Long-Term Functional and Oncological Outcomes Following Intersphincteric Resection for Low Rectal Cancers

Risk factors, quality of life, and oncological effects of refractory anastomotic leakage for laparoscopic intersphincteric resection

BACKGROUND AND AIM

Refractory anastomotic leakage (RAL) after intersphincteric resection (ISR) usually leads to failure of protective stoma reversal in ultralow rectal cancers. The aim of this study is to assess the risk factors and oncological outcomes of both anastomotic leakage (AL) and RAL, and quality of life (QoL) of RAL after laparoscopic ISR (LsISR).

METHODS

A total of 371 ultralow rectal cancer patients with LsISR were enrolled from a tertiary colorectal surgery referral center. Risk factors for AL and RAL were identified by logistic regression. Three-year disease-free survival (DFS) of AL and RAL was analyzed by the Cox regression. QoL of RAL group (compared with non-RAL group) was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR29 questionnaires.

RESULTS

The rates of AL and RAL after LsISR accounted for 8.4% (31/371) and 4.6% (17/371) in this cohort, respectively. Non-left colic artery preservation (odds ratio [OR] = 3.491, P = 0.009), neoadjuvant chemoradiotherapy (nCRT) (OR = 6.038, P < 0.001), and lower anastomosis height (OR = 5.271, P = 0.010) were independent risk factors for AL, while nCRT (OR = 11.602, P < 0.001) was the only independent risk factor for RAL. Male (hazard ratio [HR] = 1.989, P = 0.014), age > 60 years (HR = 1.877, P = 0.018), and lymph node metastasis (HR = 2.125, P = 0.005) were independent risk factors of poor 3-year DFS, but not RAL (P = 0.646). RAL patients have significantly worse global health status, worse emotional and social function scores at the late postoperative stage, and worse urinary and sexual function at the early postoperative stage (all P < 0.05).

CONCLUSIONS

Neoadjuvant chemoradiotherapy was an independent risk factor for RAL after LsISR. RAL shows similar oncological outcomes, but with poor QoL.

Nutritional Treatment of Patients with Colorectal Cancer

Colorectal cancer is one of the most common cancers in Europe and the world. Cancer treatments have side effects and cause significant deterioration of the patient’s nutritional status. Patient malnutrition may worsen the health condition and prevent the deliberate effects of the therapy. The aim of this review was to describe the available data about clinical nutrition in colorectal cancer patients. A large proportion of colorectal cancer patients suffer from malnutrition, which negatively affects the survival prognosis, quality of life, and oncological therapy. Therefore, monitoring nutritional status during the treatment is essential and can be used to arrange proper nutritional therapy to enhance patient responses, prevent side effects, and shorten recovery time. The principles of nutrition during anticancer therapy should mainly consider light and low-fat foods, the exclusion of lactose and gluten-containing foods in certain cases, or the introduction of special dietary products such as oral nutrition supplements and it should be tailored to patients’ individual needs.

Impact of defecation dysfunction on quality of life in mid-low rectal cancer patients following sphincter-sparing surgery

Objectives

A large proportion of mid-low rectal cancer patients develop low anterior resection syndrome (LARS) after Sphincter-sparing surgery. This study aimed to investigate the effect of low anterior resection syndrome (LARS) on quality of life (QoL) in Chinese rectal cancer patients following sphincter-sparing surgery.

Methods

This was a comparative cross-sectional study. Between Jan 2019 to Jun 2020, 146 mid-low rectal cancer patients following sphincter-sparing surgery were enrolled. The low anterior resection syndrome (LARS) score was used to assess bowel dysfunction. According to the LARS score, patients were divided into three levels, no LARS (n ​= ​34), minor LARS (n ​= ​60), and major LARS (n ​= ​52). The Functional Assessment of Cancer Therapy-Colorectal (FACT-C) was used to assess the QoL of the patients.

