International Consensus Definition of Low Anterior Resection Syndrome

Effects on anorectal function of endoscopic submucosal dissection for rectal tumors involving the dentate line

OBJECTIVE

Endoscopic submucosal dissection (ESD) is a specific procedure that uses an electrosurgical knife for en-bloc resectioning large tumors. However, no study has examined the effect of ESD on the defecation function of patients with rectal tumors. We aimed to investigate the potential effects caused by ESD by analyzing changes in the morphology and movement of the anorectum pre- and post-ESD.

METHODS

This prospective observational study included 11 patients with anorectal tumors who underwent ESD between April 2020 and February 2022. Pre-ESD assessments included anorectal manometry and defecography. Post-ESD assessments were conducted 2 months later, including anorectal manometry, defecography, and proctoscopy for ulcer and stenosis evaluation.

RESULTS

The median patient age was 73 years, including seven males and four females. Eight patients (73%) had a tumor in the lower rectum, and the extent of resection was less than 50% of the rectal lumen. Resection reached the dentate line in six cases (55%). In the patients with post-ESD mucosal defects involving the dentate line, the median of functional anal canal length significantly decreased from (3.4 cm pre-ESD to 2.8 cm post-ESD, p = 0.04). Defecography revealed one case with incomplete evacuation (<50%) and incontinence post-ESD. Interestingly, patients with pre-existing rectoceles noted resolution of lesions post-ESD. None of the patients reported daily constipation or fecal incontinence.

CONCLUSIONS

While rectal ESD is unlikely to cause significant real-world defecation difficulties, alterations in rectal and anal canal morphology and function may occur if the dentate line is involved in the resection range.

Long-Term Functional Outcome After Early vs. Late Stoma Closure in Rectal Cancer Surgery: Sub-analysis of the Multicenter FORCE Trial

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.

Effect of a Mobile Health-Based Remote Interaction Management Intervention on the Quality of Life and Self-Management Behavior of Patients With Low Anterior Resection Syndrome: Randomized Controlled Trial

BACKGROUND

People who undergo sphincter-preserving surgery have high rates of anorectal functional disturbances, known as low anterior resection syndrome (LARS). LARS negatively affects patients' quality of life (QoL) and increases their need for self-management behaviors. Therefore, approaches to enhance self-management behavior and QoL are vital.

OBJECTIVE

This study aims to assess the effectiveness of a remote digital management intervention designed to enhance the QoL and self-management behavior of patients with LARS.

METHODS

From July 2022 to May 2023, we conducted a single-blinded randomized controlled trial and recruited 120 patients with LARS in a tertiary hospital in Hefei, China. All patients were randomly assigned to the intervention group (using the "e-bowel safety" applet and monthly motivational interviewing) or the control group (usual care and an information booklet). Our team provided a 3-month intervention and followed up with all patients for an additional 3 months. The primary outcome was patient QoL measured using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30. The secondary outcomes were evaluated using the Bowel Symptoms Self-Management Behaviors Questionnaire, LARS score, and Perceived Social Support Scale. Data collection occurred at study enrollment, the end of the 3-month intervention, and the 3-month follow-up. Generalized estimating equations were used to analyze changes in all outcome variables.

RESULTS

In the end, 111 patients completed the study. In the intervention group, 5 patients withdrew; 4 patients withdrew in the control group. Patients in the intervention group had significantly larger improvements in the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 total score (mean difference 11.51; 95% CI 10.68-12.35; Cohen d=1.73) and Bowel Symptoms Self-Management Behaviors Questionnaire total score (mean difference 8.80; 95% CI 8.28-9.32; Cohen d=1.94) than those in the control group. This improvement effect remained stable at 3-month follow-up (mean difference 14.47; 95% CI 13.65-15.30; Cohen d=1.58 and mean difference 8.85; 95% CI 8.25-9.42; Cohen d=2.23). The LARS score total score had significantly larger decreases after intervention (mean difference -3.28; 95% CI -4.03 to -2.54; Cohen d=-0.39) and at 3-month follow-up (mean difference -6.69; 95% CI -7.45 to -5.93; Cohen d=-0.69). The Perceived Social Support Scale total score had significantly larger improvements after intervention (mean difference 0.47; 95% CI 0.22-0.71; Cohen d=1.81).

CONCLUSIONS

Our preliminary findings suggest that the mobile health-based remote interaction management intervention significantly enhanced the self-management behaviors and QoL of patients with LARS, and the effect was sustained. Mobile health-based remote interventions become an effective method to improve health outcomes for many patients with LARS.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200061317; https://tinyurl.com/tmmvpq3.

Patients' experiences of living with low anterior resection syndrome three to six months after colorectal cancer surgery: A phenomenological study

BACKGROUND

Increased use of sphincter-preserving surgery following colorectal cancer has led to more people living with low anterior resection syndrome (LARS), a disordered bowel function that significantly impacts quality of life. Little is known about how patients experience the first months following sphincter-preserving surgery and having LARS.

OBJECTIVE

To shed light on what it means to live with LARS in the first three to six months after colorectal cancer sphincter-preserving surgery.

METHOD

A qualitative study with a phenomenological approach constitutes the study design. Semi-structured interviews were conducted with five participants from September 2022 to January 2023. The transcribed interviews were analysed using Giorgi's phenomenological method.

RESULTS

Five themes emerged from the analysis: bowel emptying becomes all-consuming and affects both daily life and working life, you hear what they're saying, but don't understand what it means until your body goes through it, low anterior resection syndrome may impact sexual life, leaving feelings of guilt, it doesn't matter what the circumstances are, but rather how one deals with them, and support and follow-up from healthcare professionals, employers, family and friends are crucial for living a good life with LARS.

CONCLUSION

Participants described struggles living with major LARS in the early period following hospital discharge. However, few months later, they had developed strategies enabling them to control their everyday life. Support and follow-up from healthcare professionals, employers, family, and friends were crucial when learning to live with major LARS. Participants expressed desire for a systematic and proactive follow-up from healthcare professionals and contact with peer-support groups.

Biofeedback combined with percutaneous electrical pudendal nerve stimulation for the treatment of low anterior rectal resection syndrome: a study protocol for a randomized controlled trial

BACKGROUND

Low anterior resection syndrome (LARS) is a distressing condition that affects approximately 25-80% of patients following surgery for rectal cancer. LARS is characterized by debilitating bowel dysfunction symptoms, including fecal incontinence, urgent bowel movements, and increased frequency of bowel movements. Although biofeedback therapy has demonstrated effectiveness in improving postoperative rectal control, the research results have not fulfilled expectations. Recent research has highlighted that stimulating the pudendal perineal nerves has a superior impact on enhancing pelvic floor muscle function than biofeedback alone. Hence, this study aims to evaluate the efficacy of a combined approach integrating biofeedback with percutaneous electrical pudendal nerve stimulation (B-PEPNS) in patients with LARS through a randomized controlled trial (RCT).

