Evaluation of Postoperative Damage to Anal Sphincter/Levator Ani Muscles with Three-Dimensional Vector Manometry after Sphincter-Preserving Operation for Rectal Cancer

Low anterior resection syndrome following rectal cancer surgery: are incidence and severity lower with long-term follow-up?

BACKGROUND

Low anterior resection syndrome (LARS) is a functional disorder that may follow restorative proctectomy. The aim of this study was to evaluate the long-term incidence and risk factors for LARS following surgery for rectal cancer.

METHODS

A retrospective study was performed on patients from a prospectively maintained database, who underwent a restorative proctectomy between January 2014 and December 2019 at Hadassah Hebrew University Medical Center. The study cohort was divided into two groups: patients following partial proctectomy with a partial mesorectal excision and a colorectal anastomosis (PME group) and patients following total proctectomy with total mesorectal excision and a coloanal anastomosis (TME group). The incidence and severity of LARS were evaluated using the LARS questionnaire. Risk factors for LARS were also evaluated.

RESULTS

A total of 240 patients (male: female ratio 134:106, median age 64 years [interquartile range 55-71 years]) were included in the analysis. There were 160 patients in the PME group and 80 patients in the TME group. The overall incidence of LARS was 37.4% (26.5% major LARS and 10.9% minor LARS). Major LARS was observed in 53.8% of patients who underwent TME and in 12.7% of patients who underwent PME (p < 0.001). On multivariate analysis, distance of the anastomosis from the anal verge, TME, and neoadjuvant radiotherapy were independent prognostic factors for LARS. The incidence and severity of LARS were significantly lower in patients with longer follow-up (p = 0.05).

CONCLUSIONS

Significant improvement in LARS can be expected with longer follow-up. Distance of the anastomosis from the anal verge, TME and neoadjuvant radiotherapy are independent risk factors for LARS.

Defecation disorder and anal function after surgery for lower rectal cancer in elderly patients

AIM

This study aims to investigate the association of patient age with defecation disorders and anal function after lower rectal cancer surgery.

METHODS

We retrospectively reviewed the data of 141 consecutive patients with lower rectal cancer who underwent sphincter-preserving operation. The patients were classified into five categories by age thresholds at 65, 70, 75, 80, and 85 years, for disaggregate analysis. Anal manometry was used for measuring the maximum resting pressure, high-pressure zone, and maximum squeeze pressure. Anal manometry was performed preoperatively and at 3, 6, 9, and 12 months postoperatively. The Wexner and low anterior resection syndrome scores were assessed at 1, 3, 6, 9, and 12 months after rectal surgery or stoma closure for patients with ileostomy.

RESULTS

The data of 117 patients were reviewed. No significant differences were found between the younger and elderly groups in any characteristics across the six age groups. The preoperative intra-anal pressures of the elderly patients were slightly lower than those of the younger patients; however, there was no significant difference in the course of postoperative intra-anal pressures. Defecation disorder, as measured by the Wexner and low anterior resection syndrome scores, improved significantly in elderly patients compared to younger patients.

CONCLUSION

There was no significant difference in the course of postoperative intra-anal pressures between the elderly and younger patients. However, defecation disorders in elderly patients significantly improved compared with younger patients. Sphincter-preserving operation can be a viable treatment option for active elderly patients.

[Low anterior resection syndrome-Causes and treatment approaches]

BACKGROUND

With improvement of the oncological prognosis and more sphincter-preserving procedures for rectal cancer of the lower third, the functional sequelae of anterior rectal resection become more and more predominant and are summarized under the term low anterior resection syndrome (LARS).

MATERIAL AND METHODS

In this narrative review the causes, associated factors, prevalence, diagnostics and treatment strategies are presented based on an evaluation of the international literature.

RESULTS

The central role of the rectum in the physiology of defecation and continence explains the frequency of symptoms following anterior rectal resection. In an unselected patient population a major LARS is to be expected in approximately 40% and a minor LARS in approximately 20%. The most important factor is the length of the remaining rectal stump. The diagnosis of LARS is made clinically and can be quantified by scores, especially by the LARS score. Treatment options range from patient counselling to stoma construction and a symptom-related, stepwise approach is generally accepted.

CONCLUSION

While the evidence for the causes, the quantification and determination of associated factors of LARS is good, the treatment options are based either on experience or on only few studies.

Preservation of the Arterial Arc Formed by Left Colic Artery, Proximal Inferior Mesenteric Artery, and the First Branch of Sigmoid Arteries in Anus Saving Treatment of Low Rectal Cancer

BACKGROUND

Low anterior, ultralow anterior, and intersphincteric resection are conventional, elective anus-sparing techniques for low rectal cancer, and good prognosis depends on a good blood supply and tension-free anastomosis.