Results

The major LARS group had a significantly shorter level of tumor from the dentate line than the no LARS group. The total FACT-C score of 146 patients was 98.45 ​± ​17.83. The total FACT-C score and the score of each dimension (physical, emotional, functional dimensions, and colorectal cancer subscale) were significantly different between the minor LARS and major LARS groups, as well as between the no LARS and major LARS groups. Subgroups analyses of the FACT-C score stratified by each item in the LARS scales showed that except for flatus incontinence, patients with different frequencies of other symptoms (bowel frequency, liquid stool incontinence, liquid stool incontinence, stool clustering, urgent bowel movement) had a significantly different total score of FACT (all P ​< ​0.01).

Conclusions

The LARS had a significant impact on the QoL in Chinese mid-low rectal cancer patients following sphincter-sparing surgery, especially in patients with major LARS.

Robotic Intersphincteric Resection for Low Rectal Cancer: Technical Controversies and a Systematic Review on the Perioperative, Oncological, and Functional Outcomes

Intersphincteric resection (ISR) is the ultimate anus-sparing technique for low rectal cancer and is considered an oncologically safe alternative to abdominoperineal resection. The application of the robotic approach to ISR (RISR) has been described by few specialized surgical teams with several differences regarding approach and technique. This review aims to discuss the technical aspects of RISR by evaluating point by point each surgical controversy. Moreover, a systematic review was performed to report the perioperative, oncological, and functional outcomes of RISR. Postoperative morbidities after RISR are acceptable. RISR allows adequate surgical margins and adequate oncological outcomes. RISR may result in severe bowel and genitourinary dysfunction affecting the quality of life in a portion of patients.

Assessment of defecation function after sphincter-saving resection for mid to low rectal cancer: A cross-sectional study

PURPOSE

Patients with mid-to low-rectal cancer can have various dysfunctions of defecation after sphincter-saving resection. Defecation dysfunction can manifest as incontinence, urgency, or frequent bowel movements, and is called low anterior resection syndrome (LARS). This study aimed to examine LARS score and objective anorectal function indices in Chinese patients receiving sphincter-saving surgery for mid-to low-rectal cancer.

METHOD

This was a single-center cross-sectional study of patients undergoing sphincter-saving resection for low- or mid-rectal cancer and had restoration of trans-anal defecation for at least 1 month seen between January 2019 and June 2020. Patients completed a questionnaire regarding clinical characteristics, and Low Anterior Resection Syndrome (LARS) score and high-resolution anorectal manometry (HR-ARM) were used to assess defecation function. Multivariable analysis was used to identify variables significantly associated with defecation dysfunction.

RESULTS

146 patients completed and returned the questionnaires. 25 healthy adults also participated as control group for the anorectal manometry. Approximately 76% of patients developed LARS after surgery, of which 35.6% had major LARS. In these patients, anorectal manometry indices including initial rectal sensory capacity and rectal fecal sensory capacity, were significantly lower than normal. Logistic regression analysis showed that preoperative chemo-radiotherapy and the tumor inferior margins being close to the dentate line, especially 2-5 cm, were independent risk factors for defecation dysfunction after surgery.

CONCLUSIONS

Defecation dysfunction is a frequent occurrence after sphincter-saving resection for mid- and low-rectal cancer. Preoperative chemo-radiotherapy and a shorter tumor inferior margins distance to the dentate line are independent factors for defecation dysfunction.

