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Ota E, Nagasaki T, Akiyoshi T, Mukai T, Hiyoshi Y, Yamaguchi T, Fukunaga Y. Incidence and risk factors of bowel dysfunction after minimally invasive rectal cancer surgery and discrepancies between the Wexner score and the low anterior resection syndrome (LARS) score. Surg Today 2024; 54:763-770. [PMID: 38170223 DOI: 10.1007/s00595-023-02789-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/14/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE Bowel dysfunction after sphincter-preserving-surgery (SPS) impacts quality of life. The Wexner score (WS) and the low anterior resection syndrome (LARS) score (LS) are instruments for assessing postoperative bowel dysfunction. We analyzed the incidence of and risk factors for each symptom and examined the discrepancies between the two scores. METHODS A total of 142 patients with rectal cancer, who underwent minimally invasive SPS between May, 2018 and July, 2019, were included. A questionnaire survey using the two scores was given to the patients 2 years after SPS. RESULTS Tumor location and preoperative radiotherapy were independent risk factors for major LARS. Intersphincteric resection with a hand-sewn anastomosis (HSA) was an independent risk factor for high WS. Among the patients who underwent HSA, 82% experienced incontinence for liquid stools, needed to wear pads, and suffered lifestyle alterations. Of the 35 patients with minor LARS, only 1 had a high WS, and 80.0% reported no lifestyle alterations. Among the 75 patients with major LARS, 58.7% had a low WS and 21.3% reported no lifestyle alterations. CONCLUSION The results of this study provide practical data to help patients understand potential bowel dysfunction after SPS. The discrepancies between the WS and LS were clarified, and further efforts are required to utilize these scores in clinical practice.
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Affiliation(s)
- Emi Ota
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiya Nagasaki
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Takashi Akiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Toshiki Mukai
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yukiharu Hiyoshi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tomohiro Yamaguchi
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yosuke Fukunaga
- Gastroenterological Center, Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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Meyer VM, Bosch N, van der Heijden JAG, Kalkdijk-Dijkstra AJ, Pierie JPEN, Beets GL, Broens PMA, Klarenbeek BR, van Westreenen HL. Long-Term Functional Outcome After Early vs. Late Stoma Closure in Rectal Cancer Surgery: Sub-analysis of the Multicenter FORCE Trial. J Gastrointest Cancer 2024:10.1007/s12029-024-01062-2. [PMID: 38922517 DOI: 10.1007/s12029-024-01062-2] [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: 04/21/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE The aim of this study was to assess the effect of early stoma closure on bowel function after low anterior resection (LAR) for rectal cancer. METHODS Patients participating in the FORCE trial who underwent LAR with protective stoma were included in this study. Patients were subdivided into an early closure group (< 3 months) and late closure group (> 3 months). Endpoints of this study were the Wexner Incontinence, low anterior resection syndrome (LARS), EORTC QLQ-CR29, and fecal incontinence quality of life (FIQL) scores at 1 year. RESULTS Between 2017 and 2020, 38 patients had received a diverting stoma after LAR for rectal cancer and could be included. There was no significant difference in LARS (31 vs. 30, p = 0.63) and Wexner score (6.2 vs. 5.8, p = 0.77) between the early and late closure groups. Time to stoma closure in days was not a predictor for LARS (R2 = 0.001, F (1,36) = 0.049, p = 0.83) or Wexner score (R2 = 0.008, F (1,36) = 0.287, p = 0.60) after restored continuity. There was no significant difference between any of the FIQL domains of lifestyle, coping, depression, and embarrassment. In the EORTC QLQ-29, body image scored higher in the late closure group (21.3 vs. 1.6, p = 0.004). CONCLUSION Timing of stoma closure does not appear to affect long-term bowel function and quality of life, except for body image. To improve functional outcome, attention should be focused on other contributing factors.
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Affiliation(s)
- V M Meyer
- Dept of Surgery, Isala Hospitals, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands.
- Dept of Surgery, University Medical Center Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands.
| | - N Bosch
- Dept of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - J A G van der Heijden
- Dept of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - A J Kalkdijk-Dijkstra
- Dept of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - J P E N Pierie
- Post Graduate School of Medicine (PGSOM), University Medical Center Groningen and University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
- Dept of Surgery, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - G L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, The Netherlands
- GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - P M A Broens
- Dept of Surgery, University Medical Center Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - B R Klarenbeek
- Dept of Surgery, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525GA, Nijmegen, The Netherlands
| | - H L van Westreenen
- Dept of Surgery, Isala Hospitals, Dokter Van Heesweg 2, 8025 AB, Zwolle, The Netherlands
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Garfinkle RC, McKenna NP. Low Anterior Resection Syndrome following Restorative Proctectomy for Rectal Cancer: Can the Surgeon Have Any Meaningful Impact? Cancers (Basel) 2024; 16:2307. [PMID: 39001370 PMCID: PMC11240414 DOI: 10.3390/cancers16132307] [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: 06/05/2024] [Revised: 06/20/2024] [Accepted: 06/22/2024] [Indexed: 07/16/2024] Open
Abstract
Postoperative bowel dysfunction following restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long term sequela of rectal cancer treatment. While many of the established risk factors for LARS are non-modifiable, others may be well within the surgeon's control. Several pre-, intra-, and postoperative decisions may have a significant impact on postoperative bowel function. Some of these factors include the extent of surgical resection, surgical approach, choice of anastomotic reconstruction, and use of fecal diversion. This review article summarizes the available evidence regarding how surgical decision-making can affect postoperative bowel function.
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Affiliation(s)
| | - Nicholas P. McKenna
- Division of Colon and Rectal Surgery, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA;
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Rutegård M, Jutesten H, Buchwald P, Angenete E, Lydrup ML. Minor impact of anastomotic leakage in anterior resection for rectal cancer on long-term male urinary and sexual function. Int J Colorectal Dis 2024; 39:49. [PMID: 38589520 PMCID: PMC11001750 DOI: 10.1007/s00384-024-04626-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE Anastomotic leakage after anterior resection for rectal cancer induces bowel dysfunction, but the influence on urinary and sexual function is largely unknown. This cross-sectional cohort study evaluated long-term effect of anastomotic leakage on urinary and sexual function in male patients. METHODS Patients operated with anterior resection for rectal cancer in 15 Swedish hospitals 2007-2013 were identified. Anastomotic leakage and other clinical variables were retrieved from the Swedish Colorectal Cancer Registry and medical records. Urinary and sexual dysfunction were evaluated at 4 to 11 years after surgery using the International Prostate Symptom Score, International Index of Erectile Function, and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire CR29. The effect of anastomotic leakage on average scores of urinary and sexual dysfunction was evaluated as a primary outcome, and the single items permanent urinary catheter and sexual inactivity as secondary outcomes. The association of anastomotic leakage and functional outcomes was analyzed using regression models with adjustment for confounders. RESULTS After a median follow-up of 84 months (interquartile range: 67-110), 379 out of 864 eligible men were included. Fifty-nine (16%) patients had anastomotic leakage. Urinary incontinence was more common in the leakage group, with an adjusted mean score difference measured by EORTC QLQ ColoRectal-29 of 8.69 (95% confidence interval: 0.72-16.67). The higher risks of urinary frequency, permanent urinary catheter, and sexual inactivity did not reach significance. CONCLUSION Anastomotic leakage after anterior resection had a minor negative impact on urinary and sexual function in men.
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Affiliation(s)
- Martin Rutegård
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Henrik Jutesten
- Department of Surgery, Institution for Clinical Sciences Malmö, Lund University, Skåne University Hospital Malmö, Carl-Bertil Laurells Gata 9, 205 02, Malmö, Sweden
| | - Pamela Buchwald
- Department of Surgery, Institution for Clinical Sciences Malmö, Lund University, Skåne University Hospital Malmö, Carl-Bertil Laurells Gata 9, 205 02, Malmö, Sweden
| | - Eva Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital/Östra, Region Västra Götaland, Gothenburg, Sweden
| | - Marie-Louise Lydrup
- Department of Surgery, Institution for Clinical Sciences Malmö, Lund University, Skåne University Hospital Malmö, Carl-Bertil Laurells Gata 9, 205 02, Malmö, Sweden.
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McFeetors C, O'Connell LV, Choy M, Dundon N, Regan M, Joyce M, Meshkat B, Hogan A, Nugent E. Influence of neoadjuvant treatment strategy on perioperative outcomes in locally advanced rectal cancer. Colorectal Dis 2024; 26:684-691. [PMID: 38424706 DOI: 10.1111/codi.16929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/20/2023] [Accepted: 12/28/2023] [Indexed: 03/02/2024]
Abstract
AIM Neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer facilitates tumour downstaging and complete pathological response (pCR). The goal of neoadjuvant systemic chemotherapy (total neoadjuvant chemotherapy, TNT) is to further improve local and systemic control. While some patients forgo surgery, total mesorectal excision (TME) remains the standard of care. While TNT appears to be noninferior to nCRT with respect to short-term oncological outcomes few data exist on perioperative outcomes. Perioperative morbidity including anastomotic leaks is associated with a negative effect on oncological outcomes, probably due to a delay in proceeding to adjuvant therapy. Thus, we aimed to compare conversion rates, rates of sphincter-preserving surgery and anastomosis formation rates in patients undergoing rectal resection after either TNT or standard nCRT. METHODS An institutional colorectal oncology database was searched from January 2018 to July 2023. Inclusion criteria comprised patients with histologically confirmed rectal cancer who had undergone neoadjuvant therapy and TME. Exclusion criteria comprised patients with a noncolorectal primary, those operated on emergently or who had local excision only. Outcomes evaluated included rates of conversion to open, sphincter-preserving surgery, anastomosis formation and anastomotic leak. RESULTS A total of 119 patients were eligible for inclusion (60 with standard nCRT, 59 with TNT). There were no differences in rates of sphincter preservation or primary anastomosis formation between the groups. However, a significant increase in conversion to open (p = 0.03) and anastomotic leak (p = 0.03) was observed in the TNT cohort. CONCLUSION In this series TNT appears to be associated with higher rates of conversion to open surgery and higher anastomotic leak rates. While larger studies will be required to confirm these findings, these factors should be considered alongside oncological benefits when selecting treatment strategies.
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Affiliation(s)
- Carson McFeetors
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Lauren V O'Connell
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Megan Choy
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Niamh Dundon
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Mark Regan
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Myles Joyce
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Babak Meshkat
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Aisling Hogan
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
| | - Emmeline Nugent
- Department of Colorectal Surgery, University Hospital Galway, Co. Galway, Ireland
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Lucarini A, Guida AM, Orville M, Panis Y. Indocyanine green fluorescence angiography could reduce the risk of anastomotic leakage in rectal cancer surgery: a systematic review and meta-analysis of randomized controlled trials. Colorectal Dis 2024; 26:408-416. [PMID: 38247221 DOI: 10.1111/codi.16868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/17/2023] [Accepted: 12/24/2023] [Indexed: 01/23/2024]
Abstract
AIM Several papers have shown that use of indocyanine green (ICG) decreases incidence of anastomotic leakage (AL) during colonic surgery, but no clear evidence has been found for rectal cancer surgery. Therefore, with this systematic review and meta-analysis of randomized controlled trials (RCTs) we aimed to assess if ICG could also reduce risk of AL in rectal cancer surgery. METHOD PubMed, Scopus, CINAHL and Cochrane databases were searched for RCTs assessing the effect of intraoperative ICG on the incidence of AL of the colorectal anastomosis. Pooled relative risk (RR) and pooled risk difference (RD) were obtained using models with random effects. Risk of bias was evaluated with the Rob2 tool and the quality of evidence was assessed using the GRADE Pro tool. RESULTS Four RCTs were included for analysis, with a total of 1510 patients (743 controls and 767 ICG patients). The rate of AL was 9% in the ICG group (69/767) and 13.9% (103/743) in the control group (p = 0.003, RR -0.5, 95% CI -0.827 to -0.172, heterogeneity test 0%, p = 0.460). The RD in terms of incidence of AL was significantly decreased by 4.51% (p = 0.031, 95% CI -0.086 to -0.004, heterogeneity test 28%, p = 0.182) when using ICG. CONCLUSION Our meta-analysis suggested that use of ICG during rectal cancer surgery could reduce the rate of AL.
