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Garfinkle RC, McKenna NP. Low Anterior Resection Syndrome following Restorative Proctectomy for Rectal Cancer: Can the Surgeon Have Any Meaningful Impact? Cancers (Basel) 2024; 16:2307. [PMID: 39001370 PMCID: PMC11240414 DOI: 10.3390/cancers16132307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 06/20/2024] [Accepted: 06/22/2024] [Indexed: 07/16/2024] Open
Abstract
Postoperative bowel dysfunction following restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long term sequela of rectal cancer treatment. While many of the established risk factors for LARS are non-modifiable, others may be well within the surgeon's control. Several pre-, intra-, and postoperative decisions may have a significant impact on postoperative bowel function. Some of these factors include the extent of surgical resection, surgical approach, choice of anastomotic reconstruction, and use of fecal diversion. This review article summarizes the available evidence regarding how surgical decision-making can affect postoperative bowel function.
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Affiliation(s)
| | - Nicholas P. McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA;
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2
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Popeskou SG, Roesel R, Faes S, Vanoni A, Galafassi J, di Tor Vajana AF, Piotet LM, Christoforidis D. Ondansetron for Low Anterior Resection Syndrome (LARS): A Double-Blind, Placebo-Controlled, Cross-Over, Randomized Study. Ann Surg 2024; 279:196-202. [PMID: 37436844 DOI: 10.1097/sla.0000000000005995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE The aim of the study was to examine the efficacity and safety of ondansetron, a serotonin receptor antagonist, to treat patients with low anterior resection syndrome (LARS). BACKGROUND LARS after rectal resection is common and debilitating. Current management strategies include behavioral and dietary modifications, physiotherapy, antidiarrheal drugs, enemas, and neuromodulation, but the results are not always satisfactory. METHODS This is a randomized, multicentric, double-blinded, placebo-controlled, and cross-over study. Patients with LARS (LARS score >20) no longer than 2 years after rectal resection were randomized to receive either 4 weeks of ondansetron followed by 4 weeks of placebo (O-P group) or 4 weeks of placebo followed by 4 weeks of ondansetron (P-O group). The primary endpoint was LARS severity measured using the LARS score; secondary endpoints were incontinence (Vaizey score) and irritable bowel syndrome quality of life (IBS-QoL questionnaire). Patients' scores and questionnaires were completed at baseline and after each 4-week treatment period. RESULTS Of 46 randomized patients, 38 were included in the analysis. From baseline to the end of the first period, in the O-P group, the mean (SD) LARS score decreased by 25% [from 36.6 (5.6) to 27.3 (11.5)] and the proportion of patients with major LARS (score >30) went from 15/17 (88%) to 7/17 (41%), ( P =0.001). In the P-O group, the mean (SD) LARS score decreased by 12% [from 37 (4.8) to 32.6 (9.1)], and the proportion of major LARS went from 19/21 (90%) to 16/21 (76%). After crossover, LARS scores deteriorated again in the O-P group receiving placebo, but further improved in the P-O group receiving ondansetron. Mean Vaizey scores and IBS QoL scores followed a similar pattern. CONCLUSIONS Ondansetron is a safe and simple treatment that appears to improve both symptoms and QoL in LARS patients.
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Affiliation(s)
| | - Raffaello Roesel
- Department of Visceral Surgery, Hospital of Lugano (EOC), Lugano, Switzerland
| | - Seraina Faes
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alice Vanoni
- Department of Visceral Surgery, Hospital of Lugano (EOC), Lugano, Switzerland
| | - Jacopo Galafassi
- Department of Visceral Surgery, Hospital of Lugano (EOC), Lugano, Switzerland
| | | | - Laure-Meline Piotet
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Dimitri Christoforidis
- Department of Visceral Surgery, Hospital of Lugano (EOC), Lugano, Switzerland
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
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Baik H. To go high, or to go low: the never-ending debate of inferior mesenteric artery ligation. Ann Coloproctol 2024; 40:1-2. [PMID: 38325809 PMCID: PMC10915534 DOI: 10.3393/ac.2024.00094.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/04/2024] [Indexed: 02/09/2024] Open
Affiliation(s)
- HyungJoo Baik
- Division of Colorectal Surgery, Department of Surgery, Inje University Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
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Lee MW, Park SS, You K, Lee DE, Lee DW, Park SC, Han KS, Sohn DK, Hong CW, Kim B, Kim BC, Chang HJ, Kim DY, Oh JH. Long-term clinical outcomes after high and low ligations with lymph node dissection around the root of the inferior mesenteric artery in patients with rectal cancer. Ann Coloproctol 2024; 40:62-73. [PMID: 38414122 PMCID: PMC10915527 DOI: 10.3393/ac.2023.00094.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/25/2023] [Accepted: 04/30/2023] [Indexed: 02/29/2024] Open
Abstract
PURPOSE This study aimed to evaluate the long-term clinical outcomes based on the ligation level of the inferior mesenteric artery (IMA) in patients with rectal cancer. METHODS This was a retrospective analysis of a prospectively collected database that included all patients who underwent elective low anterior resection for rectal cancer between January 2013 and December 2019. The clinical outcomes included oncological outcomes, postoperative complications, and functional outcomes. The oncological outcomes included overall survival (OS) and relapse-free survival (RFS). The functional outcomes, including defecatory and urogenital functions, were analyzed using the Fecal Incontinence Severity Index, International Prostate Symptom Score, and International Index of Erectile Function questionnaires. RESULTS In total, 545 patients were included in the analysis. Of these, 244 patients underwent high ligation (HL), whereas 301 underwent low ligation (LL). The tumor size was larger in the HL group than in the LL group. The number of harvested lymph nodes (LNs) was higher in the HL group than in the LL group. There were no significant differences in complication rates and recurrence patterns between the groups. There were no significant differences in 5-year RFS and OS between the groups. Cox regression analysis revealed that the ligation level (HL vs. LL) was not a significant risk factor for oncological outcomes. Regarding functional outcomes, the LL group showed a significant recovery in defecatory function 1 year postoperatively compared with the HL group. CONCLUSION LL with LNs dissection around the root of the IMA might not affect the oncologic outcomes comparing to HL; however, it has minimal benefit for defecatory function.
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Affiliation(s)
- Min Wan Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Sil Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kiho You
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Eun Lee
- Biostatistics Collaboration Team, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dong Woon Lee
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Sung Chan Park
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Kyung Su Han
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Kyung Sohn
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Chang Won Hong
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Bun Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Byung Chang Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Hee Jin Chang
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Dae Yong Kim
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Jae Hwan Oh
- Center for Colorectal Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
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5
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Ryoo S. Low anterior resection syndrome. Ann Gastroenterol Surg 2023; 7:719-724. [PMID: 37663958 PMCID: PMC10472409 DOI: 10.1002/ags3.12695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 09/05/2023] Open
Abstract
Low anterior resection syndrome (LARS) is the distressful defecatory functional problem after sphincter-saving surgery for rectal cancer. Although the symptoms of fecal urgency, frequency, and incontinence may develop in most of the patients after surgery, there is no definitive treatments for LARS. Multifactorial etiologies and various risk factors have been identified, but the reduction of storage capacity in the rectum is one of the main reasons for LARS. Anal sphincter muscle or nerve damage during rectoanal resection or anastomosis construction, and intersphincteric resection for low-lying tumors or hand-sewing anastomosis, are the absolute risk factors for LARS. Preoperative radiotherapy, postoperative complications, such as anastomosis leakage, or longer duration of stoma, are also risk factors. The severity of LARS can be confirmed using the LARS score questionnaire. The questionnaire has been translated to numerous language versions including Korean and have been validated. Diverse empirical treatments, such as loperamide, fiber, probiotics, or enema, have been tried, but the safety and efficacy have not been verified yet. The 5-Hydroxytryptamine (5-HT) receptor antagonist, ramosetron, used for diarrhea-dominant irritable bowel syndrome, is one potential drug for relieving the symptoms of major LARS. A randomized-controlled trial suggested the use of ramosetron could be safe and efficacious for patients who have major LARS after sphincter-saving rectal cancer surgery. Novel techniques or drugs for relieving the symptoms of LARS should be developed more and further studies are necessary.