METHODS AND ANALYSIS

In this two-armed multicenter RCT, 242 participants with LARS after rectal surgery will be randomly assigned to undergo B-PEPNS (intervention group) or biofeedback (control group). Over 4 weeks, each participant will undergo 20 treatment sessions. The primary outcome will be the LARS score. The secondary outcomes will be anorectal manometry and pelvic floor muscle electromyography findings and the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-Colorectal 29 (EORTC QLQ-CR29) scores. Data will be collected at baseline, post-intervention (1 month), and follow-up (6 months).

DISCUSSION

We anticipate that this study will contribute further evidence regarding the efficacy of B-PEPNS in alleviating LARS symptoms and enhancing the quality of life for patients following rectal cancer surgery.

TRIAL REGISTRATION

Chinese Clincal Trials Register ChiCTR2300078101. Registered 28 November 2023.

Shared Decision-Making, Sphincter Preservation, and Rectal Cancer Treatment: Identifying and Executing What Matters Most to Patients

Rectal cancer treatment often encompasses multiple steps and options, with benefits and risks that vary based on the individual. Additionally, patients facing rectal cancer often have preferences regarding overall quality of life, which includes bowel function, sphincter preservation, and ostomies. This article reviews these data in the context of shared decision-making approaches in an effort to better inform patients deliberating treatment options for rectal cancer.

Predicting bowel function after diverting stoma closure in patients with rectal cancer

Background

Patients with rectal cancer undergoing laparoscopic anterior resection and diverting stomas often suffer from bowel dysfunction after stoma closure, impairing their quality of life. This study aims to develop a machine learning tool to predict bowel function after diverting stoma closure.

Methods

Clinicopathological data and post-operative follow-up information from patients with mid-low rectal cancer after diverting stoma closure were collected and analyzed. Patients were randomly divided into training and test sets in a 7:3 ratio. A machine learning model was developed in the training set to predict major low anterior resection syndrome (LARS) and evaluated in the test set. Decision curve analysis (DCA) was used to assess clinical utility.

Results

The study included 396 eligible patients who underwent laparoscopic anterior resection and diverting stoma in Tongji Hospital affiliated with Huazhong University of Science and Technology from 1 January 2012 to 31 December 2020. The interval between stoma creation and closure, neoadjuvant therapy, and body mass index were identified as the three most crucial characteristics associated with patients experiencing major LARS in our cohort. The machine learning model achieved an area under the receiver operating characteristic curve (AUC) of 0.78 [95% confidence interval (CI): 0.74-0.83] in the training set (n=277) and 0.74 (95% CI: 0.70-0.79) in the test set (n=119), and area under the precision-recall curve (AUPRC) of 0.73 and 0.69, respectively, with sensitivity of 0.67 and specificity of 0.66 for the test set. DCA confirmed clinical applicability.

Conclusions

This study developed a machine learning model to predict major LARS in rectal cancer patients after diverting stoma closure, aiding their decision-making and counseling.

Long-term Changes in Low Anterior Resection Syndrome in Survivors of Rectal Cancer: Longitudinal Follow-up of a Randomized Controlled Trial

BACKGROUND

Postoperative bowel dysfunction, also known as low anterior resection syndrome, is common in rectal cancer survivors and significantly impacts quality of life. Although long-term longitudinal follow-up is lacking, improvement of the syndrome is commonly believed to happen only within the first 2 years.

OBJECTIVE

This study aimed to depict the longitudinal evolvement of low anterior resection syndrome beyond 3 years and explore factors associated with changes.

DESIGN

Longitudinal long-term follow-ups were performed for the single center with the largest cohort within the multicenter FOWARC randomized controlled trial.

SETTING

A quaternary referral center.

PATIENTS

Individuals diagnosed with rectal cancer who received long-course neoadjuvant chemotherapy or chemoradiotherapy, followed by sphincter-preserving radical proctectomy.

MAIN OUTCOME MEASUREMENTS

Change of low anterior resection syndrome score and stoma status.

RESULTS

Of the 220 patients responding to the first follow-up at a median of 39 months, 178 (80.9%) responded to the second follow-up after a median of 83 months. During this interval, the mean low anterior resection syndrome score improved from 29.5 (95% CI, 28.3-30.7) to 18.6 (95% CI, 16.6-20.6). Fifty-six (31.5%) patients reported improvement from major to no/minor severity, and 6 (3.4%) patients had new stomas because of severe bowel dysfunction. Neoadjuvant radiotherapy ( p = 0.016) was independently and negatively associated with improvement of the score.

LIMITATIONS

Loss of follow-up during the long-term follow-ups.

CONCLUSIONS

Most rectal cancer survivors with low anterior resection syndrome continued to improve beyond 3 years after proctectomy. Neoadjuvant radiotherapy was negatively associated with long-term improvement of low anterior resection syndrome. See Video Abstract .

CAMBIO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA EN SUPERVIVIENTES DE CNCER DE RECTO SEGUIMIENTO LONGITUDINAL DE UN ENSAYO CONTROLADO ALEATORIO

ANTECEDENTES:La disfunción intestinal posoperatoria, también conocida como síndrome de resección anterior baja, es común en los sobrevivientes de cáncer de recto y afecta significativamente la calidad de vida. Aunque falta un seguimiento longitudinal a largo plazo, comúnmente se cree que la mejoría del síndrome ocurre sólo dentro de los primeros dos años.OBJETIVO:Este estudio tiene como objetivo representar la evolución longitudinal del síndrome de resección anterior baja más allá de los 3 años y explora los factores asociados con el cambio.DISEÑO:Se realizaron seguimientos longitudinales a largo plazo para el único centro con la cohorte más grande dentro del ensayo controlado aleatorio multicéntrico FOWARC.AJUSTE:Un centro de referencia cuaternario.PACIENTES:Individuos diagnosticados con cáncer de recto que recibieron quimioterapia neoadyuvante de larga duración o quimiorradioterapia, seguida de proctectomía radical con preservación del esfínter.PRINCIPALES MEDICIONES DE RESULTADO:Cambio en la puntuación del síndrome de resección anterior baja y el estado del estoma.RESULTADOS:De los 220 pacientes que respondieron al primer seguimiento con una mediana de 39 meses, 178 (80,9%) respondieron al segundo seguimiento después de una mediana de 83 meses. Durante el intervalo, la puntuación media del síndrome de resección anterior baja mejoró de 29,5 (intervalo de confianza [IC] del 95%: 28,3-30,7) a 18,6 (IC del 95%: 16,6-20,6). 56 (31,5%) pacientes informaron una mejoría de mayor a ninguna gravedad, y 6 (3,4%) pacientes tuvieron un nuevo estoma debido a una disfunción intestinal grave. La radiación neoadyuvante (p = 0,016) se asoció de forma independiente y negativa con la mejora de la puntuación.LIMITACIONES:Pérdida de seguimiento durante los seguimientos a largo plazo.CONCLUSIÓN:La mayoría de los sobrevivientes de cáncer de recto con síndrome de resección anterior baja continuaron mejorando más allá de los 3 años después de la proctectomía. La radiación neoadyuvante se asoció negativamente con la mejora a largo plazo del síndrome de resección anterior baja. (Traducción-Dr Yolanda Colorado ).

