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Shu XP, Lv Q, Li ZW, Liu F, Liu XR, Li LS, Tong Y, Liu XY, Wang CY, Peng D, Cheng Y. Does one-stitch method of temporary ileostomy affect the stoma-related complications after laparoscopic low anterior resection in rectal cancer patients? Eur J Med Res 2024; 29:403. [PMID: 39095909 PMCID: PMC11297555 DOI: 10.1186/s40001-024-01995-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 07/22/2024] [Indexed: 08/04/2024] Open
Abstract
PURPOSE This current study attempted to investigate whether one-stitch method (OM) of temporary ileostomy influenced the stoma-related complications after laparoscopic low anterior resection (LLAR). METHODS We searched for eligible studies in four databases including PubMed, Embase, Cochrane Library, and CNKI from inception to July 20, 2023. Both surgical outcomes and stoma-related complications were compared between the OM group and the traditional method (TM) group. The Newcastle-Ottawa Scale (NOS) was adopted for quality assessment. RevMan 5.4 was conducted for data analyzing. RESULTS Totally 590 patients from six studies were enrolled in this study (272 patients in the OM group and 318 patients in the TM group). No significant difference was found in baseline information (P > 0.05). Patients in the OM group had shorter operative time in both the primary LLAR surgery (MD = - 17.73, 95%CI = - 25.65 to - 9.80, P < 0.01) and the stoma reversal surgery (MD = - 18.70, 95%CI = - 22.48 to -14.92, P < 0.01) than patients in the TM group. There was no significant difference in intraoperative blood loss of the primary LLAR surgery (MD = - 2.92, 95%CI = - 7.15 to 1.32, P = 0.18). Moreover, patients in the OM group had fewer stoma-related complications than patients in the TM group (OR = 0.55, 95%CI = 0.38 to 0.79, P < 0.01). CONCLUSION The OM group had shorter operation time in both the primary LLAR surgery and the stoma reversal surgery than the TM group. Moreover, the OM group had less stoma-related complications.
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Affiliation(s)
- Xin-Peng Shu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Quan Lv
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zi-Wei Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Fei Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xu-Rui Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lian-Shuo Li
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yue Tong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao-Yu Liu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chun-Yi Wang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Dong Peng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yong Cheng
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Homma Y, Mimura T, Koinuma K, Horie H, Sata N. Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors. Surg Today 2024; 54:857-865. [PMID: 38472547 DOI: 10.1007/s00595-024-02796-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/11/2023] [Indexed: 03/14/2024]
Abstract
PURPOSE Low anterior resection syndrome (LARS) causes devastating symptoms and impairs the quality of life (QOL). This study investigated the incidence and risk factors of LARS and their association with the QOL in patients with lower rectal tumors. METHODS Patients who underwent anus-preserving surgery for lower rectal tumors between 2014 and 2019 and who had anal defecation between 2020 and 2021 were surveyed. The LARS score measured severity, and the QOL was evaluated using the Japanese version of the Fecal Incontinence Quality-of-Life Scale (JFIQL). The primary endpoint was the incidence of Major LARS, and the secondary endpoints were risk factors and association with the JFIQL. RESULTS Of 107 eligible patients, 82 (76.6%) completed the LARS survey. The incidence of Major LARS was 48%. Independent risk factors included neoadjuvant chemoradiotherapy (CRT) and a short interval (< 24 months after surgery; odds ratio, 4.6; 95% confidence interval: 1.1-19, both). The LARS score was moderately correlated with the JFIQL generic score (correlation coefficient: - 0.54). The JFIQL scores were significantly worse in the Minor and Major LARS groups than in the No LARS group. CONCLUSIONS Major LARS was found in 48% of lower rectal tumors, and independent risk factors include neoadjuvant CRT and a short interval. The QOL was significantly impaired in patients with both Minor and Major LARS.
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Affiliation(s)
- Yuko Homma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan.