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Affiliation(s)
- Seung‐Bum Ryoo
- Division of Colorectal Surgery, Department of SurgerySeoul National University Hospital, Seoul National University College of MedicineSeoulKorea
- Colorectal Cancer CenterSeoul National University Cancer HospitalSeoulKorea
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6
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Silvestri V, Pontecorvi E, Sciuto A, Pacella D, Peltrini R, D'Ambra M, Lionetti R, Filotico M, Lauria F, Sarnelli G, Pirozzi F, Ruotolo F, Bracale U, Corcione F. Preservation of the inferior mesenteric artery VS ligation of the inferior mesenteric artery in left colectomy: evaluation of functional outcomes-a prospective non-randomized controlled trial. Updates Surg 2023; 75:1569-1578. [PMID: 37505437 DOI: 10.1007/s13304-023-01593-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023]
Abstract
Vascular approach during elective laparoscopic left colectomy impacts post-operative outcomes. The aim of our study was to evaluate how different approaches impact positively defecatory, urinary and sexual functions and quality of life during elective laparoscopic left colectomy. A prospective non-randomized controlled trial at two tertiary center was conducted. All patients who underwent elective laparoscopic left colonic resection from January 2019 to July 2022 were analyzed. They were divided into two groups based on Inferior Mesenteric Artery (IMA) preservation with distal ligation of sigmoid branches close to a colonic wall for complicated diverticular disease and IMA high tie ligation for oncological disease. Patients were asked to fulfil standardized, validated questionnaires to evaluate pre and post-operative defecatory, urinary and sexual functions and quality of life. Defecatory disorders were assessed by high-resolution anorectal manometry preoperatively and six months after surgery. A total of 122 patients were included in the study. The 62 patients with IMA preservation showed a lower incidence of defecatory disorders also confirmed by manometer data, minor incontinence and less lifestyle alteration than the 60 patients with IMA high tie ligation. No urinary disorders such as incomplete emptying, frequency, intermittence or urgency were highlighted after surgery in the IMA preservation group. Evidence of any sexual disorders remained controversial. The IMA-preserving vascular approach seems to be an effective strategy to prevent postoperative functional disorders. It is a safe and feasible technique especially for diverticular disease. New prospective randomized and highly probative studies are needed to confirm the effectiveness in specific clinical situations.
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Affiliation(s)
- Vania Silvestri
- Department of General Surgery, SS Annunziata Hospital, 67039, Sulmona, L'Aquila, Italy.
| | - Emanuele Pontecorvi
- Department of General Surgery, SS Annunziata Hospital, 67039, Sulmona, L'Aquila, Italy
| | - Antonio Sciuto
- Department of General Surgery, Santa Maria Delle Grazie Hospital, Pozzuoli, 80078, Naples, Italy
| | - Daniela Pacella
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Roberto Peltrini
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Michele D'Ambra
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Ruggero Lionetti
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Marcello Filotico
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Federica Lauria
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
| | - Giovanni Sarnelli
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131, Naples, Italy
| | - Felice Pirozzi
- Department of General Surgery, Santa Maria Delle Grazie Hospital, Pozzuoli, 80078, Naples, Italy
| | | | - Umberto Bracale
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084, Salerno, Italy
| | - Francesco Corcione
- Department of Public Health, University of Naples Federico II, 80131, Naples, Italy
- Department of General Surgery, Clinica Mediterranea, 80122, Naples, Italy
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Therapie des tiefen anterioren Resektionssyndroms (LARS). COLOPROCTOLOGY 2023. [DOI: 10.1007/s00053-022-00673-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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WANG C, HUANG T, WANG X. Ligation level of inferior mesenteric artery in rectal cancer: a meta-analysis. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2023. [DOI: 10.23736/s0393-3660.22.04868-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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9
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Verkuijl SJ, Hoff C, Furnée EJ, Kelder W, Hess DA, Wit F, Zijlstra RJ, Trzpis M, Broens PM. Anastomotic Height Is a Valuable Indicator of Long-term Bowel Function Following Surgery for Rectal Cancer. Dis Colon Rectum 2023; 66:221-232. [PMID: 35714360 PMCID: PMC9829038 DOI: 10.1097/dcr.0000000000002168] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The exact relation between anastomotic height after rectal cancer surgery and postoperative bowel function problems has not been investigated in the long term, resulting in ineffective treatment. OBJECTIVE The goal of this study was to determine the effect of anastomotic height on long-term bowel function and generic quality of life. DESIGN This was a multicenter, cross-sectional study. SETTINGS Seven hospitals in the north of the Netherlands participated. PATIENTS All patients who underwent rectal cancer surgery between 2009 and 2015 in participating hospitals received the validated Defecation and Fecal Continence and Short-Form 36 questionnaires. Deceased patients, patients with a permanent stoma or an anastomosis >15 cm from the anal verge, patients with intellectual disability, and patients living abroad were excluded. MAIN OUTCOME MEASURES Primary outcomes were constipation (Rome IV), fecal incontinence (Rome IV), and major low anterior resection syndrome. Secondary outcomes were the generic quality of life scores. RESULTS The study population ( n = 630) had a median follow-up of 58.0 months. In multivariable analysis, constipation (OR = 1.08; 95% CI, 1.02-1.15; p = 0.011), fecal incontinence (OR = 0.91; 95% CI, 0.84-0.97; p = 0.006), and major low anterior resection syndrome (OR = 0.93; 95% CI, 0.87-0.99; p = 0.027), were significantly associated with anastomotic height. The curves illustrating the probability of constipation and fecal incontinence crossed at an anastomotic height of 7 cm, with 95% CIs overlapping between 4.5 and 9.5 cm. There was no relation between quality-of-life scores and anastomotic height. LIMITATIONS The study is limited by its cross-sectional design. CONCLUSIONS This study might serve as a guide for the clinician to effectively screen and treat fecal incontinence and constipation during patient follow-up after rectal cancer surgery. More attention should be paid to fecal incontinence in patients with an anastomosis below 4.5 cm and toward constipation in patients with an anastomosis above 9.5 cm. See Video Abstract at http://links.lww.com/DCR/B858 . LA ALTURA ANASTOMTICA ES UN INDICADOR VALIOSO DE LA FUNCIN INTESTINAL A LARGO PLAZO DESPUS DE LA CIRUGA PARA EL CNCER DE RECTO ANTECEDENTES:La relación exacta entre la altura anastomótica después de la cirugía de cáncer de recto y los problemas posoperatorios de la función intestinal no se ha investigado a largo plazo, lo que causa un tratamiento ineficaz.OBJETIVO:Determinar el efecto de la altura anastomótica sobre la función intestinal a largo plazo y la calidad de vida genérica.DISEÑO:Estudio multicéntrico transversal.DISEÑO DEL ESTUDIO:Participaron siete hospitales holandeses en el norte de los Países Bajos.PACIENTES:Todos los pacientes que se sometieron a cirugía de cáncer de recto entre 2009 y 2015 en los hospitales participantes recibieron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36. Se excluyeron pacientes fallecidos, pacientes con estoma permanente o anastomosis > 15 cm del borde anal, discapacidad intelectual o residentes en el extranjero.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron estreñimiento (Roma IV), incontinencia fecal (Roma IV) y síndrome de resección anterior baja mayor. Los resultados secundarios fueron las puntuaciones genéricas de calidad de vida.RESULTADOS:La población de estudio (N = 630) tuvo una mediana de seguimiento de 58.0 meses. En el análisis multivariable el estreñimiento (OR = 1,08, IC del 95%, 1,02-1,15, p = 0,011), incontinencia fecal (OR = 0,91, IC del 95%, 0,84-0,97, p = 0,006) y síndrome de resección anterior baja mayor (OR = 0,93, IC del 95%, 0,87-0,99, p = 0,027) se asociaron significativamente con la altura anastomótica. Las curvas que ilustran la probabilidad de estreñimiento e incontinencia fecal se cruzaron a una altura anastomótica de 7 cm, con IC del 95% superpuestos entre 4,5 y 9,5 cm. No hubo relación entre las puntuaciones de calidad de vida y la altura anastomótica.LIMITACIONES:El estudio está limitado por su diseño transversal.CONCLUSIONES:Este estudio podría servir como una guía para que el médico evalúe y trate eficazmente la incontinencia fecal y el estreñimiento durante el seguimiento de los pacientes después de la cirugía de cáncer de recto. Se debe prestar más atención a la incontinencia fecal en pacientes con anastomosis por debajo de 4,5 cm y al estreñimiento en pacientes con anastomosis por encima de 9,5 cm. Consulte Video Resumen en http://links.lww.com/DCR/B858 . (Traducción-Dr. Yazmin Berrones-Medina ).
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Affiliation(s)
- Sanne J. Verkuijl
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Edgar J.B. Furnée
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wendy Kelder
- Department of Surgery, Martini Hospital, Groningen, the Netherlands
| | - Daniel A. Hess
- Department of Surgery, Antonius Hospital, Sneek, the Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - Ronald J. Zijlstra
- Department of Surgery, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Paul M.A. Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Management of Low Anterior Resection Syndrome (LARS) Following Resection for Rectal Cancer. Cancers (Basel) 2023; 15:cancers15030778. [PMID: 36765736 PMCID: PMC9913853 DOI: 10.3390/cancers15030778] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/21/2023] [Accepted: 01/22/2023] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION A total of 60-80% of patients undergoing rectal resection (mostly as a treatment for rectal cancer) suffer from a variety of partly severe functional problems despite preservation of the anal sphincter. These patients are summarized under the term low anterior resection syndrome (LARS). Preoperative radiotherapy, vascular dissection and surgical excision of the low rectum and mesorectum lead, alone or all together, to a significant impairment of colonic and (neo-) rectal motility. This results in a variety of symptoms (multiple defecation episodes, recurrent episodes of urge, clustering, incontinence, etc.) which are associated with severe impairment of quality of life (QOL). METHODS This narrative review summarizes the present state of knowledge regarding the pathophysiology of LARS as well as the evidence for the available treatment options to control the symptoms resulting from this condition. RESULTS A review of the literature (Medline, Pubmed) reveals a variety of treatment options available to control symptoms of LARS. Medical therapy, with or without dietary modification, shows only a modest effect. Pelvic floor rehabilitation consisting of muscle exercise techniques as well as biofeedback training has been associated with improvement in LARS scores and incontinence, albeit with limited scientific evidence. Transanal irrigation (TAI) has gained interest as a treatment modality for patients with LARS due to an increasing number of promising data from recently published studies. Despite this promising observation, open questions about still-unclear issues of TAI remain under debate. Neuromodulation has been applied in LARS only in a few studies with small numbers of patients and partly conflicting results. CONCLUSION LARS is a frequent problem after sphincter-preserving rectal surgery and leads to a marked impairment of QOL. Due to the large number of patients suffering from this condition, mandatory identification, as well as treatment of affected patients, must be considered during surgical as well as oncological follow-up. The use of a standardized treatment algorithm will lead to sufficient control of symptoms and a high probability of a marked improvement in QOL.