Baseline characteristics and recruitment for SWOG S1820: altering intake, managing bowel symptoms in survivors of rectal cancer (AIMS-RC)

PURPOSE

Many survivors of rectal cancer experience persistent bowel dysfunction. There are few evidence-based symptom management interventions to improve bowel control. The purpose of this study is to describe recruitment and pre-randomization baseline sociodemographic, health status, and clinical characteristics for SWOG S1820, a trial of the Altering Intake, Managing Symptoms in Rectal Cancer (AIMS-RC) intervention.

METHODS

SWOG S1820 aimed to determine the preliminary efficacy, feasibility, and acceptability of AIMS-RC, a symptom management intervention for bowel health, comparing intervention to attention control. Survivors with a history of cancers of the rectosigmoid colon or rectum, within 6-24 months of primary treatment completion, with a post-surgical permanent ostomy or anastomosis, and over 18 years of age were enrolled. Outcomes included total bowel function, low anterior resection syndrome, quality of life, motivation for managing bowel health, self-efficacy for managing symptoms, positive and negative affect, and study feasibility and acceptability.

RESULTS

The trial completed accrual over a 29-month period and enrolled 117 participants from 34 institutions across 17 states and one US Pacific territory. At baseline, most enrolled participants reported self-imposed diet adjustments after surgery, persistent dietary intolerances, and bowel discomfort post-treatment, with high levels of constipation and diarrhea (grades 1-4).

CONCLUSIONS

SWOG S1820 was able to recruit, in a timely manner, a study cohort that is demographically representative of US survivors of rectal cancer. Baseline characteristics illustrate the connection between diet/eating and bowel symptoms post-treatment, with many participants reporting diet adjustments and persistent inability to be comfortable with dietary intake.

CLINICALTRIALS

GOV REGISTRATION DATE

12/19/2019.

CLINICALTRIALS

GOV IDENTIFIER

NCT#04205955.

Management of Rectal Cancer in Lynch Syndrome: Balancing Risk Reduction and Quality of Life

Patients with Lynch syndrome are predisposed to developing colorectal cancer and a variety of extracolonic malignancies, at a young age. The management of rectal cancer in the setting of Lynch syndrome is a complex clinical scenario that requires the expertise of a multidisciplinary management team. In this review, we delve into the approach for rectal cancer in these patients, and specifically focus on several key aspects of treatment. Some unique aspects of rectal cancer in Lynch syndrome include the decision between proctectomy alone versus total proctocolectomy with or without an ileal pouch, the utility of chemotherapy and immunotherapy, nonoperative rectal cancer management, and the management of rectal polyps. Throughout, we highlight the delicate interplay between future cancer risk reduction and quality of life optimization.

Assessing Severity of Low Anterior Resection Syndrome After Intersphincteric Resection for Ultralow Rectal Cancer: A Pilot Study Using an Exploratory Instrument

BACKGROUND

The Delphi consensus identified 8 symptoms and 8 consequences as the highest priorities for defining low anterior resection syndrome.

OBJECTIVE

To describe an exploratory scoring instrument correlating the Delphi consensus on low anterior resection syndrome with functional and quality-of-life scores following intersphincteric resection for ultralow rectal cancer.

DESIGN

This was a prospective pilot study. In accordance with the Wexner incontinence score, 5 frequency responses ranging from never (score 0) to always (score 4) were used to measure the severity of symptom- and consequence-specific variables.

SETTINGS

Colorectal surgery referral center.

PATIENTS

Among 161 eligible patients, 137 participants (85%) completed an electronic self-assessment survey regarding function and quality of life at scheduled follow-up, including 3 to 6, 12, and ≥24 months after ileostomy reversal.

MAIN OUTCOME MEASURES

Outcome measures included patient-reported severity of the identified priorities, and their correlation with condition-specific quality of life.

RESULTS

The most frequent symptom and consequence were "emptying difficulties" and "dissatisfaction with the bowels," respectively. Aside from "emptying difficulties," the proportions of negative symptom domains increased after reversal. In particular, neither the frequency responses nor the severity scores of "emptying difficulties" differed between groups. The percentages of "always" selection for consequence domains improved at 12-month follow-up, whereas a higher rate was observed at 24 months, except for "toilet dependence" and "dissatisfaction with the bowels." We found significant improvements in the summary score of the Fecal Incontinence Quality-of-Life Scale ( p = 0.04) and our exploratory instrument ( p = 0.009) but not in functional scores measured by traditional questionnaires. Furthermore, the condition-specific quality of life strongly correlated with the Delphi consensus severity score ( rs = -0.73).

LIMITATIONS

Single-institution data and limited sample size.

CONCLUSIONS

The important priorities identified by the Delphi consensus might enable a comprehensive overview and a better assessment of low anterior resection syndrome after intersphincteric resection. See Video Abstract .

EVALE LA GRAVEDAD DEL SNDROME DE RESECCIN ANTERIOR BAJA DESPUS DE LA RESECCIN INTERESFINTRICA PARA EL CNCER DE RECTO ULTRABAJO UN ESTUDIO PILOTO QUE UTILIZA UN INSTRUMENTO EXPLORATORIO

ANTECEDENTES:El consenso Delphi identificó ocho síntomas y ocho consecuencias como las máximas prioridades para definir el síndrome de resección anterior baja.OBJETIVO:Describir un instrumento de puntuación exploratorio que correlaciona el consenso Delphi sobre el síndrome de resección anterior baja con puntuaciones funcionales y de calidad de vida después de la resección interesfinteriana para el cáncer de recto ultrabajo.DISEÑO:Este fue un estudio piloto prospectivo. De acuerdo con la puntuación de incontinencia de Wexner, se utilizaron cinco respuestas de frecuencia que van desde nunca (puntuación 0) hasta siempre (puntuación 4) para medir la gravedad de las variables específicas de los síntomas y las consecuencias.AJUSTES:Centro de referencia de cirugía colorrectal.PACIENTES:Entre 161 pacientes elegibles, 137 (85%) participantes completaron una encuesta electrónica de autoevaluación sobre la función y la calidad de vida en el seguimiento programado, incluidos 3 a 6, 12 y ≥ 24 meses después de la reversión de la ileostomía.MEDIDAS PRINCIPALES DE RESULTADO:Las medidas de resultado incluyeron la gravedad de estas prioridades informada por los pacientes, así como su correlación con la calidad de vida específica de la afección.RESULTADOS:El síntoma y la consecuencia más frecuentes fueron "dificultades para vaciar" e "insatisfacción con las deposiciones", respectivamente. Aparte de las "dificultades de vaciado", las proporciones de dominios de síntomas negativos aumentaron después de la reversión. En particular, tanto las respuestas de frecuencia como las puntuaciones de gravedad de las "dificultades para vaciar" no difirieron entre los grupos. Los porcentajes de "opción siempre" para los dominios de consecuencias mejoraron a los 12 meses de seguimiento, mientras que se observó una tasa más alta a los 24 meses después, excepto para "dependencia del baño" e "insatisfacción con los intestinos". Encontramos mejoras significativas en la puntuación resumida de la Escala de calidad de vida de incontinencia fecal ( p = 0,04) y nuestro instrumento exploratorio ( p = 0,009), pero no en las puntuaciones funcionales medidas con los cuestionarios tradicionales. Además, la calidad de vida específica de la condición se correlacionó fuertemente con la puntuación de gravedad del consenso Delphi (rs = -0,73).LIMITACIONES:Datos de una sola institución y tamaño de muestra limitado.CONCLUSIONES:Las importantes prioridades identificadas por el consenso Delphi podrían permitir una visión global y una mejor evaluación del síndrome de resección anterior baja después de la resección interesfintérica. (Traducción-Dr. Yesenia Rojas-Khalil ).