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Affiliation(s)
- Alessio Lucarini
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
- Surgical and Medical Department of Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Andrea Martina Guida
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
- Department of Surgical Science, University Tor Vergata, Rome, Italy
| | - Marion Orville
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
| | - Yves Panis
- Colorectal Surgery Center, Groupe Hospitalier Privé Ambroise Paré-Hartmann, Neuilly/Seine, France
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Tomminen T, Huhtala H, Kotaluoto S, Veitonmäki T, Wirta EV, Hyöty M. Surgical and oncological results after rectal resections with or without previous treatment for prostate cancer. Front Surg 2024; 11:1298865. [PMID: 38362461 PMCID: PMC10867186 DOI: 10.3389/fsurg.2024.1298865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/15/2024] [Indexed: 02/17/2024] Open
Abstract
Introduction Previous treatment for prostate cancer (PC) may potentially affect the surgical and oncological outcomes of subsequent rectal cancer surgery, but there are only a few studies regarding this particular group. In this study, we present the 3-year surgical and oncological results of rectal cancer patients who had received previous treatment for PC at a single Finnish tertiary referral centre. Material and methods Data regarding all male patients diagnosed with rectal cancer and treated at Tampere University Hospital (TAUH) between 1997 and 2016 were gathered from medical records. In total, this study included 553 rectal cancer patients who underwent curative surgery, and 54 of them (9.8%) had a prior history of treatment for prostate cancer. Results Patients in the PC group were older and had more comorbidities compared with those in the non-PC group. The PC patients had a significantly higher risk of permanent stoma compared with the non-PC patients (61.5% vs. 45.2%, respectively, p = 0.025). The PC patients seemed to have lower tumours than the non-PC patients (87% vs. 75%, respectively, p = 0.05). Overall, the 3-year overall survival (OS) for the PC and non-PC patients was 74.1% and 80.6%, respectively. No significant differences were observed between the study groups even in the age-adjusted comparison [hazard ratio (HR): 1.07, confidence interval (CI) 95%: 0.60-1.89]. In the univariable analysis, radically operated patients without a history of PC exhibited an improved overall survival, (HR: 2.46, 95% CI: 1.34-4.53, p = 0.004). However, only a higher age-adjusted Charlson comorbidity index (CCI) and a low tumour location (<10 cm) were found to have an independent prognostic impact on worse OS in the multivariable analysis (HR: 1.57, 95% CI: 1.36-1.82, p < 0.001 and HR: 2.74, 95% CI: 1.32-5.70, p = 0.007, respectively). No significant differences were observed between the groups in terms of disease-free or local recurrence-free survival. Conclusion Rectal cancer is more frequently found in the middle or lower part of the rectum in patients who have previously received treatment for prostate cancer. These patients also have a higher likelihood of requiring a permanent stoma. In radically operated rectal cancer, the PC group had a worse OS rate, according to the univariable analysis. However, the only independent prognostic factors for a worse OS that were highlighted in the multivariable analysis included a higher CCI and a low tumour location.
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Affiliation(s)
- T. Tomminen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - H. Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - S. Kotaluoto
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - T. Veitonmäki
- Department of Urology, Tampere University Hospital, Tampere, Finland
| | - E.-V. Wirta
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - M. Hyöty
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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Gaete MI, Moreno D, Iglesias A, Navarro F, Dreyse J, Cerda J, Durán V, Molina ME, Miguieles R, Urrejola G, Larach JT, Bellolio F. Consistency between POLARS and LARS scores regarding the incidence of low anterior resection syndrome in a Chilean population undergoing rectal surgery secondary to cancer in a high-volume hospital. Colorectal Dis 2024; 26:317-325. [PMID: 38182552 DOI: 10.1111/codi.16852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/19/2023] [Accepted: 12/08/2023] [Indexed: 01/07/2024]
Abstract
AIM The aim of this work was to evaluate the concordance between the low anterior resection syndrome (LARS) and preoperative LARS (POLARS) scores regarding the incidence of LARS in a Chilean population undergoing rectal surgery for cancer in a high-volume hospital. METHOD The LARS score questionnaire, following telephone requests, was used to determine the presence and severity of LARS. The POLARS score was calculated based on variables described previously. Correlations and qualitative and quantitative concordance were evaluated using Spearman's correlation coefficient, the kappa coefficient and the Bland-Altman plot with Lin's concordance correlation coefficient. RESULTS A total of 120 patients met the inclusion criteria: 37.5% underwent neoadjuvant radiotherapy, 61% underwent total mesorectal excision (TME) and 51.6% underwent ostomy. A total of 49% of patients did not present with LARS, whereas 28% had major LARS. The correlation between scales was poor, with a fair qualitative concordance to determine the presence/absence of LARS and a slight qualitative concordance to determine the degree of the intensity. The quantitative concordance was poor. CONCLUSION In the Chilean population, concordance between the LARS and POLARS scores was qualitatively fair to determine the presence/absence of the disease and qualitatively slight to determine the degree of intensity. We do not suggest using the POLARS score in the perioperative period in the Chilean population deliberately, as the score may help to determine the presence/absence of LARS but cannot determine its degree of intensity. Additional evaluations are required to determine the factors contributing to the degree of agreement between the scales.
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Affiliation(s)
- M I Gaete
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - D Moreno
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - A Iglesias
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Navarro
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J Dreyse
- Department of Internal Medicine and Critical Patient Center, Clínica Las Condes, Santiago, Chile
| | - J Cerda
- Department of Public Health, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - V Durán
- Department of Digestive Surgery, Experimental Surgery and Simulation Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - M E Molina
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - R Miguieles
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - G Urrejola
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - J T Larach
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - F Bellolio
- Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
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Collard MK, Rullier E, Tuech JJ, Sabbagh C, Souadka A, Loriau J, Faucheron JL, Benoist S, Dubois A, Dumont F, Germain A, Manceau G, Marchal F, Sourrouille I, Lakkis Z, Lelong B, Derieux S, Piessen G, Laforest A, Venara A, Prudhomme M, Brigand C, Duchalais E, Ouaissi M, Lebreton G, Rouanet P, Mège D, Pautrat K, Reynolds IS, Pocard M, Parc Y, Denost Q, Lefevre JH. Is Delaying a Coloanal Anastomosis the Ideal Solution for Rectal Surgery?: Analysis of a Multicentric Cohort of 564 Patients From the GRECCAR. Ann Surg 2023; 278:781-789. [PMID: 37522163 DOI: 10.1097/sla.0000000000006025] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVES To assess the specific results of delayed coloanal anastomosis (DCAA) in light of its 2 main indications. BACKGROUND DCAA can be proposed either immediately after a low anterior resection (primary DCAA) or after the failure of a primary pelvic surgery as a salvage procedure (salvage DCAA). METHODS All patients who underwent DCAA intervention at 30 GRECCAR-affiliated hospitals between 2010 and 2021 were retrospectively included. RESULTS Five hundred sixty-four patients (male: 63%; median age: 62 years; interquartile range: 53-69) underwent a DCAA: 66% for primary DCAA and 34% for salvage DCAA. Overall morbidity, major morbidity, and mortality were 57%, 30%, and 1.1%, respectively, without any significant differences between primary DCAA and salvage DCAA ( P = 0.933; P = 0.238, and P = 0.410, respectively). Anastomotic leakage was more frequent after salvage DCAA (23%) than after primary DCAA (15%), ( P = 0.016).Fifty-five patients (10%) developed necrosis of the intra-abdominal colon. In multivariate analysis, intra-abdominal colon necrosis was significantly associated with male sex [odds ratio (OR) = 2.67 95% CI: 1.22-6.49; P = 0.020], body mass index >25 (OR = 2.78 95% CI: 1.37-6.00; P = 0.006), and peripheral artery disease (OR = 4.68 95% CI: 1.12-19.1; P = 0.030). The occurrence of this complication was similar between primary DCAA (11%) and salvage DCAA (8%), ( P = 0.289).Preservation of bowel continuity was reached 3 years after DCAA in 74% of the cohort (primary DCAA: 77% vs salvage DCAA: 68%, P = 0.031). Among patients with a DCAA mannered without diverting stoma, 75% (301/403) have never required a stoma at the last follow-up. CONCLUSIONS DCAA makes it possible to definitively avoid a stoma in 75% of patients when mannered initially without a stoma and to save bowel continuity in 68% of the patients in the setting of failure of primary pelvic surgery.
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Affiliation(s)
- Maxime K Collard
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Eric Rullier
- Department of General and Digestive Surgery, Saint André Hospital, Bordeaux, France
| | - Jean-Jacques Tuech
- Department of General and Digestive Surgery, Hospital Charles Nicole, Rouen, France
| | - Charles Sabbagh
- Department of General and Digestive surgery, Amiens Hospital, France
| | - Amine Souadka
- Department of General and Digestive surgery, National Institute of Oncology, Rabat, Marocco
| | - Jérome Loriau
- Department of Digestive Surgery, Saint-Joseph Hospital, Paris, France
| | - Jean-Luc Faucheron
- Department of Colorectal Surgery, Hôpital Unversitaire de Grenoble, France
| | - Stéphane Benoist
- Department of General and Digestive surgery, Hôpital du Kremlin-Bicêtre, Kremlin-Bicêtre, France
| | - Anne Dubois
- Department of General and Digestive surgery, CHU Clermont-Ferrand Site Estaing, Clermont-Ferrand, France
| | - Frédéric Dumont
- Department of General and Digestive Surgery, Institut de cancérologie de l'ouest, Saint-Herblain, France
| | - Adeline Germain
- Department of General and Digestive Surgery, Hôpital Universitaire de Nancy, France
| | - Gilles Manceau
- Department of General and Digestive Surgery, Hôpital Européen Georges Pompidou, Paris, France
| | - Frédéric Marchal
- Department of Surgical Oncology, Institut de Cancérologie de Lorraine, Université de Lorraine, Vandoeuvre-les-Nancy, France
| | | | - Zaher Lakkis
- Department of Digestive Surgery, University Hospital of Besancon, Besancon, France
| | - Bernard Lelong
- Department of General and Digestive Surgery, Institute Paoli-Calmettes, Marseille, France
| | - Simon Derieux
- Department of General and Digestive Surgery, Groupe Hospitalier Diaconesses-Croix Saint Simon, Paris, France
| | - Guillaume Piessen
- Department of General and Digestive Surgery, Hôpital Huriez, Lille, France
| | - Anaïs Laforest
- Department of General and Digestive Surgery, Institute Monsouris, Paris, France
| | - Aurélien Venara
- Department of General and Digestive Surgery, Hôpital Universitaire d'Angers, France
| | - Michel Prudhomme
- Department of General and Digestive Surgery, Hôpital Universitaire de Nîmes, France
| | - Cécile Brigand
- Department of General and Digestive Surgery, Hôpital de Hautepierre-Hôpitaux Universitaires, Strasbourg, France
| | - Emilie Duchalais
- Department of General and Digestive Surgery, Centre Hospitalier Universitaire de Nantes, France
| | - Mehdi Ouaissi
- Department of General and Digestive Surgery, Hôpital Trousseau - CHRU Hôpitaux de Tours, Chambray-lès-Tours, France
| | - Gil Lebreton
- Department of General and Digestive Surgery, CHU côte de Nâcre, Caen, France
| | - Philippe Rouanet
- Department of General and Digestive Surgery, Institut du Cancer de Montpellier, Montpellier, France
| | - Diane Mège
- Department of General and Digestive Surgery, Hôpital de la Timone, Marseille, France
| | - Karine Pautrat
- Department of General and Digestive Surgery, Hôpital Lariboisière, Paris, France
| | - Ian S Reynolds
- Department of Colorectal Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marc Pocard
- Department of General and Digestive Surgery, Hôpital Pitié-Salpêtrère, Paris, France
| | - Yann Parc
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Quentin Denost
- Department of General and Digestive Surgery, Bordeaux Colorectal Institute, Bordeaux, France
| | - Jérémie H Lefevre
- Department of Colorectal Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
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10
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Zhang R, Luo W, Qiu Y, Chen F, Luo D, Yang Y, He W, Li Q, Li X. Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment. Cancers (Basel) 2023; 15:5011. [PMID: 37894378 PMCID: PMC10605930 DOI: 10.3390/cancers15205011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed. OBJECTIVE AND METHODS To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer. RESULTS The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy. CONCLUSIONS In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.
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Affiliation(s)
| | | | | | | | | | | | | | - Qingguo Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
| | - Xinxiang Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
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11
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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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12
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Re AD, Tooza S, Diab J, Karam C, Sarofim M, Ooi K, Turner C, Kozman D, Blomberg D, Morgan M. Outcomes following anastomotic leak from rectal resections, including bowel function and quality of life. Ann Coloproctol 2023; 39:395-401. [PMID: 35417955 PMCID: PMC10626330 DOI: 10.3393/ac.2022.00073.0010] [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: 01/16/2022] [Revised: 03/26/2022] [Accepted: 03/26/2022] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Anastomotic leak (AL) is an uncommon but potentially devastating complication after rectal resection. We aim to provide an updated assessment of bowel function and quality of life after AL, as well as associated short- and long-term outcomes. METHODS A retrospective audit of all rectal resections performed at a colorectal unit and associated private hospitals over the past 10 years was performed. Relevant demographic, operative, and histopathological data were collected. A prospective survey was performed regarding patients' quality of life and fecal continence. These patients were matched with nonAL patients who completed the same survey. RESULTS One hundred patients (out of 1,394 resections) were included. AL was contained in 66.0%, not contained in 10.0%, and only anastomotic stricture in 24.0%. Management was antibiotics only in 39.0%, percutaneous drainage in 9.0%, operative abdominal drainage in 19.0%, transrectal drainage in 6.0%, combination of percutaneous drainage and transrectal drainage in 2.0%, and combination abdominal/transrectal drainage in 1.0%. The 1-year stoma rate was 15.0%. Overall, mean Fecal Incontinence Severity Instrument scores were higher for AL patients than their matched counterparts (8.06±10.5 vs. 2.92±4.92, P=0.002). Patients with an AL had a mean EuroQol visual analogue scale (EQ-VAS) of 76.23±19.85; this was lower than the matched mean EQ-VAS for non-AL patients of 81.64±18.07, although not statistically significant (P=0.180). CONCLUSION The majority of AL patients in this study were managed with antibiotics only. AL was associated with higher fecal incontinence scores in the long-term; however, this did not equate to lower quality of life scores.