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Huang MJ, Ye L, Yu KX, Liu J, Li K, Wang XD, Li JP. Development of prediction model of low anterior resection syndrome for colorectal cancer patients after surgery based on machine-learning technique. Cancer Med 2023; 12:1501-1519. [PMID: 35899858 PMCID: PMC9883536 DOI: 10.1002/cam4.5041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/18/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a common postoperative complication in patients with colorectal cancer, which seriously affects their postoperative quality of life. At present, the aetiology of LARS is still unclear, but some risk factors have been studied. Accurate prediction and early management of medical intervention are keys to improving the quality of life of such high-risk patients. OBJECTIVES Based on machine-learning methods, this study used the follow-up results of postoperative patients with colorectal cancer to develop prediction models for LARS and conducted a comparative analysis between the different models. METHODS A total of 382 patients diagnosed with colorectal cancer and undergoing surgery at West China Hospital from April 2017 to December 2020 were retrospectively selected as the development cohort. Logistic regression, support vector machine, decision tree, random forest and artificial neural network algorithms were used to construct the prediction models of the obtained dataset. The models were internally validated using cross-validation. The area under the curve and Brier score measures were used to evaluate and compare the differentiation and calibration degrees of the models. The sensitivity, specificity, positive predictive value and negative predictive value of the different models were described for clinical use. RESULTS A total of 342 patients were included, the incidence of LARS being 47.4% (162/342) during the six-month follow-up. After feature selection, the factors influencing the occurrence of LARS were found to be location, distance, diverting stoma, exsufflation and surgical type. The prediction models based on five machine-learning methods all showed acceptable performance. CONCLUSIONS The five models developed based on the machine-learning methods showed good prediction performance. However, considering the simplicity of clinical use of the model results, the logistic regression model is most recommended. The clinical applicability of these models will also need to be evaluated with external cohort data.
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Affiliation(s)
- Ming Jun Huang
- West China School of Nursing/Day Surgery Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Ye
- West China School of Stomatology, Sichuan University, Chengdu, China.,Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Xin Yu
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Jing Liu
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Xiao Dong Wang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ji Ping Li
- Nursing Department, West China Hospital, Sichuan University, Chengdu, China
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12
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Long-term Bowel Dysfunction and Decline in Quality of Life Following Surgery for Colon Cancer: Call for Personalized Screening and Treatment. Dis Colon Rectum 2022; 65:1531-1541. [PMID: 35982522 PMCID: PMC9645552 DOI: 10.1097/dcr.0000000000002377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Differences in long-term outcomes regarding types of colon resections are inconclusive, precluding patient counseling, effective screening, and personalized treatment. OBJECTIVE This study aimed to compare long-term bowel function and quality of life in patients who underwent right or left hemicolectomy or sigmoid colon resection. DESIGN This was a multicenter cross-sectional study. SETTINGS Seven Dutch hospitals participated in this study. PATIENTS This study included patients who underwent right or left hemicolectomy or sigmoid colon resection without construction of a permanent stoma between 2009 and 2015. Patients who were deceased, mentally impaired, or living abroad were excluded. Eligible patients were sent the validated Defecation and Fecal Continence and Short-Form 36 questionnaires. MAIN OUTCOME MEASURES Constipation, fecal incontinence (both Rome IV criteria), separate bowel symptoms, and generic quality of life were the main outcomes assessed. RESULTS This study included 673 patients who underwent right hemicolectomy, 167 who underwent left hemicolectomy, and 284 who underwent sigmoid colon resection. The median follow-up was 56 months. Sigmoid colon resection increased the likelihood of constipation compared to right and left hemicolectomy (OR, 2.92; 95% CI, 1.80-4.75; p < 0.001 and OR, 1.93; 95% CI, 1.12-3.35; p = 0.019). Liquid incontinence and fecal urgency increased after right hemicolectomy compared to sigmoid colon resection (OR, 2.15; 95% CI, 1.47-3.16; p < 0.001 and OR, 2.01; 95% CI, 1.47-2.74; p < 0.001). Scores on quality-of-life domains were found to be significantly lower after right hemicolectomy. LIMITATIONS Because of the cross-sectional design, longitudinal data are still lacking. CONCLUSIONS Different long-term bowel function problems occur after right or left hemicolectomy or sigmoid colon resection. The latter seems to be associated with more constipation than right or left hemicolectomy. Liquid incontinence and fecal urgency seem to be associated with right hemicolectomy, which may explain the decline in physical and mental generic quality of life of these patients. See Video Abstract at http://links.lww.com/DCR/C13 . DISFUNCIN INTESTINAL A LARGO PLAZO Y DISMINUCIN DE LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE COLON SOLICITUD DE DETECCIN Y TRATAMIENTO PERSONALIZADOS ANTECEDENTES:Las diferencias en los resultados a largo plazo con respecto a los tipos de resecciones de colon no son concluyentes, lo que impide el asesoramiento preoperatorio del paciente y la detección eficaz y el tratamiento personalizado de la disfunción intestinal postoperatoria durante el seguimiento.OBJETIVO:Comparar la función intestinal a largo plazo y la calidad de vida en pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide.DISEÑO:Estudio transversal multicéntrico.AJUSTES:Participaron siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide sin construcción de estoma permanente entre 2009 y 2015. Se excluyeron pacientes fallecidos, con discapacidad mental o residentes en el extranjero. A los pacientes elegibles se les enviaron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron el estreñimiento, la incontinencia fecal (ambos criterios de Roma IV), los síntomas intestinales separados y la calidad de vida genérica.RESULTADOS:Se incluyeron 673 pacientes con hemicolectomía derecha, 167 con hemicolectomía izquierda y 284 con resección de colon sigmoide. La mediana de seguimiento fue de 56 meses (RIC 41-80). La resección del colon sigmoide aumentó la probabilidad de estreñimiento en comparación con la hemicolectomía derecha e izquierda (OR, 2,92, IC 95%, 1,80-4,75, p < 0,001 y OR 1,93, IC 95%, 1,12-3,35, p = 0,019). La incontinencia de líquidos y la urgencia fecal aumentaron después de la hemicolectomía derecha en comparación con la resección del colon sigmoide (OR, 2,15, IC 95%, 1,47-3,16, p < 0,001 y OR 2,01, IC 95%, 1,47-2,74, p < 0,001). Las puntuaciones en los dominios de calidad de vida fueron significativamente más bajas después de la hemicolectomía derecha.LIMITACIONES:Debido al diseño transversal, aún faltan datos longitudinales.CONCLUSIONES:Se producen diferentes problemas de función intestinal a largo plazo después de la hemicolectomía derecha o izquierda, o la resección del colon sigmoide. Este último parece estar asociado con más estreñimiento que la hemicolectomía derecha o izquierda. La incontinencia de líquidos y la urgencia fecal parecen estar asociadas a la hemicolectomía derecha, lo que puede explicar el deterioro de la calidad de vida física y mental en general de estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/C13 . (Traducción-Dr. Yolanda Colorado ).
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Asnong A, Tack J, Devoogdt N, De Groef A, Geraerts I, D'Hoore A. Exploring the pathophysiology of LARS after low anterior resection for rectal cancer with high-resolution colon manometry. Neurogastroenterol Motil 2022; 34:e14432. [PMID: 35866548 DOI: 10.1111/nmo.14432] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/16/2022] [Accepted: 06/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND A total mesorectal excision for rectal cancer-although nerve- and sphincter-sparing-can give rise to significant bowel symptoms, commonly referred to as low anterior resection syndrome (LARS). The exact pathophysiology of this syndrome still remains largely unknown, and the impact of radical surgery on colonic motility has only been scarcely investigated. METHODS High-resolution colon manometry was performed in patients, 12-24 months after restoration of transit. Patients were divided into two groups: patients with major LARS and no/minor LARS, according to the LARS-score. Colonic motor patterns were compared, and the relationship of these patterns with the LARS-scores was investigated. KEY RESULTS Data were analyzed in 18 patients (9 no/minor LARS, 9 major LARS). Cyclic short antegrade motor patterns did occur more in patients with major LARS (total: p = 0.022; post-bisacodyl: p = 0.004) and were strongly correlated to LARS-scores after administering bisacodyl (p < 0.001). High amplitude propagating contractions (HAPC's) that started in the proximal colon and ended in the mid-section of the colon occurred significantly less in patients with major LARS compared with patients with no/minor LARS (p = 0.015). CONCLUSIONS AND INFERENCES The occurrence of more cyclic short antegrade motor patterns and less HAPC's (from the proximal to the mid-colon) is more prevalent in patients with major LARS. These findings help to understand the differences in pathophysiology in patients developing major versus no/minor bowel complaints after TME for rectal cancer.