To explore the pathogenesis of anterior resection syndrome by magnetic resonance imaging rectal defecography

BACKGROUND

Over 90% of rectal cancer patients develop low anterior resection syndrome (LARS) after sphincter-preserving resection. The current globally recognized evaluation method has many drawbacks and its subjectivity is too strong, which hinders the research and treatment of LARS.

AIM

To evaluate the anorectal function after colorectal cancer surgery by quantifying the index of magnetic resonance imaging (MRI) defecography, and pathogenesis of LARS.

METHODS

We evaluated 34 patients using the standard LARS score, and a new LARS evaluation index was established using the dynamic images of MRI defecography to verify the LARS score.

RESULTS

In the LARS score model, there were 10 (29.41%) mild and 24 (70.58%) severe cases of LARS. The comparison of defecation rate between the two groups was 29.36 ± 14.17% versus 46.83 ± 18.62% (P = 0.004); and MRI-rectal compliance (MRI-RC) score was 3.63 ± 1.96 versus 7.0 ± 3.21 (P = 0.001). Severe and mild LARS had significant differences using the two evaluation methods. There was a significant negative correlation between LARS and MRI-RC score (P < 0.001), and they had a negative correlation with defecation rate (P = 0.028).

CONCLUSION

MRI defecography and standard LARS score can both be used as an evaluation index to study the pathogenesis of LARS.

Ondansetron for Low Anterior Resection Syndrome (LARS): A Double-Blind, Placebo-Controlled, Cross-Over, Randomized Study

OBJECTIVE

The aim of the study was to examine the efficacity and safety of ondansetron, a serotonin receptor antagonist, to treat patients with low anterior resection syndrome (LARS).

BACKGROUND

LARS after rectal resection is common and debilitating. Current management strategies include behavioral and dietary modifications, physiotherapy, antidiarrheal drugs, enemas, and neuromodulation, but the results are not always satisfactory.

METHODS

This is a randomized, multicentric, double-blinded, placebo-controlled, and cross-over study. Patients with LARS (LARS score >20) no longer than 2 years after rectal resection were randomized to receive either 4 weeks of ondansetron followed by 4 weeks of placebo (O-P group) or 4 weeks of placebo followed by 4 weeks of ondansetron (P-O group). The primary endpoint was LARS severity measured using the LARS score; secondary endpoints were incontinence (Vaizey score) and irritable bowel syndrome quality of life (IBS-QoL questionnaire). Patients' scores and questionnaires were completed at baseline and after each 4-week treatment period.

RESULTS

Of 46 randomized patients, 38 were included in the analysis. From baseline to the end of the first period, in the O-P group, the mean (SD) LARS score decreased by 25% [from 36.6 (5.6) to 27.3 (11.5)] and the proportion of patients with major LARS (score >30) went from 15/17 (88%) to 7/17 (41%), ( P =0.001). In the P-O group, the mean (SD) LARS score decreased by 12% [from 37 (4.8) to 32.6 (9.1)], and the proportion of major LARS went from 19/21 (90%) to 16/21 (76%). After crossover, LARS scores deteriorated again in the O-P group receiving placebo, but further improved in the P-O group receiving ondansetron. Mean Vaizey scores and IBS QoL scores followed a similar pattern.

CONCLUSIONS

Ondansetron is a safe and simple treatment that appears to improve both symptoms and QoL in LARS patients.

Reconstructive techniques following low anterior resection for carcinoma of the rectum

INTRODUCTION

Multiple reconstructive techniques have been described for reconstruction after a low anterior resection for carcinoma rectum. Colonic J pouch (CJP), Side to end anastomosis (SEA), transverse coloplasty pouch (TCP) and Straight Colo-rectal/anal anastomosis were the most widely studied.

EVIDENCE ACQUISITION

PubMed, Embase and Cochrane data base were searched for randomized, non-randomized studies and systematic reviews from inception of the databases till July 31st, 2023.

EVIDENCE SYNTHESIS

Considerable heterogeneity existed among different study findings. Reservoir techniques, including CJP, SEA, and TCP, exhibited reduced stool frequency, decreased urgency, and improved continence status compared to SCA, particularly in the short term. CJP maintained this advantage into the intermediate term. Other functional outcomes were similar among the techniques. However, these functional improvements did not translate into enhanced Quality of Life (QoL). TCP was associated with an elevated risk of anastomotic leaks. Other surgical outcomes remained comparable across all four techniques. Sexual outcomes also exhibited no significant variation. Some studies suggested that the size of the side limb in CJP or SEA may not significantly impact functional outcomes, implying that neorectum capacity may not be the primary determinant of improved function. The precise physiological mechanism underlying these findings remains unknown.

CONCLUSIONS

In the short and intermediate terms, reservoir techniques demonstrated superior functional outcomes, but long-term performance was comparable among all techniques. Notably, enhanced functional outcomes did not translate to improved Quality of Life. TCP, while effective, is linked to an increased risk of anastomotic complications, necessitating cautious utilization.

Association between personality types and low anterior resection syndrome in rectal cancer patients following surgery

PURPOSE

Low anterior resection syndrome (LARS) has had many impacts on the lives of patients and substantial differences in emotional and social functions. The aim of this study was to investigate the correlation analysis of different personality traits in rectal cancer patients with LARS after undergoing curative surgery.

METHODS

This study was designed as a prospective cohort study. The inclusion criteria included (1) participants diagnosed with rectal cancer who underwent surgical resection of malignant tumors and (2) ECOG 0-1. The primary outcome was the correlation between different personality traits and low anterior resection syndrome in rectal cancer patients after radical surgery. Low anterior resection syndrome incidence rates were estimated by questionnaires and personality groups by the Type A and Type D Scale-14 Personality Inventory.

RESULTS

For all 161 participants in this study, the presence of a tumor at the lower anal verge and the receipt of neoadjuvant CCRT had a statistically significant positive correlation with the LARS score at 1 month, 6 months, and 1 year (Pearson correlation coefficient = -0.283, -0.374, and - 0.205, respectively), with a p value of less than 0.05. Personalities with Type A, Type D, and Type D-SI scores had a statistically significant positive correlation with LARS score at 1 month (Pearson correlation coefficient = 0.172, 0.162, and 0,164, p value = 0.03, 0.04, and 0.04).

