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Dickstein DR, Edwards CR, Rowan CR, Avanessian B, Chubak BM, Wheldon CW, Simoes PK, Buckstein MH, Keefer LA, Safer JD, Sigel K, Goodman KA, Rosser BRS, Goldstone SE, Wong SY, Marshall DC. Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus. Nat Rev Gastroenterol Hepatol 2024; 21:377-405. [PMID: 38763974 DOI: 10.1038/s41575-024-00932-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/21/2024]
Abstract
The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.
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Affiliation(s)
- Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Collin R Edwards
- Department of Radiology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Catherine R Rowan
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Bella Avanessian
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barbara M Chubak
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher W Wheldon
- Department of Social and Behavioral Sciences, College of Public Health at Temple University, Philadelphia, PA, USA
| | - Priya K Simoes
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael H Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laurie A Keefer
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Keith Sigel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B R Simon Rosser
- Division of Epidemiology and Community Health, School of Public Health at University of Minnesota, Minneapolis, MN, USA
| | - Stephen E Goldstone
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Serre-Yu Wong
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deborah C Marshall
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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K C, Jacob AT, Muralee M, Sudham MW, L M, Balakrishnan S. Low Anterior Resection Syndrome and Quality of Life of Patients After Sphincter Preservation Surgery: A Prospective Study. Cureus 2024; 16:e60059. [PMID: 38860066 PMCID: PMC11162878 DOI: 10.7759/cureus.60059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2024] [Indexed: 06/12/2024] Open
Abstract
Background After anterior resection (AR), one of the most debilitating complications is low anterior resection syndrome (LARS) seen in about 64% of patients. The severity of the LARS score was significantly correlated with neoadjuvant treatment, the extent of rectal surgery, complication by the anastomotic leak, female gender, and age < 64 years. In this study, we analyzed the impact of various clinical factors on LARS and also the various domains of quality of life (QoL). Purpose To assess the incidence of LARS in patients undergoing sphincter-sparing surgery for rectal cancer after the patient starts long-term defecating per anus, change in the QoL, and relation to LARS and factors affecting it. Methods One year before, 72 patients who had undergone AR in the Regional Cancer Centre were interviewed by a trained interviewer and data was collected from the file. The questionnaires used were the Wexner Incontinence score, LARS Malayalam Questionnaire, and European Organisation For Research and Treatment of Cancer (EORTC) QLQ C30 Malayalam translations. Statistical measures The LARS score was used to categorize patients into three grades. The scores were compared with clinical and social factors using the χ2 test for association. Continuous variables were compared by the Spearman Rho test. Results Details of patients were studied (male: 55.6% (40) and female: 44.4% (32)). Fifty patients underwent low anterior resection (LAR). The mean LARS score was 25.61, with 47.2% of patients having severe LARS score. The mean Wexner score was 6.84. The relation with type of surgery, approach (laparoscopic vs open), or type of neoadjuvant therapy was not found to be significant. A higher LARS score did not impact overall QoL as assessed by FACT-C. Insomnia and diarrhea symptoms scores were significantly worsened. The pain score was worse for those undergoing stapler anastomosis. Wexner's score was worse for those who had received adjuvant chemotherapy. Role functioning score was better for AR compared to low anterior resection (LAR). Only distance from the anal verge was found to be a significant cause of LARS and was negatively correlated. Discussion LARS of severe degrees were seen in most patients. No modifiable risk factors were significantly found to affect the chance of LARS. However, LARS did not have a significant impact on QoL, neither did the type of surgery. So sphincter preservation can be offered to the patients, but all patients undergoing LAR should be counseled well about the risk of LARS before surgery.
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Affiliation(s)
- Chandramohan K
- Surgical Oncology, Regional Cancer Centre, Trivandrum, IND
| | - Akhil T Jacob
- Surgical Oncology, Regional Cancer Centre, Trivandrum, IND
| | - Madhu Muralee
- Surgical Oncology, Regional Cancer Centre, Trivandrum, IND
| | - Mira W Sudham
- Surgical Oncology, Regional Cancer Centre, Trivandrum, IND
| | - Mayadevi L
- Nursing, Regional Cancer Centre, Trivandrum, IND
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Sakr A, Yang SY, Cho MS, Hur H, Min BS, Lee KY, Kim NK. Long-term bowel functional outcomes following anal sphincter-preserving surgery for upper and middle rectal cancer: a single-center longitudinal study. Ann Coloproctol 2024; 40:27-35. [PMID: 38414121 PMCID: PMC10915532 DOI: 10.3393/ac.2022.01067.0152] [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: 12/04/2022] [Revised: 04/04/2023] [Accepted: 05/01/2023] [Indexed: 02/29/2024] Open
Abstract
PURPOSE Despite advances in neoadjuvant chemoradiotherapy and anal sphincter-preserving surgery for rectal cancer, bowel dysfunction is still unavoidable and negatively affects patients' quality of life. In this longitudinal study, we aimed to investigate the changes in bowel function with follow-up time and the effect of neoadjuvant chemoradiotherapy on bowel function following low anterior resection for rectal cancer. METHODS In this study, 171 patients with upper or middle rectal cancer who underwent low anterior resection between 2012 and 2018 were included. Bowel function was assessed longitudinally with Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores every 6 months after restoration of bowel continuity. Patients with at least 2 follow-up visits were included. RESULTS Overall, 100 patients received neoadjuvant chemoradiotherapy. Urgency, soilage, and fecal incontinence were noted within 24 months in the patients treated with neoadjuvant chemoradiotherapy. After 2 years of follow-up, significant bowel dysfunction and fecal incontinence were observed in the neoadjuvant chemoradiotherapy group. Low tumor level and neoadjuvant chemoradiotherapy were associated with delayed bowel dysfunction. CONCLUSION Neoadjuvant chemoradiotherapy in combination with low tumor level was significantly associated with delayed bowel dysfunction even after 2 years of follow-up. Therefore, careful selection and discussion with patients are paramount.
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Affiliation(s)
- Ahmad Sakr
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Yoon Yang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyuk Hur
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kang Young Lee
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Tirelli F, Lorenzon L, Biondi A, Neri I, Santoro G, Persiani R. Functional outcomes after transanal total mesorectal excision (TaTME): a random forest analysis to predict patients' outcomes. Tech Coloproctol 2023; 27:1037-1046. [PMID: 36871281 PMCID: PMC9985820 DOI: 10.1007/s10151-023-02775-5] [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] [Received: 09/29/2022] [Accepted: 02/13/2023] [Indexed: 03/06/2023]
Abstract
PURPOSE Anorectal, sexual, and urinary dysfunction are common issues after rectal cancer surgery, although seldom explored. The primary aim of this study was to investigate postoperative anorectal functional results. METHODS Patients with mid/low-rectal cancer treated with transanal TME (TaTME) with primary anastomosis with/without diverting stoma between 2015 and 2020 were reviewed and selected if they had a minimum follow-up of 6 months (from the primary procedure or stoma reversal). Patients were interviewed using validated questionnaires and the primary outcome was bowel function based on Low Anterior Resection Syndrome (LARS) scores. Statistical analyses were performed to identify clinical/operative variables correlated with worse outcomes. A random forest (RF) algorithm was computed to classify patients at a greater risk of minor/major LARS. RESULTS Ninety-seven patients were selected out of 154 TaTME performed. Overall, 88.7% of the patients had a protective stoma and 25.8% reported major LARS at mean follow-up of 19.0 months. Statistical analyses documented that age, operative time, and interval to stoma reversal correlated with LARS outcomes. The RF analysis disclosed worse LARS symptoms in patients with longer operative time (> 295 min) and stoma reversal interval (> 5.6 months). If the interval ranged between 3 and 5.6 months, older patients (> 65 years) reported worse outcomes. Finally, no statistical difference was documented when comparing the rate of minor/major LARS in the first 27 cases versus others. CONCLUSION One-quarter of the patients developed major LARS after TaTME. An algorithm based on clinical/operative variables, such as age, operative time, and time to stoma reversal, was developed to identify categories at risk for LARS symptoms.