| | - Toshiki Mimura
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Koji Koinuma
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Hisanaga Horie
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
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Crean R, Glyn T, McCombie A, Frizelle F. Comparing outcomes and cost in surgery versus watch & wait surveillance of patients with rectal cancer post neoadjuvant long course chemoradiotherapy. ANZ J Surg 2024; 94:1151-1160. [PMID: 38486505 DOI: 10.1111/ans.18916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/07/2024] [Accepted: 02/12/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Watch and wait (W&W) in complete clinical responders after neoadjuvant chemoradiotherapy has increasingly robust data supporting its oncological safety. Recently, studies have assessed the real-world costs of this strategy compared to surgical resection. Our aim was to compare our oncological safety and costs associated with operative and surveillance strategies to international literature. METHODS Data were retrospectively collected and analysed via electronic health records from March 2014 to March 2021 in Christchurch, New Zealand. Two cohorts were created based on intention to treat. All hospital events were recorded and costed, as well as oncologic outcomes. Our primary endpoints were the cumulative cost of both strategies, 3-year survival rate, and disease-free survival. RESULTS Forty-eight patients were identified who had rectal cancers resected (OT) with a yPT0N0 pathology, and 42 who were on the wait-and-watch (W&W) audit after having a clinical complete response. After exclusions, we identified 38 OT and 23 W&W patients; the W&W group were more co-morbid (P = 0.05), had worse functional status (P = 0.008), higher BMI (P = 0.34) and more favourable clinical tumour staging (P = 0.01). The operative treatment (OT) group (n = 38) had more acute admissions (34% versus 13% in W&W, P = 0.08, OR 0.29). There was a 35.7% (n = 8 of 23) local recurrence in W&W and none in the OT group (P ≤ 0.001), with successful salvage in the W&W with local recurrence in 71.5% (n = 5 of 7). Three-year distant metastasis-free rate was 97.3% in the OT group and 90.9% in W&W (p = 0.05). Overall survival was 100% (W&W) and 94.7% (OT); (P = 0.019). Care in the OT group cost more than W&W, accounting for local regrowth management; $NZ70,759.56 versus $NZ47,905.52 (P = 0.014). CONCLUSION This study found better oncological outcomes in the OT group, whilst the W&W group had reduced morbidity and acute bed days. The cost of wait and watch was approximately two-thirds that of operative treatment, even accounting for salvage procedures for local regrowth.
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Affiliation(s)
- Rory Crean
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
| | - Tamara Glyn
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
| | - Andrew McCombie
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
| | - Frank Frizelle
- Department of Surgery, Christchurch Hospital, Health New Zealand, Canterbury, New Zealand
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Gaete MI, Moreno D, Iglesias A, Navarro F, Dreyse J, Cerda J, Durán V, Molina ME, Miguieles R, Urrejola G, Larach JT, Bellolio F. Consistency between POLARS and LARS scores regarding the incidence of low anterior resection syndrome in a Chilean population undergoing rectal surgery secondary to cancer in a high-volume hospital. Colorectal Dis 2024; 26:317-325. [PMID: 38182552 DOI: 10.1111/codi.16852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/19/2023] [Accepted: 12/08/2023] [Indexed: 01/07/2024]
Abstract
AIM The aim of this work was to evaluate the concordance between the low anterior resection syndrome (LARS) and preoperative LARS (POLARS) scores regarding the incidence of LARS in a Chilean population undergoing rectal surgery for cancer in a high-volume hospital. METHOD The LARS score questionnaire, following telephone requests, was used to determine the presence and severity of LARS. The POLARS score was calculated based on variables described previously. Correlations and qualitative and quantitative concordance were evaluated using Spearman's correlation coefficient, the kappa coefficient and the Bland-Altman plot with Lin's concordance correlation coefficient. RESULTS A total of 120 patients met the inclusion criteria: 37.5% underwent neoadjuvant radiotherapy, 61% underwent total mesorectal excision (TME) and 51.6% underwent ostomy. A total of 49% of patients did not present with LARS, whereas 28% had major LARS. The correlation between scales was poor, with a fair qualitative concordance to determine the presence/absence of LARS and a slight qualitative concordance to determine the degree of the intensity. The quantitative concordance was poor. CONCLUSION In the Chilean population, concordance between the LARS and POLARS scores was qualitatively fair to determine the presence/absence of the disease and qualitatively slight to determine the degree of intensity. We do not suggest using the POLARS score in the perioperative period in the Chilean population deliberately, as the score may help to determine the presence/absence of LARS but cannot determine its degree of intensity. Additional evaluations are required to determine the factors contributing to the degree of agreement between the scales.
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Affiliation(s)
- M I Gaete
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - D Moreno
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A Iglesias
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Navarro
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J Dreyse
- Department of Internal Medicine and Critical Patient Center, Clínica Las Condes, Santiago, Chile
| | - J Cerda
- Department of Public Health, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - V Durán
- Department of Digestive Surgery, Experimental Surgery and Simulation Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - M E Molina
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - R Miguieles
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - G Urrejola
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J T Larach
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Bellolio
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
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Koifman E, Armoni M, Gorelik Y, Harbi A, Streltsin Y, Duek SD, Brun R, Mazor Y. Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer. BMC Gastroenterol 2024; 24:31. [PMID: 38216868 PMCID: PMC10787434 DOI: 10.1186/s12876-023-03112-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up. AIMS To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment. METHODS One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires. RESULTS 80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1-8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF. CONCLUSIONS A significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.