CONCLUSION

Type A and Type D personalities are highly linked to LARS. Personalized support approaches can ultimately assist rectal cancer patients in overcoming difficulties after surgery and recovery and enhance their functional outcomes.

Risk factors for severe low anterior resection syndrome in patients with rectal cancer undergoing sphincter‑preserving resection: A systematic review and meta‑analysis

The present study aimed to evaluate the incidence and risk factors of severe low anterior resection syndrome (LARS) in patients with rectal cancer undergoing sphincter-preserving resection, and to provide the clinical basis and reference for the treatment of rectal cancer and the prevention of LARS. Studies on the incidence and risk factors for severe LARS in patients with rectal cancer undergoing sphincter-preserving resection were searched using PubMed, Embase, Cochrane Library, Scopus and Web of Science, according to the inclusion and exclusion criteria. After evaluating the study quality and extracting relevant data, RevMan 5.2 and STATA software were used to conduct a meta-analysis. A total of 12 articles were considered eligible for the present meta-analysis. Within these articles, there were 3,877 cases of sphincter-preserving resection for rectal cancer and 1,589 cases of severe LARS; the incidence of severe LARS was 40.99%. The results of the meta-analysis revealed that sex [female; odds ratio (OR), 6.54; 95% CI, 3.63-11.76; Z, 6.27; P<0.00001], radiotherapy and chemotherapy (OR, 3.45; 95% CI, 2.29-5.21; Z, 5.91; P<0.00001), total mesorectal excision (TME; OR, 4.39; 95% CI, 3.32-5.79; Z, 10.41; P<0.00001), and distance between tumor and anal margin (OR, 2.74; 95% CI, 0.86-8.72; Z, 1.70; P<0.00001) may be the risk factors for severe LARS.

Laparoscopic natural orifice specimen extraction colectomy versus conventional laparoscopic colorectal resection in patients with rectal endometriosis: a randomized, controlled trial

BACKGROUND

The conventional laparoscopic approach for the surgical management of deep endometriosis (DE) infiltrating the rectum appears to ensure improved digestive functional outcomes. The natural orifice specimen extraction (NOSE) technique for the treatment of colorectal DE can significantly accelerate postoperative recovery; however, data on gastrointestinal function following conventional laparoscopic segmental bowel resection (CLR) compared with NOSE colectomy (NC) for DE are sparse.

MATERIALS AND METHODS

Between 30 September 2019 and 31 December 2020, a randomized, open-label, two-arm, parallel-group controlled trial with women aged 18-45 years was conducted at University Hospital.Ninety-nine patients were randomized to CLR or NC, with DE infiltrating at least the muscular layer, at least 50% of the circumference of the bowel, up to 15 cm from the anal verge, exhibiting pain and bowel symptoms and/or infertility. The primary endpoint was bowel function, represented by low anterior resection syndrome (LARS). Secondary parameters included the Endometriosis Health Profile 30 (EHP30), Gastrointestinal Quality of Life Index (GIQLI), Visual Analog Scale (VAS) scores preoperatively and at set times (1 and 6 months, 1 year) following surgery.

RESULTS

No significant differences were observed in the postoperative LARS scores, VAS, EHP30, and GIQLI between the NC and CLR groups. LARS scores did not reveal significant differences 12 months postoperatively compared to the preoperative values in both groups (CLR group P =0.93 versus NC group, P =0.87). GIQLI scores were significantly improved 12 months after the operation compared with baseline values in the CLR group ( P =0.002) and NC group ( P =0.001). Pain symptoms and quality of life scores significantly improved 12 months postoperatively in both groups.

CONCLUSIONS

NC is a feasible surgical approach for treating patients with rectal DE. Our study did not show a statistically significant difference between CLR and NC techniques in mid-term digestive and pain outcomes.

Development and Validation of a Post-Radiotherapy Prediction Model for Bowel Dysfunction After Rectal Cancer Resection

BACKGROUND & AIMS

The benefit of radiotherapy for rectal cancer is based largely on a balance between a decrease in local recurrence and an increase in bowel dysfunction. Predicting postoperative disability is helpful for recovery plans and early intervention. We aimed to develop and validate a risk model to improve the prediction of major bowel dysfunction after restorative rectal cancer resection with neoadjuvant radiotherapy using perioperative features.

METHODS

Eligible patients more than 1 year after restorative resection following radiotherapy were invited to complete the low anterior resection syndrome (LARS) score at 3 national hospitals in China. Clinical characteristics and imaging parameters were assessed with machine learning algorithms. The post-radiotherapy LARS prediction model (PORTLARS) was constructed by means of logistic regression on the basis of key factors with proportional weighs. The accuracy of the model for major LARS prediction was internally and externally validated.

RESULTS

A total of 868 patients reported a mean LARS score of 28.4 after an average time of 4.7 years since surgery. Key predictors for major LARS included the length of distal rectum, anastomotic leakage, proximal colon of neorectum, and pathologic nodal stage. PORTLARS had a favorable area under the curve for predicting major LARS in the internal dataset (0.835; 95% CI, 0.800-0.870, n = 521) and external dataset (0.884; 95% CI, 0.848-0.921, n = 347). The model achieved both sensitivity and specificity >0.83 in the external validation. In addition, PORTLARS outperformed the preoperative LARS score for prediction of major events.

CONCLUSIONS

PORTLARS could predict major bowel dysfunction after rectal cancer resection following radiotherapy with high accuracy and robustness. It may serve as a useful tool to identify patients who need additional support for long-term dysfunction in the early stage.

CLINICALTRIALS

gov, number NCT05129215.

Preventive strategies for low anterior resection syndrome: a protocol for systematic review and evidence mapping

INTRODUCTION

Rectal cancer is one of the top 10 cancers worldwide. Up to 80% of patients with rectal tumours have had sphincter-saving surgery, mainly due to the large expectation of anal preservation. However, patients tend to experience low anterior resection syndrome (LARS) after rectal resection, which is disordered bowel function that includes faecal incontinence, urgency, frequent defecation, constipation and evacuation difficulties. LARS, with an estimated prevalence of 41%, has been reported to substantially decrease the quality of life of patients. However, no comprehensive preventive strategies are currently available for LARS. This systematic review aims to synthesise evidence on the current LARS preventive strategies.

METHODS AND ANALYSIS

This protocol is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. Literature in PubMed (via Medline), Embase and the Cochrane Library from inception to July 2023 will be searched to identify articles relevant to preventive effectiveness against LARS. The Cochrane Collaboration's risk of bias tool for randomised controlled trials and the Newcastle-Ottawa Scale for clinical controlled trials, cohort studies and case-control studies will be used to assess the risk of bias. We will group the included studies by the type of LARS prevention strategy and present an overview of the main findings in the form of evidence mapping. A meta-analysis is planned if there is no substantial clinical heterogeneity between the included studies. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) will be used to evaluate the quality of the evidence.

ETHICS AND DISSEMINATION

Ethical approval is not needed for systematic review of published data. The findings will be published in a peer-reviewed journal and disseminated at scientific conferences.

PROSPERO REGISTRATION NUMBER

CRD42023402886.

