Risk factors for bowel dysfunction after sphincter-preserving rectal cancer surgery: a prospective study using the Memorial Sloan Kettering Cancer Center bowel function instrument

The effect of robotic surgery on low anterior resection syndrome in patients with lower rectal cancer: a propensity score-matched analysis

BACKGROUND

Many patients experience anorectal dysfunction after rectal surgery, which is known as low anterior resection syndrome (LARS). Robotic systems have many technical advantages that may be suitable for functional preservation after low rectal resection. Thus, the study aimed to explore whether robotic surgery can reduce the incidence and severity of LARS.

METHODS

Patients undergoing minimally invasive sphincter-sparing surgery for low rectal cancer were enrolled between January 2015 and December 2020. The patients were divided into robotic or laparoscopic groups. The LARS survey was conducted at 6, 12 and 18 months postoperatively. Major LARS scores were analysed as the primary endpoint. In order to reduce confounding factors, one-to-two propensity score matches were used.

RESULTS

In total, 342 patients were enrolled in the study. At 18 months postoperatively, the incidence of LARS was 68.7% (235/342); minor LARS was identified in 112/342 patients (32.7%), and major LARS in 123/342 (36.0%). After matching, the robotic group included 74 patients, and the laparoscopic group included 148 patients. The incidence of major LARS in the robotic group was significantly lower than that in the laparoscopic group at 6, 12, and 18 months after surgery. In multivariate logistic regression analysis, tumour location, laparoscopic surgery, intersphincteric resection, neoadjuvant therapy, and anastomotic leakage were independent risk factors for major LARS after minimally invasive sphincter-sparing surgery for low rectal cancer. Furthermore, a major LARS prediction model was constructed. Results of model evaluation showed that the nomogram had good prediction accuracy and efficiency.

CONCLUSIONS

Patients with low rectal cancer may benefit from robotic surgery to reduce the incidence and severity of LARS. Our nomogram could aid surgeons in setting an individualized treatment program for low rectal cancer patients.

Low Anterior Resection Syndrome in Total Mesorectal Excision: Risk Factors and Its Relationship with Quality of Life

Background: Low anterior resection syndrome (LARS) is a bowel dysfunction following sphincter-sparing proctectomy. The occurrence of LARS may affect a patient's overall quality of life (QoL) after surgery. Current research was aimed to investigate related factors of LARS and major LARS in total mesorectal excision (TME) and its relationship with QoL. Methods: This study included patients who underwent TME at authors' institutes. LARS was evaluated with an LARS score. QoL was identified using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, version 3.0. Appropriate statistical methods were used to ascertain risk factors for LARS and major LARS and to analyze the relationships between QoL and LARS. The primary objective was to identify related factors of LARS and major LARS. The secondary objective was to examine the relationships between QoL and LARS. Results: Multivariable analysis identified neoadjuvant chemoradiotherapy (odds ratio [OR] 4.923, 95% confidence interval [CI] 2.335-10.379, P < .001), local anal distance from the lower edge of the tumor (OR 6.199, 95% CI 2.701-14.266, P < .001), and anastomotic leakage (OR 5.624, 95% CI 1.463-21.614, P = .012) as independent predictors for development of LARS. Meanwhile, neoadjuvant chemoradiotherapy (OR 4.693, 95% CI 1.368-16.107, P = .014) and local anal distance from the lower edge of the tumor (OR 4.935, 95% CI 1.332-18.285, P = .017) were dramatically correlated with development of major LARS in a multivariable analysis. In the major LARS group, statistically significant differences (P < .05) were ascertained, include physical functioning, role functioning, emotional functioning, social functioning, and global health. In addition, pain and diarrhea were evidently higher. Conclusions: Neoadjuvant chemoradiotherapy, local anal distance from the lower edge of the tumor, and anastomotic leakage correlated strongly with development of LARS, and neoadjuvant chemoradiotherapy and local anal distance from the lower edge of the tumor correlated strongly with development of major LARS. Meanwhile, the QoL of patients with major LARS was lower than that of patients with no/minor LARS.