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Affiliation(s)
- E Koifman
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel.
| | - M Armoni
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - Y Gorelik
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - A Harbi
- Rambam Health Care Campus, Department of General Surgery, Haifa, Israel
| | - Y Streltsin
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - S D Duek
- Rambam Health Care Campus, Department of General Surgery, Haifa, Israel
| | - R Brun
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
| | - Y Mazor
- Rambam Health Care Campus, Department of Gastroenterology, Haifa, Israel
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
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Homma Y, Mimura T, Koinuma K, Horie H, Lefor AK, Sata N. Low anterior resection syndrome: Incidence and association with quality of life. Ann Gastroenterol Surg 2024; 8:114-123. [PMID: 38250691 PMCID: PMC10797839 DOI: 10.1002/ags3.12724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 01/23/2024] Open
Abstract
Aim Low anterior resection syndrome (LARS) causes devastating symptoms and impairs quality of life (QOL). Although its incidence and risk factors have been reported, these data are scarce in Japan. This study aimed to elucidate the incidence and risk factors of LARS as well as to evaluate its association with QOL in Japanese patients. Method Patients with anal defecation at the time of the survey between November 2020 and April 2021 were included, among those who underwent anus-preserving surgery for rectal tumors between 2014 and 2019 in tertiary referral university hospital. The severity of LARS and QOL were evaluated with the LARS score and the Japanese version of the fecal incontinence quality of life scale (JFIQL), respectively. Primary endpoint was the incidence of major LARS. Secondary endpoints were risk factors and association with JFIQL. Results Of 332 eligible patients, 238 (71.7%) answered the LARS survey completely. The incidence of major LARS was 22% overall, and 48% when limited to lower tumors. Independent risk factors included lower tumors (OR: 7.0, 95% CI: 2.1-23.1, p = 0.001) and surgical procedures with lower anastomoses (OR: 4.6, 95% CI: 1.2-18.5, p = 0.03). The JFIQL generic score correlated moderately with the LARS score (correlation coefficient of -0.65). The JFIQL generic score was also significantly lower in lower tumors. Conclusions The incidence of major LARS is 22% in Japanese patients, and independent risk factors include lower tumors and surgical procedures with lower anastomoses. More severe LARS is associated with worse QOL which is significantly more impaired in patients with lower tumors.
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Affiliation(s)
- Yuko Homma
- Department of Surgery, Division of Gastroenterological, General and Transplant SurgeryJichi Medical UniversityTochigiJapan
| | - Toshiki Mimura
- Department of Surgery, Division of Gastroenterological, General and Transplant SurgeryJichi Medical UniversityTochigiJapan
| | - Koji Koinuma
- Department of Surgery, Division of Gastroenterological, General and Transplant SurgeryJichi Medical UniversityTochigiJapan
| | - Hisanaga Horie
- Department of Surgery, Division of Gastroenterological, General and Transplant SurgeryJichi Medical UniversityTochigiJapan
| | - Alan Kawarai Lefor
- Department of Surgery, Division of Gastroenterological, General and Transplant SurgeryJichi Medical UniversityTochigiJapan
| | - Naohiro Sata
- Department of Surgery, Division of Gastroenterological, General and Transplant SurgeryJichi Medical UniversityTochigiJapan
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Xu LL, Xiang NJ, Cheng TC, Li YX, Chen P, Jiang ZW, Liu XX. Application of electroacupuncture in the prevention of low anterior resection syndrome after rectal cancer surgery. World J Gastrointest Surg 2023; 15:2765-2773. [PMID: 38221997 PMCID: PMC10784840 DOI: 10.4240/wjgs.v15.i12.2765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/10/2023] [Accepted: 11/24/2023] [Indexed: 12/27/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is one of the common postoperative complications in patients with rectal cancer, which seriously affects their postoperative recovery and quality of life (QoL). Electroacupuncture therapy is one of the characteristic therapies of traditional Chinese medicine. There are few reports on the prevention and treatment of LARS by electroacupuncture therapy. AIM To explore the clinical effectiveness of electroacupuncture in managing rectal cancer patients with postoperative LARS. METHODS A total of 50 patients with LARS after rectal cancer surgery were retrospectively selected as the research subjects. According to the treatment methods, they were divided into an observation group (n = 25) and a control group (n = 25). During the four-week treatment period, the control group received standard defecation function training, while the observation group received electroacupuncture care and traditional defecation function training. The anal pressure index (which includes anal resting pressure, anal systolic pressure, and maximum tolerable volume), European Organization of Research and Treatment of Cancer (EORTC) QoL C30 (QLQ-C30) score, LARS Scale (LARSS) score, Wexner anal incontinence scale score, Xu Zhongfa five-item 10-point scale score, and the occurrence of adverse reactions were compared between the two groups before and after treatment. RESULTS The experimental group showed considerably enhanced LARSS scores compared to those in the control group after four weeks of treatment. In the first week, second week, and fourth week, the LARSS score and Wexner anal incontinence scale score decreased, and the Xu Zhong method five-item 10-point scale score increased, with significant differences (P < 0.05). The experimental group showed substantial improvements in anal resting pressure, anal systolic pressure, and maximum tolerance volume after undergoing 4 wk of therapy in the untreated group (P < 0.05). The experimental group's QLQ-C30 score on the EORTC QoL questionnaire was higher than that of the control group during the 1st, 2nd, and 4th wk (P < 0.05). No significant variation between the groups in the frequency of adverse reactions (P > 0.05) was observed. CONCLUSION Electroacupuncture positively impacted LARS following rectal cancer surgery, effectively improving clinical symptoms and anal pressure indicators and patients' standard of life.