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Affiliation(s)
- F Tirelli
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Largo Francesco Vito 1, 00168, Rome, Italy
| | - L Lorenzon
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Largo Francesco Vito 1, 00168, Rome, Italy
| | - A Biondi
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Largo Francesco Vito 1, 00168, Rome, Italy.
| | - I Neri
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Largo Francesco Vito 1, 00168, Rome, Italy
| | - G Santoro
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Largo Francesco Vito 1, 00168, Rome, Italy
| | - R Persiani
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Largo Francesco Vito 1, 00168, Rome, Italy
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Lim SL, Wan Zain WZ, Zahari Z, Zakaria AD, Hashim MNM, Wong MPK, Zakaria Z, Ramely R, Sidek ASM. Risk factors associated with low anterior resection syndrome: a cross-sectional study. Ann Coloproctol 2023; 39:427-434. [PMID: 35655395 PMCID: PMC10626329 DOI: 10.3393/ac.2022.00227.0032] [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: 04/01/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Oncological outcomes following rectal cancer surgery have improved significantly over recent decades with lower recurrences and longer overall survival. However, many of the patients experienced low anterior resection syndrome (LARS). This study identified the prevalence and risk factors associated with the development of LARS. METHODS This cross-sectional study involved patients who were diagnosed with rectal cancer and had undergone sphincter-preserving low anterior resection from January 2011 to December 2020. Upon clinic follow-up, patients were asked to complete an interviewed based questionnaire (LARS score) designed to assess bowel dysfunction after rectal cancer surgery. RESULTS Out of 76 patients, 25 patients (32.9%) had major LARS, 10 patients (13.2%) had minor LARS, and 41 patients (53.9%) had no LARS. The height of tumor from anal verge showed an association with the development of major LARS (P=0.039). Those patients with less than 8 cm tumor from anal verge had an increased risk of LARS by 3 times compared to those with 8 cm and above (adjusted odds ratio, 3.11; 95% confidence interval, 1.06-9.13). CONCLUSION Results from our study show that low tumor height was a significant risk factor that has a negative impact on bowel function after surgery. The high prevalence of LARS emphasizes the need for study regarding risk factors and the importance of understanding the pathophysiology of LARS, in order for us to improve patient bowel function and quality of life after rectal cancer surgery.
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Affiliation(s)
- See Liang Lim
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Wan Zainira Wan Zain
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Zalina Zahari
- Faculty of Pharmacy, Universiti Sultan Zainal Abidin (UniSZA), Besut Campus, Besut, Malaysia
| | - Andee Dzulkarnaen Zakaria
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Mohd Nizam Md Hashim
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Michael Pak-Kai Wong
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Zaidi Zakaria
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
| | - Rosnelifaizur Ramely
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Department of Surgery, Universiti Sains Malaysia Hospital, Kubang Kerian, Malaysia
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Mai-Phan TA, Pham VQ. Validation of the Vietnamese version of the low anterior resection syndrome score questionnaire. Ann Coloproctol 2022:ac.2022.00514.0073. [PMID: 36426406 DOI: 10.3393/ac.2022.00514.0073] [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: 07/24/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose The aim of this study was to validate the low anterior resection syndrome (LARS) score questionnaire in the Vietnamese language among Vietnamese patients who underwent sphincter-preserving surgery for rectal cancer. Methods The LARS score questionnaire was translated from English into Vietnamese and then back-translated as recommended internationally. From January 2018 to December 2020, 93 patients who underwent sphincter-preserving surgery completed the Vietnamese version of the LARS score questionnaire together with an anchored question assessing the influence of bowel function on quality of life (QoL). To validate test-retest reliability, patients were requested to answer the LARS score questionnaire twice. Results Ninety-three patients completed the LARS score questionnaire, of whom 89 responded twice. The patients who responded twice were included in the analysis of test-retest reliability. Fifty-eight patients had a "major" LARS score. The LARS score was able to discriminate between patients who were obese and those who were not (P<0.001) and between the low anterior resection and anterior resection procedures (P<0.001). Age and sex were not associated with higher LARS scores (P=0.975). There was a perfect fit between the QoL category question and the LARS score in 56.2% of cases, and a moderate fit was found in 42.7% of cases, showing reasonable convergent validity. The test-retest reliability of 89 patients showed a high intraclass correlation coefficient. Conclusion The Vietnamese version of the LARS score questionnaire is a valid tool for measuring LARS.
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Affiliation(s)
- Tuong-Anh Mai-Phan
- Department of General Surgery, Nhan dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
- Department of Medicine, Nguyen Tat Thanh University, Ho Chi Minh City, Vietnam
| | - Vu Quang Pham
- Department of General Surgery, Nhan dan Gia Dinh Hospital, Ho Chi Minh City, Vietnam
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Laurberg T, Frandsen S, Larsen HM, Lehrskov LL, Graversen SB, Drewes AM, Emmertsen KJ, Krogh K. The impact of type 2 diabetes on long-term gastrointestinal sequelae after colorectal cancer surgery: national population-based study. BJS Open 2022; 6:6673944. [PMID: 35998089 PMCID: PMC9397505 DOI: 10.1093/bjsopen/zrac095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/16/2022] [Accepted: 06/26/2022] [Indexed: 12/24/2022] Open
Abstract
Background Long-term gastrointestinal sequelae are common after colorectal cancer surgery, but the impact of type 2 diabetes (T2D) is unknown. Methods In a cross-sectional design, questionnaires regarding bowel function and quality of life (QoL) were sent to all Danish colorectal cancer survivors, who had undergone surgery between 2001 and 2014 and had more than 2 years follow-up without relapse. The prevalence of long-term gastrointestinal sequelae among colorectal cancer survivors with and without T2D were compared while stratifying for type of surgical resection and adjusting for age, sex, and time since surgery. Results A total of 8747 out of 14 488 colorectal cancer survivors answered the questionnaire (response rate 60 per cent), consisting of 3116 right-sided colonic, 2861 sigmoid, and 2770 rectal resections. Of these, 690 (7.9 per cent) had a diagnosis of T2D before surgery. Survivors with T2D following rectal resection had a 15 per cent (95 per cent c.i. 7.8 to 22) higher absolute risk of major low anterior resection syndrome, whereas survivors with T2D following right-sided and sigmoid resection had an 8 per cent higher risk of constipation (P < 0.001) but otherwise nearly the same long-term risk of bowel symptoms as those without T2D. For all types of colorectal cancer resections, T2D was associated with a 6–10 per cent higher risk of severe pain (P < 0.035) and a 4–8 per cent higher risk of impaired QoL. Conclusion T2D at time of surgery was associated with a higher risk of long-term bowel dysfunction after rectal resection, but not after colon resection excluding a higher risk of constipation. T2D was associated with a slightly higher frequency of severe pain and inferior QoL after both rectal and colonic cancer resection.
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Affiliation(s)
- Tinne Laurberg
- Steno Diabetes Center Aarhus, Aarhus University Hospital , Aarhus , Denmark
| | | | - Helene M Larsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs , Aarhus/Aalborg , Denmark
- Department of Emergency, Regional Hospital Horsens , Horsens , Denmark
| | - Louise L Lehrskov
- The Centre for Physical Activity Research, Copenhagen University Hospital – Rigshospitalet , Copenhagen , Denmark
| | | | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital , Aalborg , Denmark
| | - Katrine J Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs , Aarhus/Aalborg , Denmark
- Department of Surgery, Regional Hospital Randers , Randers , Denmark
| | - Klaus Krogh
- Steno Diabetes Center Aarhus, Aarhus University Hospital , Aarhus , Denmark
- Department of Hepatology and Gastroenterology, Aarhus University Hospital , Aarhus , Denmark
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Pi YN, Xiao Y, Wang ZF, Lin GL, Qiu HZ, Fang XC. Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry. World J Clin Cases 2022; 10:3754-3763. [PMID: 35647175 PMCID: PMC9100741 DOI: 10.12998/wjcc.v10.i12.3754] [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: 11/04/2021] [Revised: 01/08/2022] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The quality of life in patients who develop low anterior resection syndrome (LARS) after surgery for mid-low rectal cancer is seriously impaired. The underlying pathophysiological mechanism of LARS has not been fully investigated.
AIM To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively.