Transverse Coloplasty Pouch versus Straight Coloanal Anastomosis Following Intersphincteric Resection for Low Rectal Cancer: the Functional Benefits May Emerge After Two Years

PURPOSE

This study aimed to compare the oncological and functional outcomes following intersphincteric resection (ISR) with transverse coloplasty pouch (TCP) or straight coloanal anastomosis (SCAA) for low rectal cancer.

METHODS

A single-center retrospective analysis was performed on patients with low rectal cancer who received ISR between January 2016 and June 2021. The primary endpoint was to compare the outcomes of bowel function within 1 year, 1 to 2 years, and 2 years after ileostomy closure in patients undergoing two different bowel reconstruction procedures (TCP or SCAA). The postoperative complications and oncological results were also compared between the two groups.

RESULTS

A total of 235 patients were enrolled in this study (SCAA group: 166; TCP group: 69). There was no significant difference in complications, including grades A-C anastomotic leakage (9.6% vs 15.9%), 3-year local recurrence rates (6.1% vs 3.9%), disease-free survival (82.4%vs 83.8%), or overall survival (94.1% vs 94.7%) between the two groups. Two years after ileostomy closure, 52.7% of patients in the SCAA group were assessed as having major low anterior resection syndrome (LARS), which was significantly higher than the 25.9% of patients in the TCP group (P = 0.014), but no difference was found prior to 2 years. Similar differences were seen in Wexner scores 2 years after surgery (P = 0.032). Additionally, TCP was an independent protective factor for postoperative bowel function as measured by both the LARS (OR, 0.28; 95% CI, 0.10-0.82; p = 0.020) and Wexner scoring (OR, 0.28; 95% CI, 0.09-0.84; p = 0.023).

CONCLUSION

This study suggests that TCP is a safe technique that may decrease bowel dysfunction after ISR for low rectal cancer compared with SCAA 2 years after ileostomy closure.

Management of Low Anterior Resection Syndrome (LARS) Following Resection for Rectal Cancer

INTRODUCTION

A total of 60-80% of patients undergoing rectal resection (mostly as a treatment for rectal cancer) suffer from a variety of partly severe functional problems despite preservation of the anal sphincter. These patients are summarized under the term low anterior resection syndrome (LARS). Preoperative radiotherapy, vascular dissection and surgical excision of the low rectum and mesorectum lead, alone or all together, to a significant impairment of colonic and (neo-) rectal motility. This results in a variety of symptoms (multiple defecation episodes, recurrent episodes of urge, clustering, incontinence, etc.) which are associated with severe impairment of quality of life (QOL).

METHODS

This narrative review summarizes the present state of knowledge regarding the pathophysiology of LARS as well as the evidence for the available treatment options to control the symptoms resulting from this condition.

RESULTS

A review of the literature (Medline, Pubmed) reveals a variety of treatment options available to control symptoms of LARS. Medical therapy, with or without dietary modification, shows only a modest effect. Pelvic floor rehabilitation consisting of muscle exercise techniques as well as biofeedback training has been associated with improvement in LARS scores and incontinence, albeit with limited scientific evidence. Transanal irrigation (TAI) has gained interest as a treatment modality for patients with LARS due to an increasing number of promising data from recently published studies. Despite this promising observation, open questions about still-unclear issues of TAI remain under debate. Neuromodulation has been applied in LARS only in a few studies with small numbers of patients and partly conflicting results.

CONCLUSION

LARS is a frequent problem after sphincter-preserving rectal surgery and leads to a marked impairment of QOL. Due to the large number of patients suffering from this condition, mandatory identification, as well as treatment of affected patients, must be considered during surgical as well as oncological follow-up. The use of a standardized treatment algorithm will lead to sufficient control of symptoms and a high probability of a marked improvement in QOL.