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Affiliation(s)
- Lu-Lu Xu
- The First Clinical Medical College, Nanjing University of Traditional Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Neng-Jun Xiang
- The First Clinical Medical College, Nanjing University of Traditional Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Tian-Cheng Cheng
- The First Clinical Medical College, Nanjing University of Traditional Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Yi-Xian Li
- The First Clinical Medical College, Nanjing University of Traditional Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Peng Chen
- The First Clinical Medical College, Nanjing University of Traditional Chinese Medicine, Nanjing 210023, Jiangsu Province, China
| | - Zhi-Wei Jiang
- Department of General Surger, Jiangsu Provincial Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 210029, Jiangsu Province, China
| | - Xin-Xin Liu
- Department of General Surger, Jiangsu Provincial Hospital of Traditional Chinese Medicine Affiliated to Nanjing University of Traditional Chinese Medicine, Nanjing 210029, Jiangsu Province, China
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Brock H, Lambrineas L, Ong HI, Chen WY, Das A, Edsell A, Proud D, Carrington E, Smart P, Mohan H, Burgess A. Preventative strategies for low anterior resection syndrome. Tech Coloproctol 2023; 28:10. [PMID: 38091118 DOI: 10.1007/s10151-023-02872-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques. METHODS A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed. RESULTS Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically. CONCLUSIONS To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.
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Affiliation(s)
- H Brock
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Western General, Melbourne, Australia
| | - L Lambrineas
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - H I Ong
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia.
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia.
| | - W Y Chen
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - A Das
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Edsell
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - D Proud
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | | | - P Smart
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - H Mohan
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Burgess
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
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Zhang R, Luo W, Qiu Y, Chen F, Luo D, Yang Y, He W, Li Q, Li X. Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment. Cancers (Basel) 2023; 15:5011. [PMID: 37894378 PMCID: PMC10605930 DOI: 10.3390/cancers15205011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed. OBJECTIVE AND METHODS To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer. RESULTS The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy. CONCLUSIONS In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.
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Affiliation(s)
- Ruijia Zhang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wenqin Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yulin Qiu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Fan Chen
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Dakui Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yufei Yang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weijing He
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qingguo Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xinxiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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10
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Kang DH. Low anterior resection syndrome: is it predictable? Ann Coloproctol 2023; 39:373-374. [PMID: 37919914 PMCID: PMC10626327 DOI: 10.3393/ac.2023.00647.0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 11/04/2023] Open
Affiliation(s)
- Dong Hyun Kang
- Department of Surgery, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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11
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Muttillo EM, La Franca A, Coppola A, Li Causi FS, Checchelani M, Ceccacci A, Castagnola G, Garbarino GM, Osti MF, Balducci G, Mercantini P. Low Anterior Resection Syndrome (LARS) after Surgery for Rectal Cancer: An Inevitable Price to Pay for Survival, or a Preventable Complication? J Clin Med 2023; 12:5962. [PMID: 37762904 PMCID: PMC10532021 DOI: 10.3390/jcm12185962] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Rectal cancer is frequent and often treated with sphincter-saving procedures that may cause LARS, a syndrome characterized by symptoms of bowel disfunction that may severely affect quality of life. LARS is common, but its pathogenesis is mostly unknown. The aim of this study is to assess the incidence of LARS and to identify potential risk factors. METHODS We performed an observational retrospective single center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, and intra- and peri-operative data. Statistical analysis was conducted, including descriptive statistics and multivariate logistic regression to identify independent risk factors. RESULTS Total LARS incidence was 31%. Statistically significant differences were found in tumor distance from anal verge, tumor extension (pT and diameter) and tumor grading (G). Multivariate analysis identified tumor distance from anal verge and tumor extension as an independent predictive factor for both major and total LARS. Adjuvant therapy, although not significant at univariate analysis, was identified as an independent predictive factor. Time to stoma closure within 10 weeks seems to reduce incidence of major LARS. CONCLUSIONS bold LARS affects a considerable portion of patients. This study identified potential predictive factors that could be useful to identify high risk patients for LARS.
