Long-term anorectal dysfunction after postoperative radiotherapy for rectal cancer

Incidence and risk factors of bowel dysfunction after minimally invasive rectal cancer surgery and discrepancies between the Wexner score and the low anterior resection syndrome (LARS) score

PURPOSE

Bowel dysfunction after sphincter-preserving-surgery (SPS) impacts quality of life. The Wexner score (WS) and the low anterior resection syndrome (LARS) score (LS) are instruments for assessing postoperative bowel dysfunction. We analyzed the incidence of and risk factors for each symptom and examined the discrepancies between the two scores.

METHODS

A total of 142 patients with rectal cancer, who underwent minimally invasive SPS between May, 2018 and July, 2019, were included. A questionnaire survey using the two scores was given to the patients 2 years after SPS.

RESULTS

Tumor location and preoperative radiotherapy were independent risk factors for major LARS. Intersphincteric resection with a hand-sewn anastomosis (HSA) was an independent risk factor for high WS. Among the patients who underwent HSA, 82% experienced incontinence for liquid stools, needed to wear pads, and suffered lifestyle alterations. Of the 35 patients with minor LARS, only 1 had a high WS, and 80.0% reported no lifestyle alterations. Among the 75 patients with major LARS, 58.7% had a low WS and 21.3% reported no lifestyle alterations.

CONCLUSION

The results of this study provide practical data to help patients understand potential bowel dysfunction after SPS. The discrepancies between the WS and LS were clarified, and further efforts are required to utilize these scores in clinical practice.

The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer

PURPOSE

The present study assessed postoperative bowel dysfunction in Japanese patients with rectal cancer, including patients who underwent preoperative radiotherapy (RT).

METHODS

A total of 277 rectal cancer patients who underwent primary resection were included in the analyses. A questionnaire survey was administered using the low anterior resection syndrome (LARS) score and Wexner score. Scores were determined one year after rectal surgery or diverting ileostomy closure. The LARS score was categorized as minor LARS (21-29) and major LARS (30-42).

RESULTS

The proportions of patients with minor and major LARS were significantly larger and Wexner scores significantly higher in patients with distal tumors and a lower anastomosis level than in those with proximal tumors and a higher anastomosis level. Among the patients with lower rectal cancer, the proportions with minor and major LARS were similar between those with and without preoperative RT. The Wexner scores in patients with preoperative RT were significantly higher than in patients without RT. A distal tumor location and lower anastomosis level were independent risk factors of major LARS in multivariate analyses.

CONCLUSION

A distal tumor location, low anastomosis level, and preoperative RT might be associated with postoperative bowel dysfunction in rectal cancer patients.

Quality of life in patients treated with radiochemotherapy for primary diagnosis of anal cancer

Anal cancer and the related treatment are generally known to affect patients’ quality of life. The aim of this study was to assess self-reported quality of life (QoL) of anal cancer patients after combined radiation and chemotherapy, and to identify patient-, disease-, and therapy-related factors associated with QoL. A total of 94 patients treated with definitive chemoradiation for anal cancer at our institution in the period from 2004 to 2018 were identified from our database. QoL was assessed in the remaining 52 patients using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the newly developed anal cancer module QLQ-ANL27 (site-specific QoL). Differences in QoL between anal cancer patients and a German age and sex adjusted reference population were examined. The median follow-up was 71 months (range, 7–176). In the cancer-specific QoL module, the anal cancer cohort presented with significantly lower scores in role (− 12.2 points), emotional (− 6.6 points), and social functioning (− 6.8 points), but higher scores in diarrhea (+ 36.3 points) and constipation (+ 13.3 points) than the German reference population. There were no significant differences in disease- or therapy-related factors, but age greater than 70 years and a follow-up time greater than 71 months had a negative impact on global QoL. As for the site-specific QoL, patients with a tumor relapse showed significantly higher symptom scores than patients with a complete clinical remission in all scales except of micturition frequency. Compared to 3D conformal radiotherapy, IMRT treatment seemed to improve non-stoma bowel function (+ 23.3 points), female sexual functioning (+ 24.2 points), and came along with less scores in the symptom scales pain (− 35.9 points), toilet proximity (− 28.6 points), and cleanliness (− 26.2 points). Most of the functional scores of anal cancer patients were lower compared to the general German population, but did not seem to affect the general QoL. Fatigue, physical, and role functioning had the strongest impact on global QoL causing psychological symptoms as important as physical.

Feasibility Study of Transanal Irrigation Using a Colostomy Irrigation System in Patients With Low Anterior Resection Syndrome

BACKGROUND

Low anterior resection syndrome has a negative impact on quality of life. Intestinal irrigation is a method of lavage consisting of a scheduled evacuation.

OBJECTIVE

This study aims to evaluate functional and quality-of-life outcomes in patients with low anterior resection syndrome after transanal irrigation using a colostomy irrigation system.

DESIGN

This was a prospective case series.

SETTINGS

This study presents a single-center experience at a tertiary oncological center in an upper-middle-income country.

PATIENTS

Patients classified as having minor or major low anterior resection syndrome 12 months after their operation were selected.

INTERVENTIONS

Transanal irrigation was performed using an ostomy irrigation kit. Questionnaires assessing patients' bowel function (low anterior resection syndrome and Wexner score) and quality of life (Short Form-36 questionnaire) were applied before and after treatment.

MAIN OUTCOME MEASURES

The primary outcomes were low anterior resection syndrome score and quality-of-life improvement after a 12-month treatment.

RESULTS

Of the 22 patients included, 20 had major and 2 had minor low anterior resection syndrome, with a median score of 39, especially high rates of incontinence for liquid stool (21; 95.5%), clustering (21; 95.5%), and urgency (17; 77.3%). All patients successfully completed the 3-day training, and there were no complications during the treatment. After the 12-month period, the median score was 8, with 90% of the patients classified as having "no syndrome" and great improvement in all domains of this score. The most improved quality-of-life sections were patient vitality (p = 0.025) and physical (p = 0.002), social (p = 0.001), and emotional aspects (p = 0.001).

LIMITATIONS

The study was limited by its small sample size and the limited follow-up period.