The role of colonic motility in low anterior resection syndrome

Low anterior resection syndrome (LARS) describes the symptoms and experiences of bowel dysfunction experienced by patients after rectal cancer surgery. LARS is a complex and multifactorial syndrome exacerbated by factors such as low anastomotic height, defunctioning of the colon and neorectum, and radiotherapy. There has recently been growing awareness and understanding regarding the role of colonic motility as a contributing mechanism for LARS. It is well established that rectosigmoid motility serves an important role in coordinating rectal filling and maintaining continence. Resection of the rectosigmoid may therefore contribute to LARS through altered distal colonic and neorectal motility. This review evaluates the role of colonic motility within the broader pathophysiology of LARS and outlines future directions of research needed to enable targeted therapy for specific LARS phenotypes.

The Longitudinal Course of Low-anterior Resection Syndrome: An individual Patient Meta-analysis

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.

Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry

BACKGROUND

The quality of life in patients who develop low anterior resection syndrome (LARS) after surgery for mid-low rectal cancer is seriously impaired. The underlying pathophysiological mechanism of LARS has not been fully investigated.

AIM

To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively.

METHODS

Patients diagnosed with mid-low rectal cancer were included. The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure. Anorectal functions were assessed by three-dimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery.

RESULTS

The study population consisted of 24 patients. The total LARS score was decreased at 6 mo compared with 3 mo after surgery (P < 0.05), but 58.3% (14/24) lasted as major LARS at 6 mo after surgery. The length of the high-pressure zone of the anal sphincter was significantly shorter, the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in all patients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focal pressure defects of the anal canal were detected in 70.8% of patients, and those patients had higher LARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spastic peristaltic contractions from the new rectum to anus were detected in 45.8% of patients, which were associated with a higher LARS score at 3 mo postoperatively (P < 0.05).

CONCLUSION

The LARS score decreases over time after surgery in the majority of patients with mid-low rectal cancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spastic peristaltic contractions from the new rectum to anus postoperatively, might be the major pathophysiological mechanisms of LARS.

Prospective evaluation of bowel dysfunction after rectal cancer surgery

PURPOSE

Bowel dysfunction after rectal cancer surgery may significantly affect the quality of life. Our study aimed to estimate the incidence and characterize the low anterior resection syndrome (LARS).

METHODS

Prospective evaluation of patients treated with anterior resection for rectal cancer at two hospitals followed for 12 months after ileostomy reversal. The assessment was performed at baseline, after neoadjuvant treatment, and 1 month, 6 months, and 12 months after bowel transit reconstruction using several scores (Bristol scale, LARS score, Memorial Sloan Kettering bowel function instrument, Fecal Incontinence Quality of Life, EORTC-QLQ30, and a visual analogue scale).

RESULTS

Of 205 patients diagnosed with rectal cancer, 78 were followed for 12 months after the exclusion criteria. "Major LARS" at 1 month, 6 months, and 12 months was 55.6%, 47.3%, and 34.6%, respectively. At 12 months, patients experienced significantly less diarrhea, higher LARS score, more percentage of "major LARS," and worse MSK-BFI score compared to baseline. Regarding the quality of life at 12 months, 77.7% of patients with "major LARS" reported impact according to the anchor question of the LARS score; all FIQL subscales were significantly lower; the overall EORTC-QLQ30 score and the functional subscales significantly correlated with the LARS and the MSK-BFI scores.

CONCLUSIONS

Bowel dysfunction with an impact on the quality of life is common after rectal cancer surgery. The knowledge of the potential consequences of the treatments is essential to be able to provide patients with the best possible information.

Outcomes of robotic partial excision of the levator ani muscle for locally advanced low rectal cancer invading the ipsilateral pelvic floor at the anorectal ring level

PURPOSE

The purpose of this study is to evaluate partial excision of the levator ani muscle (PELM) enables preservation of anal sphincter function although levator ani muscle (LAM) was invaded.

METHODS

Functional outcomes and oncologic outcomes of 23 consecutive patients who underwent robotic PELM for low rectal cancer at the anorectal ring level invading or abutting the ipsilateral LAM are analysed.

RESULTS

Secured resection margins were achieved, especially for the circumferential resection margin. During a median follow-up of 44 months, the 3-year local recurrence rate was 14.4%. Among patients who underwent diverting ileostomy closure, mean Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores were 68.3 ± 11.9 and 10.7 ± 5.3, respectively, at 1 year after closure.