Anus-Preserving Surgery in Advanced Low-Lying Rectal Cancer: A Perspective on Oncological Safety of Intersphincteric Resection

The surgical management of low-lying rectal cancer, within 5 cm from the anal verge (AV), is challenging due to the possibility, or not, to preserve the anus with its sphincter muscles maintaining oncological safety. The standardization of total mesorectal excision, the adoption of neoadjuvant chemoradiotherapy, the implementation of rectal magnetic resonance imaging, and the evolution of mechanical staplers have increased the rate of anus-preserving surgeries. Moreover, extensive anatomy and physiology studies have increased the understanding of the complexity of the deep pelvis. Intersphincteric resection (ISR) was introduced nearly three decades ago as the ultimate anus-preserving surgery. The definition and indication of ISR have changed over time. The adoption of the robotic platform provides excellent perioperative results with no differences in oncological outcomes. Pushing the boundaries of anus-preserving surgeries has risen doubts on oncological safety in order to preserve function. This review critically discusses the oncological safety of ISR by evaluating the anatomical characteristics of the deep pelvis, the clinical indications, the role of distal and circumferential resection margins, the role of the neoadjuvant chemoradiotherapy, the outcomes between surgical approaches (open, laparoscopic, and robotic), the comparison with abdominoperineal resection, the risk factors for oncological outcomes and local recurrence, the patterns of local recurrences after ISR, considerations on functional outcomes after ISR, and learning curve and surgical education on ISR.

Local recurrence with intersphincteric resection in adverse histology rectal cancers. A retrospective study with competing risk analysis

BACKGROUND

The safety of inter-sphincteric resection (ISR) for low rectal cancer with adverse histologic subtypes has been incompletely studied. The present study aims at determining the risk of local recurrence with this procedure in poorly differentiated and signet ring cell (PDSR) adenocarcinoma.

METHODS

Retrospective analysis from a single tertiary cancer centre of non-metastatic primary rectal cancer <6 cm from the anal verge that underwent ISR. Competing risk analysis and sub-distribution hazard ratios for local recurrence free survivals were calculated to determine factors that influenced local recurrence with the competing risk of death from any cause to overcome the exceeding risk of distant metastasis associated with adverse histologic types.

RESULTS

One hundred forty-two patients underwent ISR and 22.6% has PDSR histology. At a median follow up of 61 months, 15.6% of the PDSR cohort developed local recurrence (five patients) compared to 11.7% in the non-PDSR group. PDSR histology influenced overall and disease free survival but not local recurrence on cox regression. On competing risk analysis, only ypT stage ≥3 predicted worse local recurrence free survival and not histology.

CONCLUSIONS

The presence of PDSR histology did not increase the risk of local recurrence after ISR in this retrospective competing risk analysis.

Postoperative Functional Management Contributes to Anal Functional Recovery in Patients With Low Rectal Cancer After Robotic Total Intersphincteric Resection

Purpose: To evaluate the effectiveness of the comprehensive post-operative management including low-frequency endo-anal electrical stimulation and daily suppository usage on post-operative anal functional recovery for low rectal cancer patients who underwent robotic total intersphincteric resection (ISR).

Methods: A retrospective analysis was performed on 42 low rectal cancer patients who underwent robotic total ISR, of which 23 patients received comprehensive post-operative management, including biofeedback low-frequency endo-anal electrical stimulation and daily suppository usage (management group). Wexner score and anorectal manometric values, including resting pressure (RP), maximum squeeze pressure (MSP), initial perceived volume (IPV), and maximum tolerated volume (MTV), were assessed and compared.

Results: A total of 42 low rectal cancer patients were included in our study. The RP at 6 months after ISR (40.95 ± 6.95 mmHg vs. 33.29 ± 5.40 mmHg, p = 0.002) and MSP at 3 and 6 months after ISR (72.05 ± 10.16 mmHg vs. 69.05 ± 8.67 mmHg, p = 0.031; 91.57 ± 15.47 mmHg vs. 84.05 ± 12.94 mmHg, p = 0.039, respectively) were significantly higher in the management group. The median IPV at 1 and 3 months after ISR (17.81 ± 3.61 ml vs. 15.43 ± 5.08 ml, p = 0.038; 20.19 ± 4.35 ml vs. 17.67 ± 5.16 ml, p = 0.044, respectively) and MTV at 3 months after ISR (83.71 ± 5.44 ml vs. 76.10 ± 8.42 ml, p = 0.012) were significantly higher in the management group. Wexner scores at 1 and 3 months after closure of stoma (COS) in the management group were significantly lower (11.3 ± 2.9 vs. 13.4 ± 3.0, p = 0.041; 8.9 ± 2.0 vs. 10.6 ± 2.4, p = 0.036, respectively).