CONCLUSIONS

This study presents a safe implementation protocol of an ostomy irrigation device for transanal irrigation. It also adds to the literature that transanal irrigation is a safe, effective, and easily implemented procedure for patients with low anterior resection syndrome with a significant improvement in quality of life. See Video Abstract at http://links.lww.com/DCR/B563.ESTUDIO DE FACTIBILIDAD DE LA IRRIGACIÓN TRANSANAL UTILIZANDO EL SISTEMA DE IRRIGACIÓN PARA COLOSTOMÍA EN PACIENTES CON SÍNDROME DE RESECCIÓN ANTERIOR BAJAANTECEDENTES:El síndrome de resección anterior baja tiene un impacto negativo en la calidad de vida de los pacientes. La irrigación intestinal es un método de lavado que consiste en evacuaciones programadas.OBJETIVOS:Evaluar los resultados de la funcionalidad e impacto en la calidad de vida de los pacientes con síndrome de resección anterior y baja posterior a la irrigación transanal utilizando un sistema de irrigación de colostomía.DISEÑO:Es estudio prospectivo de una serie de casos.ESCENARIO:En este estudio se muestra la experiencia de un centro oncológico de tercer nivel en un país en vías de desarrollo.PACIENTES:Aquellos clasificados como síndrome con afección en menor o mayor grado doce meses después de la cirugía.METODO:Se efectuó irrigación transanal utilizando un equipo de irrigación de estomas. Se aplicaron cuestionarios para valorar la función intestinal de los pacientes (síndrome de resección anterior baja y la escala de Wexner) y para calidad de vida (Cuestionario Corto-36) antes y después del tratamiento.EVALUACION DE LOS RESULTADOS PRINCIPALES:Los principales resultados se obtuvieron de la escala del síndrome de resección baja y la mejoría en la calidad vida doce meses después de tratamiento.RESULTADOS:De los veintidós pacientes incluidos, veinte presentaron manifestaciones mayores del síndrome de resección baja y dos, manifestaciones menores. Con una media de treinta y nueve, se encontraron, especialmente, altos índices de incontinencia a líquidos (21; 95'5%) hiperdefecación "clustering" (21; 95'5%) y urgencia (17; 77'3%). Todos los pacientes completaron en forma satisfactoria el entrenamiento de tres días sin presentarse complicaciones durante el tratamiento. Al término del mes doce la media fue de ocho, con el 90% de los pacientes clasificados como "sin síndrome" y se observó una mejoría substancial en todos los puntos de la evaluación. Las secciones de calidad de vida que mostraron una mejoría significativa fueron: la vitalidad del paciente (p = 0'025), física (p = 0'002), social (p = 0'001) y emocional (p = 0'001).LIMITACIONES:El tamaño de la muestra es pequeño y el tiempo de seguimiento corto.CONCLUSIONES:Este estudio muestra la implementación de un protocolo seguro para la irrigación de estomas mediante un dispositivo transanal. Además contribuye con el concepto en la literatura de que la seguridad de la irrigación transanal es seguro, efectivo y facilmente reproducible para pacientes con síndrome de resección anterior baja con una mejoría significativa en la calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B563. (Traducción-Dr. Miguel Esquivel-Herrera).

Functional results after treatment for rectal cancer

Introduction With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving resection many patients suffer from severe bowel dysfunction with an impact on quality of life (QoL) – referred to as low anterior resection syndrome (LARS).

Study objective To provide an overview of the current knowledge of LARS regarding symptomatology, occurrence, risk factors, pathophysiology, evaluation instruments and treatment options.

Results LARS is characterized by urgency, frequent bowel movements, emptying difficulties and incontinence, and occurs in up to 50-75% of patients on a long-term basis. Known risk factors are low anastomosis, use of radiotherapy, direct nerve injury and straight anastomosis. The pathophysiology seems to be multifactorial, with elements of anatomical, sensory and motility dysfunction. Use of validated instruments for evaluation of LARS is essential. Currently, there is a lack of evidence for treatment of LARS. Yet, transanal irrigation and sacral nerve stimulation are promising.

Conclusion LARS is a common problem following sphincter-preserving resection. All patients should be informed about the risk of LARS before surgery, and routinely be screened for LARS postoperatively. Patients with severe LARS should be offered treatment in order to improve QoL. Future focus should be on the possibilities of non-resectional treatment in order to prevent LARS.

What is the risk of permanent stoma beyond 5 years after low anterior resection for rectal cancer? A 15-year follow-up of a randomized trial

AIM

Low anterior resection of the rectum for cancer (LAR) entails a risk of symptomatic anastomotic leakage as well as impaired anorectal function, both of which may eventually result in the need for a permanent stoma (PS). The aim was to investigate the incidence of and risk factors for PS beyond 5 years following LAR.

METHODS

Patients undergoing LAR and included in a multicentre trial with randomization to defunctioning stoma or not were followed for a median of 15 years. The reasons for a PS up to 5 years (PS ≤ 5 years) and beyond 5 years (PS > 5 years) were identified and compared. Risk factors for PS were analysed.

RESULTS

Of all patients, 25% (57/232) had a PS. PS ≤ 5 years occurred in 19% (44/232) at a median of 12.5 months and PS > 5 years in 6% (13/232) at a median of 118 months following LAR. The main reason for PS ≤ 5 years was impaired anorectal function in 55% (24/44) and the main reason for PS > 5 years was pelvic sepsis related to the colorectal anastomosis in 46% (6/13). The major risk factor for PS was symptomatic anastomotic leakage, which occurred in 56% (32/57) of patients with PS and 10% (17/175) of patients without PS (P < 0.001).

CONCLUSION

One-fourth of the patients who ended up with a PS had it fashioned beyond 5 years at a median of 10 years following LAR. Symptomatic anastomotic leakage was the major risk factor for PS, and impaired anorectal function was the main overall reason for a PS.

Abnormal Neuronal Response to Rectal and Anal Stimuli in Patients Treated for Distal Rectal Cancer With High-Dose Chemoradiotherapy Followed By Watchful Waiting

BACKGROUND

Watchful waiting in patients with rectal cancer with complete clinical response after chemoradiation therapy has gained increased popularity to avoid morbidity and mortality associated with surgery. Irradiation of the pelvis causes bowel dysfunction, but the effect on anorectal sensory function remains obscure in this patient category.

OBJECTIVE

The aim of this study was to characterize the sensory pathways of the gut-brain axis in patients with rectal cancer treated solely with chemoradiation therapy (nonconventional regime/dose) compared with healthy volunteers.

DESIGN

This is an explorative study.

SETTINGS

Sensory evaluation by rectal distension was performed and cortical evoked potentials were recorded during rapid balloon distensions of the rectum and anal canal. Latencies and amplitudes of cortical evoked potentials were compared, and the relative amplitude of 5 spectral bands from recorded cortical evoked potentials was used as an additional proxy of neuronal processing.

PATIENTS

Patients with rectal cancer solely with chemoradiation therapy (n = 13) a median of 3.2 years ago (range, 2.3-5.6 y) and healthy volunteers (n = 13) were included.

MAIN OUTCOME MEASURES

Cortical evoked potentials were measured.