CONCLUSION

PELM is a sphincter-preserving alternative to abdominoperineal resection (APR) or extralevator APR for low rectal cancer invading the ipsilateral LAM at the level of the anorectal ring.

CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION

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

Comparison of bowel dysfunction between colorectal cancer survivors and a non-operative non-cancer control group

AIM

Low anterior resection syndrome (LARS) detrimentally affects quality of life in colorectal cancer survivors. This study assessed the prevalence for LARS in colorectal cancer survivors and the same symptoms in a matched control group.

METHOD

Validated instruments, the LARS score and Short Form Survey 12, used to collect functional and quality of life outcomes from patients who had undergone distal colorectal resection at Auckland Hospital (2008-2015) or Dunedin Hospital (2008-2017). A matched non-operative control group was drawn from patients undergoing surveillance colonoscopy.

RESULTS

The response rate was 79%. Cross-sectional prevalence of major LARS in rectal cancer patients was 52% at a median follow-up of 52 months. Major LARS prevalence in the sigmoid cancer resection and non-cancer control groups was similar (25% vs 26%, P = 0.6). On univariate analysis anastomotic height [risk ratio (RR) for low anterior resection 4.6, P < 0.001; ultralow anterior resection RR = 15.5, P < 0.001], radiotherapy (RR = 2.6; P = 0.009), stoma (RR = 3.6; P = 0.001) and J pouch reconstruction (vs straight anastomosis, RR = 4.6; P = 0.008) were associated with major LARS for rectal cancer patients. These factors were not significant when the analysis was stratified for anastomotic height. Despite correlation between LARS and Short Form Survey 12 outcomes (physical ρ = -0.2; mental ρ = -0.2) there was no difference in quality of life outcomes between the groups.

CONCLUSION

Bowel dysfunction after low anterior resection affects the majority of rectal cancer patients. The high background rate of bowel dysfunction must be considered when assessing the prevalence of LARS.

The Acceptability of Faecal Microbiota Transplant for Anterior Resection Syndrome (AFFINITY) Study

Low anterior resection syndrome (LARS) is recognised as disordered bowel function after rectal resection. Temporary ileostomy is associated with LARS and with reduced colonic bacteria. Faecal microbiota transplant (FMT) is the introduction of enteric bacteria from healthy donors into a patient’s gut. We hypothesise that FMT could improve bowel function after ileostomy reversal. We aim to determine whether FMT would be acceptable to patients. Patients who had undergone anterior resection in the previous two years across four sites were sent questionnaires. A group of patients were invited to a focus group to explore their views further. There were 98 eligible patients, of whom 40 responded (41%); 67% were male, median age was 67 (range 31–83) years, and 11 still had a stoma. Of those who had their stoma reversed, 52% had major LARS symptoms. Sixty-five percent thought the concept of FMT sounded effective and 70% were willing to try it. A healthy anonymous donor and FMT via enema were the most acceptable options to the respondents. Seven patients attended the focus group; 2 female, 5 male, mean age 66 (range 45–75) years. All patients thought FMT was acceptable but the word “faecal” made it less acceptable. All participants would consider entering a trial with FMT as a treatment option. The main concerns were safety and efficacy. The majority of patients who responded thought FMT was acceptable and were willing to try it as a potential treatment option.

Effectiveness and safety of acupuncture and moxibustion for defecation dysfunction after sphincter-preserving surgery for rectal cancer: protocol for systematic review and meta-analysis

INTRODUCTION

Defecation dysfunction (DD) is one of the most common complications following sphincter-preserving surgery for rectal cancer. And there is no effective treatment of DD after sphincter-preserving surgery for rectal cancer. Although some studies suggested that acupuncture and moxibustion (AM) is effective and safe for DD after sphincter-preserving surgery for rectal cancer, lacking strong evidence, for instance, the relevant systematic review, meta-analysis and randomised controlled trial (RCT) of a large, multicentre sample, makes the effects and safety remain uncertain. The present protocol is described for a systematic review and meta-analysis to investigate the effectiveness and safety of AM for DD after sphincter-preserving surgery for rectal cancer.