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Affiliation(s)
- Angelina Di Re
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- Department of Colorectal Surgery, Westmead Hospital, Westmead, NSW, Australia
| | - Salam Tooza
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Jason Diab
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Charbel Karam
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Mina Sarofim
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Kevin Ooi
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- Department of General Surgery, Fairfield Hospital, Prairiewood, NSW, Australia
| | - Catherine Turner
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Daniel Kozman
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- Department of Colorectal Surgery, St George Hospital, Kogarah, NSW, Australia
| | - David Blomberg
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
| | - Matthew Morgan
- Department of Colorectal Surgery, Bankstown-Lidcombe Hospital, Bankstown, NSW, Australia
- Department of General Surgery, Fairfield Hospital, Prairiewood, NSW, Australia
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13
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Muttillo EM, La Franca A, Coppola A, Li Causi FS, Checchelani M, Ceccacci A, Castagnola G, Garbarino GM, Osti MF, Balducci G, Mercantini P. Low Anterior Resection Syndrome (LARS) after Surgery for Rectal Cancer: An Inevitable Price to Pay for Survival, or a Preventable Complication? J Clin Med 2023; 12:5962. [PMID: 37762904 PMCID: PMC10532021 DOI: 10.3390/jcm12185962] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/07/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Rectal cancer is frequent and often treated with sphincter-saving procedures that may cause LARS, a syndrome characterized by symptoms of bowel disfunction that may severely affect quality of life. LARS is common, but its pathogenesis is mostly unknown. The aim of this study is to assess the incidence of LARS and to identify potential risk factors. METHODS We performed an observational retrospective single center analysis. The following data were collected and analyzed for each patient: demographics, tumor-related data, and intra- and peri-operative data. Statistical analysis was conducted, including descriptive statistics and multivariate logistic regression to identify independent risk factors. RESULTS Total LARS incidence was 31%. Statistically significant differences were found in tumor distance from anal verge, tumor extension (pT and diameter) and tumor grading (G). Multivariate analysis identified tumor distance from anal verge and tumor extension as an independent predictive factor for both major and total LARS. Adjuvant therapy, although not significant at univariate analysis, was identified as an independent predictive factor. Time to stoma closure within 10 weeks seems to reduce incidence of major LARS. CONCLUSIONS bold LARS affects a considerable portion of patients. This study identified potential predictive factors that could be useful to identify high risk patients for LARS.
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Affiliation(s)
- Edoardo Maria Muttillo
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Alice La Franca
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Alessandro Coppola
- Department of Surgery, Sapienza University of Rome, Viale Regina Elena 291, 00161 Rome, Italy;
| | - Francesco Saverio Li Causi
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Marzia Checchelani
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Alice Ceccacci
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Giorgio Castagnola
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | | | - Mattia Falchetto Osti
- Radiotherapy Oncology, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy;
| | - Genoveffa Balducci
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
| | - Paolo Mercantini
- Department of Medical Surgical Science and Translational Medicine, Sant’Andrea Hospital, Sapienza University of Rome, 00191 Rome, Italy; (A.L.F.); (F.S.L.C.); (M.C.); (A.C.); (G.C.); (G.B.); (P.M.)
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14
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Chierici A, Granieri S, Frontali A. Diagnostic accuracy of water-soluble contrast enema, contrast-enema computed tomography and endoscopy in detecting anastomotic leakage after (Colo) proctectomy: A meta-analysis. Colorectal Dis 2023; 25:1371-1380. [PMID: 37264714 DOI: 10.1111/codi.16591] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/19/2023] [Accepted: 04/02/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Anastomotic leakage (AL) as a result of creation of a colorectal/anal anastomosis still represents a frequent complication of colorectal surgery, with short- and long-term consequences on postoperative morbidity, quality of life and oncological outcomes. However, early diagnosis of AL may result in improved outcomes. The aims of this study were to evaluate the diagnostic accuracy of water-soluble contrast enema (WSCE), contrast enema computed tomography (CECT) and endoscopy in identifying AL and to identify the diagnostic procedure that is most accurate. METHODS A systematic review and meta-analysis of 19 studies accounting for a total of 25 tests reporting diagnostic accuracy estimates was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy Studies (PRISMA-DTA) guidelines up to June 2021. For the diagnostic tests we evaluated the pooled estimates and conducted pairwise comparisons. RESULTS For WSCE, the pooled sensitivity was 0.50, the pooled specificity was 0.99 and the area under the curve (AUC) was 0.91. For endoscopy, the pooled sensitivity was 0.69, specificity was 1.00 and AUC was 0.99. The pooled sensitivity and specificity for CECT were 0.89 and 1.00, respectively; the AUC was 0.99. The comparison between CECT and WSCE highlighted a significantly greater sensitivity (p = 0.04) for CECT, whereas no difference was found for specificity. Compared with CECT, endoscopy was not significantly more accurate in terms of either sensitivity or specificity. Endoscopy was found to be significantly more specific than WSCE (p = 0.031) but no difference was found for sensitivity. CONCLUSION Water-soluble contrast enema, endoscopy and CECT have an elevated diagnostic accuracy. However, WSCE is less accurate than either endoscopy or CECT. Although greater sensitivity was demonstrated for CECT compared with endoscopy, this was not significant.
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Affiliation(s)
- Andrea Chierici
- Service de Chirurgie Digestive et Transplantation Hépatique - Hôpital l'Archet 2, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Stefano Granieri
- General Surgery Unit, ASST-Brianza, Vimercate Hospital, Via Santi Cosma e Damiano, Vimercate, Italy
| | - Alice Frontali
- Coloproctology and IBD Surgery Unit, IRCCS San Raffaele, Milan, Italy
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15
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Xia F, Zou Y, Zhang Q, Wu J, Sun Z. A novel nomogram to predict low anterior resection syndrome (LARS) after ileostomy reversal for rectal cancer patients. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:452-460. [PMID: 37406079 DOI: 10.1016/j.ejso.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIM Low anterior resection syndrome (LARS) in patients undergoing low or ultra-low anterior resection (LAR) is a common problem and significantly impacts the quality of life. Patients with an ileostomy after LAR are more likely to develop LARS. However, there hasn't been a model predicting LARS occurrence in these patients. This study aims to construct a nomogram to predict the probability of LARS occurrence in patients with temporary ileostomy and guide preventive strategies before reversal. METHODS 168 patients undergoing LAR with ileostomy from one center were enrolled as the training cohort, and 134 patients of the same inclusion criteria from another center were enrolled as the validation cohort. The training cohort was screened for risk factors for major LARS using univariate and multivariate logistic regression. The nomogram was constructed using the filtered variables, the ROC curve was used to describe the model's discrimination, and the calibration was used to describe the accuracy. RESULTS The optimal cut-off value for stoma closure time was 128 days. Three risk factors were identified using logistic regression analysis: preoperative radiotherapy (OR = 3.038, [95%CI 1.75-5.015], P = 0.005), stoma closure time (OR = 2.298, [95%CI 1.088-4.858], P = 0.029) and pN stage (OR = 1.739, [95%CI 1.235-3.980], P = 0.001). A nomogram was constructed based on these three variables and showed good performance predicting major LARS after stoma reversal. The area under the curve (AUC) was 0.827 in the training group and 0.821 in the validation group; The calibration curve suggested good precision in both groups. CONCLUSIONS This novel nomogram can accurately predict the probability of major LARS occurrence after ileostomy reversal for rectal cancer patients. This model can help screen ileostomy patients with high risks and guide individualized preventive strategies before stoma reversal.
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Affiliation(s)
- Feng Xia
- Department of Hepatic Surgery, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - You Zou
- Gastrointestinal Surgery Center, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei, China
| | - Qiao Zhang
- Zhongshan People's Hospital Affiliated to Guangdong Medical University, Guangdong, China
| | - Jianhong Wu
- Gastrointestinal Surgery Center, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei, China
| | - Zhen Sun
- Gastrointestinal Surgery Center, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, 1095, Jiefang Avenue, Wuhan, Hubei, China.
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16
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Postoperative Morbidity Following Loop Ileostomy Reversal after Primary Elective or Urgent Surgery: A Retrospective Study with 145 Patients. J Clin Med 2023; 12:jcm12020452. [PMID: 36675381 PMCID: PMC9866519 DOI: 10.3390/jcm12020452] [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: 11/30/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023] Open
Abstract
Temporary loop ileostomy is usually performed to protect distal anastomosis or to treat urgent surgical cases. The aim of this study is to evaluate whether, after primary urgent stoma construction, patients undergoing ileostomy reversal have different postoperative outcomes compared with patients who have protective stoma performed in an elective setting. A retrospective observational study was conducted including patients who underwent ileostomy reversal. Baseline patient characteristics and perioperative outcomes were collected in a single database. The overall morbidity rate during recovery was fixed as a primary outcome. Between 2011 and 2021, the complete data records of 145 patients were evaluated. After ileostomy reversal, the postoperative morbidity rate did not differ between groups (14.4% vs. 11.5%, p = 0.790). Even considering each complication, such as ileus, small bowel obstruction, bleeding and wound infection, no significant difference was detected. Similarly, the time to first flatus was 2.25 ± 1.24 vs. 2.1 ± 0.99 (p = 0.379) and the length of hospital stay was 5.43 ± 3.03 vs. 5.84 ± 5.15 (p = 0.568). The only significant factor associated with postoperative complications on logistic regression analysis was the presence of comorbidities (OR 4.49; 95% CI 1.19-29.4, p = 0.05). In the present cohort of patients, there was no difference in the postoperative complication rate after stoma closure following elective or urgent indication for surgery.
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17
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Huang MJ, Ye L, Yu KX, Liu J, Li K, Wang XD, Li JP. Development of prediction model of low anterior resection syndrome for colorectal cancer patients after surgery based on machine-learning technique. Cancer Med 2023; 12:1501-1519. [PMID: 35899858 PMCID: PMC9883536 DOI: 10.1002/cam4.5041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/18/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a common postoperative complication in patients with colorectal cancer, which seriously affects their postoperative quality of life. At present, the aetiology of LARS is still unclear, but some risk factors have been studied. Accurate prediction and early management of medical intervention are keys to improving the quality of life of such high-risk patients. OBJECTIVES Based on machine-learning methods, this study used the follow-up results of postoperative patients with colorectal cancer to develop prediction models for LARS and conducted a comparative analysis between the different models. METHODS A total of 382 patients diagnosed with colorectal cancer and undergoing surgery at West China Hospital from April 2017 to December 2020 were retrospectively selected as the development cohort. Logistic regression, support vector machine, decision tree, random forest and artificial neural network algorithms were used to construct the prediction models of the obtained dataset. The models were internally validated using cross-validation. The area under the curve and Brier score measures were used to evaluate and compare the differentiation and calibration degrees of the models. The sensitivity, specificity, positive predictive value and negative predictive value of the different models were described for clinical use. RESULTS A total of 342 patients were included, the incidence of LARS being 47.4% (162/342) during the six-month follow-up. After feature selection, the factors influencing the occurrence of LARS were found to be location, distance, diverting stoma, exsufflation and surgical type. The prediction models based on five machine-learning methods all showed acceptable performance. CONCLUSIONS The five models developed based on the machine-learning methods showed good prediction performance. However, considering the simplicity of clinical use of the model results, the logistic regression model is most recommended. The clinical applicability of these models will also need to be evaluated with external cohort data.