RESULTS

Patients had 35% lower rectal capacity at a maximum tolerable volume (p = 0.007). We found no differences in rectal cortical evoked potential latencies (p = 0.09) and amplitudes (p = 0.38) between groups. However, spectral analysis of rectal cortical evoked potentials showed a decrease in θ (4-8 Hz) and an increase in β (12-32 Hz) band activity in patients (all p < 0.001). Anal cortical potentials showed an increase in α (8-12 Hz) and β and a decrease in γ (32-70 Hz) band activity (all p < 0.001) in patients compared with healthy volunteers.

LIMITATIONS

This is an explorative study of limited size.

CONCLUSIONS

Chemoradiation therapy for distal rectal cancer causes abnormal cortical processing of both anal and rectal sensory input. Such central changes may play a role in symptomatic patients, especially when refractory to local treatments. See Video Abstract at http://links.lww.com/DCR/B270. RESPUESTA NEURONAL ANORMAL A ESTÍMULOS RECTALES Y ANALES, EN PACIENTES TRATADOS POR CÁNCER RECTAL DISTAL, CON QUIMIORRADIOTERAPIA DE DOSIS ALTA, SEGUIDA DE ESPERA VIGILANTE: La espera vigilante en pacientes de cáncer rectal, con respuesta clínica completa después de la quimiorradiación, ha ganado una mayor popularidad en evitar la morbilidad y mortalidad asociadas con la cirugía. La irradiación de la pelvis causa disfunción intestinal, pero el efecto sobre la función sensorial ano-rectal sigue siendo no claro, en esta categoría de pacientes.El objetivo de este estudio, fue caracterizar las vías sensoriales del eje intestino-cerebro en pacientes con cáncer rectal, tratados únicamente con quimiorradiación (régimen / dosis no convencional), en comparación con voluntarios sanos.Es un estudio exploratorio.Se realizó una evaluación sensorial por distensión rectal y se registraron los potenciales evocados corticales, durante las distensiones rápidas con balón en recto y canal anal. Se compararon las latencias y amplitudes de los potenciales evocados corticales, y la amplitud relativa de cinco bandas espectrales registradas, de potenciales evocados corticales, se usaron como proxy adicional del procesamiento neuronal.Pacientes de cáncer rectal, únicamente con terapia de quimiorradiación (n = 13) mediana de 3.2 años (rango 2.3-5.6) y voluntarios sanos (n = 13).Potenciales evocados corticales.Pacientes tuvieron una capacidad rectal menor del 35%, al volumen máximo tolerable (p = 0.007). No encontramos diferencias en las latencias potenciales evocadas corticales rectales (p = 0.09) y amplitudes (p = 0.38) entre los grupos. Sin embargo, el análisis espectral de los potenciales evocados corticales rectales, mostró una disminución en theta (4-8 Hz) aumento en beta (12-32 Hz), y actividad en banda en pacientes (todos p <0.001). Los potenciales evocados corticales anales mostraron un aumento en alfa (8-12 Hz) y beta, disminución en gamma (32-70 Hz), y actividad en banda (todos p <0.001), en pacientes comparados a voluntarios sanos.Este es un estudio exploratorio de tamaño limitado.La quimiorradiación para el cáncer rectal distal, ocasiona procesos corticales sensoriales anormales anales y rectales. Tales cambios centrales pueden desempeñar un papel en pacientes sintomáticos, especialmente cuando son refractarios a tratamientos locales. Consulte Video Resumen en http://links.lww.com/DCR/B270.

Comparison of bowel dysfunction between colorectal cancer survivors and a non-operative non-cancer control group

AIM

Low anterior resection syndrome (LARS) detrimentally affects quality of life in colorectal cancer survivors. This study assessed the prevalence for LARS in colorectal cancer survivors and the same symptoms in a matched control group.

METHOD

Validated instruments, the LARS score and Short Form Survey 12, used to collect functional and quality of life outcomes from patients who had undergone distal colorectal resection at Auckland Hospital (2008-2015) or Dunedin Hospital (2008-2017). A matched non-operative control group was drawn from patients undergoing surveillance colonoscopy.

RESULTS

The response rate was 79%. Cross-sectional prevalence of major LARS in rectal cancer patients was 52% at a median follow-up of 52 months. Major LARS prevalence in the sigmoid cancer resection and non-cancer control groups was similar (25% vs 26%, P = 0.6). On univariate analysis anastomotic height [risk ratio (RR) for low anterior resection 4.6, P < 0.001; ultralow anterior resection RR = 15.5, P < 0.001], radiotherapy (RR = 2.6; P = 0.009), stoma (RR = 3.6; P = 0.001) and J pouch reconstruction (vs straight anastomosis, RR = 4.6; P = 0.008) were associated with major LARS for rectal cancer patients. These factors were not significant when the analysis was stratified for anastomotic height. Despite correlation between LARS and Short Form Survey 12 outcomes (physical ρ = -0.2; mental ρ = -0.2) there was no difference in quality of life outcomes between the groups.

CONCLUSION

Bowel dysfunction after low anterior resection affects the majority of rectal cancer patients. The high background rate of bowel dysfunction must be considered when assessing the prevalence of LARS.

Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy

BACKGROUND

Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers.

METHODS

Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing.

RESULTS

Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers.

CONCLUSIONS

Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.

Risk Factors for Fecal Urgency Among Individuals With and Without Diarrhea, Based on Data From the National Health and Nutrition Examination Survey

BACKGROUND & AIMS

Fecal urgency is a common symptom among patients with gastrointestinal disorders, but can also occur in healthy individuals with normal bowel habits. There have been few studies of fecal urgency in the general population. We performed a cross-sectional analysis of data from the National Health and Nutrition Examination Survey (NHANES) to analyze the prevalence of and risk factors for this symptom.

METHODS

We analyzed data from 4676 persons who completed the Bowel Health Questionnaire from the NHANES, from 2009 through 2010. The NHANES sampled a nationally representative group of adults in the United States and provides information on demographics, medical comorbidities, and dietary habits of survey participants. The Bowel Health Questionnaire provided additional information about bowel symptoms such as urgency, incontinence, constipation, and diarrhea. We identified individuals with fecal urgency and calculated differences in fecal urgency among subgroups using chi-squared analysis. We used logistic regression to identify factors associated with urgency.

RESULTS

In our study population, the prevalence of fecal urgency was 3.3%; 29.5% of individuals with fecal urgency had diarrhea. The prevalence of fecal urgency was significantly higher in individuals who had diarrhea (14.8%) than in individuals without diarrhea (3.1%). Older age, female sex, poverty, urinary urge incontinence, diarrhea, and increased stool frequency were all associated with fecal urgency on multivariable analysis. Decreased fiber intake and increased carbohydrate intake were associated with urgency among individuals with diarrhea.

