 2 stages. During the first stage, 29 patients with LARS (17 (58.6%) men, mean age of the participants' 61.5±9.5 years), 12 (41.4%) women (mean age 61.2±7.8 years) were examined and received the course of conservative treatment with the use of biofeedback-therapy performed by the standard protocol. On the second stage, 17 patients (mean age 61.4±12.7 years) - 9 (52.9%) men, 8 (47.1%) women received biofeedback therapy in combination with tibial neuromodulation (TNM). Functional state of the rectum and the locking apparatus in all patients were evaluated by anorectal manometry: sphincterometry and studies of the reservoir function of the rectum before and after treatment.

RESULTS

The developed complex of rehabilitation measures led to improved treatment results for patients with rectal cancer by improving the quality of life after low anterior resection, reducing the manifestations of LARS (by 47.8%). Stable positive results of treatment were maintained in 36.4% of patients, positive dynamics from the treatment according to the LARS scale decreased slightly in 54.5%, deterioration of indicators in 3-6 months after conservative rehabilitation was registered in 9.1% of cases. At the first stage maximal squeeze pressure improvement was reached in the whole cohort (p=0.047), at the second stage these trend was seen only for women for the pressure values at rest (p=0.01) and during squeeze (p=0.025). The data obtained allowed us to recommend a repeat course of treatment to 63.6% of patients. The authors modified and optimized a special complex of physical therapy for the rehabilitation of patients both in a medical institution and at home. These exercises are aimed at improving the functional state of the pelvic floor muscles and sphincter apparatus.

CONCLUSION

Rehabilitation program for patients with low anterior resection syndrome should include: 1) biofeedback therapy to improve the holding function; 2) biofeedback therapy aimed at improving the reservoir function and sensitivity of the rectum to filling; 3) tibial neuromodulation. This program may help improving the contractility of the anal sphincter and reservoir function of the rectum, as well as the appearance of the urge to defecate.

Evaluation of the anorectal motor response after percutaneous stimulation of the posterior tibial nerve in patients with fecal incontinence

BACKGROUND

The effect of posterior tibial nerve stimulation (PTNS) on the mechanisms of anal continence has not been fully demonstrated. The aim of this study was to assess the anal manometric response after percutaneous PTNS in patients with fecal incontinence (FI).

METHODS

This was a prospective study in patients with FI undergoing 1 weekly session of percutaneous PTNS for 8 weeks. A clinical assessment (Wexner scale) and a complete study of up to 22 manometric parameters were carried out prior to treatment and 2-4 weeks after the end of treatment.

RESULTS

A total of 32 patients were evaluated. After therapy, there was a decrease in the average Wexner score [12.6 (± 5.2) to 9.5 (± 5.2) (P < 0.005)] and an increase in the "anal canal length at rest" [4.55 (± 0.60) to 4.95 (± 0.21) P = 0.004], without observing variations in other manometric parameters. The decrease in the Wexner score was significantly correlated with an increase in the "pressure at 5 cm at rest" after therapy (r = 0.464 P = 0.030).

CONCLUSIONS

In our study, PTNS was associated with a significant decrease in the Wexner score and with an increase in the functional length of the anal canal at rest. The improvement in the Wexner scale was correlated with an increase in pressure at rest in the theoretical area of the anorectal junction.

Role of transanal irrigation in the treatment of anterior resection syndrome

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.

Treatment possibilities for low anterior resection syndrome: a review of the literature

AIM

Up to 80% of patients after low anterior resection, experience (low) anterior resection syndrome (ARS/LARS). However, there is no standard treatment option currently available. This systemic review aims to summarize treatment possibilities for LARS after surgical treatment of rectal cancer in the medical literature.

METHODS

Embase, PubMed, and the Cochrane Library were searched using the terms anterior resection syndrome, low anterior resection, colorectal/rectal/rectum, surgery/operation, pelvic floor rehabilitation, biofeedback, transanal irrigation, sacral nerve stimulation, and tibial nerve stimulation. All English language articles presenting original patient data regarding treatment and outcome of LARS were included. We focused on the effects of different treatment modalities for LARS. The Jadad score was used to assess the methodological quality of trials. The quality scale ranges from 0 to 5 points, with a score ≤ 2 indicating a low quality report, and a score of ≥ 3 indicating a high quality report.

RESULTS

Twenty-one of 160 studies met the inclusion criteria, of which 8 were reporting sacral nerve stimulation, 6 were designed to determine pelvic floor rehabilitation, 3 studies evaluated the effect of transanal irrigation, 2-percutaneous tibial nerve stimulation, and the rest of the studies assessed probiotics and 5-HT₃ receptor antagonists for LARS in patients who had undergone rectal resection. All except one study were poor quality reports according to the Jadad score.

CONCLUSIONS

LARS treatment still carries difficulties because of a lack of well-conducted, randomized multicenter trials. Well-performed randomized controlled trials are needed.