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Affiliation(s)
- Ming Jun Huang
- West China School of Nursing/Day Surgery Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lin Ye
- West China School of Stomatology, Sichuan University, Chengdu, China.,Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ke Xin Yu
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China Medical School, Sichuan University, Chengdu, China
| | - Jing Liu
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Ka Li
- West China School of Nursing/West China Hospital, Sichuan University, Chengdu, China
| | - Xiao Dong Wang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ji Ping Li
- Nursing Department, West China Hospital, Sichuan University, Chengdu, China
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18
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High Risk of Low Anterior Resection Syndrome in Long-term Follow-up After Anastomotic Leakage in Anterior Resection for Rectal Cancer. Dis Colon Rectum 2022; 65:1264-1273. [PMID: 35482994 DOI: 10.1097/dcr.0000000000002334] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Low anterior resection syndrome is common after sphincter-sparing surgery, but it is unclear to what extent anastomotic leakage after anterior resection contributes to this condition. OBJECTIVE The aim of this study is to assess the long-term effect of anastomotic leakage on the occurrence of major low anterior resection syndrome. DESIGN This is a retrospective observational cohort study evaluating low anterior resection syndrome 4 to 11 years after index surgery. After propensity score-matching using the covariates sex, age, tumor stage, comorbidity, neoadjuvant treatment, extent of mesorectal excision, and defunctioning stoma at index surgery, the effect of anastomotic leakage on low anterior resection syndrome was investigated using relative risk and 95% CI. SETTINGS This multicenter study included patients from 15 Swedish hospitals between 2007 and 2013. PATIENTS Patients who underwent anterior resection for rectal cancer were included. MAIN OUTCOME MEASURES Outcome measures included patient-reported major low anterior resection syndrome, obtained via a postal questionnaire that included a question on stoma status. RESULTS Among 1099 patients, 653 (59.4%) responded in at a median of 83.5 (interquartile range 66 to 110) months postoperatively. After excluding patients with residual stoma or incomplete responses, 544 remained; of these, 42 had anastomotic leakage. Patients with anastomotic leakage were more likely to have major low anterior resection syndrome (66.7% [28/42]) than patients without leakage (45.8% [230/502]). After matching, anastomotic leakage was significantly related to major low anterior resection syndrome (relative risk 2.3; 95% CI 1.4-3.9) and the individual symptom of urgency (relative risk 2.1; 95% CI 1.1-4.1). LIMITATIONS This study was limited by its retrospective observational study design. CONCLUSIONS In long-term follow-up, major low anterior resection syndrome is common after anterior resection for rectal cancer. Anastomotic leakage appears to increase the risk of major low anterior resection syndrome, with urgency as a major contributing symptom. See Video Abstract at http://links.lww.com/DCR/B868 . ALTO RIESGO DE SNDROME DE RESECCIN ANTERIOR BAJA EN EL SEGUIMIENTO A LARGO PLAZO TRAS FUGA ANASTOMTICA EN RESECCIN ANTERIOR POR CNCER DE RECTO ANTECEDENTES:El síndrome de resección anterior baja es común después de una cirugía con preservación de esfínter pero no está claro hasta qué punto contribuye a esta condición la fuga anastomótica después de una resección anterior.OBJETIVO:El objetivo de este estudio es evaluar el efecto a largo plazo de la fuga anastomótica sobre la aparición de un síndrome de resección anterior baja mayor.DISEÑO:Se trata de un estudio de cohorte observacional retrospectivo que evalúa el síndrome de resección anterior baja 4-11 años después de la cirugía índice. Después del apareamiento por puntuación de propensión utilizando las covariables sexo, edad, estadio del tumor, comorbilidad, tratamiento neoadyuvante, extensión de la escisión mesorrectal y estoma de derivación en la cirugía índice, se investigó el efecto de la fuga anastomótica en el síndrome de resección anterior baja utilizando el riesgo relativo y intervalos de confianza de 95%.AJUSTES:Este estudio multicéntrico incluyó pacientes de 15 hospitales suecos entre 2007 y 2013.PACIENTES:Se incluyeron pacientes que fueron sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE DESENLACE:Síndrome de resección anterior baja mayor informado por el paciente, obtenido a través de un cuestionario postal que incluye una pregunta sobre el estado de estomas.RESULTADOS:De 1099 pacientes, 653 (59,4%) respondieron una mediana de 83,5 meses después de la operación (rango intercuartílico 66-110).Después de excluir a los pacientes con estoma residual o respuestas incompletas, quedaron 544; de estos, 42 tuvieron fuga anastomótica. Los pacientes con fuga anastomótica tenían síndrome de resección anterior baja mayor en el 66,7% (28/42) en comparación con el 45,8% (230/502) de los pacientes sin fuga. Después del apareamiento, la fuga anastomótica se relacionó significativamente con el síndrome de resección anterior baja mayor (riesgo relativo 2,3; intervalo de confianza del 95%: 1,4-3,9) y con el síntoma individual de urgencia (riesgo relativo 2,1; intervalo de confianza del 95% 1,1-4,1).LIMITACIONES:Este estudio estuvo limitado por su diseño de estudio observacional retrospectivo.CONCLUSIONES:En el seguimiento a largo plazo, el síndrome de resección anterior baja mayor es común después de la resección anterior por cáncer de recto. La fuga anastomótica parece aumentar el riesgo de síndrome de resección anterior baja mayor, siendo la urgencia uno de los principales síntomas contribuyentes. Consulte Video Resumen en http://links.lww.com/DCR/B868 . (Traducción-Dr. Juan Carlos Reyes ).
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Anterior Resection Syndrome and Quality of Life With Long-term Follow-up After Rectal Cancer Resection. Dis Colon Rectum 2022; 65:1251-1263. [PMID: 34840295 DOI: 10.1097/dcr.0000000000002107] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality of life remain unclear. OBJECTIVE The purpose of this study was to assess the impact of anterior resection and reversal of ileostomy on long-term health-related quality of life and low anterior resection syndrome. DESIGN Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires. SETTING Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at 2 high-volume centers in the United Kingdom were identified, excluding those experiencing anastomotic leakage. PATIENTS Among 478 eligible patients, 311 (65.1%) participated at a mean of 6.5 ± 0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar ( p > 0.05) between participants and nonparticipants. RESULTS The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). Health-related quality-of-life functional domain scores improved in the years after reversal of ileostomy, with significant changes in constipation ( p = 0.01), social function ( p = 0.03), and emotional scores ( p = 0.02), as well as a reduction in the prevalence of major low anterior resection syndrome ( p = 0.003). LIMITATIONS The main limitation of this study was that the data collected were cross-sectional rather than longitudinal, and that nonresponders may have had worse cancer symptoms. CONCLUSIONS In this first large-scale study assessing long-term function after anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825 . SEGUIMIENTO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA Y LA CALIDAD DE VIDA POR CNCER DE RECTO ANTECEDENTES:Los tratamientos tanto quirúrgicos como sistémicos continúan evolucionando día a día, así éstos permiten resecciones restaurativas por cáncer de recto distal. Estas operaciones están asociadas con el síndrome de resección anterior baja. Estudios recientes con limitaciones tanto metodológicas como de talla han estudiado la incidencia del síndrome de resección anterior bajo post-quirúrgico. Sin embargo, la evolución a largo plazo del síndrome de resección anterior baja y su acción sobre la calidad de vida relacionadas con la salud siguen sin estar claros.OBJETIVO:Evaluar el impacto de la resección anterior baja y el cierre de la ileostomía en la calidad de vida relacionadas con la salud a largo plazo y el síndrome post-resección anterior.AJUSTE:Se incluyeron todos los pacientes sometidos a una reseccción anterior baja de recto por cáncer asociada a una ileostomía de protección entre 2003 y 2016 en dos centros de gran volumen en el Reino Unido, se excluyeron los pacientes que presentaron fuga anastomótica.DISEÑO:Se revisaron los datos demográficos de todos los pacientes que presentaban el síndrome de resección anterior baja, se revisaron las puntuaciones de la calidad de vida relacionadas con el estado general de salud (EORTC-QLQ-C30) obtenidas a través de cuestionarios transversales enviados por correo.PACIENTES:478 pacientes fueron escogidos, 311 (65,1%) participaron del estudio en una media de 6,5 ± 0,2 años después de la resección anterior. Las tasas demográficas y de radio-quimioterapia neoadyuvante fueron similares (p > 0,05) entre los participantes y los no participantes.RESULTADOS:El porcentaje de pacientes que experimentaron síndrome de resección anterior baja mayor fue del 53,4% (166/311).PRINCIPALES MEDIDAS DE RESULTADO:Las puntuaciones funcionales en la calidad de vida relacionadas con estado general de salud mejoraron en los años posteriores al cierre de la ileostomía de protección, los cambios fueron significativos con relación al estreñimiento (p = 0,01), con relación a la actividad social (p = 0,03) y con las puntuaciones emocionales (p = 0,02), así como con la reducción de la prevalencia del síndrome de resección anterior baja mayor (p = 0,003).LIMITACIONES:La principal limitación del presente estudio mostró que los datos recopilados fueron transversales y no longitudinales, y que los pacientes no respondedores pueden haber tenido peores síntomas relacionados con el cáncer.CONCLUSIONES:Este primer estudio a gran escala, evalúa la función a largo plazo después de la resección anterior baja y el cierre de la ileostomía, demuestra una mejoría lineal en el síndrome de resección anterior baja de grado importante, más allá de los 6 años, asociado con la mejoría en las medidas clave de calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B825 . (Traducción-Dr. Xavier Delgadillo ).
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Ri H, Kang H, Xu Z, Kim K, Ren Y, Gong Z, Chen X. The risk factors of low anterior resection syndrome after colorectal cancer surgery: A retrospective study of 566 patients in a single institution in China. Front Surg 2022; 9:990702. [PMID: 36439535 PMCID: PMC9683037 DOI: 10.3389/fsurg.2022.990702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 08/05/2022] [Indexed: 09/02/2023] Open
Abstract
PURPOSE This study aims to identify the independent risk factors in the low anterior resection syndrome (LARS) after surgery for colorectal cancer (CRC). METHOD This was a retrospective, single-institution study in the Second Affiliation Hospital of Dalian Medical University, China. Patients underwent sphincter-preserving low anterior resection with total or partial mesorectal resection (with or without protective ileostomy) and completed a self-filled questionnaire over the phone to assess postoperative bowel dysfunction from January 2017 to December 2019. The predictors of LAR were evaluated using univariate and multivariate analyses. RESULT The study population was 566 patients, 264 (46.64%), 224 (39.58%), and 78 (13.78%) patients with no, minor, and major LARS, respectively. In the univariate analysis, independent factors such as tumor location and size, anastomotic height, protective ileostomy, post-operation chemoradiotherapy, tumor T stage, lymphatic nodal metastasis classification, surgery duration, and time interval for closure of stoma were significantly associated with LARS points while we found the tumor T stage and lymphatic nodal metastasis classification as the new independent risk factors compared with the last decade studies. In the multivariate analysis, factors such as low and middle tumor location and protective ileostomy, and post operation treatment, nodal metastasis classification were the independent risk factors for major LARS. CONCLUSION The new independence risk factors were tumor T stage and lymphatic nodal metastasis status in univariate analysis in our study, with anastomotic height, low and middle tumor location, protective ileostomy, post-operation chemoradiotherapy, nodal metastasis status increasing LARS point in multivariate analysis after surgery for CRC.
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Affiliation(s)
- HyokJu Ri
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
- Department of Colorectal Surgery, The Hospital of Pyongyang Medical College, Pyongyang, Democratic people's republic of Korea, Korea
| | - HaoNan Kang
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
| | - ZhaoHui Xu
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
| | - KunHyok Kim
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
- Department of Pathophysiology, The University of Hamhung Medical College, Hamhung, Democratic people's republic of Korea, Korea
| | - YanYing Ren
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
| | - ZeZhong Gong
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
| | - Xin Chen
- Department of Hernia and Colorectal Surgery, The Second Affiliation Hospital of Dalian Medical University, Dalian, China
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Zhong X, Xie X, Hu H, Li Y, Tian S, Qian Q, Jiang C, Ren X. Trans-Anastomotic Drainage Tube Placement After Hand-Sewn Anastomosis in Patients Undergoing Intersphincteric Resection for Low Rectal Cancer: An Alternative Drainage Method. Front Oncol 2022; 12:872120. [PMID: 35965574 PMCID: PMC9365931 DOI: 10.3389/fonc.2022.872120] [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: 02/09/2022] [Accepted: 05/13/2022] [Indexed: 11/30/2022] Open
Abstract
Anastomotic leakage (AL) is a common complication after intersphincteric resection (ISR). It significantly reduces quality of life and causes great distress to patients. Although traditional drainage (e.g., anal and pelvic catheters) may reduce the impact of AL to some extent, their role in reducing the incidence of AL remains controversial. In this study, we developed a novel drainage technique involving the placement of drainage tubes through the gap between sutures during handsewn anastomosis, to reduce the occurrence of anastomotic leakage. We retrospectively analyzed 34 consecutive patients who underwent intersphincteric resection requiring handsewn anastomosis between February 1, 2017, and January 1, 2021. Patients were classified into the trans-anastomotic drainage tube group (TADT, n = 14) and the non-TADT group (n = 20) based on whether trans-anastomotic tube placement was performed. The incidence of postoperative complications, such as AL, was compared between the two groups, and anal function of patients at 1-year post-ISR was evaluated. Six cases of AL occurred in the non-TADT group, while none occurred in the TADT group; this difference was statistically significant (p=0.031). The TADT group also had a shorter hospital stay (p=0.007). There were no other significant intergroup differences in operation time, blood loss, pain score, anastomotic stenosis, intestinal obstruction, or incidence of wound infection. In the 30 patients (88.2%) evaluated for anal function, there were no significant intergroup differences in stool frequency, urgency, daytime/nocturnal soiling, Wexner incontinence score, or Kirwan grading. Taken together, trans-anastomotic tube placement is a novel drainage method that may reduce AL after ISR requiring handsewn anastomosis and without adversely affecting anal function.