CONCLUSIONS

In an analysis of data from 4676 individuals who completed a Bowel Health Questionnaire from the NHANES, we found a significantly higher proportion of individuals with diarrhea to have fecal urgency. However, most individuals with fecal urgency do not have diarrhea. Factors associated with fecal urgency vary among individuals with and without diarrhea.

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

INTRODUCTION

Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

AIM

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

MATERIAL AND METHODS

We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

RESULTS

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98-47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55-0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51-26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86-156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07-61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

CONCLUSIONS

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.

Anterior resection syndrome: What should we tell practitioners and patients in 2018?

Multidisciplinary management of infra-peritoneal rectal cancer has pushed back the frontiers of sphincter preservation, without impairment of carcinological outcome. However, functional intestinal sequelae, grouping together several symptoms known under the name of anterior resection syndrome (ARS), have emerged and become an increasingly frequent concern for both patients and physicians. The pathophysiology is complex: ARS is a combination in various degrees of stool frequency, incontinence for flatus and/or stools, urgency, and disorders in discrimination and evacuation. The "Low Anterior Resection Score" (LARS), validated in 2012, is currently used to evaluate the severity of ARS and its impact on quality of life. While ARS can show improvement over the first two years, symptoms persist for longer than two years in nearly 60% of patients and in half of these patients, ARS is considered severe. The most frequently reported independent risk factors of severe ARS include neo-adjuvant radiation therapy, the extent of resection (total mesorectal excision that includes inter-sphincteric resection), absence of colonic pouch and anastomotic leak. In the absence of surgical complications and/or local recurrence, physicians can draw from a wide therapeutic armamentarium in order to improve the functional outcome of patients, including diet and lifestyle modifications, gut motility regulators, multimodal rehabilitation (biofeedback, electro-stimulation) and sacral nerve modulation. Permanent colostomy is an alternative of last resort, proposed only when all other solutions fail. A better understanding of the natural history of ARS, its risk factors as well as the array of therapeutic alternatives should provide better patient information and optimize management.

Perioperative radiotherapy is an independent risk factor for major LARS: a cross-sectional observational study

PURPOSE

Sphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time.

METHODS

This study includes a prospective database of 100 patients who underwent total or partial mesorectal excision between January 2009 and September 2014. Patients were contacted after a median postoperative time of 38 (5-45) months to determine the LARS score and to identify LARS symptoms that were considered most disabling. Uni- and multivariate regression analysis was performed to identify risk factors for LARS and major LARS. Finally, the LARS score was evaluated over time after restoration of bowel continuity.

RESULTS

Out of the 100 patients, 16 had minor LARS (score 21-29) and 51 patients had major LARS (score 30-42). Radiotherapy was an independent risk factor for major LARS (p = 0.04). For the majority of patients with major LARS (22%), fragmentation was considered the most disabling complaint. There was no correlation between interval after restoration of bowel continuity and the severity of the LARS score.

CONCLUSIONS

Perioperative radiotherapy is an independent risk factor for major LARS. Fragmentation is considered the most disabling complaint in the majority of patients with major LARS. There is no significant adaptation of the LARS score over time.

Pathophysiological aspects of the low anterior resection syndrome for treatment of rectal cancer

The number of patients with bowel dysfunction due to the treatment of rectal cancer has increased during the recent decades. Anatomical and functional disorders after the removal of the rectum are followed by increased stool frequency, urgency, multiple evacuations and flatus or stool incontinence characterizing the low anterior resection syndrome - LARS. The purpose of this article is to present a review of the literature on current concepts and pathophysiological aspects of bowel dysfunction after resection of rectal cancer. It is essential to understand these mechanisms for a better management of patients and recovery of their quality of life.

Anal sphincter dysfunction in patients treated with primary radiotherapy for anal cancer: a study with the functional lumen imaging probe

BACKGROUND

Sphincter-sparing radiotherapy or chemoradiation are standard treatments for patients with anal cancer. The ultimate treatment goal is full recovery from anal cancer with preserved anorectal function. Unfortunately, long-term survivors often suffer from severe anorectal symptoms. The aim of the present study was to characterize changes in anorectal physiology after radiotherapy for anal cancer.

METHOD

We included 13 patients (10 women, age 63.4 ± 1.9) treated with radiotherapy or chemoradiation for anal cancer and 14 healthy volunteers (9 women, age 61.4 ± 1.5). Symptoms were assessed with scores for fecal incontinence and low anterior resection syndrome. Anorectal physiology was examined with anorectal manometry and the Functional Lumen Imaging Probe.

RESULTS

Patients had a median Wexner fecal incontinence score of 5 (0-13) and a median LARS score of 29 (0-39). Compared to healthy volunteers, patients had lower mean (±SE) anal -resting (38 ± 5 vs. 71 ± 6, p < .001) and -squeeze pressures (76 ± 11 vs. 165 ± 15, p < .001). Patients also had lower anal yield pressure (15.5 ± 1.3 mmHg vs. 28.0 ± 2.0 mmHg, p < .001), higher distensibility, and lower resistance to flow (reduced resistance ratio of the anal canal during distension, q = 5.09, p < .001). No differences were found in median (range) rectal volumes at first sensation (70.5 (15-131) vs. 57 (18-132) ml, p > .4), urge (103 (54-176) vs. 90 (32-212), p > .6) or maximum tolerable volume (173 (86-413) vs. 119.5 (54-269) ml, p > .10).

CONCLUSION

Patients treated with radiotherapy or chemoradiation for anal cancer have low anal resting and squeeze pressures as well as reduced resistance to distension and flow.

Long-term Anorectal Function after Postoperative Chemoradiotherapy in High-Risk Rectal Cancer Patients

Aims and background

After sphincter-preserving surgery for rectal cancer and postoperative radiochemotherapy, many patients have unsatisfactory anorectal functional results which are not considered by the most common toxicity scales. The aim of the present study was to retrospectively assess the long-term incidence of impaired anorectal function in rectal cancer patients who underwent anterior resection and postoperative radiochemotherapy.

Methods

Ninety-nine patients who underwent sphincter-saving surgery and postoperative radiochemotherapy for stage II-III rectal cancer from July 1991 to January 2002 were given a questionnaire on anorectal function. Postoperative incontinence was evaluated according to a scale proposed by Jorge and Wexner. Factors influencing anorectal function were examined.

Results

The median follow-up from surgery was 10 years. Ten (10.1%) patients reported ≥ 5 bowel movements per day and 26 (26.3%) experienced clustering. The median frequency of bowel movements per 24 h was 2 (range, 1–10). Stool fragmentation was recorded in 56 (56.6%) cases, and 36 (36.4%) patients experienced urgency to defecate with inability to delay defecation for more than 15 min. The mean continence score was 4.91 (median 1, range 0–18). Incontinence to flatus, liquid and solid stools was reported at least once a week in 24 (24.2%), 11 (11.1%) and 5 (5.1%) patients, respectively. According to the study criteria, 61% of patients had good functional results. None of the variables analyzed showed a significant correlation with functional outcome.