METHODS Patients diagnosed with mid-low rectal cancer were included. The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure. Anorectal functions were assessed by three-dimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery.
RESULTS The study population consisted of 24 patients. The total LARS score was decreased at 6 mo compared with 3 mo after surgery (P < 0.05), but 58.3% (14/24) lasted as major LARS at 6 mo after surgery. The length of the high-pressure zone of the anal sphincter was significantly shorter, the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in all patients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focal pressure defects of the anal canal were detected in 70.8% of patients, and those patients had higher LARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spastic peristaltic contractions from the new rectum to anus were detected in 45.8% of patients, which were associated with a higher LARS score at 3 mo postoperatively (P < 0.05).
CONCLUSION The LARS score decreases over time after surgery in the majority of patients with mid-low rectal cancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spastic peristaltic contractions from the new rectum to anus postoperatively, might be the major pathophysiological mechanisms of LARS.
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Affiliation(s)
- Yan-Na Pi
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zhi-Feng Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Guo-Le Lin
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hui-Zhong Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiu-Cai Fang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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Chen SC, Futaba K, Leung WW, Wong C, Mak T, Ng S, Gregersen H. Functional anorectal studies in patients with low anterior resection syndrome. Neurogastroenterol Motil 2022; 34:e14208. [PMID: 34145694 DOI: 10.1111/nmo.14208] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device. METHODS Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores. KEY RESULTS The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p < 0.01). The resting anal pressure and squeeze pressure were lowest in LARS patients (p < 0.05). The urge volume was 11.8 ± 4.2, 59.6 ± 6.4, and 41.6 ± 6.4 ml in the LARS, FI, and NS groups, respectively (p < 0.001). The expulsion duration did not differ between groups. Defecation indices were lowest in the LARS patients (p < 0.05). ARM-BET confirmed the low urge volume in LARS patients whereas anal pressures did not differ between groups. CONCLUSIONS AND INFERENCES The LARS patients had low anal pressures and urge volume. Most Defecation Indices differed between the LARS group and the other groups.
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Affiliation(s)
- Ssu-Chi Chen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Kaori Futaba
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Wing Wa Leung
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cherry Wong
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Tony Mak
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Simon Ng
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong
| | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Shatin, Hong Kong.,California Medical Innovations Institute, San Diego, CA, USA
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Luo BJ, Zheng MC, Xia Y, Ying Z, Peng JH, Li LR, Pan ZZ, Qin HY. Assessment of defecation function after sphincter-saving resection for mid to low rectal cancer: A cross-sectional study. Eur J Oncol Nurs 2021; 55:102059. [PMID: 34757270 DOI: 10.1016/j.ejon.2021.102059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Bao-Jia Luo
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Mei-Chun Zheng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Yang Xia
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Zhu Ying
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Jian-Hong Peng
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Li-Ren Li
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Zhi-Zhong Pan
- Department of Colorectal Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China
| | - Hui-Ying Qin
- Nursing Department, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, 510060, Guangdong, PR China.
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Cho HM, Kim H, Yoo R, Kim G, Kye BH. Effect of Biofeedback Therapy during Temporary Stoma Period in Rectal Cancer Patients: A Prospective Randomized Trial. J Clin Med 2021; 10:5172. [PMID: 34768692 PMCID: PMC8584867 DOI: 10.3390/jcm10215172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This prospective randomized controlled study was designed to evaluate the effect of biofeedback therapy (BFT) during temporary stoma period to prevent defecation dysfunction after sphincter-preserving surgery (SPS). METHODS Following SPS with temporary stoma, patients were divided according to whether (BFT group) or not (Control group) they received BFT. BFT was performed once or twice a week during the temporary stoma period. Kegel exercise were advised to all the patients. Subjective defecation symptoms were evaluated according to Cleveland Clinic Incontinence Score (CCIS) as primary outcome at 12 months postoperatively. Manometric data of five time-points were also analyzed. RESULTS Twenty-one patients in the BFT group and 23 patients in the control group received anorectal physiologic testing. The incidence of CCIS of more than 9 points, which is the primary end point in this study, was not statistically different between BFT group and control group (p = 1.000). The liquid stool incontinence in the BFT group showed a better tendency (p = 0.06) at 12 months post-SPS. Time-dependent serial changes in maximal sensory threshold (Max RST) was significantly different between the BFT and control groups (p = 0.048). Also, the change of mean resting pressure (MRP) tended to be more stable in the BFT group (p = 0.074). CONCLUSIONS The BFT in the period of temporary stoma may be related to liquid stool incontinence at 12 months post-SPS and lead to stable MRP and better Max RST. Therefore, BFT during temporary stoma might be helpful for preventing and minimizing defecation dysfunction in high risk patients after SPS, NCT01661829).
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Affiliation(s)
- Hyeon-Min Cho
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
| | - Hyungjin Kim
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - RiNa Yoo
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
| | - Gun Kim
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
| | - Bong-Hyeon Kye
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
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12
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Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology and investigation. Neurogastroenterol Motil 2021; 33:e14050. [PMID: 33263938 DOI: 10.1111/nmo.14050] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/12/2020] [Accepted: 11/06/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic constipation is a prevalent disorder that affects patients' quality of life and consumes resources in healthcare systems worldwide. In clinical practice, it is still considered a challenge as clinicians frequently are unsure as to which treatments to use and when. Over a decade ago, a Neurogastroenterology & Motility journal supplement devoted to the investigation and management of constipation was published (2009; 21 (Suppl.2)). This included seven articles, disseminating all themes covered during a preceding 2-day meeting held in London, entitled "Current perspectives in chronic constipation: a scientific and clinical symposium." In October 2018, the 3rd London Masterclass, entitled "Contemporary management of constipation" was held, again over 2 days. All faculty members were invited to author two new review articles, which represent a collective synthesis of talks presented and discussions held during this meeting. PURPOSE This article represents the first of these reviews, addressing epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Clearly, not all aspects of the condition can be covered in adequate detail; hence, there is a focus on particular "hot topics" and themes that are of contemporary interest. The second review addresses management of chronic constipation, covering behavioral, conservative, medical, and surgical therapies.
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Affiliation(s)
- S Mark Scott
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adam D Farmer
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Institute of Applied Clinical Science, University of Keele, Keele, UK
| | - Philip G Dinning
- College of Medicine and Public Health, Flinders Medical Centre, Flinders University & Discipline of Gastroenterology, Adelaide, SA, Australia
| | - Emma V Carrington
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Surgical Professorial Unit, St Vincent's University Hospital, Dublin, Ireland
| | - Marc A Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca E Burgell
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Vic., Australia
| | - Eirini Dimidi
- Department of Nutritional Sciences, King's College London, London, UK
| | - Asma Fikree
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK.,Gastroenterology Department, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Mark Fox
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland.,Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Centre for Integrative Gastroenterology, Klinik Arlesheim, Arlesheim, Switzerland
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, UK.,NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK
| | - Charles H Knowles
- Centre for Neuroscience, Surgery & Trauma, Blizard Institute, Queen Mary University of London, London, UK
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Karen Nugent
- Department of Surgery, Southampton University Hospital NHS Foundation Trust, Southampton, UK
| | - Jose Maria Remes-Troche
- Digestive Physiology and Motility Lab, Medical Biological Research Institute, Universidad Veracruzana, Veracruz, Mexico
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College London, London, UK
| | - Maura Corsetti
- NIHR Nottingham Biomedical Research Centre (BRC), Hospitals NHS Trust and the University of Nottingham, Nottingham University, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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13
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Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl) 2021; 133:1824-1833. [PMID: 32604174 PMCID: PMC7469998 DOI: 10.1097/cm9.0000000000000852] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients’ quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.
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Abstract
Abstract
Introduction With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving resection many patients suffer from severe bowel dysfunction with an impact on quality of life (QoL) – referred to as low anterior resection syndrome (LARS).
Study objective To provide an overview of the current knowledge of LARS regarding symptomatology, occurrence, risk factors, pathophysiology, evaluation instruments and treatment options.