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Affiliation(s)
- Anne Asnong
- Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven, Belgium
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing, Faculty of Medicine, Leuven, Belgium.,Department of Translational Research in Gastrointestinal Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Nele Devoogdt
- Center for lymphedema, University Hospitals Leuven, Leuven, Belgium.,Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - An De Groef
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Rehabilitation Sciences, University of Antwerp, Antwerp, Belgium.,International Research Group Pain in Motion, Leuven, Belgium
| | - Inge Geraerts
- Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, University Hospitals Leuven
| | - André D'Hoore
- Department of Oncology, Faculty of Medicine, Leuven, Belgium.,Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
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Marinello F, Pellino G, Espín-Basany E. Low anterior resection syndrome: An unavoidable price to pay to preserve the rectum? Front Oncol 2022; 12:994720. [PMID: 36313684 PMCID: PMC9614064 DOI: 10.3389/fonc.2022.994720] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Franco Marinello
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Franco Marinello,
| | - Gianluca Pellino
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Eloy Espín-Basany
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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15
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Varghese C, Wells CI, Bissett IP, O'Grady G, Keane C. The role of colonic motility in low anterior resection syndrome. Front Oncol 2022; 12:975386. [PMID: 36185226 PMCID: PMC9523793 DOI: 10.3389/fonc.2022.975386] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Low anterior resection syndrome (LARS) describes the symptoms and experiences of bowel dysfunction experienced by patients after rectal cancer surgery. LARS is a complex and multifactorial syndrome exacerbated by factors such as low anastomotic height, defunctioning of the colon and neorectum, and radiotherapy. There has recently been growing awareness and understanding regarding the role of colonic motility as a contributing mechanism for LARS. It is well established that rectosigmoid motility serves an important role in coordinating rectal filling and maintaining continence. Resection of the rectosigmoid may therefore contribute to LARS through altered distal colonic and neorectal motility. This review evaluates the role of colonic motility within the broader pathophysiology of LARS and outlines future directions of research needed to enable targeted therapy for specific LARS phenotypes.
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Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of General Surgery, Counties Manukau District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Whangārei Hospital, Whangarei, New Zealand
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16
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Garfinkle R, Boutros M. Low Anterior Resection Syndrome: Predisposing Factors and Treatment. Surg Oncol 2021; 43:101691. [PMID: 34863592 DOI: 10.1016/j.suronc.2021.101691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/24/2021] [Indexed: 12/15/2022]
Abstract
Bowel dysfunction after restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long-term sequela of rectal cancer treatment that has a significant impact on quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause is likely multifactorial, and there are numerous patient, tumor, and treatment-level factors associated with its development. In accordance with these risk factors, several strategies have been proposed to mitigate LARS postoperatively, including modifications in the technical approach to restorative proctectomy and advancements in the multidisciplinary care of rectal cancer. Furthermore, a clinically applicable pre-operative nomogram has been developed to estimate the risk of LARS postoperatively, which may help in counseling patients before surgery. The management of LARS begins with identifying those who manifest symptoms, as postoperative bowel dysfunction often goes unrecognized. This goal is best achieved with the systematic screening of patients using validated Patient-Reported Outcome Measures. Once a patient with LARS is identified, conservative management strategies should be implemented. When available, a dedicated LARS nurse and/or multidisciplinary team can be an invaluable resource in engaging patients and educating them regarding LARS self-care. If symptoms of LARS persist or worsen over time despite conservative measures, second-line interventions, such as transanal irrigation or pelvic floor rehabilitation, can be initiated. A small proportion of patients will ultimately require an intervention such as sacral neuromodulation or permanent colostomy for refractory, major LARS symptoms.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.
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17
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Pilkington SA, Bhome R, Gilbert S, Harris S, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study. Colorectal Dis 2021; 23:2436-2446. [PMID: 34032359 DOI: 10.1111/codi.15754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. METHOD Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . RESULTS Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. CONCLUSIONS Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.
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Affiliation(s)
- Sophie A Pilkington
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Rahul Bhome
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Sally Gilbert
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Scott Harris
- Primary Care and Population Studies, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Carl Richardson
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Thomas C Dudding
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - John S Knight
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Andrew T King
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Alex H Mirnezami
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Nicholas E Beck
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Paul H Nichols
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Karen P Nugent
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK
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18
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Bai X, Zhang CD, Pei JP, Dai DQ. Genitourinary function and defecation after colorectal cancer surgery with low- and high-ligation of the inferior mesenteric artery: A meta-analysis. World J Gastrointest Surg 2021; 13:871-884. [PMID: 34512910 PMCID: PMC8394385 DOI: 10.4240/wjgs.v13.i8.871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/12/2021] [Accepted: 07/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The effect of low ligation (LL) vs high ligation (HL) of the inferior mesenteric artery (IMA) on functional outcomes during sigmoid colon and rectal cancer surgery, including urinary, sexual, and bowel function, is still controversial.
AIM To assess the effect of LL of the IMA on genitourinary function and defecation after colorectal cancer (CRC) surgery.
METHODS EMBASE, PubMed, Web of Science, and the Cochrane Library were systematically searched to retrieve studies describing sigmoid colon and rectal cancer surgery in order to compare outcomes following LL and HL. A total of 14 articles, including 4750 patients, were analyzed using Review Manager 5.3 software. Dichotomous results are expressed as odds ratios (ORs) with 95% confidence intervals (CIs) and continuous outcomes are expressed as weighted mean differences (WMDs) with 95%CIs.
RESULTS LL resulted in a significantly lower incidence of nocturnal bowel movement (OR = 0.73, 95%CI: 0.55 to 0.97, P = 0.03) and anastomotic stenosis (OR = 0.31, 95%CI: 0.16 to 0.62, P = 0.0009) compared with HL. The risk of postoperative urinary dysfunction, however, did not differ significantly between the two techniques. The meta-analysis also showed no significant differences between LL and HL in terms of anastomotic leakage, postoperative complications, total lymph nodes harvested, blood loss, operation time, tumor recurrence, mortality, 5-year overall survival rate, or 5-year disease-free survival rate.
CONCLUSION Since LL may result in better bowel function and a reduced rate of anastomotic stenosis following CRC surgeries, we suggest that LL be preferred over HL.
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Affiliation(s)
- Xiao Bai
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Jun-Peng Pei
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
| | - Dong-Qiu Dai
- Department of Gastrointestinal Surgery, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province, China
- Cancer Center, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, Liaoning Province , China
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Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl) 2021; 133:1824-1833. [PMID: 32604174 PMCID: PMC7469998 DOI: 10.1097/cm9.0000000000000852] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
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20
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Enomoto H, Nishizawa Y, Inamori K, Hasegawa H, Ikeda K, Tsukada Y, Sasaki T, Ito M. Sacral neuromodulation for the prevention of a permanent stoma in patients with severe defecation disorder following intersphincteric resection. Surg Today 2021; 51:1379-1386. [PMID: 33591452 DOI: 10.1007/s00595-021-02233-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/27/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE Severe defecation disorder occurs frequently in coloanal anastomosis for low rectal cancer, and may affect quality of life. Sacral neuromodulation (SNM) has been reported to be successful after rectal resection, but there are no results for patients treated with intersphincteric resection (ISR). METHODS A retrospective single-center study of SNM was performed for patient with defecation disorder following ISR. Pre- and post-treatment bowel frequencies, fecal incontinence episodes, and Wexner, LARS and FIQL scores were assessed to evaluate the efficacy. A good response was defined as ≥ 50% reduction of bowel frequency per day or fecal incontinence episodes per week. RESULTS 10 patients (7 males, mean age 67.5 years) underwent SNM. All patients had severe fecal incontinence with a median Wexner score of 15 (13-20) and a median LARS score of 41 (36-41). The Wexner score improved after SNM, but not significantly (p = 0.06). LARS and FIQL scores significantly improved after SNM (p = 0.02, p = 0.01). At the end of follow-up, the good response rate was 40%. Three cases without a good response required creation of a permanent stoma. CONCLUSION Seven out of 10 patients did not require a permanent colostomy after SNM. SNM should be considered before performing a permanent colostomy.
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Affiliation(s)
- Hiroya Enomoto
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuji Nishizawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
| | - Koji Inamori
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Hiro Hasegawa
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Koji Ikeda
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Yuichiro Tsukada
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Takeshi Sasaki
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan
| | - Masaaki Ito
- Department of Colorectal Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa, Chiba, 277-8577, Japan.
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Totally intracorporeal colorectal anastomosis after segmental sigmoid resection with inferior mesenteric artery preservation for deep infiltrating endometriosis. Tech Coloproctol 2021; 25:745-746. [PMID: 33449256 DOI: 10.1007/s10151-020-02405-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
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Abstract
PURPOSE OF REVIEW Low anterior resection syndrome is a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life. In this review, we summarize the major features and pathophysiology of this syndrome and discuss treatment approaches. RECENT FINDINGS Quality of life correlates significantly with severity of low anterior resection syndrome. Prompt assessment and initiation of therapy are essential to rehabilitating damaged mechanical and neural structures. Anorectal manometry demonstrates a global decrease in sphincteric function postoperatively, though in many patients, function does recover. Transanal irrigation, pelvic floor rehabilitation, and biofeedback are the mainstays of the treatment of major LARS. Definitive stoma can be considered in therapy refractory LARS > 2 years. The development of low anterior resection syndrome likely involves an interplay between mechanical and neural pathways. Clinically, patients present at varying levels of severity, and scoring systems are available to help assess patient symptoms and guide therapy. Treatment approaches range from conservative therapies to biofeedback and sacral nerve stimulation. Future randomized controlled trials aimed at risk stratification of patients and development of severity-based treatment algorithms are warranted.