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Affiliation(s)
- Xinjian Zhong
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Xiaoyu Xie
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Hang Hu
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Yi Li
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Shunhua Tian
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Qun Qian
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
| | - Congqing Jiang
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
- *Correspondence: Congqing Jiang, ; Xianghai Ren,
| | - Xianghai Ren
- Department of Colorectal and Anal Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Clinical Center of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Key Laboratory of Intestinal and Colorectal Diseases of Hubei Province, Wuhan, China
- Colorectal and Anal Disease Research Center, Medical School of Wuhan University, Wuhan, China
- Quality Control Center of Colorectal and Anal Surgery, Health Commission of Hubei Province, Wuhan, China
- *Correspondence: Congqing Jiang, ; Xianghai Ren,
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The Longitudinal Course of Low-anterior Resection Syndrome: An individual Patient Meta-analysis. Ann Surg 2022; 276:46-54. [PMID: 35185131 DOI: 10.1097/sla.0000000000005423] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to better understand the longitudinal course of low anterior resection syndrome (LARS) to guide patient expectations and identify those at risk of persisting dysfunction. SUMMARY BACKGROUND DATA LARS describes disordered bowel function after rectal resection that significantly impacts quality of life. METHODS MEDLINE, EMBASE, CENTRAL, and CINAHL databases were systematically searched for studies that enrolled adults undergoing anterior resection for rectal cancer and used the LARS score to assess bowel function at ≥2 postoperative time points. Regression analyses were performed on deidentified patient-level data to identify predictors of change in LARS score from baseline (3-6months) to 12-months and 18-24 months. RESULTS Eight studies with a total of 701 eligible patients were included. The mean LARS score improved over time, from 29.4 (95% confidence interval 28.6-30.1) at baseline to 16.6 at 36 months (95% confidence interval 14.2%-18.9%). On multivariable analysis, a greater improvement in mean LARS score between baseline and 12 months was associated with no ileostomy formation [mean difference (MD) -1.7 vs 1.7, P < 0.001], and presence of LARS (major vs minor vs no LARS) at baseline (MD -3.8 vs -1.7 vs 5.4, P < 0.001). Greater improvement in mean LARS score between baseline and 18-24 months was associated with partial mesorectal excision vs total mesorectal excision (MD-8.6 vs 1.5, P < 0.001) and presence of LARS (major vs minor vs no LARS) at baseline (MD -8.8 vs -5.3 vs 3.4, P < 0.001). CONCLUSIONS LARS improves by 18 months postoperatively then remains stable for up to 3 years. Total mesorectal excision, neoadjuvant radiotherapy, and ileostomy formation negatively impact upon bowel function recovery.
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Plastiras A, Korkolis D, Frountzas M, Theodoropoulos G. The effect of anastomotic leak on postoperative pelvic function and quality of life in rectal cancer patients. Discov Oncol 2022; 13:52. [PMID: 35751713 PMCID: PMC9233722 DOI: 10.1007/s12672-022-00518-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/07/2022] [Indexed: 11/30/2022] Open
Abstract
AIM The aim of this review was to collect all available literature data analysing the effects of the anastomotic leak (AL) on post-sphincter preserving rectal cancer surgery bowel and urogenital function as well as to quality of life (QoL) dimensions. METHODS A literature search of the PubMed and Embase electronic databases was conducted by two independent investigators and all studies using either functional parameters or QoL as a primary or secondary endpoint after a rectal cancer surgery AL were included. RESULTS Amongst the 13 identified studies focusing on the post-AL neorecto-anal function, 3 case-matched studies,3 comparative studies and 1 population-based study supported the deleterious effects of the AL on bowel function, with disturbances of the types of high bowel movement frequency, urgency and increased incontinent episodes to predominate. At one case-matched study the Low Anterior Resection Syndrome (LARS) score was inferior in the AL patients. At limited under-powered studies, urinary frequency, reduced male sexual activity and female dyspareunia may be linked to a prior AL. According to two QoL-targeted detailed studies, QoL disturbances, such as physical and emotional function difficulties may persist up to 3 years after the AL occurrence. CONCLUSIONS AL may have adverse effects on postoperative pelvic function and QoL in rectal cancer patients. As evidenced by this literature review, the limited reports on this intriguing topic may trigger the initiative for planning and undertaking larger, multicentre studies on rectal cancer patients with varying degrees of AL severity.
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Affiliation(s)
- Aris Plastiras
- Department of Surgical Oncology, St Savvas Oncologic Centre of Athens, Athens, Greece
| | - Dimitrios Korkolis
- Department of Surgical Oncology, St Savvas Oncologic Centre of Athens, Athens, Greece
| | - Maximos Frountzas
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National and Kapodistrian University of Athens, Hippocration Hospital, 114 Vas Sofias Ave, 11527, Athens, Greece
| | - George Theodoropoulos
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National and Kapodistrian University of Athens, Hippocration Hospital, 114 Vas Sofias Ave, 11527, Athens, Greece.
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Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer. Front Oncol 2022; 12:868359. [PMID: 35707361 PMCID: PMC9190512 DOI: 10.3389/fonc.2022.868359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 03/18/2022] [Indexed: 12/17/2022] Open
Abstract
Background Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group. Methods The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes. Results A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%). Conclusion A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters.
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Melka D, Leiritz E, Labiad C, Blondeau M, Frontali A, Giacca M, Monsinjon M, Panis Y. Delayed pull-through coloanal anastomosis without temporary stoma: an alternative to the standard manual side-to-end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer. Colorectal Dis 2022; 24:587-593. [PMID: 35094470 DOI: 10.1111/codi.16069] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 11/28/2021] [Accepted: 01/16/2022] [Indexed: 02/08/2023]
Abstract
AIM After total mesorectal excision (TME) for low rectal cancer, current guideline recommendations for sphincter-saving surgery are to perform a side-to-end manual coloanal anastomosis (CAA) (or with J-pouch) with a temporary stoma. Our study aimed to evaluate if delayed pull-through coloanal anastomosis (DCAA) without a temporary stoma could represent a safe alternative in low rectal cancer. METHOD From 2003 to 2020, 223 consecutive patients with low rectal cancer undergoing TME were compared: CAA and diverting stoma (n = 190) versus DCAA without stoma (n = 33). RESULTS Overall 3-month and severe (Dindo ≥ IIIb) morbidity rates were similar in CAA versus DCAA groups: 34% (65/190) vs. 36% (12/33) and 2.6% (5/190) vs. 3% (1/33), respectively. In the DCAA group, only one patient (3%) underwent reoperation (Hartmann's procedure) at day 3 due to colon necrosis. The anastomotic leakage rate (both clinical and radiological) was significantly higher after CAA than DCAA: 28% (53/190) vs. 3% (1/33; p = 0.00138). Failure of the procedure (with return to stoma) was observed in 8% (15/190) vs. 6% (2/33) of patients after CAA and DCAA respectively (not significant). CONCLUSION Our comparative study suggested that in patients with low rectal cancer, DCAA without a temporary stoma could represent an interesting alternative to the actual recommended CAA with a temporary ileostomy. DCAA could offer two major advantages over CAA: a significantly lower rate of anastomotic leakage and absence of a temporary stoma and its potential complications (rehospitalization, dehydration, wound hernia after stoma closure).
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Affiliation(s)
- Dan Melka
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Elsa Leiritz
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Camélia Labiad
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Marc Blondeau
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Alice Frontali
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Massimo Giacca
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Marie Monsinjon
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
| | - Yves Panis
- Department of Colorectal Surgery, DMU DIGEST Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Clichy, France
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Calmels M, Collard MK, O'Connell L, Voron T, Debove C, Chafai N, Parc Y, Lefevre JH. Redo-surgery after failed colorectal or coloanal anastomosis: Morbidity, mortality and factors predictive of success. A retrospective study of 200 patients. Colorectal Dis 2022; 24:511-519. [PMID: 34914160 DOI: 10.1111/codi.16025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/02/2021] [Accepted: 12/12/2021] [Indexed: 12/22/2022]
Abstract
AIM In cases of anastomotic failure after colorectal (CRA) or coloanal anastomosis (CAA), revision of the anastomosis is an ambitious surgical option that can be proposed in order to maintain bowel continuity. Our aim was to assess postoperative morbidity, risk of failure and risk factor for failure in patients after CRA or CAA. METHODS All consecutive patients who underwent redo-CRA/CAA in our institution between 2007-2018 were retrospectively included. The success of redo-CRA/CAA was defined by the restoration of bowel continuity 12 months after the surgery. RESULTS Two hundred patients (114 male: 57%) were analyzed. The indication for redo-CRA/CAA was chronic pelvic infection in 74 patients (37%), recto-vaginal or urinary fistula in 59 patients (30%), anastomotic stenosis in 36 patients (18%) and redo anastomosis after previous anastomosis takedown in 31 patients (15%). Twenty-three percent of the patients developed a severe postoperative complication. Anastomotic leakage was diagnosed in 39 patients (20%). One-year-success of the redo-CRA/CAA was obtained in 80% of patients. In multivariate analysis, only obesity was associated with redo-CRA/CAA failure (p = 0.042). We elaborated a pre-operative predictive score of success using the four variables: male sex, age > 60 years, obesity and history of pelvic radiotherapy. The success of redo-CRA/CAA was 92%, 86%, 80% and 62% for a preoperative predictive score value of 0, 1, 2 and ≥3, respectively (p = 0.010). CONCLUSIONS In case of failure of primary CRA/CAA, bowel continuity can be saved in 4 out of 5 patients by redo-CRA/CAA despite 23% suffering severe postoperative morbidity.
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Affiliation(s)
- Mélanie Calmels
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Maxime K Collard
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Lauren O'Connell
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
| | - Thibault Voron
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Clotilde Debove
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Najim Chafai
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Yann Parc
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
| | - Jérémie H Lefevre
- Department of colorectal surgery, AP-HP, Hôpital Saint Antoine, Sorbonne University, Paris, France
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Ketelaers SHJ, van Heinsbergen M, Orsini RG, Vogelaar FJ, Konsten JLM, Nieuwenhuijzen GAP, Rutten HJT, Burger JWA, Bloemen JG. Functional Bowel Complaints and the Impact on Quality of Life After Colorectal Cancer Surgery in the Elderly. Front Oncol 2022; 12:832377. [PMID: 35242714 PMCID: PMC8886503 DOI: 10.3389/fonc.2022.832377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/17/2022] [Indexed: 12/11/2022] Open
Abstract
Background The Low Anterior Resection Syndrome (LARS) is commonly reported after colorectal cancer surgery and significantly impairs quality of life. The prevalence and impact of LARS in the elderly after rectal cancer as well as colon cancer surgery is unclear. We aimed to describe the prevalence of LARS complaints and the impact on quality of life in the elderly after colorectal cancer surgery. Materials and Methods Patients were included from seven Dutch hospitals if they were at least one year after they underwent colorectal cancer surgery between 2008 and 2015. Functional bowel complaints were assessed by the LARS score. Quality of life was assessed by the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Outcomes in patients ≥70 years were compared to a reference group of patients <70 years. Results In total 440 rectal cancer and 1183 colon cancer patients were eligible for analyses, of whom 133 (30.2%) rectal and 536 (45.3%) colon cancer patients were ≥70 years. Major LARS was reported by 40.6% of rectal cancer and 22.2% of colon cancer patients ≥70 years. In comparison, patients <70 years reported major LARS in 57.3% after rectal cancer surgery (p=0.001) and in 20.4% after colon cancer surgery (p=0.41). Age ≥70 years was independently associated with reduced rates of major LARS after rectal cancer surgery (OR 0.63, p=0.04). Patients with major LARS reported significantly impaired quality of life on almost all domains. Conclusion Elderly should not be withheld a restorative colorectal cancer resection based on age alone. However, a substantial part of the elderly colorectal cancer patients develops major LARS after surgery, which often severely impairs quality of life. Since elderly frequently consider quality of life and functional outcomes as one of the most important outcomes after treatment, major LARS and its impact on quality of life should be incorporated in the decision-making process.
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Affiliation(s)
| | | | - Ricardo G Orsini
- Department of Surgery, Elisabeth-Tweesteden Hospital, Tilburg, Netherlands
| | | | - Joop L M Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, Netherlands
| | | | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, Netherlands.,GROW, School for Developmental Biology & Oncology, Maastricht University, Maastricht, Netherlands
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In for the Long Haul: Managing the Consequences of Anastomotic Leak. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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29
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Clinical Utility and Characteristics of the LARS Score Compared to the CCIS. World J Surg 2022; 46:925-932. [PMID: 35119510 DOI: 10.1007/s00268-021-06405-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The low anterior resection syndrome (LARS) score (LS) has been widely validated and has become an international tool for evaluating postoperative bowel dysfunction. However, many physicians still use the conventional incontinence scores in LARS treatment. Moreover, interpretation of LS and its relationship with conventional incontinence scores are not yet well understood. Here we compared the LS with the Cleveland Clinic Incontinence Score (CCIS) to clarify the clinical utility and characteristics of the LARS score. METHODS We performed a multicentre observational study, recruiting 246 rectal cancer patients following sphincter-preserving surgery. Patients completed the LS, CCIS, and SF36 questionnaires. RESULTS The response rate was 76.4%, and a total of 180 patients were analysed. The LS was strongly correlated with the CCIS (P < 0.001, rs = 0.727). However, among 116 patients determined to not have incontinence (CCIS 0-5), 51 (44%) were diagnosed with LARS (29 with minor LARS and 22 with major LARS). Among 68 patients without LARS, only 3 were diagnosed as having incontinence (CCIS > 6). In comparison with background factors, aging and elapsed time were associated with only LS. High LS and CCIS both showed significant quality-of-life impairment as assessed by the SF-36. CONCLUSION This is the first study to determine the difference in the numeric values between the CCIS and LS. The LS can be a convenient tool for LARS screening, identifying a wide range of patients with LARS, including those with incontinence evaluated by CCIS. Assessment using the CCIS may often underestimate LARS.