METHODS AND ANALYSIS

We will search nine online databases from inception to 1 October 2019; the language of included trials will not be restricted. This study will include RCTs that performed AM as the main method of the experimental group for patients with DD after sphincter-preserving surgery for rectal cancer. Two of the researchers will independently select the studies, conduct risk of bias assessment and extract the data. We will use the fixed-effects model or random-effects model of RevMan V.5.2 software to analyse data synthesis. The risk ratios with 95% CIs and weighted mean differences or standardised mean differences with 95% CIs will be used to present the data synthesis outcome of dichotomous data respectively and the continuous data. Evidence quality of outcome will be assessed by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

ETHICS AND DISSEMINATION

Ethical approval is not required in this secondary research evidence, and we will publish the results of this study in a journal or concerned conferences.

TRIAL REGISTRATION NUMBER

CRD42019140097.

Oncologic safety and bowel function after ultralow anterior resection with or without intersphincteric resection for low lying rectal cancer: Comparative cross sectional study

BACKGROUND

Despite acceptable oncologic outcomes of sphincter preserving surgeries for low rectal cancer, bowel dysfunction occurs. This study aimed to compare the oncologic and functional bowel outcomes between ultralow anterior resection (ULAR) and intersphincteric resection (ISR) for low rectal cancer.

METHODS

One hundred sixty-four patients who underwent ULAR with or without ISR for low rectal cancer between December 2010 and May 2018 were included. The Wexner and Memorial Sloan Kettering Cancer Center (MSKCC) scores were used to evaluate the bowel function of patients. Overall survival (OS) and disease-free survival (DFS) were compared between patients.

RESULTS

The ISR group had higher incidence of major fecal incontinence than the ULAR group (75.9% vs 49.3%; P = .016). The median Wexner score decreased from 12 to 9 (P = .062) at 1-year follow-up. However, the frequency and urgency/soilage subscales of MSKCC score improved significantly in the ULAR group. ISR and follow-up interval less than 1-year significantly increased the major incontinence risk. The OS in the ULAR and ISR groups was 91.4% and 91.7%. Whereas the DFS in both groups was 79% and 79.2%, respectively.

CONCLUSION

ULAR and ISR are comparable in oncologic outcomes. Severe bowel dysfunctions and major incontinence were noted in ISR group. Careful selection of patients is mandatory.

Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis

BACKGROUND

Defunctioning ileostomy is widely used to protect a low colorectal anastomosis. However, the use of an ileostomy may have an impact on long-term bowel function and quality of life after anterior resection. The objectives were to compare bowel function and quality of life outcomes between patients undergoing an anterior resection for rectal cancer, with and without the formation of a diverting ileostomy, and to compare outcomes for early versus late closure of diverting ileostomy.

METHOD

A systematic literature review was performed to identify studies published between 2007 and 2018 comparing bowel function and quality of life outcomes after an anterior resection for rectal cancer in those with and without formation of a diverting ileostomy.

RESULTS

Four studies (three randomized controlled trials) reported bowel function and quality of life outcomes. Pooled analysis for 227 participants showed that having an ileostomy is associated with twice the risk of suffering from low anterior resection syndrome (odds ratio (major low anterior resection syndrome) 1.96, 95% confidence interval 1.1, 3.5; P = 0.02). There were no consistent differences in quality of life. Based on single studies there is limited evidence of some improvements in bowel function but no difference in quality of life after early compared to late closure of ileostomy.

CONCLUSION

There is some evidence for an association between low anterior resection syndrome and the use of a diverting ileostomy to protect a rectal anastomosis. Potential confounders include height of the anastomosis. Further research into the mechanisms underlying this potential association may inform methods to mitigate the harms of an ileostomy.

Predictive Factors for Bowel Dysfunction After Sphincter-Preserving Surgery for Rectal Cancer: A Single-Center Cross-sectional Study

BACKGROUND

With increasing rates of sphincter preservation because of advances in preoperative chemoradiation, restoration of bowel continuity has become a main goal of rectal cancer treatment. However, in many patients, postoperative bowel dysfunction negatively affects the quality of life.