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Affiliation(s)
- Theresa H Nguyen
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Ave., Ste. 8B, BCM 901, Houston, TX, 77030, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Reena V Chokshi
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Ave., Ste. 8B, BCM 901, Houston, TX, 77030, USA.
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Nocera F, Angehrn F, von Flüe M, Steinemann DC. Optimising functional outcomes in rectal cancer surgery. Langenbecks Arch Surg 2020; 406:233-250. [PMID: 32712705 PMCID: PMC7936967 DOI: 10.1007/s00423-020-01937-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Background By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention. Purpose This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted. Conclusion Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.
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Affiliation(s)
- Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Fiorenzo Angehrn
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
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Yoo RN, Cho HM, Kye BH, Kim HJ, Shin S, Kim G. Rapid transit in the left-sided colon is related to poor defecatory function at early period after stoma closure. Sci Rep 2020; 10:3739. [PMID: 32111913 PMCID: PMC7048930 DOI: 10.1038/s41598-020-60808-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/17/2020] [Indexed: 01/04/2023] Open
Abstract
Sphincter-saving surgery (SSS) is the gold standard for rectal cancer surgery but results in a wide spectrum of bowel dysfunction. This study investigated the impact of colonic dysmotility on the incontinent form of bowel dysfunction. Bowel function of patients who received SSS with loop ileostomy for treating rectal cancer was reviewed retrospectively from June 2013 two August 2015 at a single hospital. Immediately after closure of a diverting stoma, patients were tested for the colonic transit time (CTT) using radiopaque markers. Bowel dysfunction at 6 and 12 months after SSS was measured as the severity of fecal incontinence according to the Cleveland Clinic Incontinence Score (CCIS) and the use of an anti-diarrheal drug. A short CTT for the left colonic segment was significantly associated with the high CCIS and use of an antidiarrheal agent at 6 months after sphincter preservation. However, the CTT didn't correlate with the CCIS at 12 months after SSS. Rather, age and surgical method demonstrated a significant association. Colonic dysmotility after SSS appears to intensify fecal incontinence for a relatively short period. Its impact abates within a year.
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Affiliation(s)
- Ri Na Yoo
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea.
| | - Hyeon-Min Cho
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
| | - Bong-Hyeon Kye
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea.
| | - Hyung Jin Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
| | - Sukhyun Shin
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
| | - Gun Kim
- Division of Colorectal Surgery, Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Gyeonggi-do, Korea
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Park SS, Park B, Park EY, Park SC, Kim MJ, Sohn DK, Oh JH. Outcomes of high versus low ligation of the inferior mesenteric artery with lymph node dissection for distal sigmoid colon or rectal cancer. Surg Today 2020; 50:560-568. [DOI: 10.1007/s00595-019-01942-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023]
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Lee SY, Yeom SS, Kim CH, Kim YJ, Kim HR. Distribution of lymph node metastasis and the extent of lymph node dissection in descending colon cancer patients. ANZ J Surg 2019; 89:E373-E378. [PMID: 31452333 DOI: 10.1111/ans.15400] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/09/2019] [Accepted: 07/16/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND The optimal extent of lymph node dissection in patients with descending colon cancer is still debatable. We designed this study to evaluate the distribution of lymph node metastasis and the appropriate extent of lymph node dissection in descending colon cancer patients. METHODS We retrospectively reviewed the medical records of 118 descending colon cancer patients without distant metastasis, who underwent curative resection between January 2004 and December 2014. The distribution of lymph node metastasis was evaluated, and prognostic factors were analysed. RESULTS The median follow-up period was 52 months (range 1-125 months). Twenty-six (22.0%) patients underwent high ligation of the inferior mesenteric artery (IMA), whereas 92 (78.0%) patients underwent ligation of the left colic artery, saving the IMA. Lymph nodes at the origin of the IMA showed no metastasis in any of the 26 patients who underwent high ligation of the IMA. After propensity score matching, 3-year disease-free survival (80.4% versus 92.9%, P = 0.471) and 5-year overall survival (81.8% versus 90.9%, P = 0.875) were not significantly different according to the type of IMA ligation. CONCLUSION In patients with descending colon cancer, there was no lymph node metastasis at the origin of the IMA, and ligation of the IMA showed no prognostic benefit.
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Affiliation(s)
- Soo Young Lee
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
| | - Seung-Seop Yeom
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
| | - Chang Hyun Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
| | - Young Jin Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
| | - Hyeong Rok Kim
- Department of Surgery, Chonnam National University Hwasun Hospital and Medical School, Hwasun, Korea
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The burden of low anterior resection syndrome on quality of life in patients with mid or low rectal cancer. Support Care Cancer 2019; 28:1199-1206. [DOI: 10.1007/s00520-019-04901-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/30/2019] [Indexed: 12/21/2022]
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Etiology and management of low anterior resection syndrome based on the normal defecation mechanism. Surg Today 2019; 49:803-808. [PMID: 30937634 DOI: 10.1007/s00595-019-01795-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/07/2019] [Indexed: 12/27/2022]
Abstract
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.
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Felder S, Lee JT. Techniques for Colorectal Anastomotic Construction Following Proctectomy and Variables Influencing Anastomotic Leak. CURRENT COLORECTAL CANCER REPORTS 2019. [DOI: 10.1007/s11888-019-00425-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Yang X, Ma P, Zhang X, Wei M, He Y, Gu C, Deng X, Wang Z. Preservation versus non-preservation of left colic artery in colorectal cancer surgery: An updated systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e13720. [PMID: 30702552 PMCID: PMC6380791 DOI: 10.1097/md.0000000000013720] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND It remains unclear whether or not preservation of the left colic artery (LCA) for colorectal cancer surgery. The objective of this updated systematic review and meta-analysis is to evaluate the current scientific evidence of LCA non-preservation versus LCA preservation in colorectal cancer surgery. METHODS A systematic search was conducted in the Medline, Embase, PubMed, Cochrane Library, ClinicalTrials, Web of Science, China National Knowledge Infrastructure and Chinese BioMedical Literature Database, and reference without limits. Quality of studies was evaluated by using the Newcastle-Ottawa scale and the Cochrane Collaboration's tool for assessing the risk of bias. Effective sizes were pooled under a random- or fixed-effects model. The funnel plot was used to assess the publication bias. The outcomes of interest were oncologic consideration including the number of apical lymph nodes, overall recurrence, 5-years overall survival, and 5-years disease-free survival (DFS); safety consideration including overall 30-day postoperative morbidity and overall 30-day postoperative mortality; anatomic consideration including anastomotic circulation, anastomotic leakage, urogenital, and defaecatory dysfunction. RESULTS Twenty-four studies including 4 randomized controlled trials (RCTs) and 20 cohort studies with a total of 8456 patients (4058 patients underwent LCA non-preservation surgery vs 4398 patients underwent LCA preservation surgery) were enrolled in this meta-analysis. The preservation of LCA was associated with significantly less anastomotic leakage (odds ratio 1.23, 95% confidence interval 1.02-1.48, P = .03). In term of sexual dysfunction, urinary retention, the number of apical lymph nodes, and long-term oncologic outcomes, there were no significant differences between the LCA non-preservation and LCA preservation group. It was hard to draw definitive conclusions on other outcomes including operation time, blood loss, the first postoperative exhaust time, and perioperative morbidity and mortality for insufficient data and highly significant heterogeneity among studies. CONCLUSIONS The pooled data provided evidence to support the LCA preservation preferred over LCA non-preservation in anastomotic leakage. Future more large-volume, well-designed RCTs with extensive follow-up are needed to draw a definitive conclusion on this dilemma.