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McGiffin T, Clark DA, Edmundson A, Steffens D, Stevenson A, Solomon M. Surgical management and long‐term functional outcomes after anastomotic leak in patients undergoing minimally invasive restorative rectal resection and without a diverting ileostomy. ANZ J Surg 2022; 92:806-812. [DOI: 10.1111/ans.17475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tony McGiffin
- Departmentt of Surgery Royal Brisbane and Women's Hospital Brisbane Queensland Australia
| | - David A. Clark
- Departmentt of Surgery Royal Brisbane and Women's Hospital Brisbane Queensland Australia
- Faculty of Medicine and Health, Central Clinical School The University of Sydney Sydney Australia
- Surgical Outcomes Research Centre (SOuRCe) Royal Prince Alfred Hospital Sydney New South Wales Australia
- Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Aleks Edmundson
- Departmentt of Surgery Royal Brisbane and Women's Hospital Brisbane Queensland Australia
- Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Daniel Steffens
- Faculty of Medicine and Health, Central Clinical School The University of Sydney Sydney Australia
- Surgical Outcomes Research Centre (SOuRCe) Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Andrew Stevenson
- Departmentt of Surgery Royal Brisbane and Women's Hospital Brisbane Queensland Australia
- Faculty of Medicine University of Queensland Brisbane Queensland Australia
| | - Michael Solomon
- Faculty of Medicine and Health, Central Clinical School The University of Sydney Sydney Australia
- Surgical Outcomes Research Centre (SOuRCe) Royal Prince Alfred Hospital Sydney New South Wales Australia
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31
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Park EJ, Baik SH. Functional outcomes after sphincter-preserving surgeries for low-lying rectal cancer: A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Sphincter preservation and organ restoration during rectal cancer surgery avoids permanent stoma creation and diminishes psychosocial damages. However, decreased rectal volumes and sphincter dysfunction—including pelvic nerve damage—results in low anterior resection syndrome, as well as urinary and sexual dysfunction after rectal resection. Bowel habit changes such as fecal incontinence, fecal urgency, frequent bowel movements, clustered stools, and difficulties in bowel emptying can be treated using medications, pelvic floor rehabilitation, sacral neuromodulation, or neorectal reservoir reconstruction. Pelvic nerve damage resulting from superior and inferior hypogastric plexi during sphincter-preserving rectal cancer surgery can induce urologic and sexual dysfunctions. Preoperative voiding difficulty, perioperative blood loss, and autonomic nerve injury are considered independent risk factors for postoperative urinary dysfunction. Retrograde ejaculation and erectile dysfunction, female dyspareunia, and vaginal dryness are manifestations of sexual dysfunction resulting from autonomic nerve injury during rectal cancer surgery. Multifactorial causes for functional outcomes after sphincter- preserving surgeries are considered to improve patient’s quality of life with acceptable oncologic outcomes in the treatment of rectal cancer patients.
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Tan X, Zhang M, Li L, Wang H, Liu X, Jiang H. Retrospective study of active drainage in the management of anastomotic leakage after anterior resection for rectal cancer. J Int Med Res 2021; 49:3000605211065942. [PMID: 34918983 PMCID: PMC8721718 DOI: 10.1177/03000605211065942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Objective Anastomotic leakage (AL) is the most serious postoperative complication following anterior resection for rectal cancer. We aimed to investigate the efficacy of active drainage for the management of AL. Methods This was a retrospective study using information from a database of patients who underwent colorectal resection without a defunctioning ileostomy at our center between September 2013 and January 2021. We identified 122 cases with definitive AL who did not require revision emergent laparotomy. Among these patients, we evaluated those who received active drainage to replace the original passive drainage. Results There were 62 cases in the active drainage group and 60 cases in the passive drainage group. The active drainage group had a shorter mean AL spontaneous resolution time (26.9 ± 3.3 vs. 32.2 ± 4.8 days) and lower average hospitalization costs (82,680.6 vs. 92,299.3 renminbi (RMB)) compared with the passive drainage group, respectively. Moreover, seven patients in the passive drainage group subsequently underwent diverting stoma to resolve the Al, while all ALs resolved spontaneously after replacing the passive drainage with active drainage. Conclusions Our study suggests that active drainage may accelerate the spontaneous resolution of AL.
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Affiliation(s)
- Xiaojie Tan
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Mei Zhang
- Department of Gastrointestinal Surgery, the People's Hospital of Jimo District of Qingdao, Shandong Province, 266200, China
| | - Lai Li
- Department of General Surgery, the Second Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266042, China
| | - He Wang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Xiaodong Liu
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
| | - Haitao Jiang
- Department of Gastrointestinal Surgery, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, 266003, China
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Ellis CT, Maykel JA. Defining Anastomotic Leak and the Clinical Relevance of Leaks. Clin Colon Rectal Surg 2021; 34:359-365. [PMID: 34853555 DOI: 10.1055/s-0041-1735265] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Surgeons universally dread gastrointestinal anastomotic leaks, yet the precise definition is not widely agreed on despite international consensus guidelines. Likewise, leaks are not uniformly reported which makes comparisons across studies flawed. Leak rates range from 1 to 3% for ileocolonic, 0.5 to 18% for colorectal, and 5 to 19% for coloanal anastomoses. The sequelae of an anastomotic leak vary but generally correlate with the need for a change in clinical management, from minimal changes to the need for reoperation. Short- and long-term outcomes can be life-altering or life-threatening. Temporary or permanent stomas may be necessary and low pelvic anastomotic leaks may affect bowel function. For cancer patients, leaks can delay treatment and negatively affect oncologic outcomes. In Crohn's patients, leaks are associated with higher recurrence rates. In essence, the lack of agreement on the definition of an anastomotic leak inhibits meaningful understand of its epidemiology, prevention, and treatment.
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Affiliation(s)
- Clayton Tyler Ellis
- Division of Colorectal Surgery, Hiram C. Polk, Jr., MD, Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Worcester, Massachusetts
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34
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Risk factors for the development of low anterior resection syndrome. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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35
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Garfinkle R, Dell'Aniello S, Bhatnagar S, Morin N, Ghitulescu G, Faria J, Vasilevsky CA, Brassard P, Boutros M. Assessment of long-term bowel dysfunction after restorative proctectomy for neoplastic disease: A population-based cohort study. Surgery 2021; 172:782-788. [PMID: 34848073 DOI: 10.1016/j.surg.2021.10.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The purpose of this study was to describe postoperative bowel dysfunction after restorative proctectomy, and to identify factors associated with its development. METHODS Patients who underwent restorative proctectomy for rectal cancer between April 1998 and November 2018 were identified from the Hospital Episode Statistics database and linked to the Clinical Practice Research Datalink for postoperative follow-up. Bowel dysfunction was defined according to relevant symptom-based read codes and medication prescription-product codes. A Cox proportional hazards model was performed to identify factors associated with postoperative bowel dysfunction, adjusting for relevant covariates. RESULTS In total, 2,197 patients were included. The median age was 70.0 (interquartile range: 62.0-77.0) years old, and the majority (59.2%) of patients were male. After a median follow-up of 51.6 (24.0-90.0) months, bowel dysfunction was identified in 620 (28.2%) patients. Risk factors for postoperative bowel dysfunction included extremes of age (<40 years old: adjusted hazards ratio 2.35, 95% confidence interval 1.18-4.65; 70-79 years old: adjusted hazards ratio 1.25, 95% confidence interval 1.03-1.52), radiotherapy (adjusted hazards ratio 1.94, 95% confidence interval 1.56-2.42), distal tumors (adjusted hazards ratio 1.62, 95% confidence interval 1.34-1.94), history of diverting ostomy (adjusted hazards ratio 1.58, 95% confidence interval 1.33-1.89), and anastomotic leak (adjusted hazards ratio 1.48, 95% confidence interval 1.06-2.05). A minimally invasive surgical approach was protective for postoperative bowel dysfunction (adjusted hazards ratio 0.68, 95% confidence interval 0.53-0.86). CONCLUSION Bowel dysfunction was common after restorative proctectomy, and several patient, disease, and treatment-level factors were associated with its development.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada. https://twitter.com/Garfinkle_R
| | - Sophie Dell'Aniello
- Center for Clinical Epidemiology, Lady Davis Institute, Montreal, QC, Canada
| | - Sahir Bhatnagar
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada; Department of Diagnostic Radiology, McGill University, Montreal, QC, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Gabriela Ghitulescu
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Julio Faria
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Paul Brassard
- Center for Clinical Epidemiology, Lady Davis Institute, Montreal, QC, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.
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36
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Garfinkle R, Boutros M. Low Anterior Resection Syndrome: Predisposing Factors and Treatment. Surg Oncol 2021; 43:101691. [PMID: 34863592 DOI: 10.1016/j.suronc.2021.101691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/24/2021] [Indexed: 12/15/2022]
Abstract
Bowel dysfunction after restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long-term sequela of rectal cancer treatment that has a significant impact on quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause is likely multifactorial, and there are numerous patient, tumor, and treatment-level factors associated with its development. In accordance with these risk factors, several strategies have been proposed to mitigate LARS postoperatively, including modifications in the technical approach to restorative proctectomy and advancements in the multidisciplinary care of rectal cancer. Furthermore, a clinically applicable pre-operative nomogram has been developed to estimate the risk of LARS postoperatively, which may help in counseling patients before surgery. The management of LARS begins with identifying those who manifest symptoms, as postoperative bowel dysfunction often goes unrecognized. This goal is best achieved with the systematic screening of patients using validated Patient-Reported Outcome Measures. Once a patient with LARS is identified, conservative management strategies should be implemented. When available, a dedicated LARS nurse and/or multidisciplinary team can be an invaluable resource in engaging patients and educating them regarding LARS self-care. If symptoms of LARS persist or worsen over time despite conservative measures, second-line interventions, such as transanal irrigation or pelvic floor rehabilitation, can be initiated. A small proportion of patients will ultimately require an intervention such as sacral neuromodulation or permanent colostomy for refractory, major LARS symptoms.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.
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Deng J, Su M, Hu J, Lin D, Li J, Liu W, Zhang J, Zhong Q, Guo X. A nomogram to predict risk factors of frequent defecation early after ileostomy reversal for rectal cancer patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1595. [PMID: 34790801 PMCID: PMC8576722 DOI: 10.21037/atm-21-4660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
Background Defecation disorders after ileostomy reversal are among the most common complications for rectal cancer patients, and significantly diminish their quality of life. The aim of this study was to identify the risk factors associated with frequent defecation early after ileostomy reversal for rectal cancer patients. Methods We retrospectively collected the data of rectal cancer patients who underwent ileostomy reversal from January 2018 to December 2019 at the Sixth Affiliated Hospital of Sun Yat-sen University. We divided patients into two groups: a no frequent defecation group (≤7 times/day) and a frequent defecation group (>7 times/day). Results Of the 264 included patients, 59 patients (22.35%) had frequent defecation within 1 month after ileostomy closure and were defined as the frequent defecation group. There were no significant differences between the two groups in terms of gender, age, hypertension, and diabetes. Univariate and multivariate analyses showed that proctitis (P=0.04) and anastomotic stenosis (P=0.02) were independent risk factors for frequent defecation. Four factors, including proctitis, anastomotic stenosis, hypertension, and age were included to construct the nomogram. The consistency index of the nomogram was 0.949 and the area under the curve value was 0.623. Conclusions For rectal cancer patients, proctitis and anastomotic stenosis were correlated with frequent defecation within 1 month after ileostomy closure. Surgeons should pay attention to the rectal examination before ileostomy reversal surgery.
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Affiliation(s)
- Jiaxin Deng
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mingli Su
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiancong Hu
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dezheng Lin
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Juan Li
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Liu
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiawei Zhang
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qinghua Zhong
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xuefeng Guo
- Department of Endoscopic Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Alverdy JC, Schardey HM. Anastomotic Leak: Toward an Understanding of Its Root Causes. J Gastrointest Surg 2021; 25:2966-2975. [PMID: 34100248 PMCID: PMC8815793 DOI: 10.1007/s11605-021-05048-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/18/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND When an anastomotic leak is discussed at a typical surgical morbidity and mortality conference, it is often presented as a due to an error in surgical technique involving ischemia, tension, or device failure. Here we assert that without direct visual analysis of the leak site and its tissue histology, an ex post facto claim that an anastomotic leak is due to an error in surgical technique remains speculative. METHODS The arguments and rationale used to conclude that an anastomotic leak is due to an error in surgical technique are critically reviewed and assessed for their validity. RESULTS No case series or literature exists in which a root cause analysis has been carried out with visual and tissue level evidence to determine the root cause(s) of an anastomotic leak. CONCLUSIONS At the individual case level, declaring that an anastomotic leak is due to an error in surgical technique without clear and compelling evidence either visually and/or at the tissue level to substantiate such a claim remains speculative.