Conclusions: Comprehensive post-operative management could accelerate the recovery of sphincteric function and anal sensitivity after robotic total ISR and could also contribute to treatment of fecal incontinence followed by COS.

Latest Advances in Intersphincteric Resection for Low Rectal Cancer

Background

Intersphincteric resection (ISR) has been a preferable alternative to abdominoperineal resection (APR) for anal preservation in patients with low rectal cancer. Laparoscopic ISR and robotic ISR have been widely used with the proposal of 2 cm or even 1 cm rule of distal free margin and the development of minimally invasive technology. The aim of this review was to describe the newest advancements of ISR.

Methods

A comprehensive literature review was performed to identify studies on ISR techniques, preoperative chemoradiotherapy (PCRT), complications, oncological outcomes, and functional outcomes and thereby to summarize relevant information and controversies involved in ISR.

Results

Although PCRT is employed to avoid positive circumferential resection margin (CRM) and decrease local recurrence, it tends to engender damage of anorectal function and patients' quality of life (QoL). Common complications after ISR include anastomotic leakage (AL), anastomotic stricture (AS), urinary retention, fistula, pelvic sepsis, and prolapse. CRM involvement is the most important predictor for local recurrence. Preoperative assessment and particularly rectal endosonography are essential for selecting suitable patients. Anal dysfunction is associated with age, PCRT, location and growth of anastomotic stoma, tumour stage, and resection of internal sphincter.

Conclusions

The ISR technique seems feasible for selected patients with low rectal cancer. However, the postoperative QoL as a result of functional disorder should be fully discussed with patients before surgery.

The Effects of Continuous Care Model of Information-Based Hospital-Family Integration on Colostomy Patients: a Randomized Controlled Trial

The purpose of this research was to examine the effects of continuous care model of information-based hospital-family integration on colostomy patients. Miles' operation is a major operative method for treating low rectal cancer, and this operation results in a permanent colostomy. It is difficult for patients to adapt to their colostomy. Previous studies have applied generally conventional nursing models to colostomy patients. This was a single-blind randomized controlled trial study. The sample of 155 patients who met the inclusion criteria was randomly assigned to either the experimental (n = 81) or control group (n = 74). The control group was provided with a routine standard of care. The experimental group was provided with an experimental treatment that consisted of an information-based (WeChat, blog, QQ, telephone, etc.) hospital-family integration continuous care model. Study variables were collected and instruments were selected as follows: basic information, State-Trait Anxiety Inventory (STAI), a self-efficacy scale, a colostomy complication assessment table, a quality of life scale, and a table of the degree of satisfaction. No statistically significant differences were found in demographic information between the experimental and control groups. In comparison with the control group, subjects in the experimental group had less anxiety and could better cope with anxiety, had a better self-efficacy and quality of life scores, and had fewer complications. The patients in the experimental group were shown to be more satisfied with the care model. In addition, the most useful and popular service is the online social tools WeChat and QQ, because they can communicate with video, and they are more real-time, efficient, and cheap. The continuous care model of information-based hospital-family integration significantly strengthened patients' self-efficacy and confidence, which decreased colostomy complications, ultimately improving the quality of life.

The effect of biofeedback training on intestinal function among patients with middle and low rectal cancer: a randomized controlled study

Background

To evaluate the effect of biofeedback on intestinal function among patients with middle and low rectal cancer.

Methods

Using a randomized controlled trial design, 109 patients with middle and low rectal cancer indicated to have preoperative radiochemotherapy, anterior resection of the rectum, and preventive stoma were randomly divided into three groups: the blank control group, the pelvic floor muscle exercise group, and the biofeedback training group. A 16-month intervention and longitudinal follow-up study was conducted, and a questionnaire on intestinal function by the Memorial Sloan-Kettering Cancer Center (MSKCC) was adopted into a Chinese version to evaluate patients' intestinal function situation.