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Affiliation(s)
- Xuyang Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Pingfan Ma
- State Key Laboratory of Biotherapy and Collaborative Innovation Center of Biotherapy, Sichuan University,Chengdu, China
| | - Xubing Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Mingtian Wei
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Yazhou He
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Chaoyang Gu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Xiangbing Deng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
| | - Ziqiang Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University
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Raffaelli R, Garzon S, Baggio S, Genna M, Pomini P, Laganà AS, Ghezzi F, Franchi M. Mesenteric vascular and nerve sparing surgery in laparoscopic segmental intestinal resection for deep infiltrating endometriosis. Eur J Obstet Gynecol Reprod Biol 2018; 231:214-219. [PMID: 30415128 DOI: 10.1016/j.ejogrb.2018.10.057] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 10/29/2018] [Accepted: 10/30/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE(S) To investigate Mesenteric vascular and nerve Sparing Surgery (MSS) as surgical laparoscopic technique to perform segmental intestinal resection for deep infiltrating endometriosis (DIE). STUDY DESIGN Prospective cohort study between January 2013 and December 2016. Consecutive patients with suspected intestinal DIE underwent clinical and imaging evaluation to confirm intestinal involvement. Indications for radical surgery and surgical technique (intestinal resection versus shaving) were consistent with Abrão algorithm. Surgeons aimed to perform MSS in all the consecutive patients that required intestinal resection. MSS consists in mesenteric artery, branching arteries, and surrounding nerve fibers preservation by dissecting mesentery adherent to the intestinal wall. Data about history, preoperative and post-operative evaluation, surgery and complications were recorded. Symptoms were evaluated before and 30-60 days after surgery with numeric rating scale for pain. Constipation was evaluated with the Constipation Assessment Scale (CAS). Patients with diagnosis of irritable bowel syndrome, inflammatory bowel diseases, diverticulitis, and previous segmental intestinal resection were excluded. RESULTS Sixty-two out of 75 (82.7%) consecutive women with intestinal endometriosis underwent laparoscopic segmental intestinal resection performed with MSS. Major complications that required repeated operation occurred in 4 cases (6.5%). Anastomotic leakage occurred in only 1 case (1.6%). Dysmenorrhea (p < .001; r = -0.86), dyspareunia (p < .001; r = -0.80), dyschezia (p < .001; r = -0.86) and dysuria (p < .001; r = -0.56) were significantly improved after surgery. After an average of 33.1 months from surgery, severe constipation was reported only by two patients (3.6%) (CAS: 13-16). The median time from surgery to intestinal function recovery (flatus or stool passage) was one day. Logistic regression analysis showed constipation related to the distance from anal verge and time since surgery. CONCLUSION(S) MSS in laparoscopic intestinal resection for DIE may be reproducible, safe and effective. MSS could be combined with pelvic nerve-sparing surgery as an effective approach to improve intestinal symptoms after radical surgery for DIE that requires segmental intestinal resection.
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Affiliation(s)
- Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy.
| | - Silvia Baggio
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Michele Genna
- Department of General Surgery, AOUI Verona, Verona, Italy
| | - Paola Pomini
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Elfeki H, Larsen HM, Emmertsen KJ, Christensen P, Youssef M, Khafagy W, Omar W, Laurberg S. Bowel dysfunction after sigmoid resection for cancer and its impact on quality of life. Br J Surg 2018; 106:142-151. [PMID: 30211443 DOI: 10.1002/bjs.10979] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/12/2018] [Accepted: 07/13/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Several studies have explored functional outcomes after rectal cancer surgery, but bowel dysfunction after sigmoid resection for cancer has hardly been considered. The aim of this study was to identify the prevalence and pattern of bowel dysfunction after resection for sigmoid cancer, and the impact of bowel function on quality of life (QoL) by comparison with patients who had polypectomy for cancer. METHODS This was a national cross-sectional study. Data were collected from the Danish Colorectal Cancer Group database, and a questionnaire regarding bowel function and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 QoL questionnaire was sent to all Danish colonic cancer survivors treated with sigmoid resection or polypectomy between 2001 and 2014. RESULTS A total of 3295 patients (3061 sigmoid resection, 234 polypectomy) responded to the questionnaire (response rate 63·8 per cent). Twelve bowel symptoms were more prevalent after sigmoid resection, including: excessive straining, fragmentation, bloating, nocturnal defaecation, bowel false alarm, liquid stool incontinence, incomplete evacuation and sense of outlet obstruction. QoL impairment owing to bowel symptoms was reported in 16·6 per cent of patients in the resection group and 10·1 per cent after polypectomy (P = 0·008). Obstructed defaecation symptoms (ODS) were encountered significantly more often after sigmoid resection than following polypectomy (17·9 versus 7·3 per cent; P < 0·001). In the resection group, patients with ODS had substantial impairment on most aspects of QoL assessed by the EORTC QLQ-C30. CONCLUSION Sigmoid resection for cancer is associated with an increased risk of long-term bowel dysfunction; obstructed defaecation is prevalent and associated with substantial impairment of QoL.
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Affiliation(s)
- H Elfeki
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark.,Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - H M Larsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - K J Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, Regional Hospital Randers, Randers, Denmark
| | - P Christensen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - M Youssef
- Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - W Khafagy
- Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - W Omar
- Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - S Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
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Yamamoto M, Egi H, Kochi M, Mukai S, Ohdan H. Left colic artery-preserving D3 lymphadenectomy using near-infrared spectroscopy was effective for double advanced cancers of the transverse colon and rectum: A case report. Int J Surg Case Rep 2018; 49:131-135. [PMID: 30005365 PMCID: PMC6037831 DOI: 10.1016/j.ijscr.2018.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/04/2018] [Accepted: 06/20/2018] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Exact assessment of intestinal viability is necessary, since the risk of anastomotic complications increases due to the reduction in anastomotic blood supply. Near-infrared spectroscopy is useful in assessing blood flow because it allows real-time monitoring and quantifying of tissue oxygen saturation. Herein, we report a case in which two intestinal resections were performed safely by using near-infrared spectroscopy to evaluate the blood flow at the anastomotic sites. PRESENTATION OF CASE A 67-year-old man was diagnosed with multiple cancers of the transverse colon and rectum. Laparoscopic transverse colon resection and low anterior resection were performed along with left colic artery-preserving lymphadenectomy, including tissues around the origin of the inferior mesenteric artery. After mesenteric dissection, the tissue oxygen saturation of the proximal side and distal side stumps were 93% and 87%, respectively. The tissue oxygen saturation of the anastomotic proximal side after mesenteric dissection was 76%, thus confirming sufficient blood flow. DISCUSSION Performance of transverse colon resection and low anterior resection for multiple cancers of the transverse colon and rectum resulted in blockage of the blood flow to the descending colon; therefore, it was necessary to preserve the blood flow to the descending colon by preserving the left colic artery. Near-infrared spectroscopy was used to evaluate blood flow to the anastomotic sites, in order to perform the surgery safely. CONCLUSION Near-infrared spectroscopy is a safe, simple and low-cost method for assessing blood flow intraoperatively in conjunction with left colic artery-preserving surgery.
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Affiliation(s)
- Masateru Yamamoto
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Hiroyuki Egi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Masatoshi Kochi
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Shoichiro Mukai
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Science, Hiroshima University, 1-2-3, Kasumi, Minami-ku, Hiroshima City, Hiroshima, 734-8551, Japan.
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van Praagh JB, Bakker IS, Havenga K. Stercoral perforation proximal to the stapled anastomosis after low anterior resection with an intraluminal device. Int J Colorectal Dis 2018; 33:87-90. [PMID: 29058085 PMCID: PMC5748420 DOI: 10.1007/s00384-017-2924-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2017] [Indexed: 02/04/2023]
Abstract
Stercoral perforation of the colon is a rare phenomenon and a potential life-threatening condition requiring acute intervention. A little more than 200 cases have been described to date. The mechanism is not completely understood. In this short communication, we present three patients with a colon perforation proximal to the anastomosis, similar to a stercoral perforation, following colorectal cancer resection with application of an intraluminal device, the C-seal.
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Affiliation(s)
- J. B. van Praagh
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - I. S. Bakker
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands ,Treant Zorggroep, Department of Surgery, Emmen, The Netherlands
| | - K. Havenga
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Kverneng Hultberg D, Afshar AA, Rutegård J, Lange M, Haapamäki MM, Matthiessen P, Rutegård M. Level of vascular tie and its effect on functional outcome 2 years after anterior resection for rectal cancer. Colorectal Dis 2017; 19:987-995. [PMID: 28544473 DOI: 10.1111/codi.13745] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 04/12/2017] [Indexed: 02/08/2023]
Abstract
AIM Previous research indicates that high tie of the inferior mesenteric artery during anterior resection for rectal cancer might be associated with an increased risk of postoperative functional disturbances. The goal of this population-based retrospective cohort study was to further investigate that association. METHOD Patients who underwent anterior resection for rectal cancer from April 2011 to September 2012 were identified through the Swedish Colorectal Cancer Registry. Bowel and urogenital function were assessed by a postal questionnaire 2 years after surgery. Information on the level of mesenteric tie and clinical variables was retrieved from the registry. The outcome was defined as any defaecatory, urinary or sexual dysfunction as reported by the patient. The association between high tie and the outcome was evaluated with multivariable logistic and linear regression with adjustment for confounders, such as sex, body mass index, comorbidity and preoperative radiation. RESULTS With a response rate of 86%, 805 patients were included in the study. Of these, 46% were operated with high tie. After adjustment for confounders, high tie did not affect the risk of faecal incontinence (OR 0.85; 95% CI 0.59-1.22), urinary incontinence (OR 0.94; 95% CI 0.63-1.41) or various aspects of sexual dysfunction (erectile dysfunction, anejaculation, dyspareunia and coital vaginal dryness). However, an association between high tie and defaecation at night was detected (OR 1.44; 95% CI 1.02-2.03). CONCLUSION This study does not support that the level of vascular tie influences the risk of major defaecatory, urinary or sexual disturbances 2 years after anterior resection for rectal cancer.