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Affiliation(s)
- Edoardo Maria Muttillo
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Alice La Franca
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Alessandro Coppola
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena 291, 00161 Rome, Italy;
| | - Francesco Saverio Li Causi
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Marzia Checchelani
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Alice Ceccacci
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Giorgio Castagnola
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | | | - Mattia Falchetto Osti
- Radiotherapy Oncology, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy;
| | - Genoveffa Balducci
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Paolo Mercantini
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
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12
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Ryoo S. Low anterior resection syndrome. Ann Gastroenterol Surg 2023; 7:719-724. [PMID: 37663958 PMCID: PMC10472409 DOI: 10.1002/ags3.12695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 09/05/2023] Open
Abstract
Low anterior resection syndrome (LARS) is the distressful defecatory functional problem after sphincter-saving surgery for rectal cancer. Although the symptoms of fecal urgency, frequency, and incontinence may develop in most of the patients after surgery, there is no definitive treatments for LARS. Multifactorial etiologies and various risk factors have been identified, but the reduction of storage capacity in the rectum is one of the main reasons for LARS. Anal sphincter muscle or nerve damage during rectoanal resection or anastomosis construction, and intersphincteric resection for low-lying tumors or hand-sewing anastomosis, are the absolute risk factors for LARS. Preoperative radiotherapy, postoperative complications, such as anastomosis leakage, or longer duration of stoma, are also risk factors. The severity of LARS can be confirmed using the LARS score questionnaire. The questionnaire has been translated to numerous language versions including Korean and have been validated. Diverse empirical treatments, such as loperamide, fiber, probiotics, or enema, have been tried, but the safety and efficacy have not been verified yet. The 5-Hydroxytryptamine (5-HT) receptor antagonist, ramosetron, used for diarrhea-dominant irritable bowel syndrome, is one potential drug for relieving the symptoms of major LARS. A randomized-controlled trial suggested the use of ramosetron could be safe and efficacious for patients who have major LARS after sphincter-saving rectal cancer surgery. Novel techniques or drugs for relieving the symptoms of LARS should be developed more and further studies are necessary.
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Affiliation(s)
- Seung‐Bum Ryoo
- Division of Colorectal Surgery, Department of SurgerySeoul National University Hospital, Seoul National University College of MedicineSeoulKorea
- Colorectal Cancer CenterSeoul National University Cancer HospitalSeoulKorea
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13
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Hashempour MR, Moradi M, Oroomi RG, Daneshvar S, Meysamie A, Nikshoar M, Anaraki F. Assessing the role of anastomotic level in low anterior resection (LAR) surgery among rectal cancer patients in the development of LAR syndrome: a systematic review study. BMC Surg 2023; 23:263. [PMID: 37653424 PMCID: PMC10472547 DOI: 10.1186/s12893-023-02166-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The etiology of LARS has not been elaborated on clearly. Studies have reported neoadjuvant therapy, low-lying rectal cancers, adjuvant therapy and anastomotic leakage as risk factors for the development of LARS. Anastomotic level has also been proposed as a possible risk factor; However, there have been conflicting results. This study aims to evaluate the role of the level of anastomosis as a potential risk factor for the development of LARS. METHOD A systematic literature search was conducted on Pubmed, Scopus, Embase, and Web of Science databases using Mesh terms and non-Mesh terms from 2012 to 2023. Original English studies conducted on rectal cancer patients reporting of anastomotic level and LARS status were included in this study. Eligible studies were assessed regarding quality control with Joanna-Briggs Institute (JBI) questionnaires. RESULTS A total of 396 articles were found using the research queries, and after applying selection criteria 4 articles were selected. A sample population of 808 patients were included in this study with a mean age of 61.51 years with male patients consisting 59.28% of the cases. The Mean assessment time was 15.6 months which revealed a mean prevalence of 48.89% for LAR syndrome. Regression analysis revealed significantly increased risk of LAR syndrome development due to low anastomosis level in all 4 studies with odds ratios of 5.336 (95% CI:3.197-8.907), 3.76 (95% CI: 1.34-10.61), 1.145 (95% CI: 1.141-2.149) and 2.11 (95% CI: 1.05-4.27) for low anastomoses and 4.34 (95% CI: 1.05-18.04) for ultralow anastomoses. CONCLUSIONS LARS is a long-term complication following surgery, leading to reduced quality of life. Low anastomosis level has been reported as a possible risk factor. All of the studies in this systematic review were associated with an increased risk of LARS development among patients with low anastomosis.