"You're just on your own": Exploring bowel symptom management needs after rectal cancer surgery through patient and clinician focus groups

PURPOSE

Currently cancer survivorship often leaves the needs of patients unidentified and unmet. The study aims to establish the views of experts on managing bowel symptoms following rectal cancer surgery.

METHOD

People living with bowel symptoms as well as clinicians with expertise in rectal cancer and subsequent bowel changes were invited to participate in online focus groups. Focus groups were recorded, transcribed verbatim and analysed using a modified framework analysis. Results were presented narratively with interpretations and quotations.

RESULTS

Fourteen patients following rectal cancer treatment attended one of two focus groups. Sixteen clinicians attended one of four groups. Participants described their opinions about bowel symptom management. Three themes were described by both patients and clinicians: expectations of bodily changes, supported self-repair and knowledgeable self-repair. Data from participants frequently concurred; all recognised clinicians needed to support and empower patients to independently manage their cancer consequences.

CONCLUSION

Well-managed expectations enable patients to set realistic goals and make plans. Clinicians need to support patients to understand potential bowel changes that might occur after rectal cancer surgery, providing support, information and signposting to other relevant information and colleagues. Effective communication through avoidance of jargon and rapport building as well as providing a point of contact help prevent patients feeling alone with their symptoms. Education is needed by both clinicians and patients to ensure consistent and useful advice is provided and understood. A recommendation from the focus groups is to create opportunities for patients to access information with clinician support and signposting.

The Role of Percutaneous Tibial Nerve Stimulation (PTNS) in Low Anterior Resection Syndrome (LARS): A Systematic Review and Meta-analysis

PURPOSE

The aim of the present study was to evaluate the pooled efficacy of percutaneous tibial nerve stimulation (PTNS) in patients with low anterior resection syndrome (LARS).

MATERIAL AND METHODS

This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The primary endpoint was the pooled effect size of PTNS in LARS score (LARSS). Secondary endpoints included incontinence (Fecal Incontinence Score-FIC, Obstructive Defecation Syndrome-ODS), sexual functionality and quality of life (QoL) questionnaires, and manometric evaluations. Continuous outcomes were reported as weighted mean difference (WMD), with the corresponding 95% confidence interval (95% CI). Quality evaluation was performed via the National Institutes of Health (NIH) quality assessment tool.

RESULTS

Overall, 5 studies were included. PTNS resulted to reduced LARSS values (WMD: - 5.68, 95%CI: - 7.73, - 3.63, p < 0.001). A similar effect was noted in St Mark's FIC (p < 0.001) and ODS (p = 0.02) score. An improvement in several QoL scales was found. There was no effect in sexual functionality and manometric measurements. Compared to sham, PTNS significantly improved LARSS.

CONCLUSIONS

The application of PTNS in patients with LARS results in an improvement in multiple clinical parameters, including defecation functionality and quality of life. Due to several study limitations, further high quality RCTs are required to delineate the exact efficacy of PTNS.

Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment

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.

Low Anterior Resection Syndrome (LARS) after Surgery for Rectal Cancer: An Inevitable Price to Pay for Survival, or a Preventable Complication?

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.

Understanding the Impact of Bowel Dysfunction on Quality of Life After Rectal Cancer Surgery From the Patient's Perspective

BACKGROUND

Bowel dysfunction is an important consequence of rectal cancer surgery' and the specific quality-of-life domains that are affected remain unclear and unaddressed by generic surveys.

OBJECTIVE

This study aimed to identify quality-of-life domains most affected by rectal cancer surgery.

DESIGN

Qualitative content analysis.

SETTINGS

Semistructured interviews conducted by telephone with patients recruited from a single university-affiliated colorectal referral center.

PATIENTS

Adult patients were included if they underwent rectal cancer surgery with sphincter preservation from July 2017 to July 2020. Patients were excluded if their surgery was <1 year since the recruitment date, received a permanent stoma, or developed recurrence or metastasis.

MAIN OUTCOME MEASURES

Bowel dysfunction was evaluated via the low anterior resection syndrome score. Interview transcripts were coded by 2 independent reviewers and evaluated for concordance. Qualitative content analysis was used to identify themes, and their frequency of occurrence was quantified (percent total number of interviews).

RESULTS

A total of 54 patient interviews were conducted. Analysis revealed 5 quality-of-life-related themes impacted by bowel dysfunction: experiencing psychological and emotional stress, challenging roles and relationships within society, encountering physical limitations, restricting leisure and recreational activities, and learning self-empowerment and adapting to change. Patients with minor and major bowel dysfunction were more likely to report disruption to their social activities and their role as a sexual partner versus those with no bowel dysfunction. Patients with major bowel dysfunction were more likely to report effects on sleep versus those with no and minor bowel dysfunction.

LIMITATIONS

Single center, self-reported, and observer bias.

CONCLUSION

The impact of bowel dysfunction on quality of life includes a wide range of themes that extend beyond traditional measures. These results may help better inform patients in the preoperative setting and serve as a basis for the development of a more patient-centered quality-of-life survey.

COMPRENDER EL IMPACTO DE LA DISFUNCIN INTESTINAL EN LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE RECTO DESDE LA PERSPECTIVA DEL PACIENTE

ANTECEDENTES:La disfunción intestinal es una consecuencia importante de la cirugía del cáncer de recto y los dominios específicos de la calidad de vida que se ven afectados siguen sin estar claros y sin abordarse en las encuestas genéricas.OBJETIVO:Identificar los dominios de calidad de vida más afectados por la cirugía del cáncer de recto.DISEÑO:Análisis cualitativo de contenido.ÁMBITOS:Entrevistas semiestructuradas realizadas por teléfono con pacientes reclutados de un único centro de referencia colorrectal afiliado a una universidad.PACIENTES:Pacientes adultos intervenidos de cáncer de recto con preservación de esfínter del 07/2017 al 07/2020. Los pacientes fueron excluidos si su cirugía fue <1 año desde la fecha de reclutamiento, recibieron un estoma permanente o desarrollaron recurrencia o metástasis.PRINCIPALES MEDIDAS DE RESULTADO:La disfunción intestinal se evaluó a través de la puntuación del síndrome de resección anterior baja. Dos revisores independientes codificaron las transcripciones de las entrevistas y evaluaron su concordancia. Se utilizó el análisis de contenido cualitativo para identificar los temas, cuantificando su frecuencia de aparición (porcentaje del número total de entrevistas).RESULTADOS:Se realizaron un total de 54 entrevistas a pacientes. El análisis reveló cinco temas relacionados con la calidad de vida afectados por la disfunción intestinal: experimentar estrés psicológico y emocional, roles y relaciones desafiantes dentro de la sociedad, encontrar limitaciones físicas, restringir actividades recreativas y de ocio, y autoempoderamiento y adaptación al cambio. Los pacientes con disfunción intestinal menor y mayor tenían más probabilidades de informar la interrupción de las actividades sociales y el papel como pareja sexual en comparación con aquellos sin disfunción intestinal. Los pacientes con disfunción intestinal importante tenían más probabilidades de informar efectos sobre el sueño en comparación con aquellos sin disfunción intestinal o con disfunción intestinal menor.LIMITACIONES:Sesgo de un solo centro, autoinformado y observador.CONCLUSIÓN:El impacto de la disfunción intestinal en la calidad de vida incluye una amplia gama de temas que se extienden más allá de las medidas tradicionales. Estos resultados pueden ayudar a informar mejor a los pacientes en el entorno preoperatorio y servir como base para el desarrollo de una encuesta de calidad de vida más centrada en el paciente. (Traducción-Dr. Yesenia Rojas-Khalil ).