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Affiliation(s)
- D Kverneng Hultberg
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - A A Afshar
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - M Lange
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - M M Haapamäki
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - M Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Ambrosetti P, Gervaz P. Management of sigmoid diverticulitis: an update. Updates Surg 2016; 68:25-35. [PMID: 27086288 DOI: 10.1007/s13304-016-0365-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/29/2016] [Indexed: 12/17/2022]
Abstract
The role, indications and modalities of elective resection for sigmoid diverticulitis remain the cause of fierce debate. During the past two decades clinicians have increasingly recognized that: (1) young patients (<50) are no more at risk to develop more aggressive course of the disease; and (2) patients who present initially with a first uncomplicated attack are no more at risk for developing subsequent complicated diverticulitis requiring emergency surgery. Hence, the previously well-recognized indications (based upon age of the patients or the number of attacks) are no longer valid. Yet, the number of sigmoid resections performed for diverticulitis in industrialized countries is increasing, which seems to indicate that in many cases, uncomplicated sigmoid diverticulitis progressively evolves towards a chronic symptomatic condition, which significantly impacts upon the patients' quality of life. The aims of this review are twofold: (1) to identify which disease presentation still represents good indications for elective laparoscopic sigmoid resection; and (2) to summarize the technical aspects of surgery for a benign condition, such as diverticular disease.
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Affiliation(s)
- Patrick Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Ch. Beau-Soleil, 1205, Geneva, Switzerland
| | - Pascal Gervaz
- Coloproctology Unit, Clinique Hirslanden La Colline, Geneva, Switzerland.
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37
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Dulskas A, Miliauskas P, Tikuisis R, Escalante R, Samalavicius NE. The functional results of radical rectal cancer surgery: review of the literature. Acta Chir Belg 2016; 116:1-10. [PMID: 27385133 DOI: 10.1080/00015458.2015.1136482] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called "low anterior resection syndrome" (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.
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Matsuda K, Hotta T, Takifuji K, Yokoyama S, Oku Y, Watanabe T, Mitani Y, Ieda J, Mizumoto Y, Yamaue H. Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery. Br J Surg 2015; 102:501-8. [DOI: 10.1002/bjs.9739] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 10/10/2014] [Accepted: 11/10/2014] [Indexed: 12/11/2022]
Abstract
Abstract
Background
Defaecatory function is often poor after anterior resection. Denervation of the neorectum following high ligation of the inferior mesenteric artery (IMA) is a possible cause of impaired defaecatory function. The purpose of this randomized clinical trial was to clarify whether the level of ligation of the IMA in patients with rectal cancer affects defaecatory function.
Methods
Between 2008 and 2011, patients who underwent anterior resection for rectal cancer were randomized to receive either high or low ligation of the IMA. The primary endpoint was to demonstrate the superiority of low ligation in terms of defaecatory function.
Results
One hundred patients were enrolled in the study; 51 were randomized to high ligation of the IMA and 49 to low ligation. There were no differences between the groups in terms of clinical data, except tumour stage, which was more advanced in the high-ligation group (P = 0·046). Nor were there any differences in defaecatory function, self-assessment of defaecation, Faecal Incontinence Quality of Life scale or continence score between groups at 3 months and 1 year. The number of harvested lymph nodes was similar. The rate of symptomatic anastomotic leakage was 16 per cent in the high-ligation group and 10 per cent in the low-ligation group (P = 0·415).
Conclusion
The level of ligation of the IMA in patients with rectal cancer did not affect defaecatory function or the incidence of postoperative complications. Registration number: NCT00701012 (http://www.clinicaltrials.gov).
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Affiliation(s)
- K Matsuda
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - T Hotta
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - K Takifuji
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - S Yokoyama
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - Y Oku
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - T Watanabe
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - Y Mitani
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - J Ieda
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - Y Mizumoto
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
| | - H Yamaue
- Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan
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Fecoflowmetric analysis of anorectal motor function in postoperative anal-preserving surgery patients with low rectal cancer comparison with the wexner score and anorectal manometry. Int Surg 2015; 100:29-37. [PMID: 25594637 DOI: 10.9738/intsurg-d-13-00142.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The aim of this study was to elucidate whether fecoflowmetry (FFM) could evaluate more detailed evacuative function than anorectal manometry by comparing between FFM or anorectal manometric findings and the clinical questionnaires and the types of surgical procedure in the patients who received anal-preserving surgery. Fifty-three patients who underwent anal-preserving surgery for low rectal cancer were enrolled. The relationships between FFM or the manometric findings and the clinical questionnaires and the types of procedure of anal-preserving surgery were evaluated. There were significant differences between FFM markers and the clinical questionnaire and the types of the surgical procedure, whereas no significant relationship was observed between the manometric findings and the clinical questionnaire and the types of the surgical procedure. FFM might be feasible and useful for the objective assessment of evacuative function and may be superior to manometry for patients undergoing anal-preserving surgery.
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Borycka-Kiciak K, Wawiernia K, Namysł J, Garstka-Namysł K, Tarnowski W. Role of electromyography and functional electrical stimulation in the treatment of anorectal diseases. POLISH JOURNAL OF SURGERY 2015; 87:194-202. [DOI: 10.1515/pjs-2015-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Indexed: 11/15/2022]
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Emmertsen KJ, Bregendahl S, Fassov J, Krogh K, Laurberg S. A hyperactive postprandial response in the neorectum--the clue to low anterior resection syndrome after total mesorectal excision surgery? Colorectal Dis 2014; 15:e599-606. [PMID: 23869468 DOI: 10.1111/codi.12360] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 03/21/2013] [Indexed: 02/07/2023]
Abstract
AIM To investigate neorectal properties regarding biomechanical, sensory and postprandial response in patients after total mesorectal excision without neoadjuvant radiotherapy in groups of no low anterior resection syndrome (LARS) patients and major LARS patients. METHOD Patients without LARS (n = 9) and patients with major LARS (n = 23) were investigated by multimodal rectal stimulation and standard anorectal physiological tests, and results were compared. RESULTS Patients with major LARS had an increased postprandial response with a significant increase in pressure in the neorectum after a meal compared with patients without LARS (P = 0.017). No biomechanical differences could be detected. CONCLUSION Low anterior resection syndrome seems to be caused by physiological changes due to neural damage more than structural changes in the ano-neorectum.
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Affiliation(s)
- K J Emmertsen
- Surgical Research Unit, Colorectal Surgical Department, Aarhus University Hospital, Aarhus, Denmark
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Itagaki R, Koda K, Yamazaki M, Shuto K, Kosugi C, Hirano A, Arimitsu H, Shiragami R, Yoshimura Y, Suzuki M. Serotonin (5-HT3) receptor antagonists for the reduction of symptoms of low anterior resection syndrome. Clin Exp Gastroenterol 2014; 7:47-52. [PMID: 24648748 PMCID: PMC3956481 DOI: 10.2147/ceg.s55410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose Serotonin (5-hydroxytryptamine [5-HT])3 receptor antagonists are effective for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D), in which exaggerated intestinal/colonic hypermotility is often observed. Recent studies have suggested that the motility disorder, especially spastic hypermotility, seen in the neorectum following sphincter-preserving operations for rectal cancer may be the basis of the postoperative defecatory malfunction seen in these patients. We investigated the efficacy of 5-HT3 receptor antagonists in patients suffering from severe low anterior resection syndrome. Patients and methods A total of 25 male patients with complaints of uncontrollable urgency or fecal incontinence following sphincter-preserving operations were enrolled in this study. Defecatory status, assessed on the basis of incontinence score (0–20), urgency grade (0–3), and number of toilet visits per day, was evaluated using a questionnaire before and 1 month after the administration of the 5-HT3 antagonist ramosetron. Results All the parameters assessed improved significantly after taking ramosetron for 1 month. The effect was more prominent in cases whose anastomotic line was lower, ie, inside the anal canal. Defecatory function was better in patients who commenced ramosetron therapy within 6 months postoperatively, as compared to those who were not prescribed ramosetron for more than 7 months postoperatively. Conclusion These results suggest that 5-HT3 antagonists are effective for the treatment of low anterior resection syndrome, as in diarrhea-predominant irritable bowel syndrome. The improvement in symptoms is not merely time dependent, but it is related to treatment with 5-HT3 antagonists.
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Affiliation(s)
- Ryohei Itagaki
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Masato Yamazaki
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Kiyohiko Shuto
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Chihiro Kosugi
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Atsushi Hirano
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Hidehito Arimitsu
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Risa Shiragami
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Yukino Yoshimura
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
| | - Masato Suzuki
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, Japan
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Ambrosetti P, Gervaz P. Laparoscopic elective sigmoidectomy for diverticular disease: a plea for standardization of the procedure. Colorectal Dis 2014; 16:90-4. [PMID: 24128302 DOI: 10.1111/codi.12455] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- P Ambrosetti
- Department of Surgery, Clinique Générale Beaulieu, Geneva, Switzerland.