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Affiliation(s)
- John C Alverdy
- Department of Surgery, University of Chicago, Pritzker School of Medicine, 5841 S. Maryland, Chicago, IL, 60637, USA,Corresponding author
| | - Hans Martin Schardey
- Department of General, Visceral, and Transplantation Surgery, Ludwig-Maximilians-University Munich, Marchioninistr. 15, 81377, Munich, Germany and Department of General, Visceral and Vascular Surgery, Agatharied Hospital, Norbert-Kerkel-Platz, 83734, Hausham, Germany
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39
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Lao W, Prasoon P, Pan Y, Lv Y, Tan LT. The EORTC QLQ-C30 and QLQ-CR29 may play a complementary role to LARS score in evaluating the quality of life for patients following laparoscopic and robotic rectal cancer surgery. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2021. [DOI: 10.1016/j.lers.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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40
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Grass JK, Chen CC, Melling N, Lingala B, Kemper M, Scognamiglio P, Persiani R, Tirelli F, Caricato M, Capolupo GT, Izbicki JR, Perez DR. Robotic rectal resection preserves anorectal function: Systematic review and meta-analysis. Int J Med Robot 2021; 17:e2329. [PMID: 34463416 DOI: 10.1002/rcs.2329] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/25/2021] [Accepted: 08/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Improving survival rates in rectal cancer patients has generated a growing interest in functional outcomes after total mesorectal excision (TME). The well-established low anterior resection syndrome (LARS) score assesses postoperative anorectal impairment after TME. Our meta-analysis is the first to compare bowel function after open, laparoscopic, transanal, and robotic TME. METHODS All studies reporting functional outcomes after rectal cancer surgery (LARS score) were included, and were compared with a consecutive series of robotic TME (n = 48). RESULTS Thirty-two publications were identified, including 5 565 patients. Anorectal function recovered significantly better within one year after robotic TME (3.8 [95%CI -9.709-17.309]) versus laparoscopic TME (26.4 [95%CI 19.524-33.286]), p = 0.006), open TME (26.0 [95%CI 24.338-29.702], p = 0.002) and transanal TME (27.9 [95%CI 22.127-33.669], p = 0.003). CONCLUSIONS Robotic TME enables better recovery of anorectal function compared to other techniques. Further prospective, high-quality studies are needed to confirm the benefits of robotic surgery.
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Affiliation(s)
- Julia K Grass
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chien-Chih Chen
- Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.,Department of Surgery, College of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Nathaniel Melling
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bharathi Lingala
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA, USA
| | - Marius Kemper
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Pasquale Scognamiglio
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roberto Persiani
- Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Flavio Tirelli
- Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Caricato
- Department of Colorectal Surgery, Università Campus Bio-Medico, Rome, Italy
| | | | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel R Perez
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ye L, Huang M, Huang Y, Yu K, Wang X. Risk factors of postoperative low anterior resection syndrome for colorectal cancer: A meta-analysis. Asian J Surg 2021; 45:39-50. [PMID: 34362620 DOI: 10.1016/j.asjsur.2021.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/15/2021] [Accepted: 05/20/2021] [Indexed: 02/08/2023] Open
Abstract
The prevalence of postoperative low anterior resection syndrome (LARS) in patients with colorectal cancer is high, which seriously affects the quality of life after operation. The purpose of this meta-analysis is to systematically evaluate the related factors of LARS in patients with colorectal cancer and provide reference for clinicians when making reasoned decisions. A systematic electronic search of PubMed, Embase, The Cochrane Library, WANFANG and CNKI was performed from 2012 to Dec 2020. We analyzed the risk factors of LARS by extracting baseline data and clinical results. The odds ratio (OR) was used to analyze binary variables. A total of 5102 patients were included in 21 literatures, of which the prevalence of LARS was 49.7% (2538/5102). Meta-analysis showed that there was no significant difference in the influence of age (P = 0.48) and sex (P = 0.68) on LARS, but low tumor height (P < 0.001), low anastomotic height (P < 0.001), radiotherapy and chemotherapy (P < 0.001) and postoperative anastomotic leakage (P < 0.001), disfunction stoma (P < 0.001) are high risk factors for the prevalence of LARS. Low tumor height, low anastomotic height, radiotherapy and chemotherapy, anastomotic leakage and disfunction stoma are risk factors for postoperative LARS in patients with colorectal cancer. Clinicians should pay attention to these indicators of patients to provide better clinical intervention for patients and improve their quality of life after operation.
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Affiliation(s)
- Lin Ye
- Gastrointestinal Surgery, West China Hospital, Chengdu 610041, China; West China School of Stomatology, Sichuan University, Chengdu 610041, China
| | - MingJun Huang
- Day Surgery Center, West China Hospital, Chengdu 610041, China
| | - YuWei Huang
- Gastrointestinal Surgery, West China Hospital, Chengdu 610041, China; West China Medical School, Sichuan University, Chengdu, 610041, China
| | - KeXin Yu
- Gastrointestinal Surgery, West China Hospital, Chengdu 610041, China; West China Medical School, Sichuan University, Chengdu, 610041, China
| | - XiaoDong Wang
- Gastrointestinal Surgery, West China Hospital, Chengdu 610041, China.
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Sun R, Dai Z, Zhang Y, Lu J, Zhang Y, Xiao Y. The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis. Support Care Cancer 2021; 29:7249-7258. [PMID: 34296335 DOI: 10.1007/s00520-021-06326-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 05/30/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Many patients after sphincter-preserving surgery experienced anorectal functional disturbances which were known as low anterior resection syndrome (LARS). Although many studies investigated LARS, there was inconsistency of their assessment tools and results. The aim of this systematic review was to elucidate the incidence and risk factors of LARS by a validated tool-LARS score. METHODS A systematic literature search in Pubmed, Embase, and Cochrane Library was conducted in April 2020. Studies investigating patients who were evaluated by LARS score 1 year after their sphincter-preserving surgery due to rectal cancer were included. Meta-analysis of incidence was conducted using the double arcsine method. Meta-analysis of each risk factor was conducted using a random effects model. RESULTS A total of 50 studies were included. The pooled incidence of major LARS was 44% (95% CI 40-48%; I2 = 88%; 36 studies). Long course neoadjuvant radiotherapy (OR 2.89, 95% CI 2.06-4.05; I2 = 47%; P < 0.01; 10 studies), total mesorectal excision (TME) (OR 2.13, 95% CI 1.49-3.04; I2 = 53%; P < 0.01; 7 studies), anastomotic leak (OR 1.98, 95% CI 1.34-2.93; I2 = 39%; P < 0.01; 9 studies), and diverting stoma (OR 1.89, 95% CI 1.58-2.27; I2 = 0%; P < 0.01; 13 studies) were associated with increased risk of major LARS. No significant difference was found in major LARS incidence between transanal TME and laparoscopic TME (OR 1.36, 95% CI 0.78-2.40; I2 = 19%; P = 0.28; 4 studies). Pouch reconstruction failed to lower the risk of major LARS in long term (OR 1.43, 95% CI 0.88-2.33; I2 = 70%; P = 0.29; 9 studies). CONCLUSION The incidence of major LARS after sphincter-preserving surgery is relatively high. Neoadjuvant radiotherapy, TME, anastomostic leak, and diverting stoma are major risk factors. No significant differences in postoperative anorectal functions were observed between transanal and laparoscopic TME. Pouch reconstruction was not found to be significantly beneficial to anorectal functions in long term.
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Affiliation(s)
- Rui Sun
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Ziyi Dai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Yin Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Junyang Lu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Yuelun Zhang
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuai fuyuan 1, Dongcheng District, Beijing, China.
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Sacomori C, Lorca LA, Martinez-Mardones M, Salas-Ocaranza RI, Reyes-Reyes GP, Pizarro-Hinojosa MN, Plasser-Troncoso J. A randomized clinical trial to assess the effectiveness of pre- and post-surgical pelvic floor physiotherapy for bowel symptoms, pelvic floor function, and quality of life of patients with rectal cancer: CARRET protocol. Trials 2021; 22:448. [PMID: 34256795 PMCID: PMC8276537 DOI: 10.1186/s13063-021-05396-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/24/2021] [Indexed: 01/22/2023] Open
Abstract
Background There is scarcity of trials about preventative strategies for low anterior resection syndrome (LARS) in rectal cancer patients. The aim of this study is to evaluate the effectiveness of a pre- and post-surgical pelvic floor rehabilitation program on the bowel symptoms, pelvic floor function, and quality of life of rectal cancer patients. Methods A randomized controlled trial with parallel groups (pelvic floor rehabilitation versus control group), with a blinded evaluator. Participants and setting: 56 stage I to III rectal cancer patients aged from 18 to 80 years old undergoing sphincter preservation surgery at Hospital del Salvador and who have a sufficient knowledge of Spanish. Main outcome measures: ICIQ-B questionnaire for intestinal symptoms, high-resolution anorectal manometry (Alacer Multiplex 24-channel manometry equipment) for anorectal function, pelvic floor muscle strength test with Oxford Modified Scale, and a quality of life test with the EORTC QLQ C30 questionnaire. The evaluations will be carried out at five stages: before surgery, before and after the pelvic floor rehabilitation, and during a 3-month and 1-year follow-up. Interventions: one pre-rehabilitation session and 9 to 12 sessions of pelvic floor rehabilitation, including patient education, pelvic floor muscle exercises, pelvic floor electromyography biofeedback, and capacitive and sensory rectal training with a balloon probe. Rehabilitation will begin 3–5 weeks before the ileostomy is removed (four sessions) and around 3 weeks after stoma removal (5–8 sessions). Discussion We expect the program to improve the bowel symptoms, pelvic floor function, and quality of life of rectal cancer patients. Trial registration Australian New Zealand Clinical Trials Register ACTRN12620000040965. Registered on 21 January 2020.
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Affiliation(s)
- Cinara Sacomori
- Universidad Bernardo O'Higgins, Escuela de Kinesiología, Santiago, Chile.
| | - Luz Alejandra Lorca
- Hospital del Salvador, Servicio de Medicina Física y Rehabilitación, Santiago, Chile
| | - Mónica Martinez-Mardones
- Hospital del Salvador, Servicio de Cirugía y Servicio de Coloproctologia, Santiago, Chile.,Universidad Finnis Terrae, Escuela de Medicina, Santiago, Chile
| | | | | | | | - Jorge Plasser-Troncoso
- Hospital del Salvador, Servicio de Cirugía y Servicio de Coloproctologia, Santiago, Chile.,Fundación Arturo López Pérez, Santiago, Chile
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Functional Outcomes and Quality of Life after Redo Anastomosis in Patients With Rectal Cancer: An International Multicenter Comparative Cohort Study. Dis Colon Rectum 2021; 64:822-832. [PMID: 33902088 DOI: 10.1097/dcr.0000000000002025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery. OBJECTIVE The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer. DESIGN This study was designed as an international multicenter comparative cohort study. SETTINGS The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France. PATIENTS Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes. RESULTS In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02). LIMITATIONS This study is limited by the possible response bias. CONCLUSIONS Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565. RESULTADOS FUNCIONALES Y DE CALIDAD DE VIDA POSTERIOR A LA RECONSTRUCCIN DE LA ANASTOMOSIS EN PACIENTES CON CNCER DE RECTO ESTUDIO INTERNACIONAL MULTICNTRICO DE COHORTE COMPARATIVO ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565.
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Chierici A, Frontali A, Godefroy W, Spiezio G, Panis Y. Can end-to-end anastomosis reduce the risks of anastomotic leak compared to side-to-end anastomosis? A comparative study of 518 consecutive patients undergoing laparoscopic total mesorectal excision for low- or mid-rectal cancer. Tech Coloproctol 2021; 25:1019-1026. [PMID: 34120290 DOI: 10.1007/s10151-021-02468-x] [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: 01/22/2021] [Accepted: 05/29/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND After laparoscopic total mesorectal excision (TME) for low or mid-rectal cancer, we observed several cases of anastomotic leakage (AL) in patients with side-to-end anastomosis (STE). Thus, from December 2018, we routinely performed end-to-end anastomosis (ETE). The aim of this study was to assess if this new strategy changed AL and chronic pelvic sepsis rates in our department. METHODS A retrospective study was conducted on all the patients who underwent a laparoscopic rectal resection with TME and sphincter-saving surgery for mid- and low-rectal adenocarcinoma from January 2006 to December 2019. A comparative study between STE and routine ETE was performed. The primary outcome was the assessment of postoperative AL rate. The secondary outcomes were: (a) overall morbidity rate; (c) severe morbidity rate defined by a Clavien-Dindo score > 3; (c) chronic leak rate. RESULTS Five hundred eighteen patients underwent TME: STE was performed in 394 cases (76%) and ETE in 124 but for the first 66 cases only if STE was impossible (i.e., too short colon, obese patients). AL rates for STE were 57/204 (23%) after stapled colorectal anastomosis (CRA) and 34/190 (18%) after manual coloanal anastomosis (CAA). Since December 2018, routine ETE was performed in 58 cases. The AL rate for routine ETE was 3/24 (12%) for CRA, and 2/34 (6%) for CAA: thus, The AL rate dropped from 23% (91/394) after STE to 9% (5/58) after routine ETE (p = 0.0005). After a mean follow-up of 43 months (6-156), incidence of chronic AL was 68/394 (17%) after STE and 15/117 (13%) after ETE (p = 0.32). In the group of ETE with chronic AL, 11 patients (73%) spontaneously healed and stoma reversal was possible, whereas this happened in only 20 patients (29%) after STE (p = 0.0025). CONCLUSIONS ETE seems to be associated with a significantly lower rate of AL and higher rate of spontaneous healing after chronic AL than STE.