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Affiliation(s)
- Mohammad Reza Hashempour
- Colorectal Division of Surgical Ward, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Reza Ghasemian Oroomi
- Colorectal Division of Surgical Ward, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Siamak Daneshvar
- Colorectal Division of Surgical Ward, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alipasha Meysamie
- Community and Preventive Medicine Department, Medical Faculty, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Nikshoar
- Colorectal Division of Surgical Ward, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fakhrosadat Anaraki
- Colorectal Division of Surgical Ward, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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14
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Scognamiglio P, Seeger A, Reeh M, Melling N, Karstens KF, Rösch T, Izbicki JR, Kantowski M, Tachezy M. Challenges in the interdisciplinary treatment of leakages after left-sided colorectal surgery: endoscopic negative pressure therapy, open-pore film drainage therapy and beyond. Int J Colorectal Dis 2023; 38:138. [PMID: 37204614 PMCID: PMC10198851 DOI: 10.1007/s00384-023-04418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE The treatment of anastomotic leakage after left colorectal surgery remains challenging. Since its introduction, endoscopic negative pressure therapy (ENPT) has proven to be advantageous, reducing the necessity of surgical revision. The aim of our study is to present our experience with endoscopic treatment of colorectal leakages and to identify potential factors influencing treatment outcome. METHODS Patients who underwent endoscopic treatment of colorectal leakage were retrospectively analyzed. Primary endpoint was the healing rate and success of endoscopic therapy. RESULTS We identified 59 patients treated with ENPT between January 2009 and December 2019. The overall closure rate was 83%, whereas only 60% of the patients were successfully treated with ENPT and 23% needed further surgery. The time between diagnosis of leakage and uptake of endoscopic treatment did not influence the closure rate, but patients with chronic fistula (> 4 weeks) showed a significantly higher reoperation rate than those with an acute fistula (94% vs 6%, p = 0.01). CONCLUSION ENPT is a successful treatment option for colorectal leakages, which appears to be more favorable when started early. Further studies are still needed to better describe its healing potential, but it deserves an integral role in the interdisciplinary treatment of anastomotic leakages.
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Affiliation(s)
- Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany.
| | - Anja Seeger
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Matthias Reeh
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Karl F Karstens
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Thomas Rösch
- Clinic of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
| | - Marcus Kantowski
- Elisabethinum Medical Care Center, Hamburg, Germany
- Clinic of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Tachezy
- Department of General, Visceral and Thoracic Surgery, University-Hospital Hamburg-Eppendorf, Martini Str. 52, 20246, Hamburg, Germany
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15
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Liu H, Xiong M, Zeng Y, Shi Y, Pei Z, Liao C. Comparison of complications and bowel function among different reconstruction techniques after low anterior resection for rectal cancer: a systematic review and network meta-analysis. World J Surg Oncol 2023; 21:87. [PMID: 36899350 PMCID: PMC9999608 DOI: 10.1186/s12957-023-02977-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/27/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Anastomosis for gastrointestinal reconstruction has been contentious after low anterior resection of rectal cancer for the past 30 years. Despite the abundance of randomized controlled trials (RCTs) on colon J-pouch (CJP), straight colorectal anastomosis (SCA), transverse coloplast (TCP), and side-to-end anastomosis (SEA), most studies are small and lack reliable clinical evidence. We conducted a systematic review and network meta-analysis to evaluate the effects of the four anastomoses on postoperative complications, bowel function, and quality of life in rectal cancer. METHODS We assessed the safety and efficacy of CJP, SCA, TCP, and SEA in adult patients with rectal cancer after surgery by searching the Cochrane Library, Embase, and PubMed databases to collect RCTs from the date of establishment to May 20, 2022. Anastomotic leakage and defecation frequency were the main outcome indicators. We pooled data through a random effects model in a Bayesian framework and assessed model inconsistency using the deviance information criterion (DIC) and node-splitting method and inter-study heterogeneity using the I-squared statistics (I2). The interventions were ranked according to the surface under the cumulative ranking curve (SUCRA) to compare each outcome indicator. RESULTS Of the 474 studies initially evaluated, 29 were eligible RCTs comprising 2631 patients. Among the four anastomoses, the SEA group had the lowest incidence of anastomotic leakage, ranking first (SUCRASEA = 0.982), followed by the CJP group (SUCRACJP = 0.628). The defecation frequency in the SEA group was comparable to those in the CJP and TCP groups at 3, 6, 12, and 24 months postoperatively. In comparison, the defecation frequency in the SCA group 12 months after surgery all ranked fourth. No statistically significant differences were found among the four anastomoses in terms of anastomotic stricture, reoperation, postoperative mortality within 30 days, fecal urgency, incomplete defecation, use of antidiarrheal medication, or quality of life. CONCLUSIONS This study demonstrated that SEA had the lowest risk of complications, comparable bowel function, and quality of life compared to the CJP and TCP, but further research is required to determine its long-term consequences. Furthermore, we should be aware that SCA is associated with a high defecation frequency.