Results LARS is characterized by urgency, frequent bowel movements, emptying difficulties and incontinence, and occurs in up to 50-75% of patients on a long-term basis. Known risk factors are low anastomosis, use of radiotherapy, direct nerve injury and straight anastomosis. The pathophysiology seems to be multifactorial, with elements of anatomical, sensory and motility dysfunction. Use of validated instruments for evaluation of LARS is essential. Currently, there is a lack of evidence for treatment of LARS. Yet, transanal irrigation and sacral nerve stimulation are promising.
Conclusion LARS is a common problem following sphincter-preserving resection. All patients should be informed about the risk of LARS before surgery, and routinely be screened for LARS postoperatively. Patients with severe LARS should be offered treatment in order to improve QoL. Future focus should be on the possibilities of non-resectional treatment in order to prevent LARS.
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15
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Christensen P, IM Baeten C, Espín‐Basany E, Martellucci J, Nugent KP, Zerbib F, Pellino G, Rosen H. Management guidelines for low anterior resection syndrome - the MANUEL project. Colorectal Dis 2021; 23:461-475. [PMID: 33411977 PMCID: PMC7986060 DOI: 10.1111/codi.15517] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023]
Abstract
AIM Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS. METHOD The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project. RESULTS The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts. CONCLUSIONS The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.
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Affiliation(s)
- Peter Christensen
- Department of SurgeryDanish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic OrgansAarhus University HospitalAarhusDenmark
| | - Coen IM Baeten
- Department of SurgeryGroene Hart ZiekenhuisGoudaThe Netherlands
| | | | | | | | - Frank Zerbib
- Gastroenterology DepartmentCHU de BordeauxCentre Medico‐Chirurgical MagellanHôpital Haut‐LévêqueUniversité de BordeauxBordeauxFrance
| | - Gianluca Pellino
- Colorectal SurgeryVall d'Hebron University HospitalBarcelonaSpain,Department of Advanced Medical and Surgical SciencesUniversitá degli Studi della Campania ‘Luigi Vanvitelli’NaplesItaly
| | - Harald Rosen
- Department of Surgical OncologySigmund Freud UniversityViennaAustria
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16
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Abnormal Neuronal Response to Rectal and Anal Stimuli in Patients Treated for Distal Rectal Cancer With High-Dose Chemoradiotherapy Followed By Watchful Waiting. Dis Colon Rectum 2020; 63:1234-1241. [PMID: 33216494 DOI: 10.1097/dcr.0000000000001610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Watchful waiting in patients with rectal cancer with complete clinical response after chemoradiation therapy has gained increased popularity to avoid morbidity and mortality associated with surgery. Irradiation of the pelvis causes bowel dysfunction, but the effect on anorectal sensory function remains obscure in this patient category. OBJECTIVE The aim of this study was to characterize the sensory pathways of the gut-brain axis in patients with rectal cancer treated solely with chemoradiation therapy (nonconventional regime/dose) compared with healthy volunteers. DESIGN This is an explorative study. SETTINGS Sensory evaluation by rectal distension was performed and cortical evoked potentials were recorded during rapid balloon distensions of the rectum and anal canal. Latencies and amplitudes of cortical evoked potentials were compared, and the relative amplitude of 5 spectral bands from recorded cortical evoked potentials was used as an additional proxy of neuronal processing. PATIENTS Patients with rectal cancer solely with chemoradiation therapy (n = 13) a median of 3.2 years ago (range, 2.3-5.6 y) and healthy volunteers (n = 13) were included. MAIN OUTCOME MEASURES Cortical evoked potentials were measured. RESULTS Patients had 35% lower rectal capacity at a maximum tolerable volume (p = 0.007). We found no differences in rectal cortical evoked potential latencies (p = 0.09) and amplitudes (p = 0.38) between groups. However, spectral analysis of rectal cortical evoked potentials showed a decrease in θ (4-8 Hz) and an increase in β (12-32 Hz) band activity in patients (all p < 0.001). Anal cortical potentials showed an increase in α (8-12 Hz) and β and a decrease in γ (32-70 Hz) band activity (all p < 0.001) in patients compared with healthy volunteers. LIMITATIONS This is an explorative study of limited size. CONCLUSIONS Chemoradiation therapy for distal rectal cancer causes abnormal cortical processing of both anal and rectal sensory input. Such central changes may play a role in symptomatic patients, especially when refractory to local treatments. See Video Abstract at http://links.lww.com/DCR/B270. RESPUESTA NEURONAL ANORMAL A ESTÍMULOS RECTALES Y ANALES, EN PACIENTES TRATADOS POR CÁNCER RECTAL DISTAL, CON QUIMIORRADIOTERAPIA DE DOSIS ALTA, SEGUIDA DE ESPERA VIGILANTE: La espera vigilante en pacientes de cáncer rectal, con respuesta clínica completa después de la quimiorradiación, ha ganado una mayor popularidad en evitar la morbilidad y mortalidad asociadas con la cirugía. La irradiación de la pelvis causa disfunción intestinal, pero el efecto sobre la función sensorial ano-rectal sigue siendo no claro, en esta categoría de pacientes.El objetivo de este estudio, fue caracterizar las vías sensoriales del eje intestino-cerebro en pacientes con cáncer rectal, tratados únicamente con quimiorradiación (régimen / dosis no convencional), en comparación con voluntarios sanos.Es un estudio exploratorio.Se realizó una evaluación sensorial por distensión rectal y se registraron los potenciales evocados corticales, durante las distensiones rápidas con balón en recto y canal anal. Se compararon las latencias y amplitudes de los potenciales evocados corticales, y la amplitud relativa de cinco bandas espectrales registradas, de potenciales evocados corticales, se usaron como proxy adicional del procesamiento neuronal.Pacientes de cáncer rectal, únicamente con terapia de quimiorradiación (n = 13) mediana de 3.2 años (rango 2.3-5.6) y voluntarios sanos (n = 13).Potenciales evocados corticales.Pacientes tuvieron una capacidad rectal menor del 35%, al volumen máximo tolerable (p = 0.007). No encontramos diferencias en las latencias potenciales evocadas corticales rectales (p = 0.09) y amplitudes (p = 0.38) entre los grupos. Sin embargo, el análisis espectral de los potenciales evocados corticales rectales, mostró una disminución en theta (4-8 Hz) aumento en beta (12-32 Hz), y actividad en banda en pacientes (todos p <0.001). Los potenciales evocados corticales anales mostraron un aumento en alfa (8-12 Hz) y beta, disminución en gamma (32-70 Hz), y actividad en banda (todos p <0.001), en pacientes comparados a voluntarios sanos.Este es un estudio exploratorio de tamaño limitado.La quimiorradiación para el cáncer rectal distal, ocasiona procesos corticales sensoriales anormales anales y rectales. Tales cambios centrales pueden desempeñar un papel en pacientes sintomáticos, especialmente cuando son refractarios a tratamientos locales. Consulte Video Resumen en http://links.lww.com/DCR/B270.
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Ram E, Meyer R, Carter D, Gutman M, Rosin D, Horesh N. The efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome: a systematic review and meta-analysis. Tech Coloproctol 2020; 24:803-815. [PMID: 32350733 DOI: 10.1007/s10151-020-02231-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/22/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sacral neuromodulation (SNM) has become one of the main treatment options in patients with fecal incontinence. The aim of this study was to determine the efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome (LARS). METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was conducted using the Pubmed, Embase, Ovid, and Cochrane databases, restricted to the English language and to articles published from 2000 to November 2018. RESULTS A total of 434 articles on the efficacy of SNM in the treatment of LARS were retrieved, and 13 studies were included in the final analysis, with a total of 114 patients treated with SNM for LARS The overall success rate excluding study heterogeneity was 83.30% [95% CI (71.33-95.25%)]. Improvement in anal continence was seen in several clinical and functional parameters, including the Wexner Score [10.78 points, 95% CI (8.55-13.02), p < 0.0001], manometric maximum resting pressure [mean improvement of 6.37 mm/Hg, 95% CI (2.67-10.07), p = 0.0007], maximum squeeze pressure [mean improvement of 17.99 mm/Hg, 95% CI (17.42-18.56), p < 0.0001] and maximum tolerated volume [mean improvement of 22.74 ml, 95% CI (10.65-34.83), p = 0.0002]. Quality of life questionnaires also demonstrated significant improvement in patients' quality of life, but were reported only in a small group of included patients. CONCLUSIONS SNM significantly improves symptoms and quality of life in patients suffering from fecal incontinence following low anterior resection.