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Emmertsen KJ, Laurberg S. Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer. Br J Surg 2013; 100:1377-87. [PMID: 23939851 DOI: 10.1002/bjs.9223] [Citation(s) in RCA: 276] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bowel dysfunction after sphincter-preserving surgery for rectal cancer is a common complication, with the potential to affect quality of life (QoL) strongly. The aim of this study was to examine the extent of bowel dysfunction and impact on health-related QoL after curative sphincter-preserving resection for rectal cancer. METHODS QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, and bowel function using a validated questionnaire, including the recently developed low anterior resection syndrome (LARS) score. Assessments were carried out at the time of diagnosis, and at 3 and 12 months after surgery. RESULTS A total of 260 patients were included in the study. At 3 months, 58·0 per cent of patients had a LARS score of 30 or more (major LARS), which declined to 45·9 per cent at 12 months (P < 0·001). The risk of major LARS was significantly increased in patients who received neoadjuvant therapy (odds ratio 2·41, 95 per cent confidence interval 1·00 to 5·83), and after total versus partial mesorectal excision (odds ratio 2·81, 1·35 to 5·88). Global health status was closely associated with LARS, and significant differences in global health status, functional and symptom scales of QoL were found between patients without LARS and those with major LARS. CONCLUSION Bowel dysfunction is a major problem with an immense impact on QoL following sphincter-preserving resection. The risk of major LARS was significantly increased after neoadjuvant therapy and total mesorectal excision.
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Affiliation(s)
- K J Emmertsen
- Colorectal Research Unit, Colorectal Surgical Department P, Aarhus University Hospital, Tage-Hansens Gade 2, DK-8000, Aarhus C, Denmark.
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Abstract
Up to 80% of patients with rectal cancer undergo sphincter-preserving surgery. It is widely accepted that up to 90% of such patients will subsequently have a change in bowel habit, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection and reconstruction of the rectum has been termed anterior resection syndrome. Currently, no precise definition or causal mechanisms have been established. This disordered bowel function has a substantial negative effect on quality of life. Previous reviews have mainly focused on different colonic reconstructive configurations and their comparative effects on daily function and quality of life. The present Review explores the potential mechanisms underlying disturbed functions, as well as current, novel, and future treatment options.
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Affiliation(s)
- Catherine L C Bryant
- Academic Surgical Unit, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Recovery of upper gastrointestinal bowel movement after rectosigmoid cancer surgery: a pilot transit analysis. Int Surg 2012; 96:281-5. [PMID: 22808607 DOI: 10.9738/cc51.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Postoperative gastrointestinal bowel transit right after colorectal resection has not yet been clarified. Thirty patients with rectosigmoid cancer were treated in this pilot study. The nasogastric tube was removed on the first postoperative day. One Sitzmarks capsule was given to each patient on the second postoperative day. Abdominal X-rays were taken at 3, 6, 8, 24, 48, and 72 hours after capsule intake. Distribution of the remaining Sitzmarks capsules were counted on X-ray films to clarify postoperative gastrointestinal movement after bowel resection. All Sitzmarks capsules were observed in the stomach at 3 and 6 hours after capsule intake. At 8 hours (second postoperative day), the Sitzmarks capsules were distributed from the stomach to the small intestine. Sitzmarks capsules were distributed in the right side colon at 24 hours (third postoperative day) after intake. Although the main distribution was still in the right side colon, several patients had evacuations accompanied by the disappearance of the Sitzmarks capsules. In 50% of the patients, it took approximately 72 hours (fifth postoperative day) for the first defecation after intake of the capsules. However, the Sitzmarks capsules remained mainly in the right side colon. Eight hours after intake, the majority of the Sitzmarks capsules shifted to the small intestine. Therefore, medication or feeding should be safely possible starting on the second postoperative day. There was no particular impact of bowel resection on upper gastrointestinal transit in patients with rectosigmoid cancer.
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Masoni L, Mari FS, Nigri G, Favi F, Gasparrini M, Dall'Oglio A, Pindozzi F, Pancaldi A, Brescia A. Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial. Surg Endosc 2012; 27:199-206. [PMID: 22733197 DOI: 10.1007/s00464-012-2420-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 05/25/2012] [Indexed: 12/15/2022]
Abstract
BACKGROUND Defecatory disorders are very common complications after left hemicolectomy and anterior rectal resection. These disorders seem related primarily to colonic denervation after the resection. To evaluate the real benefits of inferior mesenteric artery (IMA) preservation via laparoscopic left hemicolectomy performed for diverticular disease in terms of reduced colonic denervation and improved postoperative intestinal functions, a randomized, single-blinded (patients) controlled clinical trial was conducted. METHODS From January 2004 to January 2010, patients with symptomatic diverticular disease and a surgical indication were enrolled in the study and randomly assigned to two treatment groups. The first group underwent laparoscopic left hemicolectomy, which preserved the IMA by sectioning the sigmoid arteries one by one near the colonic wall, In the second group, the IMA was sectioned immediately below the origin of left colic artery. Defecation disorders were assessed by anorectal manometry and by three questionnaires to evaluate constipation, incontinence, and quality of life 6 months after the intervention. RESULTS A total of 107 patients were included in the study. The 54 patients with preserved IMA showed a statistically lower incidence of defecation disorders such as fragmented evacuations, alternating bowel function, constipation, and minor incontinence, as well as less lifestyle alteration than the 53 patients with the IMA sectioned just below the left colic artery. CONCLUSIONS This study confirmed that preservation of the IMA should be recommended to reduce the incidence of defecatory disorders after left hemicolectomy for benign disease.
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Affiliation(s)
- Luigi Masoni
- Department of Surgery, St. Andrea Hospital, School of Medicine and Psicology, University Sapienza of Rome, Rome, Italy
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Gribovskaja-Rupp I, Takahashi T, Ridolfi T, Kosinski L, Ludwig K. Upregulation of mucosal 5-HT3 receptors is involved in restoration of colonic transit after pelvic nerve transection. Neurogastroenterol Motil 2012; 24:472-8, e218. [PMID: 22304456 DOI: 10.1111/j.1365-2982.2012.01890.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Colonic dysfunction occurs after pelvic autonomic nerve damage. The enteric nervous system can compensate. We investigated the role of mucosal serotonin receptors, 5-HT(3) and 5-HT(4) , in the colonic motility restoration over 2 weeks after parasympathetic pelvic nerve transection in a rat model. METHODS Male Sprague-Dawley rats underwent pelvic nerve transection or sham operation. Colonic transit was expressed as the geometric center of (51) Cr distribution. Mucosal 5-HT(3) and 5-HT(4) receptor expression was evaluated by Western blot. Intraluminal pressure increase was measured after 5-HT(3) (ondansetron) or 5-HT(4) receptor antagonist (GR125487) administration in vitro in sham and denervated distal colons. KEY RESULTS At 2 weeks, colonic transit in the denervated group was 30% slower compared to the sham group (P < 0.01). At 1 and 2 weeks, 5-HT(3) receptor expression was increased two-fold in the denervated group, compared to shams (P < 0.05). A three-fold smaller dose of ondansetron was required in denervated tissues to inhibit intraluminal pressure rise than in sham colons (P < 0.01). There was no difference in the expression of 5-HT(4) receptor or the response to GR125487 in denervated vs sham colons. CONCLUSIONS & INFERENCES Colonic motility was restored to approximately 70% normal over 1 week without further improvement at 2 weeks. Enteric nervous system compensated by upregulating mucosal 5-HT(3,) but not 5-HT(4,) receptors.
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Affiliation(s)
- I Gribovskaja-Rupp
- Department of Surgery, Medical College of Wisconsin, Clement J Zablocki VA Medical Center, Milwaukee, WI, USA
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Internal anal sphincter parasympathetic-nitrergic and sympathetic-adrenergic innervation: a 3-dimensional morphological and functional analysis. Dis Colon Rectum 2012; 55:473-81. [PMID: 22426273 DOI: 10.1097/dcr.0b013e318245190e] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Little detailed information is available concerning morphological and functional autonomic nerve supply to the internal anal sphincter. However, denervation of the sphincter potentially affects anal function after rectal surgery for cancer. OBJECTIVE The aim of this study was to identify the location and type (nitrergic, adrenergic, and cholinergic) of nerve fibers in the internal anal sphincter and to provide a 3-dimensional representation of their structural relationship in the human fetus. MATERIALS AND METHODS serial transverse sections were obtained from 14 human fetuses (7 male, 7 female, 15-31 weeks of gestation) and were studied histologically and immunohistochemically; digitized serial sections were used to construct a 3-dimensional representation of the pelvis. MAIN OUTCOMES MEASURES The location and type of internal anal sphincter nerves were assessed qualitatively. RESULTS Posteroinferior fibers originating from the inferior hypogastric plexus posteroinferior angle projected to the posterolateral and posterior rectal wall and internal anal sphincter, forming the inferior rectal plexus. The inferior rectal plexus contained vesicular acetylcholine transporter-positive (cholinergic), tyrosine hydroxylase-positive (adrenergic/sympathetic), and neural nitric oxide synthase-positive (nitrergic) fibers. The intrasphincteric vesicular acetylcholine transporter-positive fibers included both neural nitric oxide synthase-negative fibers and neural nitric oxide synthase-positive fibers (nitrergic-parasympathetic). LIMITATIONS The study focused on topographic and functional anatomy, so that quantitative data were not obtained. A small number of fetal specimens were available. CONCLUSIONS We report the precise location and distribution of the autonomic neural supply to the internal anal sphincter. This description contributes to the understanding of neurogenic postoperative sphincteric dysfunction. Three-dimensional cartography of pelvic-perineal neurotransmitters provides an anatomical and physiological basis for the selection and development of pharmacological agents to be used in the treatment of primary or postoperative continence and evacuation disorders.
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