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Affiliation(s)
- Huabing Liu
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Ming Xiong
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yu Zeng
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Yabo Shi
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Zhihui Pei
- Medical College, Nanchang University, Nanchang, 330006, China.,Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China
| | - Chuanwen Liao
- Department of Gastrointestinal Surgery, Jiangxi Provincial People's Hospital, The First Affiliated Hospital of Nanchang Medical College, 152 Aiguo Road, Nanchang, 330006, China.
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16
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Burch J, Wright J, Taylor C, Wilson A, Norton C. 'He's a surgeon, like I'm not going to waste his time': interviews to determine healthcare needs of people with low anterior resection syndrome after rectal cancer surgery. Colorectal Dis 2023; 25:880-887. [PMID: 36633117 DOI: 10.1111/codi.16475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/19/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
AIM The aim of this study was to determine the views of people on their healthcare needs when managing their bowel symptoms following an anterior resection. METHOD One-to-one, semi-structured interviews were undertaken, after consent and completion of three questionnaires. Results were analysed using a modified framework analysis and presented narratively. RESULTS Twenty three participants aged 38-75 years were interviewed; 10 were men. Most had low anterior resection syndrome (LARS) scores indicating 'major LARS', Bowel Function Index scores ranged from 28 to 65. The two most bothersome symptoms were faecal incontinence and unpredictable bowel function. Data were grouped into three broad themes: 'treatment consequences', 'strategies and compromises' and 'healthcare needs.' Each theme had four subthemes, such as 'bowel dysfunction' in the theme 'treatment consequences'. Bowel symptoms were common and persistent. Symptom management often required multiple interventions. Expressed healthcare needs included managing expectations through clinician-led information. Participants needed knowledgeable clinicians to enquire about and assess symptoms, provide and reiterate information as well as making an onward referral to enable symptom management. Peers improved the adaptation process through support and advice. Our findings indicate that participants' needs are not being fully met. CONCLUSION People with LARS have unmet healthcare requirements needed to meet their individual goals. We propose these are addressed by using the acronym 'LARS': a Learned clinician who Asks and assesses bowel symptoms, Revisiting the topic to address new or persisting symptoms as well as Signposting, advising or referring onwards as needed.
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Affiliation(s)
- Jennie Burch
- St Mark's the National Bowel Hospital, London, UK
| | | | - Claire Taylor
- Department of Surgery, London North West University Healthcare NHS Trust, London, UK
| | - Ana Wilson
- Wolfson Unit for Endoscopy, St Mark's Hospital and Departments of Surgery and Cancer, Imperial College London, London, UK.,Department of Surgery, St Mark's Hospital, London, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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17
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Huang MJ, Ye L, Yu KX, Liu J, Li K, Wang XD, Li JP. Development of prediction model of low anterior resection syndrome for colorectal cancer patients after surgery based on machine-learning technique. Cancer Med 2023; 12:1501-1519. [PMID: 35899858 PMCID: PMC9883536 DOI: 10.1002/cam4.5041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/18/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a common postoperative complication in patients with colorectal cancer, which seriously affects their postoperative quality of life. At present, the aetiology of LARS is still unclear, but some risk factors have been studied. Accurate prediction and early management of medical intervention are keys to improving the quality of life of such high-risk patients. OBJECTIVES Based on machine-learning methods, this study used the follow-up results of postoperative patients with colorectal cancer to develop prediction models for LARS and conducted a comparative analysis between the different models. METHODS A total of 382 patients diagnosed with colorectal cancer and undergoing surgery at West China Hospital from April 2017 to December 2020 were retrospectively selected as the development cohort. Logistic regression, support vector machine, decision tree, random forest and artificial neural network algorithms were used to construct the prediction models of the obtained dataset. The models were internally validated using cross-validation. The area under the curve and Brier score measures were used to evaluate and compare the differentiation and calibration degrees of the models. The sensitivity, specificity, positive predictive value and negative predictive value of the different models were described for clinical use. RESULTS A total of 342 patients were included, the incidence of LARS being 47.4% (162/342) during the six-month follow-up. After feature selection, the factors influencing the occurrence of LARS were found to be location, distance, diverting stoma, exsufflation and surgical type. The prediction models based on five machine-learning methods all showed acceptable performance. CONCLUSIONS The five models developed based on the machine-learning methods showed good prediction performance. However, considering the simplicity of clinical use of the model results, the logistic regression model is most recommended. The clinical applicability of these models will also need to be evaluated with external cohort data.