Conclusions

Although retrospective, the present study included a large selected series that had undergone uniform adjuvant treatment and was followed for a median of 10 years. Our data demonstrated that 39% of patients did not have good functional results and suffered some degree of urgency, increased frequency and occasional incontinence even many years after the surgery. Anorectal function assessment should enter routinely in clinical practice and should have importance in the therapeutic decisions.

Anorectal dysfunction after laparoscopic low anterior rectal resection for rectal cancer with and without radiotherapy (manometry study)

BACKGROUND AND OBJECTIVES

The aim was to evaluate the impact of radiotherapy (RT) on anorectal function of patients with low rectal cancer undergoing low anterior resection (LAR).

METHODS

Prospective clinical cohort study conducted to assess the functional outcome by means of high-resolution anorectal manometry and LARS score.

RESULTS

In total, 65 patients were enrolled in the study (27 patients underwent LAR without RT, 38 patients underwent RT and LAR). There were no statistically significant differences between study subgroups regarding demographic and clinical data; postoperative morbidity was significantly higher in irradiated patients. One year after the surgery, mean LARS score was significantly higher in patients who underwent RT and surgery. Major LARS was detected in 37.0% of irradiated patients and in 14.8% of patients after surgery alone. Anorectal manometry revealed significantly lower resting pressures in patients after RT and LAR; the squeeze pressures were similar. Rectal compliance and all volumes describing rectal sensitivity (first sensation, urge to defecate, and discomfort volume) were significantly lower in irradiated patients.

CONCLUSIONS

RT significantly deteriorates the functional outcome of patients after LAR. Manometry revealed internal sphincter dysfunction, reduced capacity, and compliance of neorectum, which seem to have a significant correlation with LARS presence/seriousness.

Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome

AIM

Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms.

METHOD

A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed.

RESULTS

Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001).

CONCLUSION

Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.

Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer

AIM

In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function.

METHOD

Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B).

RESULTS

In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment.

CONCLUSION

TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.

Anastomotic leakage after sphincter-sparing surgery in a young woman diagnosed with low rectal cancer - case report

Rectal cancer is the third most common site for cancer in the world, with a high morbidity and mortality. The new techniques for the treatment of low rectal cancer have been improved recently, allowing sphincter-sparing surgery to be available for more patients, with an optimal oncological and functional outcome. The most fundamental advance in rectal cancer surgery was the concept of total mesorectal resection (TME) introduced by Heald in 1982. Association with neoadjuvant radio-chemotherapy determines regression of the disease by “down staging” the tumors and allows for sphincter-sparing surgery to be performed, with low recurrence rate and increased overall survival. We present the case of 48-year old woman who had low rectal resection with colorectal anastomosis for middle rectal cancer. The patient had a BMI of 29, was hypertensive, had uterine fibroids and underwent neoadjuvant radiotherapy. During the 4th postoperative day the patient developed an anastomotic leakage grade B which was spontaneously closed on the 15th postoperative day. The patient did not manifest fever or any other symptoms. Normal bowel function resumed on the 5th postoperative day. No recurrence was detected at the one-year follow-up.

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.

Rectal Mechano-sensory Function in Patients with Carcinoid Diarrhea

BACKGROUND/AIMS

In patients with neuroendocrine tumors, excessive production of serotonin and other amines may cause the carcinoid syndrome,which is mainly characterized by diarrhea and flushing. Little is known about the pathophysiology of carcinoid diarrhea. In severalother groups of patients, diarrhea may be associated with rectal hypersensitivity and increased rectal tone. Therefore, the aim of thepresent study was to compare rectal sensitivity and compliance in patients with carcinoid diarrhea and in healthy subjects.

METHODS

Twelve patients (6 males, aged 54-78 years, median 65 years), with carcinoid diarrhea and 19 healthy subjects (7 males, aged 50-78 years, median 61 years) were included. Rectal mechanical and heat stimulation was used for assessment of rectal mechano-sensory properties.

RESULTS

Overall, 5.3% higher temperatures were needed to elicit sensory responses in patients with carcinoid diarrhea than in healthy subjects (P = 0.015). Posthoc analyses revealed that the sensory threshold to heat was 48.1 ± 3.1°C in patients vs 44.7 ± 4.7°C in healthy subjects (P = 0.041). In contrast, patients and healthy subjects showed no overall differences in rectal sensory response to mechanical distension (P = 0.731) or rectal compliance (P = 0.990).

CONCLUSIONS

Patients with carcinoid diarrhea have higher sensory thresholds to heat stimulation in comparison to healthy subjects, but normalrectal sensation to mechanical distension and normal compliance. Therefore, treatment of carcinoid diarrhea should aim at prolonging gastrointestinal transit and decreasing secretion, rather than modifying rectal mechano-sensory function.

Pelvic radiation therapy: Between delight and disaster

In the last few decades radiotherapy was established as one of the best and most widely used treatment modalities for certain tumours. Unfortunately that came with a price. As more people with cancer survive longer an ever increasing number of patients are living with the complications of radiotherapy and have become, in certain cases, difficult to manage. Pelvic radiation disease (PRD) can result from ionising radiation-induced damage to surrounding non-cancerous tissues resulting in disruption of normal physiological functions and symptoms such as diarrhoea, tenesmus, incontinence and rectal bleeding. The burden of PRD-related symptoms, which impact on a patient's quality of life, has been under appreciated and sub-optimally managed. This article serves to promote awareness of PRD and the vast potential there is to improve current service provision and research activities.

Long-term anorectal, urinary and sexual dysfunction causing distress after radiotherapy for anal cancer: a Danish multicentre cross-sectional questionnaire study

AIM

The objective of primary radiotherapy for anal cancer is to remove cancer while maintaining anorectal function. However, little is known about anorectal function among long-term survivors without colostomy. Using a cross-sectional questionnaire study, we examined symptoms and distress related to the dysfunction of pelvic organs after radiotherapy for anal cancer.

METHOD

A questionnaire regarding anorectal, urinary and sexual symptoms was sent to anal cancer patients without recurrence or colostomy, diagnosed during 1996-2003, and treated with curative intent (chemo)radiotherapy at three Danish centres. For each symptom we assessed frequency and severity and the level of symptom-induced distress (no, little, moderate or great distress).