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Affiliation(s)
- A Chierici
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - A Frontali
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - W Godefroy
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - G Spiezio
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France
| | - Y Panis
- Department of Colorectal Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD), Beaujon Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, 100 boulevard du Général Leclerc, 92110, Clichy, France.
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Torrijo I, Balciscueta Z, Tabet J, Martín MC, López M, Uribe N. Prospective study of urinary function and analysis of risk factors after rectal cancer surgery. Tech Coloproctol 2021; 25:727-737. [PMID: 33811298 DOI: 10.1007/s10151-021-02445-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/27/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Alterations in urinary function are complications of rectal cancer surgery. The aim of this study was to prospectively analyze the changes in urinary function in patients operated on for rectal cancer, and to identify risk factors that may have an impact on the deterioration of postoperative urinary function. METHODS A prospective study of urinary function in rectal cancer patients who had elective oncological resection with curative intention at the Arnau de Vilanova Hospital in Valencia, Spain, from January 2017 to March 2019. The evaluation of urinary function was performed using the International Prostate Symptom Score (IPSS) preoperatively, at 6 and 12 months after surgery. Predictive factors of urinary dysfunction were identified by univariate and multivariate analysis. RESULTS Ninety-four patients were enrolled in the study. Eighty-seven of them completed all the follow-up assessments (48 men and 39 women, mean age 65.74 ± 10.95 years,). The mean IPSS was 7.96 ± 7.59 preoperatively, 9.01 ± 6.81 at 6 months, and 8.63 ± 5.59 at 12 months, without statistically significant differences. There were no differences in IPSS between males and females. Preoperative urinary dysfunction was 39% and at 12 months, a deterioration occurred in 23 patients (26.4%). IPSS analysis of symptoms showed a statistically significant worsening of nocturia at 6 months (p = 0.002) and 1 year after surgery (p = 0.037) in women. American Society of Anesthesiologists (ASA) class (OR: 11, [95% CI2.4-53]; p = 0.010), surgical difficulty (OR: 4.5, [95% CI 1-19]; p = 0.027) and anastomotic leakage (OR: 14, [95% CI 1.6-117]; p = 0.010), were identified as independent risk factors for deterioration of urinary function after surgery. CONCLUSIONS Our study showed worsening urinary dysfunction after rectal cancer surgery in 26.4% of the patients. However, there were no statistically significant differences in mean IPSS scores at the three assessment times (preoperatively, 6 months, 12 months). ASA class, surgical difficulty, and anastomotic leakage may predict postoperative deterioration.
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Affiliation(s)
- I Torrijo
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/San Clemente no. 12, 46015, Valencia, Spain.
| | - Z Balciscueta
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/San Clemente no. 12, 46015, Valencia, Spain
| | - J Tabet
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/San Clemente no. 12, 46015, Valencia, Spain
| | - M C Martín
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/San Clemente no. 12, 46015, Valencia, Spain
| | - M López
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/San Clemente no. 12, 46015, Valencia, Spain
| | - N Uribe
- Department of General and Digestive Surgery, Colorectal Unit, Arnau de Vilanova Hospital, C/San Clemente no. 12, 46015, Valencia, Spain
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Khomyakov EA, Nafedzov IO, Fomenko OY, Alekseyev MV, Frolov SA, Tchernyshov SV, Rybakov EG. Risk factors for major low anterior resection syndrome: meta-analysis and systematic literature review. RUSSIAN OPEN MEDICAL JOURNAL 2021. [DOI: 10.15275/rusomj.2021.0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction — Low anterior resection syndrome (LARS) is a socially significant problem that impedes social adaptation and contributes to deterioration of life quality in patients.
The objective of this study was to search for the category of patients most prone to major LARS, as well as to identify the factors determining the severity of this syndrome manifestations.
Material and Methods — Systematic review and meta-analysis were performed according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The study selected publications that included the functional results of treatment of patients operated for rectal cancer. Functional impairments were assessed according to the international LARS Score. Statistical analysis was performed using the inverse-variance weighted average method (IVW) with calculation of the odds ratio logarithm and standard error of the mean.
Results — After a critical search and analysis of all literature sources, eight studies were found suitable for meta-analysis. In total, 1042 patients (796 men and 246 women) were included into statistical analysis, 409 of which (39.2%) had symptoms of major LARS. Chemotherapy was performed on 637 (62.5%) patients, while 568 subjects (55.5%) underwent radiation therapy, and anastomotic leaks were described in 89 (8.5%) people. According to the results of the meta-analysis, statistically significant factors were: preventative ostomy (OR=3.32, 95% CI 1.99-5.55, p<0.00001), chemotherapy (OR=1.98, 95% CI 1.23-3, 19, p=0.005), radiation therapy (OR=5.00, 95% CI 2.73-9.13, p <0.00001), anastomotic leaks (OR=2.93, 95% CI 2.30-3, 73, p<0.00001), anal verge distance from anastomosis site (OR=2.61, 95% CI 1.47-4.62, p=0.001).
Conclusion — The results of our meta-analysis allowed us identifying the group of rectal cancer patients most vulnerable to LARS. The risk of developing severe functional disorders is significantly higher in patients with low colorectal anastomosis, as well as in patients undergoing neoadjuvant radiation therapy.
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Zhang Q, An L, Yu R, Peng J, Yu K, Huang M, Li L, Wang X. The impact of neoadjuvant chemotherapy on low anterior resection syndrome after rectal cancer resection: A 6 Months longitudinal follow-up. Asian J Surg 2021; 44:1260-1265. [PMID: 33722459 DOI: 10.1016/j.asjsur.2021.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/31/2021] [Accepted: 02/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND/OBJECTIVE Neoadjuvant radiotherapy plays a vital role in rectal cancer treatment, but impairs postoperative bowel function, leading to low anterior resection syndrome (LARS). Neoadjuvant chemotherapy alone might avoid the negative effect of radiotherapy on bowel function. This study aims to assess the impact of neoadjuvant chemotherapy on LARS and the development of LARS over the first 6 months after surgery. METHODS Rectal cancer patients were prospectively recruited during June 30, 2018 and December 24, 2019. Bowel function was assessed by the LARS score, which was taken at 1 month, 3 months, and 6 months after surgery via phone call interview. Patients were divided into two groups based on whether they received neoadjuvant chemotherapy (group A) or not (group B). RESULTS A total of 97 patients were included in the analysis. There was no significant difference between the LARS scores at 1 month, 3 months, and 6 months of both groups. The LARS score at 6 months showed a significant decrease from that of 1 month and 3 months in group B (P < 0.05, P < 0.01) and in all patients (P < 0.05, P = 0.001), and significant difference was found between the LARS scores in group A at the three timepoints (P < 0.05). No significant difference was found between the scores at 1 month and 3 months in both groups and in all patients. CONCLUSION Neoadjuvant chemotherapy alone did not have a negative impact on LARS. The bowel function after surgery started to show significant improvement at 6 months after surgery.
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Affiliation(s)
- Qiulu Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Limin An
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Ruixuan Yu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jing Peng
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Kexin Yu
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China; West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Mingjun Huang
- Day Surgery Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Li
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xiaodong Wang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Ahmad NZ, Abbas MH, Khan SU, Parvaiz A. A meta-analysis of the role of diverting ileostomy after rectal cancer surgery. Int J Colorectal Dis 2021; 36:445-455. [PMID: 33064212 DOI: 10.1007/s00384-020-03771-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Anastomotic leak is a feared complication of rectal cancer surgery. A diverting stoma is believed to act as a safety mechanism against this undesirable outcome. This meta-analysis aimed to examine the role of loop ileostomy in the prevention of this complication. METHODS The Medline, Embase and Cochrane databases were searched for randomized controlled trials (RCTs) comparing anastomotic complications after rectal cancer surgery in the presence or absence of diverting ileostomy. The need for reoperation and postoperative complications were also analysed. The length of hospital stay, intraoperative blood loss and operating time were analysed as secondary endpoints. RESULTS A significantly higher number of anastomotic leaks was detected in patients with no diverting ileostomies than in those with diversion (odds ratio (OR) 0.292 and 95% confidence interval (CI) 0.177-0.481), and more patients required reoperations in this group (OR 0.219 and 95% CI 0.114-0.422). The rate of complications other than anastomotic leak was significantly higher in patients with diverting ileostomies than in those without (OR 3.337 and 95% CI of 1.570-7.093). The operating time was longer in the ileostomy group than in the no ileostomy group (P 0.001), but no significant differences in the intraoperative blood loss or postoperative hospital stay length were observed between the two groups(P 0.199 and 0.191 respectively). CONCLUSION A lower leak rate in the presence of diverting ileostomy is supported by relatively weak evidence. While mitigating the consequences of leakage, diverting ileostomies lead to numerous other complications. High-quality RCTs are needed before routine ileostomy diversions can be recommended after rectal cancer surgery.
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Affiliation(s)
- Nasir Zaheer Ahmad
- Department of Surgery, University Hospital Limerick, St Nessan's Rd, Dooradoyle, Co, Limerick, V94 F858, Republic of Ireland.
| | - Muhammad Hasan Abbas
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Saad Ullah Khan
- Department of Surgery, Russells Hall Hospital NHS Trust, Pensnett Rd, West Midlands, Dudley, DY1 2HQ, UK
| | - Amjad Parvaiz
- Faculty of Health Sciences, University of Portsmouth, Portsmouth, UK.,Colorectal Department, Poole NHS Trust, Poole, UK
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50
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Theodoropoulos GE, Liapi A, Spyropoulos BG, Kourkouni E, Frountzas M, Zografos G. Temporal Changes of Low Anterior Resection Syndrome Score after Sphincter Preservation: A Prospective Cohort Study on Repetitive Assessment of Rectal Cancer Patients. J INVEST SURG 2021; 35:354-362. [PMID: 33491509 DOI: 10.1080/08941939.2020.1864684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: There is a relative shortage of studies directly addressing the postoperative rectal cancer patients' evacuatory dysfunction, as estimated by the low anterior resection syndrome (LARS) score at repeated assessment time-points. The aim of the present study was to prospectively evaluate the incidence of LARS at predefined time intervals during the first 3 years after sphincter preserving rectal cancer surgery and to enlighten the effect of identified risk factors.Materials and methods: Seventy-eight patients, who remained alive and recurrence-free 2 years after (ultra-) low anterior resection were prospectively assessed at 6, 12, 18, 24, 30 and 36 months postoperatively, using the LARS score as bowel dysfunction outcome measure. All patients have completed the 2-year follow-up functional assessment, while 56 and 37 of them have been evaluated up to the 30th and the 36th postoperative month, respectively.Results: The proportion of patients with "major and minor" LARS significantly decreased during the first 3 evaluations (up to 18 months) (74% vs 62% vs 35%, p = 0.0001). The tumor distance from the anal verge and the neoadjuvant radiotherapy were identified as risk factors for high LARS score at 6 months (p < 0.03). The tumor distance remained as risk factor throughout the entire follow-up. All patients with high tumors were alleviated from symptoms reflecting "major" or "minor" LARS at 18 months. Most patients (90%) after radiotherapy showed a high LARS score in the first semester, but improved afterwards.Conclusion: Overall, the LARS score improves in the majority of patients after 18 months, with low tumor height and radiation adversely affecting them. Our results may be useful in more accurately define the postoperative "functional course" of rectal cancer patients and in aiding their consultation on expected functional outcome.
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Affiliation(s)
- George E Theodoropoulos
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National, Kapodistrian University of Athens, Athens, Greece
| | - Artemis Liapi
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National, Kapodistrian University of Athens, Athens, Greece
| | - Basileios G Spyropoulos
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National, Kapodistrian University of Athens, Athens, Greece
| | - Eleni Kourkouni
- Center for Clinical Epidemiology and Outcomes Research (CLEO), Athens, Greece
| | - Maximos Frountzas
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National, Kapodistrian University of Athens, Athens, Greece
| | - George Zografos
- Colorectal Unit, First Department of Propaedeutic Surgery, Medical School of National, Kapodistrian University of Athens, Athens, Greece
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