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Affiliation(s)
- E Ram
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel.
- Tel Aviv University, Tel Aviv, Israel.
| | - R Meyer
- Tel Aviv University, Tel Aviv, Israel
- Department of Gynecology and Obstetrics, Sheba Medical Centre, Tel Hashomer, Israel
| | - D Carter
- Tel Aviv University, Tel Aviv, Israel
- Department of Gastroenterology, Sheba Medical Centre, Tel Hashomer, Israel
| | - M Gutman
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - D Rosin
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - N Horesh
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
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18
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Haas S, Faaborg PM, Gram M, Lundby L, Brock C, Drewes AM, Laurberg S, Krogh K, Christensen P. Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy. Tech Coloproctol 2020; 24:721-730. [PMID: 32323098 DOI: 10.1007/s10151-020-02210-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers. METHODS Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing. RESULTS Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers. CONCLUSIONS Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.
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Affiliation(s)
- S Haas
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark. .,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark.
| | - P M Faaborg
- Department of Surgery, Vejle Hospital, Vejle, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - L Lundby
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
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19
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Sakr A, Yang SY, Kang JH, Cho MS, Han YD, Min BS, Thabet W, Elbanna HG, Morshed M, Kim NK. Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study. J Surg Oncol 2020; 121:365-374. [PMID: 31797383 DOI: 10.1002/jso.25791] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 11/19/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer. METHODS One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients. RESULTS The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively. CONCLUSION ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.
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Affiliation(s)
- Ahmad Sakr
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Seung Yoon Yang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Kang
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Min Soo Cho
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Dae Han
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Soh Min
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Waleed Thabet
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Hosam Ghazy Elbanna
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Mosaad Morshed
- Colorectal Surgery Unit, Department of General Surgery, Mansoura Faculty of Medicine, Mansoura University Hospitals, Mansoura, Egypt
| | - Nam Kyu Kim
- Division of Colorectal Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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20
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van Heinsbergen M, den Haan N, Maaskant-Braat AJ, Melenhorst J, Belgers EH, Leijtens JW, Bloemen JG, Rutten HJ, Bouvy ND, Janssen-Heijnen ML, Konsten JL. Functional bowel complaints and quality of life after surgery for colon cancer: prevalence and predictive factors. Colorectal Dis 2020; 22:136-145. [PMID: 31397962 DOI: 10.1111/codi.14818] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022]
Abstract
AIM Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS-like symptoms and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery. METHOD All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ-C30 and QLQ-CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories. RESULTS A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392-2.528) and a previous diverting stoma (OR 1.84, CI 1.14-2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains. CONCLUSION The results of this study highlight the presence of LARS-like symptoms after surgery for colonic cancer. Patients suffering from major LARS-like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients.
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Affiliation(s)
- M van Heinsbergen
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - N den Haan
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - A J Maaskant-Braat
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - E H Belgers
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - J W Leijtens
- Department of Surgery, Laurentius Medical Centre, Roermond, The Netherlands
| | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - H J Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M L Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J L Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
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21
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van Heinsbergen M, Van der Heijden JAG, Stassen LP, Melenhorst J, de Witte E, Belgers EH, Maaskant-Braat AJG, Bloemen JG, Bouvy ND, Janssen-Heijnen ML, Konsten JL. The low anterior resection syndrome in a reference population: prevalence and predictive factors in the Netherlands. Colorectal Dis 2020; 22:46-52. [PMID: 31344293 DOI: 10.1111/codi.14790] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/15/2019] [Indexed: 02/08/2023]
Abstract
AIM The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after colorectal cancer surgery. There are no data about these complaints and the association with QoL in a reference population. The aim of this study was to assess LARS and the association with QoL in a reference population. METHODS Six hundred patients who visited the outpatient clinic because of general or trauma surgical indications were asked to participate in this study. They received an invitation letter containing three validated questionnaires to assess LARS (assessed with the LARS score) and both general [European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30] and colorectal-specific (EORTC QLQ-CR29) QoL. RESULTS Five hundred and one respondents could be included for the analyses. The median age at inclusion was 68 years and 47.3% were men. Major LARS was observed in 15% of patients (11.4% in men and 18.9% in women, P = 0.021). Women reported more urgency (P = 0.070) and incontinence for both flatus (P < 0.001) and stool (P = 0.063) compared to men. In univariate analyses, women reported major LARS significantly more often than men (OR 1.82; 95% CI 1.10-3.01). Patients with major LARS scored significantly worse in most QoL domains compared to patients with no/minor LARS. CONCLUSION This is the first study demonstrating major LARS and the association with QoL in a reference population of patients without colorectal cancer. Our data can assist in the interpretation of LARS in past and future research about abdominal complaints after colorectal cancer surgery.
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Affiliation(s)
- M van Heinsbergen
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | | | - L P Stassen
- Department of Surgery, Maastricht University Medical Centre+/Uniklinik Aachen, Maastricht, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre+/Uniklinik Aachen, Maastricht, The Netherlands
| | - E de Witte
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - E H Belgers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Centre+/Uniklinik Aachen, Maastricht, The Netherlands
| | - M L Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J L Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
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22
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Impact of radiotherapy on anorectal function in patients with rectal cancer following a watch and wait programme. Radiother Oncol 2019; 132:79-84. [DOI: 10.1016/j.radonc.2018.11.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/19/2018] [Accepted: 11/25/2018] [Indexed: 12/14/2022]
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23
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Thomas G, van Heinsbergen M, van der Heijden J, Slooter G, Konsten J, Maaskant S. Awareness and management of low anterior resection syndrome: A Dutch national survey among colorectal surgeons and specialized nurses. Eur J Surg Oncol 2019; 45:174-179. [DOI: 10.1016/j.ejso.2018.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 08/27/2018] [Accepted: 11/01/2018] [Indexed: 01/05/2023] Open
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24
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Follow-up after surgical treatment in older patients with colorectal cancer: The evaluation of emerging health problems and quality of life after implementation of a standardized shared-care model. J Geriatr Oncol 2019; 10:126-131. [DOI: 10.1016/j.jgo.2018.07.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/22/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022]
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25
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Sun W, Dou R, Chen J, Lai S, Zhang C, Ruan L, Kang L, Deng Y, Lan P, Wang L, Wang J. Impact of Long-Course Neoadjuvant Radiation on Postoperative Low Anterior Resection Syndrome and Quality of Life in Rectal Cancer: Post Hoc Analysis of a Randomized Controlled Trial. Ann Surg Oncol 2018; 26:746-755. [PMID: 30536129 DOI: 10.1245/s10434-018-07096-8] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Neoadjuvant radiation is recommended for locally advanced rectal cancer, with proven benefit in local control but not in disease-free survival. However, the impact of long-course radiation on postoperative bowel function and quality of life (QOL) remains controversial. This study aimed to investigate the impact of long-course neoadjuvant radiation on bowel function and QOL, and to identify risk factors for severe bowel dysfunction. METHODS Patients who underwent long-course neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by radical low anterior resection for locally advanced rectal cancer were recruited from the FOWARC randomized controlled trial. Low anterior resection syndrome (LARS) score and European Organisation for Research and Treatment of Cancer (EORTC) C30/CR29 questionnaires were used to assess bowel function and QOL, respectively. RESULTS Overall, 220 patients responded after a median follow-up of 40.2 months, of whom 119 (54.1%) reported major LARS, 74 (33.6%) reported minor LARS, and 27 (12.3%) reported no LARS. Compared with the nCT group, the nCRT group reported more major LARS (64.4% vs. 38.6%, p < 0.001) and worse QOL. Long-course neoadjuvant radiation (OR 2.20, 95% CI 1.24-3.91; p = 0.007), height of anastomosis (OR 0.74, 95% CI 0.63-0.88; p < 0.001), and diverting ileostomy (OR 2.59, 95% CI 1.27-5.30; p = 0.009) were independent risk factors for major LARS. CONCLUSIONS Long-course neoadjuvant radiation, along with low anastomosis, are likely independent risk factors for postoperative bowel function and QOL. Our findings might have implications for alleviating LARS and improving QOL by informing selection of neoadjuvant treatment.