AIM

The goal is to assess the effect of preserving the arc formed by the left colic and proximal inferior mesenteric arteries (IMAs), and first branch of the sigmoid arteries on the anastomotic blood supply, tension, and leakage rate in anus-sparing surgery for low rectal cancer.

METHOD

From 2011 to 2020, a patient with low rectal cancer resection was distributed into the ligation group (42 cases with inferior mesenteric artery ligation) and the preservation group (61 cases with preservation of the left colic and proximal IMAs and first branch of the sigmoid artery).

RESULTS

We evaluated patient characteristics, operative results, morbidity, and postoperative follow-up results. There were comparable outcomes between ligation and preservation groups in relations to the number of patients in each operative procedure, duration of surgery, operative blood loss, postoperative hospital stay, and the number of patients with protective stoma (P >.05). In postoperative morbidity, there were similar outcomes between ligation and preservation groups in terms of anastomotic subclinical dehiscence, bleeding and stricture, and urinary retention (P >.05). There were significant differences in anastomotic leakage and intra-abdominal abscess (P < .05).

CONCLUSION

Preservation of the arterial arc formed by left colic artery, proximal IMA, and the first branch of sigmoid arteries with apical lymph node dissection could increase anastomotic blood supply, reduce anastomotic tension, and leakage rate in anus-saving treatment of low rectal cancer.

CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION

Anterior rectal resection is a standard surgical procedure for treating carcinomas of rectum and distal sigmoid colon. In many cases of anterior rectal resection, postoperatively some level of fecal incontinence may occur. The aim of our study was to evaluate the impact of the colorectal anastomosis level on anorectal functional disorder. In our prospective study, the participants were patients diagnosed with carcinoma of rectum or distal sigmoid colon. All patients underwent standard open or laparoscopic anterior rectal resection. Six months after the surgery, the function of anorectum was evaluated in all participants. Finally, 38 patients were analyzed, including 13/38 (34.2%) patients with high rectal anastomosis, 11/38 (28.9%) with mid rectal anastomosis and 14/38 (36.8%) with low rectal anastomosis. Patients with a lower level of anastomosis had a statistically significantly greater number of stools, higher urgency and discrimination impairment, more pronounced solid, liquid and gas incontinence, and greater need for diapers (p<0.05 all). Therefore, patients with lower anastomosis had a statistically significant impairment of their quality of life and higher Wexner score (p<0.001 for both analyses). Our study results suggested reduced neorectal capacity to be the main pathophysiological factor for the development of postoperative anorectal function impairment.

Optimising functional outcomes in rectal cancer surgery

Background

By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention.

Purpose

This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted.

Conclusion

Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Safety and feasibility of laparoscopic intersphincteric resection for a lower rectal tumor

The aim of the present study was to evaluate the short-term surgical outcomes of laparoscopic intersphincteric resection (ISR) for a lower rectal tumor in comparison with a case-control series of patients undergoing open ISR. Quality of life factors and anal function were also evaluated. Between July 2008 and April 2013, 103 patients with lower rectal cancer underwent laparoscopic surgery at the Surgical Oncology Department of Gifu University School of Medicine. A total of 25 patients with lower rectal cancer underwent ISR, and 19/25 patients who underwent laparoscopic ISR were compared with the control group of 6 patients who underwent open ISR. The technical feasibility and safety of ISR, and the short- and long-term outcomes following laparoscopic ISR were evaluated. Additional data associated with fecal incontinence conditions of the postoperative patients were evaluated using the Modified Fecal Incontinence Quality of Life scale. There was no recorded perioperative mortality, three complications were observed to occur in three patients and the morbidity rate was 15.8%. The postoperative complications detected included bleeding in one patient and ileus in two patients of the laparoscopic ISR group. The rate of severe complications of grade ≥3a was 15.8% and that of grade ≥3b was 5.3%. In the matched case-control study, blood loss was significantly lower in the laparoscopic ISR group. The median postoperative hospital stay was 14.1 days in the laparoscopic ISR group, which was significantly shorter compared with in the open ISR group (18.7 days). Cancer recurrence was detected in one (5%) patient in a single inguinal lymph node. No significant differences between the ISR and ultra-low anterior resection (ULAR) groups were observed in the maximum resting and maximum squeeze pressures; the outcomes for anal function and fecal incontinence were the same for ISR and ULAR. Thus, laparoscopic ISR for lower rectal cancer may provide a benefit in the early postoperative period without increasing morbidity or mortality.

The functional results of radical rectal cancer surgery: review of the literature

Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called "low anterior resection syndrome" (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.