Patient perspectives on consequences of resection for colorectal cancer: A qualitative study

BACKGROUND

Colorectal cancer is diagnosed in approximately 500,000 patients each year in Europe, leading to a high number of patients having to cope with the consequences of resection for colorectal cancer. As treatment options tend to grow, more information on the effects of these treatments is needed to engage in shared decision-making. This study aims to explore the impact of resection for colorectal cancer on patients' daily life.

METHODS

Patients (≥18 years of age) who underwent an oncological colorectal resection between 2018 and 2021 were selected. Purposeful sampling was used to include patients who differed in age, comorbidity conditions, types of (neo)adjuvant therapy, postoperative complications and the presence/absence of a stoma. Semi-structured interviews were conducted, guided by a topic guide. Interviews were fully transcribed and subsequently thematically analysed using the framework approach. Analyses were carried out using the following predefined themes: (1) daily life and activities; (2) psychological functioning; (3) social functioning; (4) sexual functioning; and (5) healthcare experiences.

RESULTS

Sixteen patients with a follow-up period of between 0.6 and 4.4 years after surgery were included in this study. Participants reported several challenges experienced because of poor bowel function, a stoma, chemotherapy-induced neuropathy, fear of recurrence and sexual dysfunction. However, they reported these as not interfering much with daily life.

CONCLUSION

Colorectal cancer treatment leads to several challenges and treatment-related health deficits. This is often not recognized by generic patient-reported outcome measures, but the findings on treatment-related health deficits presented in this study contain valuable insights which might contribute to improving colorectal cancer care, shared decision making and value-based health care.

Excessive bowel volume loss during anus-preserving surgery for rectal cancer affects the bowel function after operation: A prospective observational cohort study (Bas-1611)

Background

Bowel volume loss during anus-preserving surgery (APS) may result in low anterior resection syndrome (LARS). We conducted this prospective observational cohort study to measure the incidence of LARS after surgery and evaluate the relationship between bowel volume loss and bowel function.

Methods

Patients with R0 resectable rectal cancer who consented to several bowel function surveys through telephone interviews after the operation were included. Enrolled patients underwent standard APS for rectal cancer, and three length indexes, viz. length of excised bowel, length of the distal margin and length of the proximal margin (LPM) of fresh bowel specimens, were measured in vitro.

Results

The three measured variables of the specimens showed a positively skewed distribution. Patient interviews revealed a trend of gradual improvement in bowel function. Univariate analyses revealed that longer LPM was associated with a significantly negative impact on bowel function at all time points. In multivariate analysis, LPM was found to be a significant risk factorstatistically significant, but its impact was not as strong as that of radiotherapy and low-middle tumour. Furthermore, there was no significant difference in the lymph node detection rate between <10-cm and ≥10-cm LPM groups.

Conclusion

In APS for rectal cancer, bowel volume loss is an important factor causing postoperative bowel dysfunction. Controlling LPM to <10 cm may help improve postoperative bowel function.

Quality of Life and Functional Outcomes After Intersphincteric Resection for Ultralow Rectal Cancer: A Prospective Observational Study

BACKGROUND

Intersphincteric resection is the ultimate sphincter-preserving surgical technique for ultralow rectal cancer, but quality-of-life changes after surgery remain unclear. It is also unknown which questionnaire has better associations with functional results for capturing clinical variation in quality of life.

OBJECTIVE

This study aimed to assess change in the quality of life and its correlation with functional outcomes among patients undergoing intersphincteric resection for ultralow rectal cancer.

DESIGN

This was a prospective, observational, single-center study.

SETTINGS

Colorectal surgery referral center.

PATIENTS

Patients with ultralow rectal cancer who underwent intersphincteric resection were included.

MAIN OUTCOME MEASURES

The primary outcomes were quality-of-life and functional results at 3 to 6, 12, and 24 months after ileostomy closure using validated questionnaires. The secondary outcome was the relationship between quality of life and neorectal function.

RESULTS

A total of 102 patients (62.7% men) completed follow-up surveys. Wexner incontinence score and Kirwan's incontinence score significantly improved at 12 months after ileostomy reversal, but such improvement in low anterior resection syndrome score was proved until 24 months later ( p = 0.01). Condition-specific quality-of-life domains improved over time, with significant changes in lifestyle ( p = 0.02) and coping/behavior ( p = 0.01), as well as the summary score of Fecal Incontinence Quality of Life ( p = 0.02) and visual analog scale score ( p < 0.001). Among health-related quality-of-life domains, the subscale scores did not differ significantly. The functional systems scores were significantly correlated with all the domains of condition-specific quality-of-life but only a few health-related quality-of-life domains. Only weak to moderate associations with the functional outcomes were observed for both quality-of-life questionnaires.

LIMITATIONS

Single-center data and limited sample size.

CONCLUSIONS

Although low anterior resection syndrome persists for years after intersphincteric resection, condition-specific quality of life and functional outcomes improve over time. Compared to health-related quality-of-life questionnaires, condition-specific quality-of-life instruments might be preferable to evaluate changes in quality-of-life after surgery. See Video Abstract at http://links.lww.com/DCR/C130 .

CALIDAD DE VIDA Y RESULTADOS FUNCIONALES DESPUS DE UNA RESECCIN INTERESFINTRICA EN CASO DE CNCER RECTAL ULTRABAJO ESTUDIO PROSPECTIVO OBSERVACIONAL