RESULTS

Of 94 eligible patients, 84 (89%) returned the completed questionnaire at a median of 33 months after radiotherapy. Incontinence for solid stools, liquid stools and gas occurred at least monthly in 31%, 54% and 79% of patients, respectively. Overall 40% of patients reported great distress from incontinence for solid or liquid stools at least monthly. Faecal urgency occurring at least monthly was experienced by 87% of patients and caused great distress in 43%. Stress, urge or another type of urinary incontinence occurred at least monthly in 45% and caused great distress in 21%. Urinary urgency occurred at least monthly in 48% but only caused great distress in 14%. Sexual desire was severely decreased in 58% and only 24% were satisfied with their sexual function.

CONCLUSION

Distressing long-term anorectal and sexual dysfunction was common after radiotherapy for anal cancer, and morbidity due to urinary dysfunction was moderate.

Predictors of Long-Term Quality of Life for Survivors of Stage II/III Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium

PURPOSE

Many patients do not receive guideline-recommended neoadjuvant chemoradiotherapy for resectable rectal cancer. Little is known regarding long-term quality of life (QOL) associated with various treatment approaches. Our objective was to determine patient characteristics and subsequent QOL associated with treatment approach.

METHODS

Our study was a geographically diverse population- and health system-based cohort study that included adults age 21 years or older with newly diagnosed stage II/III rectal cancer who were recruited from 2003 to 2005. Eligible patients were contacted 1 to 4 months after diagnosis and asked to participate in a telephone survey and to consent to medical record review, with separate follow-up QOL surveys conducted 1 and 7 years after diagnosis.

RESULTS

Two hundred thirty-nine patients with stage II/III rectal cancer were included in this analysis. Younger age (< 65 v ≥ 65 years: odds ratio, 2.49; 95% CI, 1.33 to 4.65) was significantly associated with increased odds of receiving neoadjuvant or adjuvant chemoradiotherapy. The adjuvant chemoradiotherapy group had significantly worse mean EuroQol-5D (range, 0 to 1) and Short Form-12 physical health component scores (standardized mean, 50) at 1-year follow-up than the neoadjuvant chemoradiotherapy group (0.75 v 0.85; P = .002; 37.2 v 43.3; P = .01, respectively) and the group that received only one or neither form of treatment (0.75 v 0.85; P = .02; 37.2 v 45.1; P = .008, respectively).

CONCLUSION

Neoadjuvant treatment may result in better QOL and functional status 1 year after diagnosis. Further evaluation of patient and provider reasons for not pursuing neoadjuvant therapy is necessary to determine how and where to target process improvement and/or education efforts to ensure that patients have access to recommended treatment options.

Can Anorectal Manometry Findings Predict Subsequent Late Gastrointestinal Radiation Toxicity in Prostate Cancer Patients?

PURPOSE

The purpose of this study is to investigate the influence of radiotherapy (RT) on anorectal function and radiation-induced toxicity in patients with prostate cancer.

MATERIALS AND METHODS

Fifty-four patients who were treated with RT for prostate cancer (T1c-4N0-1M0) were evaluated. To assess the changes in anorectal function, two consecutive anorectal manometry readings were performed in patients, before and after 4-6 months of RT. Late gastrointestinal (GI) toxicity was defined as symptoms occurring more than 6 months after RT. The median radiation dose was 70.0 Gy (range, 66.0 to 74.0 Gy). Whole pelvis field RT was performed in 16 patients (29.6%). Grade of late radiation toxicity was defined in accordance to the severity of symptoms (Gulliford's scoring system).

RESULTS

The median follow-up period was 60 months. Resting anal pressure (p=0.001), squeeze pressure (p < 0.001), and urge to defecate volume (p=0.025) were significantly reduced after RT. Fourteen patients (25.9%) experienced late GI toxicities. Among them, nine (16.7%) showed severe (grade ≥ 2) late toxicities. Elevated resting and squeeze external anal sphincter pressure prior to RT and large urge to defecate volumes after RT were associated with the occurrence of late GI toxicities.

CONCLUSION

RT caused symptomatic anorectal dysfunction and resulted in a weakened anal sphincter. Increased urge to defecate volumes after RT were related to late GI toxicities. Elevated resting and squeeze anal sphincter pressure prior to RT rodcan be used to identify patients with an increased risk of late GI toxicities.

Anterior resection syndrome--a risk factor analysis

BACKGROUND

Evacuatory dysfunction after distal colorectal resection varies from incontinence to obstructed defaecation and is termed anterior resection syndrome. The aim of this study was to identify risk factors for the development of anterior resection syndrome.

METHODS

All anterior resections undertaken at Auckland Hospital from 2002 to 2012 were retrospectively evaluated. An assortment of patient and peri-operative variables were recorded. Cases were stratified by the occurrence of anterior resection syndrome symptoms from 1 to 5 years post-operatively.

RESULTS

A total of 277 patients were identified. Prevalence of anterior resection syndrome decreased progressively from 61 % at 1 year to 43 % at 5 years. Univariate analysis identified anastomotic height, surgeon, pT stage, procedure year and temporary diversion ileostomy as recurring significant correlates (p < 0.05). Logistic regression identified lower anastomotic height (odds ratio (OR) 2.11, 95 % confidence interval (CI) 1.05-4.27; p = 0.04) and obstructive presenting symptoms (OR 6.71, 95 % CI 1.00-44.80; p = 0.05) as independent predictors at 1 and 2 years, respectively. Post-operative chemotherapy was a predictor at 1 year (OR 1.93, 95 % CI 1.04-3.57; p = 0.03). Temporary diverting ileostomy was an independent predictor at 2 (OR 2.49, 95 % CI 1.04-5.95; p = 0.04), 3 (OR 4.17, 95 % CI 1.04-16.78; p = 0.04), 4 (OR 8.05, 95 % CI 1.21-53.6; p = 0.03), and 5 years (OR 49.60, 95 % CI 2.17-1134.71; p = 0.02) after adjusting for anastomotic height.

CONCLUSIONS

Anastomotic height, post-operative chemotherapy and obstructive presenting symptoms were independent predictors at 1 and 2 years. Temporary diversion ileostomy was an independent predictor for the occurrence of anterior resection syndrome at 2, 3, 4 and 5 years even after correcting for anastomotic height. Prospective assessment is required to facilitate more accurate risk factor analysis.

Prognostic nomograms for predicting survival and distant metastases in locally advanced rectal cancers

Aim

To develop prognostic nomograms for predicting outcomes in patients with locally advanced rectal cancers who do not receive preoperative treatment.

Materials and Methods

A total of 883 patients with stage II–III rectal cancers were retrospectively collected from a single institution. Survival analyses were performed to assess each variable for overall survival (OS), local recurrence (LR) and distant metastases (DM). Cox models were performed to develop a predictive model for each endpoint. The performance of model prediction was validated by cross validation and on an independent group of patients.