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Affiliation(s)
- Ming Jun Huang
- West China School of Nursing/Day Surgery Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Ye
- West China School of Stomatology, Sichuan University, Chengdu, China.,Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Xin Yu
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Jing Liu
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Xiao Dong Wang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ji Ping Li
- Nursing Department, West China Hospital, Sichuan University, Chengdu, China
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Yan M, Lin Z, Wu Z, Zheng H, Shi M. A predictive nomogram model for low anterior resection syndrome after rectal cancer resection. ANZ J Surg 2022; 92:3224-3231. [PMID: 36527689 DOI: 10.1111/ans.17966] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/17/2022] [Accepted: 07/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to identify risk factors associated with the low anterior resection syndrome (LARS) and to construct a nomogram capable of predicting the risk of LARS in patients who undergo rectal cancer resection. METHODS About 538 patients who had undergone anterior resection were recruited as a development set. In addition, 114 patients with rectal cancer were analysed as a validation set to test the new nomogram. Patients in the development set were grouped into two separate cohorts: those with major LARS and those with minor or no LARS. Multiple logistic regression was conducted to detect risk factors for major LARS. RESULTS The prevalence of major LARS was 40.7%, of minor LARS was 28.6% and the proportion with no LARS was 30.7% in the development set. In multivariate analysis, female gender, preoperative chemoradiation, low tumour height, diverting ileostomy, postoperative anastomotic leakage were shown to be independently associated with major LARS occurring in patients after rectal cancer resection. The area under the curve (AUC) values of the nomogram were 0.726 (95% CI: 0.682-0.769) and 0.750 (95% CI: 0.655-0.845) in the development and validation sets, respectively. The calibration curves and Hosmer-Lemeshow goodness of fit tests showed that the model was acceptably accurate. CONCLUSION A nomogram model based on risk factors could be valuable as a predictor of the probability of major LARS after rectal cancer surgery, and provides a guide that clinical staff can use to take preventive measures for high-risk patients.
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Affiliation(s)
- Mingfang Yan
- Department of Gastrointestinal Surgery, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
| | - Zhenmeng Lin
- Department of Gastrointestinal Surgery, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
| | - Zhiying Wu
- Department of Gastrointestinal Surgery, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Huizhe Zheng
- Department of Anesthesiology Surgery, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
| | - Meiqin Shi
- Department of Operating Theatre, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
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Identification of Risk Factors for Sexual Dysfunction after Multimodal Therapy of Locally Advanced Rectal Cancer and Their Impact on Quality of Life: A Single-Center Trial. Cancers (Basel) 2022; 14:cancers14235796. [PMID: 36497279 PMCID: PMC9736520 DOI: 10.3390/cancers14235796] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/13/2022] [Accepted: 11/22/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Sexual function is crucial for the quality of life and can be highly affected by preoperative therapy and surgery. The aim of this study was to identify potential risk factors for poor sexual function and quality of life. METHODS Female patients were asked to complete the Female Sexual Function Index (FSFI-6). Male patients were demanded to answer the International Index of Erectile Function (IIEF-5). RESULTS In total, 79 patients filled in the questionary, yielding a response rate of 41.57%. The proportion of women was represented by 32.91%, and the median age was 76.0 years (66.0-81.0). Sexual dysfunction appeared in 88.46% of female patients. Severe erectile dysfunction occurred in 52.83% of male patients. Univariate analysis showed female patients (OR: 0.17, 95%CI: 0.05-0.64, p = 0.01), older age (OR: 0.34, 95%CI 0.11-1.01, p = 0.05), tumor localization under 6cm from the anal verge (OR: 4.43, 95%CI: 1.44-13.67, p = 0.01) and extension of operation (APR and ISR) (OR: 0.13, 95%CI: 0.03-0.59, p = 0.01) as significant risk factors for poor outcome. Female patients (OR: 0.12, 95%CI: 0.03-0.62, p = 0.01) and tumors below 6 cm from the anal verge (OR: 4.64, 95%CI: 1.18-18.29, p = 0.03) were shown to be independent risk factors for sexual dysfunction after multimodal therapy in the multivariate analysis. Quality of life was only affected in the case of extensive surgery (p = 0.02). CONCLUSION Higher Age, female sex, distal tumors and extensive surgery (APR, ISR) are revealed risk factors for SD in this study. Quality of life was only affected in the case of APR or ISR.
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