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Affiliation(s)
- Weipeng Sun
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ruoxu Dou
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China. .,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jiaohua Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Sicong Lai
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Chi Zhang
- Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Lei Ruan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Liang Kang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yanhong Deng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Department of Medical Oncology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ping Lan
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Lei Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China. .,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
| | - Jianping Wang
- Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China. .,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China.
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26
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Abstract
Multidisciplinary management of infra-peritoneal rectal cancer has pushed back the frontiers of sphincter preservation, without impairment of carcinological outcome. However, functional intestinal sequelae, grouping together several symptoms known under the name of anterior resection syndrome (ARS), have emerged and become an increasingly frequent concern for both patients and physicians. The pathophysiology is complex: ARS is a combination in various degrees of stool frequency, incontinence for flatus and/or stools, urgency, and disorders in discrimination and evacuation. The "Low Anterior Resection Score" (LARS), validated in 2012, is currently used to evaluate the severity of ARS and its impact on quality of life. While ARS can show improvement over the first two years, symptoms persist for longer than two years in nearly 60% of patients and in half of these patients, ARS is considered severe. The most frequently reported independent risk factors of severe ARS include neo-adjuvant radiation therapy, the extent of resection (total mesorectal excision that includes inter-sphincteric resection), absence of colonic pouch and anastomotic leak. In the absence of surgical complications and/or local recurrence, physicians can draw from a wide therapeutic armamentarium in order to improve the functional outcome of patients, including diet and lifestyle modifications, gut motility regulators, multimodal rehabilitation (biofeedback, electro-stimulation) and sacral nerve modulation. Permanent colostomy is an alternative of last resort, proposed only when all other solutions fail. A better understanding of the natural history of ARS, its risk factors as well as the array of therapeutic alternatives should provide better patient information and optimize management.
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27
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Bowel dysfunction after sigmoid resection underestimated: Multicentre study on quality of life after surgery for carcinoma of the rectum and sigmoid. Eur J Surg Oncol 2018; 44:1261-1267. [DOI: 10.1016/j.ejso.2018.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 01/11/2023] Open
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28
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Abnormal neuronal response to rectal and anal stimuli in patients treated with primary radiotherapy for anal cancer. Radiother Oncol 2018; 128:369-374. [DOI: 10.1016/j.radonc.2018.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 03/25/2018] [Accepted: 04/10/2018] [Indexed: 01/08/2023]
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Hou G, Song R, Yang J, Zhang Y, Xiao C, Wang C, Yuan J, Chai T, Liu Z. Treatment effect of conversion therapy and its correlation with VEGF expression in unresectable rectal cancer with liver metastasis. Oncol Lett 2018; 16:749-754. [PMID: 29963141 PMCID: PMC6019978 DOI: 10.3892/ol.2018.8758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 02/20/2018] [Indexed: 12/20/2022] Open
Abstract
To investigate the therapeutic effect of conversion therapy and its correlation with vascular endothelial growth factor (VEGF) expression in unresectable rectal cancer with liver metastasis. A total of 116 cases of unresectable rectal cancer patients with liver metastasis were randomly divided into control and observation group, 58 cases in each group, all of these patients were treated by conversion therapy, patients in control were treated by FOLFOXIRI treatment program, and in observation group were treated by FOLFOXIRI program treatment and bevacizumab. Efficacy and adverse reactions were compared between the two groups, the levels of VEGF in portal vein and the expression of VEGF in cancer tissue were compared, after 5 years of follow-up, the prognosis of the two groups were observed. Objective efficiency and conversion rate of observation was significantly higher than the control group, survival rate of postoperative observation was significantly higher than that of control group (P>0.05). There was no significant difference in adverse reactions between the two groups (P>0.05). The positive rate of VEGF in portal vein blood and the expression of VEGF in the observation was significantly lower than that in the control group (P<0.05). The 5-year survival rate of VEGF high expression was significantly lower than that of VEGF low expression group (P<0.05). FOLFOXIRI combined with bevacizumab in patients with unresectable hepatic metastasis of rectal cancer can provide higher conversion rate and hepatectomy opportunities, and reduce VEGF expression in patients with unresectable rectal cancer, which is closely related to VEGF expression, therefore it is beneficial to better local control and to improve long-term survival.
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Affiliation(s)
- Ge Hou
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Rui Song
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Jun Yang
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Yanling Zhang
- Department of Oncology, The Third People's Hospital of Zhengzhou University, Zhengzhou, Henan 450000, P.R. China
| | - Chenhu Xiao
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Cheng Wang
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Jinjin Yuan
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Ting Chai
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
| | - Zongwen Liu
- Department of Tumor Radiotherapy, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450014, P.R. China
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30
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Haas S, Faaborg P, Liao D, Laurberg S, Gregersen H, Lundby L, Christensen P, Krogh K. Anal sphincter dysfunction in patients treated with primary radiotherapy for anal cancer: a study with the functional lumen imaging probe. Acta Oncol 2018; 57:465-472. [PMID: 29447025 DOI: 10.1080/0284186x.2018.1438658] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Sphincter-sparing radiotherapy or chemoradiation are standard treatments for patients with anal cancer. The ultimate treatment goal is full recovery from anal cancer with preserved anorectal function. Unfortunately, long-term survivors often suffer from severe anorectal symptoms. The aim of the present study was to characterize changes in anorectal physiology after radiotherapy for anal cancer. METHOD We included 13 patients (10 women, age 63.4 ± 1.9) treated with radiotherapy or chemoradiation for anal cancer and 14 healthy volunteers (9 women, age 61.4 ± 1.5). Symptoms were assessed with scores for fecal incontinence and low anterior resection syndrome. Anorectal physiology was examined with anorectal manometry and the Functional Lumen Imaging Probe. RESULTS Patients had a median Wexner fecal incontinence score of 5 (0-13) and a median LARS score of 29 (0-39). Compared to healthy volunteers, patients had lower mean (±SE) anal -resting (38 ± 5 vs. 71 ± 6, p < .001) and -squeeze pressures (76 ± 11 vs. 165 ± 15, p < .001). Patients also had lower anal yield pressure (15.5 ± 1.3 mmHg vs. 28.0 ± 2.0 mmHg, p < .001), higher distensibility, and lower resistance to flow (reduced resistance ratio of the anal canal during distension, q = 5.09, p < .001). No differences were found in median (range) rectal volumes at first sensation (70.5 (15-131) vs. 57 (18-132) ml, p > .4), urge (103 (54-176) vs. 90 (32-212), p > .6) or maximum tolerable volume (173 (86-413) vs. 119.5 (54-269) ml, p > .10). CONCLUSION Patients treated with radiotherapy or chemoradiation for anal cancer have low anal resting and squeeze pressures as well as reduced resistance to distension and flow.
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Affiliation(s)
- Susanne Haas
- Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus N, Denmark
| | - Pia Faaborg
- Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus N, Denmark
- Department of Surgery, Vejle Hospital, Vejle, Denmark
| | - Donghua Liao
- GIOME Academia, Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus N, Denmark
| | - Hans Gregersen
- GIOME, Department of Surgery, Prince of Wales Hospital and Chinese University of Hong Kong, Hong Kong, Hong Kong SAR
| | - Lilly Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus N, Denmark
| | - Peter Christensen
- Department of Surgery, Aarhus University Hospital, Aarhus N, Denmark
- Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus N, Denmark
| | - Klaus Krogh
- Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus N, Denmark
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Århus C, Denmark
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31
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Ihnát P, Slívová I, Tulinsky L, Ihnát Rudinská L, Máca J, Penka I. Anorectal dysfunction after laparoscopic low anterior rectal resection for rectal cancer with and without radiotherapy (manometry study). J Surg Oncol 2017; 117:710-716. [PMID: 29094352 DOI: 10.1002/jso.24885] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/23/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES The aim was to evaluate the impact of radiotherapy (RT) on anorectal function of patients with low rectal cancer undergoing low anterior resection (LAR). METHODS Prospective clinical cohort study conducted to assess the functional outcome by means of high-resolution anorectal manometry and LARS score. RESULTS In total, 65 patients were enrolled in the study (27 patients underwent LAR without RT, 38 patients underwent RT and LAR). There were no statistically significant differences between study subgroups regarding demographic and clinical data; postoperative morbidity was significantly higher in irradiated patients. One year after the surgery, mean LARS score was significantly higher in patients who underwent RT and surgery. Major LARS was detected in 37.0% of irradiated patients and in 14.8% of patients after surgery alone. Anorectal manometry revealed significantly lower resting pressures in patients after RT and LAR; the squeeze pressures were similar. Rectal compliance and all volumes describing rectal sensitivity (first sensation, urge to defecate, and discomfort volume) were significantly lower in irradiated patients. CONCLUSIONS RT significantly deteriorates the functional outcome of patients after LAR. Manometry revealed internal sphincter dysfunction, reduced capacity, and compliance of neorectum, which seem to have a significant correlation with LARS presence/seriousness.