OBJECTIVE

This study aimed to analyze predictors of bowel dysfunction after sphincter-preserving surgery in patients with rectal cancer.

DESIGN

This was a cross-sectional study.

SETTINGS

Assessment of bowel dysfunction was conducted between November 2015 and June 2017 at our institution.

PATIENTS

A total of 316 patients with rectal cancer who underwent sphincter-preserving surgery between February 2009 and April 2017 and agreed with an interview for assessing bowel dysfunction were included.

MAIN OUTCOME MEASURES

Bowel dysfunction was assessed with the Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner score. All the assessments were conducted face-to-face by the same interviewer.

RESULTS

The median time interval between the restoration of bowel continuity and assessment was 10 months (interquartile range, 3-37), and the median total Memorial Sloan Kettering Cancer Center and Wexner scores were 65 (interquartile range, 58-73) and 6 (interquartile range, 0-11). The time interval was correlated with the Memorial Sloan Kettering Cancer Center scores (rho, 0.279) and Wexner scores (rho, -0.306). In a multivariate analysis, handsewn anastomosis and short time interval (≤1 year) were independently associated with poor bowel function (Memorial Sloan Kettering Cancer Center score ≤65). A short time interval (≤1 year), preoperative chemoradiation, and ileostomy were independently associated with major fecal incontinence (Wexner ≥8).

LIMITATIONS

Selection bias may be inherent.

CONCLUSIONS

Bowel function recovers with time after the restoration of bowel continuity. A short time interval, handsewn anastomosis, preoperative chemoradiation, and ileostomy were significantly associated with poor bowel function or major fecal incontinence. Surgeons should discuss postoperative bowel dysfunction and its predictive factors with the patients. See Video Abstract at http://links.lww.com/DCR/A930.

Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer

BACKGROUND

Low anterior resection syndrome (LARS) has a significant impact on postoperative quality of life. Although early closure of an ileostomy is safe in selected patients, functional outcomes have not been investigated. The aim was to compare bowel function and the prevalence of LARS in patients who underwent early or late closure of an ileostomy after rectal resection for cancer.

METHODS

Early closure (8-13 days) was compared with late closure (after 12 weeks) of the ileostomy following rectal cancer surgery in a multicentre RCT. Exclusion criteria were: signs of anastomotic leakage, diabetes mellitus, steroid treatment and postoperative complications. Bowel function was evaluated using the LARS score and the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (BFI).

RESULTS

Following index surgery, 112 participants were randomized (55 early closure, 57 late closure). Bowel function was evaluated at a median of 49 months after stoma closure. Eighty-two of 93 eligible participants responded (12 had died and 7 had a permanent stoma). Rates of bowel dysfunction were higher in the late closure group, but this did not reach statistical significance (major LARS in 29 of 40 participants in late group and 25 of 42 in early group, P = 0·250; median BFI score 63 versus 71 respectively, P = 0·207). Participants in the late closure group had worse scores on the urgency/soiling subscale of the BFI (14 versus 17; P = 0·017). One participant in the early group and six in the late group had a permanent stoma (P = 0·054).

CONCLUSION

Patients undergoing early stoma closure had fewer problems with soiling and fewer had a permanent stoma, although reduced LARS was not demonstrated in this cohort. Dedicated prospective studies are required to evaluate definitively the association between temporary ileostomy, LARS and timing of closure.

Effect of preoperative chemotherapy on distal spread of low rectal cancer located close to the anus

PURPOSE

This study aimed to clarify the frequency of distal spread and the optimal distal margin after preoperative chemotherapy for advanced low rectal cancer.

METHODS

The study included patients with advanced lower rectal cancer who received preoperative chemotherapy and underwent surgery during 2012-2015. We investigated the distal spread of tumor cells, defined as the distal distance from the intramucosal distal tumor edge to the farthest tumor cells located under the submucosal layer. Clinical characteristics were compared for distal spreads ≥ 10 and < 10 mm, and risk factors for distal spread ≥ 10 mm were investigated.