Results

The 5-year LR, DM and OS rates were 22.3%, 32.7% and 63.8%, respectively. Two prognostic nomograms were successfully developed to predict 5-year OS and DM-free survival rates, with c-index of 0.70 (95% CI = [0.66, 0.73]) and 0.68 (95% CI = [0.64, 0.72]) on the original dataset, and 0.76 (95% CI = [0.67, 0.86]) and 0.73 (95% CI = [0.63, 0.83]) on the validation dataset, respectively. Factors in our models included age, gender, carcinoembryonic antigen value, tumor location, T stage, N stage, metastatic lymph nodes ratio, adjuvant chemotherapy and chemoradiotherapy. Predicted by our nomogram, substantial variability in terms of 5-year OS and DM-free survival was observed within each TNM stage category.

Conclusions

The prognostic nomograms integrated demographic and clinicopathological factors to account for tumor and patient heterogeneity, and thereby provided a more individualized outcome prognostication. Our individualized prediction nomograms could help patients with preoperatively under-staged rectal cancer about their postoperative treatment strategies and follow-up protocols.

Risk factors for bowel dysfunction after sphincter-preserving rectal cancer surgery: a prospective study using the Memorial Sloan Kettering Cancer Center bowel function instrument

BACKGROUND

Until recently, no studies have prospectively evaluated bowel function after sphincter-preserving surgery for rectal cancer with the use of a validated bowel function scoring system.

OBJECTIVE

The aim of this study was to investigate possible risk factors for altered bowel function after sphincter-preserving surgery.

DESIGN

This was a prospective study.

SETTINGS

The study was conducted between January 2006 and May 2012 at the authors' institution.

PATIENTS

Patients who underwent sphincter-preserving rectal cancer surgery were recruited.

MAIN OUTCOME MEASURES

Bowel function was assessed 1 day before (baseline) and at 1 year after sphincter-preserving surgery or temporary ileostomy takedown with the use of the Memorial Sloan Kettering Cancer Center questionnaire. Multivariable analysis was performed to identify the factors associated with altered bowel function after surgery.

RESULTS

Overall, 266 patients were eligible for the analysis. The tumor was located in the upper, middle, and lower rectum in 68 (25.5%), 113 (42.5%), and 85 (32.0%) patients. Intersphincteric resection and temporary ileostomy were performed in 18 (6.8%) and 129 (48.5%) patients. The mean Memorial Sloan Kettering Cancer Center score was 64.5 ± 7.6 at 1 year after sphincter-preserving surgery or temporary ileostomy takedown. The Memorial Sloan Kettering Cancer Center score decreased in 163/266 patients (61.3%) between baseline and 1 year after surgery. Tumor location (p = 0.01), operative method (p = 0.03), anastomotic type (p = 0.01), and temporary ileostomy (p = 0.01) were associated with altered bowel function after sphincter-preserving surgery in univariate analyses. In multivariable analysis, only tumor location was independently associated with impaired bowel function after sphincter-preserving rectal cancer surgery.

LIMITATIONS

This study was limited by its nonrandomized design and the lack of measurement before preoperative chemoradiotherapy.

CONCLUSION

We suggest that preoperative counseling should be implemented to inform patients of the risk of bowel dysfunction, especially in patients with lower rectal cancer, although this study cannot exclude the effect of chemoradiotherapy owing to the limitation of study.

What Are the Best Questionnaires To Capture Anorectal Function After Surgery in Rectal Cancer?

With enhanced surgical techniques and neoadjuvant therapy in rectal cancer, survivorship issues are at the forefront of clinical practice and research. More and more patients are living with altered bowel habits following rectal cancer surgery. Sound assessment of anorectal function after rectal cancer surgery is the foundation for the continuing effort to explore the adverse effects of such surgery on bowel function, as well as for working towards reducing these effects. The quality of the assessment is predominantly determined by the instrument administered. This article reviews various questionnaires for capturing anorectal function after surgery in rectal cancer, discussing their attributes and suitability for different evaluation contexts.

Sphincter-sparing surgery in patients with low-lying rectal cancer: techniques, oncologic outcomes, and functional results

BACKGROUND

Rectal cancer management has evolved into a complex multimodality approach with survival, local recurrence, and quality of life parameters being the relevant endpoints. Surgical treatment for low rectal cancer has changed dramatically over the past 100 years.

DISCUSSION

Abdominoperineal resection, once the standard of care for all rectal cancers, has become much less frequently utilized as surgeons devise and test new techniques for preserving the sphincters, maintaining continuity, and performing oncologically sound ultra-low anterior or local resections. Progress in rectal cancer surgery has been driven by improved understanding of the anatomy and pathophysiology of the disease, innovative surgical technique, improved technology, multimodality approaches, and increased appreciation of the patient's quality of life. The patient with a low rectal cancer, once almost universally destined for impotence and a colostomy, now has the real potential for improved survival, avoidance of a permanent stoma, and preservation of the normal route of defecation.

Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer

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.

Neorectal hyposensitivity after neoadjuvant therapy for rectal cancer

BACKGROUND AND PURPOSE

Preoperative radiotherapy for rectal cancer has a detrimental effect on long-term anorectal function and quality of life, additional to that observed after rectal resection. The exact physiological mechanisms for the excess impairment remain unknown. We aimed to investigate neorectal and anal sphincter properties in patients treated with neoadjuvant therapy (NT) prior to total mesorectal excision (TME).

MATERIAL AND METHODS

Sixteen patients (NT+ patients) were examined by multimodal neorectal stimulation and standard anorectal physiological testing. Data were compared to the results of 23 patients, who underwent TME without NT (NT- patients).

RESULTS

NT+ patients had elevated sensory thresholds to heat (median temperature, 60 vs. 55 °C; p<0.01) and mechanical distension (median tension, 2513 vs. 1521 mmHg mm; p=0.05) in the fasting state, and altered perception of the sensory response to heat (p=0.01) and cold (p=0.01) compared to NT- patients. No differences in the biomechanical properties of the neorectal wall were detected. Anal resting pressure was lower in NT+ patients compared to NT- patients (median pressure, 31 vs. 45 cm H2O; p=0.05).

CONCLUSIONS

Pelvic radiotherapy causes neorectal hyposensitivity to mechanical and thermal stimuli in patients receiving NT prior to TME surgery for rectal cancer, possibly due to impaired afferent nerve function.