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Affiliation(s)
- Peter Ihnát
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Ivana Slívová
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Lubomir Tulinsky
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Lucia Ihnát Rudinská
- Department of Forensic Medicine, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jan Máca
- Department of Anaesthesiology and Resuscitation, University Hospital Ostrava, Ostrava, Czech Republic
| | - Igor Penka
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic.,Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
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Bowel Dysfunction After Low Anterior Resection With Neoadjuvant Chemoradiotherapy or Chemotherapy Alone for Rectal Cancer: A Cross-Sectional Study from China. Dis Colon Rectum 2017; 60:697-705. [PMID: 28594719 DOI: 10.1097/dcr.0000000000000801] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Neoadjuvant therapy plays a vital role in the treatment of locally advanced rectal cancer but impairs bowel function after restorative surgery. Optimal decision making requires adequate information of functional outcomes. OBJECTIVE This study aimed to assess postoperative bowel function and to identify predictors for severe dysfunction. DESIGN The study included a cross-sectional cohort and retrospective assessments of pelvic anatomic features. SETTINGS The study was conducted at a tertiary GI hospital in China. PATIENTS Included patients underwent neoadjuvant chemoradiotherapy or chemotherapy without radiation and curative low anterior resection for rectal cancer between 2012 and 2014. MAIN OUTCOME MEASURES Bowel function was assessed using the validated low anterior resection syndrome score. The thicknesses of the rectal wall, obturator internus, and levator ani were measured by preoperative MRI. RESULTS A total of 151 eligible patients were identified, and 142 patients (94.0%) participated after a median of 19 months from surgery. Bowel dysfunction was observed in 71.1% (101/142) of patients, with 44.4% (63/142) reporting severe dysfunction. Symptoms of urgency and clustering were found to be major disturbances. Regression analysis identified preoperative long-course radiotherapy (p < 0.001) and a lower-third tumor (p = 0.002) independently associated with severe bowel dysfunction. Irradiated patients with a lower-third tumor (OR = 14.06; p < 0.001) or thickening of the rectal wall (OR = 11.09; p < 0.001) had a markedly increased risk of developing severe dysfunction. LIMITATIONS The study was based on a limited cohort of patients and moderate follow-up after the primary surgery. CONCLUSIONS Bowel function deteriorates frequently after low anterior resection for rectal cancer. Severe bowel dysfunction is significantly associated with preoperative long-course radiotherapy and a lower-third tumor, and the thickening of rectal wall after radiation is a strong predictor. Treatment decisions and patient consent should be implemented with raising awareness of bowel symptom burdens. See Video Abstract at http://links.lww.com/DCR/A317.
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Biviano I, Balla A, Badiali D, Quaresima S, D'Ambrosio G, Lezoche E, Corazziari E, Paganini AM. Anal function after endoluminal locoregional resection by transanal endoscopic microsurgery and radiotherapy for rectal cancer. Colorectal Dis 2017; 19:O177-O185. [PMID: 28304143 DOI: 10.1111/codi.13656] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 12/29/2016] [Indexed: 12/16/2022]
Abstract
AIM In patients with rectal cancer, surgery and chemoradiotherapy may affect anal sphincter function. Few studies have evaluated anorectal function after neoadjuvant chemoradiotherapy (n-CRT) and/or transanal endoscopic microsurgery (TEM). The aim of this study was to evaluate the effects of n-CRT and TEM on anorectal function. METHOD Thirty-seven patients with rectal cancer underwent anorectal manometry and Wexner scoring for faecal incontinence at baseline, after n-CRT (cT2-T3N0 cancer) and at 4 and 12 months after surgery. Water-perfused manometry measured anal tone at rest and during squeezing, rectal sensitivity and compliance. Twenty-seven and 10 patients, respectively, underwent TEM without (Group A) or with n-CRT (Group B). RESULTS In Group A, anal resting pressure decreased from 68 ± 23 to 54 ± 26 mmHg at 4 months (P = 0.04) and improved 12 months after surgery (60 ± 30 mmHg). The Wexner score showed a significant increase in gas incontinence (59%), soiling (44%) and urgency (37%) rates at 4 months, followed by clinical improvement at 1 year (41%, 26% and 18%, respectively). In group B, anal resting pressure decreased from 65 ± 23 to 50 ± 18 mmHg at 4 months but remained stable at 12 months (44 ± 11 mmHg, P = 0.02 vs preoperative values - no significant difference compared with evaluation at 4 months). Gas incontinence, soiling and urgency were observed in 50%, 50%, 25% and in 38%, 12% and 12% of cases, respectively, 4 and 12 months after treatment. CONCLUSION TEM does not significantly affect anal function. Instead, n-CRT does affect anal function but without causing major anal incontinence.
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Affiliation(s)
- I Biviano
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A Balla
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - D Badiali
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - S Quaresima
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - G D'Ambrosio
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - E Lezoche
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
| | - E Corazziari
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Rome, Italy
| | - A M Paganini
- Department of General Surgery and Surgical Specialties 'Paride Stefanini', Sapienza University of Rome, Rome, Italy
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Sturiale A, Martellucci J, Zurli L, Vaccaro C, Brusciano L, Limongelli P, Docimo L, Valeri A. Long-term functional follow-up after anterior rectal resection for cancer. Int J Colorectal Dis 2017; 32:83-88. [PMID: 27695976 DOI: 10.1007/s00384-016-2659-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. METHOD Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. RESULTS A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. CONCLUSIONS Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.
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Affiliation(s)
- Alessandro Sturiale
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy.
| | - Jacopo Martellucci
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Letizia Zurli
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Carla Vaccaro
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Luigi Brusciano
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Paolo Limongelli
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Ludovico Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Andrea Valeri
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
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Kye BH, Kim HJ, Kim G, Yoo RN, Cho HM. The Effect of Biofeedback Therapy on Anorectal Function After the Reversal of Temporary Stoma When Administered During the Temporary Stoma Period in Rectal Cancer Patients With Sphincter-Saving Surgery: The Interim Report of a Prospective Randomized Controlled Trial. Medicine (Baltimore) 2016; 95:e3611. [PMID: 27149496 PMCID: PMC4863813 DOI: 10.1097/md.0000000000003611] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
We evaluated the effect of biofeedback therapy (BFT) on anorectal function after stoma closure when administered during the interval of temporary stoma after sphincter-preserving surgery for rectal cancer.Impaired anorectal function is common after lower anterior resections, though no specific treatment options are currently available to prevent this adverse outcome.Fifty-six patients who underwent neoadjuvant chemoradiation therapy after sphincter-preserving surgery with temporary stoma were randomized into 2 groups: group 1 (received BFT during the temporary stoma period) and group 2 (did not receive BFT). To evaluate anorectal function, anorectal manometry was performed in all patients and subjective symptoms were evaluated using the Cleveland Clinic Incontinence Score. The present study is a report at 6 months after rectal resection.Forty-seven patients, including 21 in group 1 and 26 in group 2, were evaluated by anorectal manometry. Twelve patients (57.1%) in group 1 and 13 patients (50%) in group 2 were scored above 9 points of Cleveland Clinic Incontinence Score, which is the reference value for fecal incontinence (P = 0.770). With time, there was a significant difference (P = 0.002) in the change of mean resting pressure according to time sequence between the BFT and control groups.BFT during the temporary stoma interval had no effect on preventing anorectal dysfunction after temporary stoma reversal at 6 months after rectal resection. However, BFT might be helpful for maintaining resting anal sphincter tone (NCT01661829).