RESULTS

Of the 71 patients, 42 (59%) showed distal spread. Distal spreads of 1-9, 10-19, and ≥ 20 mm were observed in 27 (38%), 11 (15%), and 4 (6%) patients, respectively. Multivariate analysis revealed two independent risk factors for distal spread ≥ 10 mm after preoperative chemotherapy. The first risk factor is the presence of different therapeutic effects between the mucosal and deeper layers (meaning that superficial tumor shrinkage was evident on colonoscopy, but little tumor shrinkage was evident on magnetic resonance imaging) (odds ratio, 11.6; 95% CI, 2.22-61.3). The second risk factor is poorly differentiated or mucinous adenocarcinoma (odds ratio, 8.86; 95% CI, 1.58-49.9).

CONCLUSION

A distal margin of 20 mm is required (10 mm is insufficient) for advanced lower rectal cancer patients who receive preoperative chemotherapy followed by surgery. Independent risk factors for distal spread ≥ 10 mm include (1) the presence of different therapeutic effects between mucosal and deeper layers and (2) poorly differentiated or mucinous adenocarcinomas.

Anterior resection syndrome: What should we tell practitioners and patients in 2018?

Multidisciplinary management of infra-peritoneal rectal cancer has pushed back the frontiers of sphincter preservation, without impairment of carcinological outcome. However, functional intestinal sequelae, grouping together several symptoms known under the name of anterior resection syndrome (ARS), have emerged and become an increasingly frequent concern for both patients and physicians. The pathophysiology is complex: ARS is a combination in various degrees of stool frequency, incontinence for flatus and/or stools, urgency, and disorders in discrimination and evacuation. The "Low Anterior Resection Score" (LARS), validated in 2012, is currently used to evaluate the severity of ARS and its impact on quality of life. While ARS can show improvement over the first two years, symptoms persist for longer than two years in nearly 60% of patients and in half of these patients, ARS is considered severe. The most frequently reported independent risk factors of severe ARS include neo-adjuvant radiation therapy, the extent of resection (total mesorectal excision that includes inter-sphincteric resection), absence of colonic pouch and anastomotic leak. In the absence of surgical complications and/or local recurrence, physicians can draw from a wide therapeutic armamentarium in order to improve the functional outcome of patients, including diet and lifestyle modifications, gut motility regulators, multimodal rehabilitation (biofeedback, electro-stimulation) and sacral nerve modulation. Permanent colostomy is an alternative of last resort, proposed only when all other solutions fail. A better understanding of the natural history of ARS, its risk factors as well as the array of therapeutic alternatives should provide better patient information and optimize management.

Physiotherapy and Anterior Resection Syndrome (PARiS) trial: feasibility study protocol

INTRODUCTION

Rectal cancer affects more than 600 patients per year in Wales, with a 5-year survival rate of around 60%. A recent report demonstrated that 19% of patients with bowel cancer had difficulty controlling their bowels after surgery, and these patients were twice as likely to report lower quality of life than those who had control. Nearly all patients will experience bowel dysfunction initially following surgery and up to 25% will experience severe bowel dysfunction on a long-term basis. The aim of this study is to test the feasibility of introducing a simple intervention in an attempt to improve bowel function following surgery for rectal cancer. We propose the introduction of an educational session from specialist nurses and physiotherapists prior to surgery and a subsequent physiotherapy programme for 3 months to teach patients how to strengthen their pelvic floor.

METHODS AND ANALYSIS

All patients with rectal cancer planned to receive an anterior resection will be approached for the study. The study will take place in three centres over 12 months, and we expect to recruit 40 patients. The primary outcome measure is the proportion of eligible patients approached who consent to and attend the educational session. The secondary outcomes include patient compliance to the pelvic floor rehabilitation programme (assessed by patient paper or electronic diary), the acceptability of the intervention to the patient (assessed using qualitative interviews) and preoperative and postoperative pelvic floor tone (assessed using the Oxford Grading System and the International Continence Society Grading System), patient bowel function and patient quality of life (assessed using validated questionnaires).

ETHICS AND DISSEMINATION

Ethics approval was granted. This feasibility study is in progress. If patients find the intervention acceptable, the next stage would be a trial comparing outcomes after anterior resection in those who have and do not have physiotherapy.