Non-operative management for locally advanced rectal cancer: critical review and future perspective

SUMMARY Over the last few decades we have observed important advances in diagnostic imaging, surgery, pathology and multimodal treatments for rectal cancer, as well as increased efforts to reduce treatment-related toxicities and preserve quality of life for curatively treated patients. Neoadjuvant short-course radiotherapy and long-course chemoradiotherapy followed by total mesorectal excision remain widely accepted as the standard of care for patients with locally advanced rectal cancer. However, a carefully selected group of patients achieving a complete response to neoadjuvant chemoradiotherapy may be spared the effects of surgery and achieve satisfactory oncologic outcomes with a ‘wait-and-see’ strategy. Although supported by the results of previous studies, this intriguing paradigm shift needs prospective evaluation within a clinical trial setting and a more accurate prediction and assessment of response by means of tumor biomarkers and diagnostic imaging.

A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome

The aim of this review is to characterize the functional results and "anterior resection syndrome" (ARS) after sphincter-saving surgery for rectal cancer. The purpose of sphincter-saving operations is to save the anal sphincters by avoiding the need for rectal abdomino-perineal resection with a permanent stoma. A variety of alternative techniques have been proposed and, today, ultra-low anterior resections of the rectum are commonplace. Inevitably rectal resections modify anorectal physiology. The backdrop of the functional asset for ultralow anterior resections is related to a small neorectal capacity with high endo-neorectal pressures that act together on a weakened sphincteric mechanism. Sometimes a defecation disorder called ARS may be induced and the patient experiences an extremely low quality of life. Impaired bowel function is usually provoked either by colonic dysmotility, neorectal reservoir dysfunction, anal sphincter damage or by a combination of these factors. Surgical technique defects can contribute to these possible causes: anastomotic ischemia, short length of the descending colon and stretching of neorectal mesentery may play a role. Unfortunately, there is no therapeutic algorithm or gold standard treatment that may be used for ARS. Nevertheless, it is rational to use conservative therapy first and then resort to surgery. Drugs, rehabilitative treatment and sacral neuromodulation may be used; after failure of conservative methods, surgical treatment can be considered.

Assessment of patient-reported measures of bowel function before and after pelvic radiotherapy: an ancillary study of the North Central Cancer Treatment Group study N00CA

PURPOSE

The Bowel Function Questionnaire (BFQ) has been used in clinical trials to assess symptoms during and after pelvic radiotherapy (RT). This study evaluated the importance of symptoms in the BFQ from a patient perspective.

METHODS

Patients reported presence or absence of symptoms and rated importance of symptoms at baseline, 4 weeks after completion of pelvic RT, and 12 and 24 months after RT. The BFQ measured overall quality of life (QOL) and symptoms of nocturnal bowel movements, incontinence, clustering, need for protective clothing, inability to differentiate stool from gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency also was recorded. A content validity questionnaire (CVQ) was used to rate symptoms as "not very important," "moderately unimportant," "neutral," "moderately important," or "very important."

RESULTS

Most of the 125 participating patients rated all symptoms as moderately or very important. Generally, patients gave similar ratings for symptom importance at all study points, and ratings were independent of whether the patient experienced the symptom. Measures of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94 %), not having to wear protective clothing (90 %), and not having rectal bleeding (94 %). With the exception of need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (P < .01 for all).

CONCLUSIONS

The BFQ has excellent content validity. Patients rated most symptoms as moderately or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT.

Anterior resection syndrome

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.

Short-term effects of neoadjuvant chemoradiotherapy on internal anal sphincter function: a human in vitro study

BACKGROUND

Neoadjuvant chemoradiotherapy is recommended in the treatment of locally advanced rectal cancer. Studies have suggested that chemoradiotherapy adversely affects anorectal function. However, the functional implication and the underlying neuromyogenic changes involved in radiation-induced damage are poorly understood.

OBJECTIVE

This study evaluated the functional changes following chemoradiotherapy on the internal anal sphincter.

DESIGN AND PATIENTS

This article describes an in vitro study on the internal anal sphincter collected from patients undergoing abdominoperineal resection or proctectomy. Five patients were treated by surgery alone (control group), and 6 received preoperative chemoradiotherapy (treatment group). Sphincter strips were mounted in organ bath, and the responses to electrical field stimulation and drugs were monitored.

SETTINGS

The study was performed at the University of Oxford.

MAIN OUTCOME MEASURES

The end points of this study were to investigate whether chemoradiotherapy has any significant effects on internal anal sphincter function and, subsequently, to establish the type of injury induced.

RESULTS

Chemoradiotherapy strips developed similar tone, but significantly lower spontaneous activity (p = 0.001) than controls. Electrical field stimulation induced relaxation, followed by contraction. At 50 Hz, electrical field stimulation produced 25.6 ± 4.9% (mean ± SE) of maximum relaxation followed by a contraction of 5.5 ± 0.9% of basal tone in chemoradiotherapy strips i9n comparison with 47.0 ± 6.2% (p = 0.009) and 17.7 ± 4.0% (p = 0.007) in controls. Relaxation was significantly attenuated by N-nitro-L-arginine. Significant differences were found in responses to carbachol (p = 0.018) and phenylephrine (p = 0.022), but not to sodium nitroprusside.

LIMITATIONS

This work was limited by the relatively small number of patients enrolled, because of the difficulty of finding human tissue for laboratory studies, and the lack of long-term results.

CONCLUSIONS

Chemoradiotherapy significantly impairs internal anal sphincter function and intrinsic nerves seem more susceptible than smooth muscle. The exclusion of anal canal from the radiation field is recommended, when oncologically safe.

The acute effect of dorsal genital nerve stimulation on rectal wall properties in patients with idiopathic faecal incontinence

AIM

Faecal continence depends on several factors, including rectal wall properties. Stimulation of the dorsal genital nerve (DGN) can suppress bladder contraction and similar effects are anticipated for the rectum. In this study, the acute effect of DGN stimulation on the rectal cross-sectional area is investigated.

METHOD

Ten female patients (median age 60 years) with idiopathic faecal incontinence were included in the study. Stimulation was applied via plaster electrodes with the maximum tolerable amplitude (pulse width was 200 μs at a pulse rate of 20 Hz). Three series of pressure-controlled phasic (10, 20 and 30 cm H(2) O) and stepwise (5-30 cm H(2) O in steps of 5 cm H(2) O) rectal distensions were conducted (unstimulated, stimulated, unstimulated), and the rectal cross-sectional area (CSA) was measured with impedance planimetry.

RESULTS

All patients completed the investigation. The median stimulation amplitude was 21 (8.5-27) mA. Comparing stimulated with unstimulated phasic distension, there was no significant difference in the median rectal CSA. Comparing stimulated with unstimulated stepwise distension, there was no significant difference in the median rectal CSA. Neither the rectal pressure-CSA relationship (CSA/P(R) ) nor the rectal wall tension changed during stimulation.

CONCLUSION

No acute effect on rectal CSA during pressure-controlled distension was demonstrated during DGN stimulation.