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Affiliation(s)
- Bong-Hyeon Kye
- From the Department of Surgery, St Vincent's Hospital, The Catholic University of Korea, Korea
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Bondeven P, Emmertsen KJ, Laurberg S, Pedersen BG. Neoadjuvant therapy abolishes the functional benefits of a larger rectal remnant, as measured by magnetic resonance imaging after restorative rectal cancer surgery. Eur J Surg Oncol 2015. [PMID: 26219852 DOI: 10.1016/j.ejso.2015.07.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The combination of advances in surgical technique and neoadjuvant therapy for rectal cancer has resulted in more patients undergoing sphincter-preserving surgery. Unfortunately, numerous patients subsequently experience bowel dysfunction, and may suffer from lifelong severe disability with major impact on their quality of life. The aim of the present study was to investigate whether the risk of severe LARS in patients was associated with the length of remnant rectum. METHODS A total of 125 patients who underwent sphincter-preserving surgery for rectal cancer were included. Postoperative bowel function was assessed using the low anterior resection syndrome (LARS) score a minimum of one year following surgery. The length of remnant rectum was measured on postoperative MRI of the pelvis and was correlated with the risk of having major LARS. RESULTS Overall, major LARS was observed in 38 per cent of patients. In the patients who underwent surgery alone, major LARS was reported by 27 per cent, and a larger remnant rectum was associated with a better functional outcome. In contrast, 80 per cent of patients who underwent combined preoperative chemoradiotherapy and surgery reported having major LARS. No association between the length of remnant rectum and the risk of major LARS was observed in patients treated with combined neoadjuvant therapy and surgery. CONCLUSION Both the length of remnant rectum and preoperative chemoradiotherapy had a major impact on the severity of bowel dysfunction after restorative rectal cancer surgery. No functional benefit from an irradiated rectal remnant was observed.
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Affiliation(s)
- P Bondeven
- Aarhus University Hospital, Department of Surgery P, Tage-Hansensgade 2, 8000 Aarhus, Denmark; Aarhus University Hospital, Department of Radiology, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - K J Emmertsen
- Aarhus University Hospital, Department of Surgery P, Tage-Hansensgade 2, 8000 Aarhus, Denmark
| | - S Laurberg
- Aarhus University Hospital, Department of Surgery P, Tage-Hansensgade 2, 8000 Aarhus, Denmark
| | - B G Pedersen
- Aarhus University Hospital, Department of Radiology, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Kye BH, Kim HJ, Cho HM, Kim JG, Kim SH, Shim BY. Reduced luminal circumference of tumors plays a key role in anorectal function during the early period after neoadjuvant chemoradiation therapy in rectal cancer patients. Int J Colorectal Dis 2015; 30:465-74. [PMID: 25712808 DOI: 10.1007/s00384-015-2155-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 02/04/2023]
Abstract
PURPOSE The deterioration of anorectal function after neoadjuvant chemoradiation therapy (nCRT) combined with surgery for rectal cancer has not been well defined. The aim of this study was to evaluate the relationship between the tumor response to nCRT and changes in anorectal function during a short-term period after nCRT. METHODS We analyzed 100 consecutive patients with available preoperative anorectal manometry data, both before and after nCRT, from 2010 to 2013. RESULTS Comparing the manometric data before and after nCRT, the values reflecting rectal sensory function after nCRT was significantly lower than those before nCRT. However, in patients who experienced changed tumor morphology and a reduction in luminal circumferential ratio (LCIR) of tumor after nCRT, the values reflecting rectal sensory function were significantly less decreased after nCRT. On multivariate analysis, the reduction of LCIR after nCRT was a very important factor preventing the impairment of anorectal function during the short-term period in terms of the first rectal sensory threshold (RST) (P = 0.002), the RST of "desire to defecate" (P = 0.006), and rectal compliance (P = 0.003). Additionally, in linear regression analysis, the RST for the desire to defecate was positively affected by tumor morphology (P = 0.015) and the reduced LCIR (P = 0.025), and rectal compliance was positively affected by the reduced LCIR (P = 0.001). CONCLUSION The nCRT impaired significantly rectal sensory function during the short-term period after nCRT and before a radical operation. However, this reduced LCIR of tumors after nCRT may prevent or minimize impediments to anorectal function during the short-term period after nCRT.
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Affiliation(s)
- Bong-Hyeon Kye
- Department of Surgery, St. Vincent Hospital, The Catholic University of Korea, 93-6, Ji-dong, Paldal-gu, Suwon-si, Gyeonggi-do, 442-723, Korea
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Nielsen M, Rasmussen P, Pedersen B, Hagemann-Madsen R, Lindegaard J, Laurberg S. Early and Late Outcomes of Surgery for Locally Recurrent Rectal Cancer: A Prospective 10-Year Study in the Total Mesorectal Excision Era. Ann Surg Oncol 2015; 22:2677-84. [DOI: 10.1245/s10434-014-4317-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Indexed: 12/21/2022]
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Bregendahl S, Emmertsen KJ, Lindegaard JC, Laurberg S. Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study. Colorectal Dis 2015; 17:26-37. [PMID: 25156386 DOI: 10.1111/codi.12758] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/29/2014] [Accepted: 07/15/2014] [Indexed: 02/08/2023]
Abstract
AIM Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction. METHOD All living female patients who underwent abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ-FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009. RESULTS Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties (OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions (OR = 4.77, 95% CI 1.97-11.55), dyspareunia (OR = 2.76, 95% CI 1.12-6.79), lack of desire (OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity (OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia (OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties (OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence (OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire (OR = 2.69, 95% CI 1.21-5.98), sexual inactivity (OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction (OR = 0.40, 95% CI 0.20-0.82). CONCLUSION Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction.
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Affiliation(s)
- S Bregendahl
- Surgical Research Unit, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
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Petersen SE, Bregendahl S, Langschwager M, Laurberg S, Brock C, Drewes AM, Krogh K, Høyer M, Lundby L. Pathophysiology of late anorectal dysfunction following external beam radiotherapy for prostate cancer. Acta Oncol 2014; 53:1398-404. [PMID: 24960583 DOI: 10.3109/0284186x.2014.926029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Patients treated with external beam radiotherapy (EBRT) may suffer from long-term anorectal adverse effects. The purpose of the present study was to assess long-term functional and structural anorectal changes in patients previously treated with EBRT for prostate cancer and to suggest the mechanism behind the development of the adverse effects. MATERIAL AND METHODS Our previously proposed RT-induced anorectal dysfunction (RT-ARD) score, developed with the intention to survey anorectal dysfunction was used to identify patients with and without anorectal symptoms. Among 309 patients surveyed with the questionnaire, we chose 23 patients with the highest RT-ARD score and 19 patients with the lowest RT-ARD score. They were investigated by multimodal rectal sensory stimulation, standard anal physiological tests. Changes of the rectal mucosa were assessed by flexible sigmoidoscopy and graded by the Vienna Rectoscopy Score (VRS). RESULTS The mean follow-up time was 3.8 (range, 2.8; 8.6) years in patients with high RT-ARD and 3.8 (range, 2.6; 5.9) in patients with low RT-ARD. Endoscopic evaluation revealed higher VRS scores in patients with high RT-ARD compared to patients with low RT-ARD (p = 0.002). Patients with high RT-ARD had increased rectal sensory response to distension manifested both as volume (p = 0.006) and cross-sectional area (p = 0.04), and they had reduced maximum anal resting pressure assessed by anal manometri (p = 0.02). CONCLUSIONS Long-term anorectal symptoms correlate to changes in anorectal biomechanical properties and rectal mucosal injury. Our data suggests that RT-induced long-term anorectal dysfunction is multifactorial caused by injury of the rectal mucosa and the internal anal sphincter combined with increased rectal sensitivity and reduced rectal functional capacity.
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