Synthesis and summary of patient-reported outcome measures to inform the development of a core outcome set in colorectal cancer surgery

AIM

Patient-reported outcome (PRO) measures (PROMs) are standard measures in the assessment of colorectal cancer (CRC) treatment, but the range and complexity of available PROMs may be hindering the synthesis of evidence. This systematic review aimed to: (i) summarize PROMs in studies of CRC surgery and (ii) categorize PRO content to inform the future development of an agreed minimum 'core' outcome set to be measured in all trials.

METHOD

All PROMs were identified from a systematic review of prospective CRC surgical studies. The type and frequency of PROMs in each study were summarized, and the number of items documented. All items were extracted and independently categorized by content by two researchers into 'health domains', and discrepancies were discussed with a patient and expert. Domain popularity and the distribution of items were summarized.

RESULTS

Fifty-eight different PROMs were identified from the 104 included studies. There were 23 generic, four cancer-specific, 11 disease-specific and 16 symptom-specific questionnaires, and three ad hoc measures. The most frequently used PROM was the EORTC QLQ-C30 (50 studies), and most PROMs (n = 40, 69%) were used in only one study. Detailed examination of the 50 available measures identified 917 items, which were categorized into 51 domains. The domains comprising the most items were 'anxiety' (n = 85, 9.2%), 'fatigue' (n = 67, 7.3%) and 'physical function' (n = 63, 6.9%). No domains were included in all PROMs.

CONCLUSION

There is major heterogeneity of PRO measurement and a wide variation in content assessed in the PROMs available for CRC. A core outcome set will improve PRO outcome measurement and reporting in CRC trials.

Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery

Background

Defaecatory function is often poor after anterior resection. Denervation of the neorectum following high ligation of the inferior mesenteric artery (IMA) is a possible cause of impaired defaecatory function. The purpose of this randomized clinical trial was to clarify whether the level of ligation of the IMA in patients with rectal cancer affects defaecatory function.

Methods

Between 2008 and 2011, patients who underwent anterior resection for rectal cancer were randomized to receive either high or low ligation of the IMA. The primary endpoint was to demonstrate the superiority of low ligation in terms of defaecatory function.

Results

One hundred patients were enrolled in the study; 51 were randomized to high ligation of the IMA and 49 to low ligation. There were no differences between the groups in terms of clinical data, except tumour stage, which was more advanced in the high-ligation group (P = 0·046). Nor were there any differences in defaecatory function, self-assessment of defaecation, Faecal Incontinence Quality of Life scale or continence score between groups at 3 months and 1 year. The number of harvested lymph nodes was similar. The rate of symptomatic anastomotic leakage was 16 per cent in the high-ligation group and 10 per cent in the low-ligation group (P = 0·415).

Conclusion

The level of ligation of the IMA in patients with rectal cancer did not affect defaecatory function or the incidence of postoperative complications. Registration number: NCT00701012 (http://www.clinicaltrials.gov).

Pelvic floor muscle training for bowel dysfunction following colorectal cancer surgery: A systematic review

AIMS

To identify, evaluate and synthesize the evidence examining the effectiveness of pelvic floor muscle training (PFMT) on bowel dysfunction in patients who have undergone colorectal cancer surgery.

METHODS

Eight electronic databases (MEDLINE 1950-2014; CINAHL 1982-2014; EMBASE 1980-2014; Scopus 1823-2014; PsycINFO 1806-2014; Web of Science 1970-2014; Cochrane Library 2014; PEDro 1999-2014) were systematically searched in March 2014. Reference lists of identified articles were cross referenced and hand searched. Randomized controlled trials, cohort studies and case series were included if they investigated the effects of conservative treatments, including PFMT on bowel function in patients with colorectal cancer following surgery. Two reviewers independently assessed the risk of bias of studies using the Newcastle-Ottawa Scale (NOS).

RESULTS

Six prospective non-randomized studies and two retrospective studies were included. The mean (SD) NOS risk of bias score was 4.9 (1.2) out of 9; studies were limited by a lack of non-exposed cohort, lack of independent blinded assessment, heterogeneous treatment protocols, and lack of long-term follow-up. The majority of studies reported significant improvements in stool frequency, incontinence episodes, severity of fecal incontinence, and health-related quality of life (HRQoL) after PFMT. Meta-analysis was not possible due to lack of randomized controlled trials.

CONCLUSIONS

Pelvic floor muscle training for patients following surgery for colorectal cancer appears to be associated with improvements in bowel function and HRQoL. Results from non-randomized studies are promising but randomized controlled trials with sufficient power are needed to confirm the effectiveness of PFMT in this population.