Results

The intestinal function of the biofeedback training group was better than the blank control group and pelvic floor muscle exercise group. The total score of intestinal function and the scores of each dimension were statistically significant (P<0.05).

Conclusions

Biofeedback training could significantly improve the intestinal function of patients with middle and low rectal cancer, promote its recovery, and is thus worthy of clinical application.

Functional outcomes after resections for low rectal tumors: comparison of Transanal with laparoscopic Total Mesorectal excision

Background

Aim of this study was to evaluate functional outcomes of transanal total mesorectal excision (TaTME) in comparison to conventional laparoscopic approach (LaTME) in terms of low anterior resection syndrome (LARS).

Methods

Forty-six patients who underwent total mesorectal excision for low rectal cancer between 2013 and 2017 were enrolled. Primary outcome was the severity of faecal incontinence, assessed both before the treatment and 6 months after ileostomy reversal. LARS score and Jorge-Wexner scale were utilized to analyze its severity.

Results

Twenty (87%) from TaTME and 21 (91%) from LaTME group developed LARS postoperatively. There were no significant differences between groups in terms of LARS occurrence (p = 0.63) and severity. The median Wexner score was comparable in both groups (8 [IQR: 4–12] vs 7 [3–11], p = 0.83). Univariate analysis revealed that postoperative complications were a risk factor for LARS development (p = 0.02). Perioperative outcomes, including operative time, blood loss and intraoperative adverse events did not differ significantly between groups either. Five TaTME patients developed postoperative complications, while there were morbidity 6 cases in LaTME group. Quality of mesorectal excision was comparable with 20 and 19 complete cases in TaTME and LaTME groups, respectively.

Conclusions

TaTME provided comparable outcomes in terms of functional outcomes in comparison to LaTME for total mesorectal excision in low rectal cancers. Having said that, LARS prevalence is still high and requires further evaluation of the technique.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Critical and Challenging Issues in the Surgical Management of Low-Lying Rectal Cancer

Despite innovative advancements, the management of distally located rectal cancer (RC) remains a formidable endeavor. The critical location of the tumor predisposes it to a circumferential resection margin that tends to involve the sphincters and surrounding organs, pelvic lymph node metastasis, and anastomotic complications. In this regard, colorectal surgeons should be aware of issues beyond the performance of total mesorectal excision (TME). For decades, abdominoperineal resection had been the standard of care for low-lying RC; however, its association with high rates of tumor recurrence, tumor perforation, and poorer survival has stimulated the development of novel surgical techniques and modifications, such as extralevator abdominoperineal excision. Similarly, difficult dissections and poor visualization, especially in obese patients with low-lying tumors, have led to the development of transanal TME or the "bottom-to-up" approach. Additionally, while neoadjuvant chemoradiotherapy has allowed for the execution of more sphincter-saving procedures without oncologic compromise, functional outcomes remain an issue. Nevertheless, neoadjuvant treatment can lead to significant tumor regression and complete pathological response, permitting the utilization of organ-preserving strategies. At present, an East and West dualism pervades the management of lateral lymph node metastasis, thereby calling for a more global and united approach. Moreover, with the increasing importance of quality of life, a tailored, individualized treatment approach is of utmost importance when taking into account oncologic and anticipated functional outcomes.

Alterations of anal physiological features after surgery for low rectal cancer and management strategies

The sphincter preserving operation has improved the quality of life (QOL) of patients with low rectal cancer. However, some patients complain of having postoperative fecal incontinence and low QOL due to sphincter injury, nerve injure, and decreased rectal capacity. Therefore, anal physiology evaluation must be done preoperatively, the sphincter muscle and nerve should be preserved in operation, and biofeedback treatment should be administered postoperatively.