TRIAL REGISTRATION NUMBER

ISRCTN77383505; Pre-results.

Defining low anterior resection syndrome: a systematic review of the literature

AIM

There is increasing awareness of the poor functional outcome suffered by many patients after sphincter-preserving rectal resection, termed 'low anterior resection syndrome' (LARS). There is no consensus definition of LARS and varying instruments have been employed to measure functional outcome, complicating research into prevalence, contributing factors and potential therapies. We therefore aimed to describe the instruments and outcome measures used in studies of bowel dysfunction after low anterior resection and identify major themes used in the assessment of LARS.

METHOD

A systematic review of the literature was performed for studies published between 1986 and 2016. The instruments and outcome measures used to report bowel function after low anterior resection were extracted and their frequency of use calculated.

RESULTS

The search revealed 128 eligible studies. These employed 18 instruments, over 30 symptoms, and follow-up time periods from 4 weeks to 14.6 years. The most frequent follow-up period was 12 months (48%). The most frequently reported outcomes were incontinence (97%), stool frequency (80%), urgency (67%), evacuatory dysfunction (47%), gas-stool discrimination (34%) and a measure of quality of life (80%). Faecal incontinence scoring systems were used frequently. The LARS score and the Bowel Function Instrument (BFI) were used in only nine studies.

CONCLUSION

LARS is common, but there is substantial variation in the reporting of functional outcomes after low anterior resection. Most studies have focused on incontinence, omitting other symptoms that correlate with patients' quality of life. To improve and standardize research into LARS, a consensus definition should be developed, and these findings should inform this goal.

Long-term effects of neoadjuvant chemoradiotherapy followed by sphincter-preserving resection on anal sphincter function in relation to quality of life among locally advanced rectal cancer patients: a cross-sectional analysis

BACKGROUND

There is growing recognition for the consequences of rectal cancer treatment to maintain an adequate functional sphincter in the long-term rather than preserving the anal sphincter itself. This study aims to evaluate long-term effects of neoadjuvant chemoradiotherapy (nCRT) followed by sphincter-preserving resection on anal sphincter function in relation to quality of life (QoL) among locally advanced rectal cancer patients.

METHODS

Twenty-nine patients treated with nCRT followed by low anterior resection surgery were included in this study. Data on patient demographics, tumor location and symptoms of urgency and fecal soiling were recorded and evaluated with respect to Wexner Fecal Incontinence Scoring Scale, European Organization for Research and Cancer (EORTC) cancer-specific (EORTC QLQ-C30) and colorectal cancer-specific (EORTC QLQ-CR38) questionnaires and anorectal manometrical findings. Correlation of manometrical findings with Wexner Scale, EORTC QLQ-CR38 scores and EORTC QLQ-C30 scores was also evaluated.

RESULTS

Median follow-up was 45.6 months (ranged 7.5-98 months. Higher scores for incontinence for gas (p = 0.001), liquid (p = 0.048) and solid (p = 0.019) stool, need to wear pad (p = 0.001) and alteration in life style (p = 0.004) in Wexner scale, while lower scores for future perspective (p = 0.010) and higher scores for defecation problems (p = 0.001) in EORTC QLQ-CR38 were noted in patients with than without urgency. Manometrical findings of resting pressure (mmHg) was positively correlated with body image (r = 0.435, p = 0.030) and sexual functioning (r = 0.479, p = 0.011) items of functional scale, while rectal sensory threshold (RST) volume (mL) was positively correlated with defecation problems (r = 0.424, p = 0.031) items of symptom scale in EORTC QLQ-CR38 and negatively correlated with social function domain (r = -0.479, p = 0.024) in EORTC QLQ-C30. RST volume was also positively correlated with Wexner scores including incontinence for liquid stool (r = 0.459, p = 0.024), need to wear pad (r = 0.466, p = 0.022) and alteration in lifestyle (r = 0.425, p = 0.038).

CONCLUSION

The high risk of developing functional anal impairment as well as the systematic registration of not only oncological but also functional and QoL related outcomes seem important in rectal cancer patients in the long-term disease follow-up.