ANTECEDENTES:La resección inter-esfintérica es la última técnica quirúrgica conservadora de esfínteres en casos de cáncer rectal ultrabajo, pero los cambios en la calidad de vida después de la cirugía siguen sin estar claros. Se desconoce también, qué tipo de cuestionario tiene mejor asociación con los resultados funcionales para así captar las variaciones clínicas en la calidad de vida.OBJETIVO:Evaluar el cambio en la calidad de vida y su correlación con los resultados funcionales durante el período postoperatorio en pacientes sometidos a resección interesfintérica por cáncer de recto ultrabajo.DISEÑO:Estudio prospectivo, observacional y de un solo centro.AJUSTES:Centro de referencia de cirugía colorrectal.PACIENTES:Se incluyeron pacientes con cáncer de recto ultra bajo que se sometieron a resección interesfintérica con el cierre de la ileostomía.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la calidad de vida y los resultados funcionales a los 3-6, 12 y 24 meses después del cierre de la ileostomía utilizando cuestionarios validados. El resultado secundario fue la relación entre la calidad de vida y la función del néorecto.RESULTADOS:Un total de 102 pacientes (62,7% hombres) completaron las encuestas de seguimiento. La puntuación de incontinencia de Wexner y la puntuación de incontinencia de Kirwan mejoraron significativamente a los 12 meses después del cierre de la ileostomía, pero dicha mejoría en la puntuación del síndrome de resección anterior baja se demostró solo hasta 24 meses después ( p = 0,01). Las condiciones en el dominio de la calidad de vida específicos mejoraron con el tiempo, con cambios significativos en el estilo de vida ( p = 0,02) y el afrontamiento/comportamiento ( p = 0,01), así como la puntuación general de la calidad de vida y de la incontinencia fecal ( p = 0,02), puntuación de la escala analógica visual ( p < 0,001). Entre los dominios de la calidad de vida relacionada con la salud, las puntuaciones de las sub-escalas no difirieron significativamente. Las puntuaciones de los sistemas funcionales se correlacionaron significativamente con todos los dominios de la calidad de vida específica de la nueva condición, pero solo con pocos dominios de calidad de vida relacionados con la salud. Solo se observaron asociaciones débiles a moderadas con los resultados funcionales para ambos cuestionarios de calidad de vida.LIMITACIONES:Datos de un solo centro y tamaño de muestra limitado.CONCLUSIONES:Aunque el síndrome de resección anterior baja persiste durante años después de la resección interesfintérica, la calidad de vida específica de la nueva condición y los resultados funcionales mejoran con el tiempo. En comparación con los cuestionarios de calidad de vida relacionados con la salud, los instrumentos de calidad de vida específicos de la nueva condición pueden ser preferibles para evaluar los cambios en la calidad de vida después de la cirugía. Consulte Video Resumen en http://links.lww.com/DCR/C130 . (Traducción-Dr. Xavier Delgadillo ).

Systematic review and meta-analysis of randomized clinical trials on the treatment of low anterior resection syndrome

BACKGROUND

We conducted a systematic review of randomized clinical trials on treating low anterior resection syndrome to help inform current practice.

METHODS

This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials involved different treatments for low anterior resection syndrome. The risk of bias 2 tool was used to assess the risk of bias. The main outcomes were improvement in low anterior resection syndrome after treatment assessed by change in low anterior resection syndrome, fecal incontinence scores, and adverse treatment effects.

RESULTS

After an initial screening of 1,286 studies, 7 randomized clinical trials were included. Sample sizes ranged between 12 to 104 patients. Posterior tibial nerve stimulation was the most frequently assessed treatment in 3 randomized clinical trials. The weighted mean difference between posterior tibial nerve stimulation and medical treatment or sham therapy in follow-up low anterior resection syndrome score (-3.31, P = .157) was insignificant. Transanal irrigation reduced major low anterior resection syndrome symptoms by 61.5% compared with 28.6% after posterior tibial nerve stimulation with a significantly lower 6-month follow-up low anterior resection syndrome score. Pelvic floor training achieved better improvement in low anterior resection syndrome than standard care (47.8% vs 21.3%) at 6 months, but this was not maintained at 12 months (40.0% vs 34.9%). Ramosetron was associated with a greater short-term improvement in major low anterior resection syndrome (23% vs 8%) and a lower low anterior resection syndrome score (29.5 vs 34.6) at 4-weeks follow-up than Kegels or Sitz baths. No significant improvement in bowel function was noted after probiotics use as probiotics and placebo had similar follow-up low anterior resection syndrome scores (33.3 vs 36).

CONCLUSION

Transanal irrigation was associated with improvement in low anterior resection syndrome according to 2 trials, and ramosetron showed promising short-term results in one trial. Posterior tibial nerve stimulation had a marginal benefit compared with standard care. In contrast, pelvic floor training was associated with short-term symptomatic improvement, and probiotics showed no tangible improvement in low anterior resection syndrome symptoms. Firm conclusions cannot be drawn due to the small number of trials published.

Comparison of the clinical efficacy of laparoscopic extralevator abdominoperineal excision (ELAPE) and non-ELAPE for low rectal cancer

This study was performed to retrospectively analyze and compare the related clinical indicators between extralevator abdominoperineal excision (ELAPE) and non-ELAPE under laparoscopic for low rectal cancer. From June 2018 to September 2021, a total of 80 patients with low rectal cancer who underwent either of the above two types of surgeries at our Hospital were enrolled. Patients were divided into the ELAPE group and non-ELAPE group based on the different surgical methods. Preoperative general indicators, intraoperative indicators, postoperative complications, positive circumferential resection margin rate, local recurrence rate, hospital stay length, hospital expenses, and other related indicators were compared between the two groups. There were no significant differences in the comparison of preoperative indexes between the ELAPE group and non-ELAPE group, including age, preoperative BMI, and gender. Similarly, there were no significant differences in abdominal operation time, total operation time, and the number of intraoperative lymph nodes dissected between the two groups. However, the perineal operation time, intraoperative blood loss, intraoperative perforation rate, and positive circumferential resection margin rate were significantly different between the two groups. In the comparison of postoperative indexes, perineal complications, postoperative hospital stay length, and IPSS score were significantly different between the two groups. The use of ELAPE in treating T3-4NxM0 phase low rectal cancer was superior to non-ELAPE in reducing intraoperative perforation rate, positive circumferential resection margin rate, local recurrence rate, etc.

Advances in diagnosis and treatment of low anterior resection syndrome

Rectal cancer is one of the most common cancers. As much as 90% of patients with low rectal cancer complain of increased frequency of defecation, fecal incontinence, and evacuation problems after surgery, which is termed as low anterior resection syndrome (LARS). LARS detrimentally affects the quality of life for patients with rectal cancer. In this paper, we review the pathogenesis, risk factors, assessment tools, and treatment strategies for LARS.

Reconstructive techniques following low anterior resection for carcinoma of the rectum: meta-analysis

BACKGROUND

Multiple trials have compared reconstruction techniques used following the resection of distal rectal cancers, including straight colorectal anastomosis (SCA), colonic J pouch (CJP), side-to-end anastomosis (SEA), and transverse coloplasty (TCP). The latest meta-analysis on the subject concluded that all the reservoir techniques produce equally good surgical and functional outcomes compared with SCA. Numerous trials have been published in this regard subsequently. Hence, a network analysis (NMA) was performed to rank these techniques.

METHODS

A literature search of MEDLINE, Embase, and the Cochrane Library from their inception until April 2021 was conducted to identify randomized trials. Functional and surgical outcome data were pooled. ORs and standardized mean differences (MDs) were used as pooled effect size measures. A frequentist NMA model was used.

RESULTS

Thirty-two trials met the eligibility criteria comprising 3072 patients. CJP showed better functional outcomes, such as low stool frequency and better incontinence score, both in the short term (stool frequency, MD -2.06, P < 0.001; incontinence, MD -1.17, P = 0.007) and intermediate term (stool frequency, MD -0.81, P = 0.021; incontinence MD -0.56, P = 0.083). Patients with an SEA (long-term OR 4.37; P = 0.030) or TCP (long-term OR 5.79; P < 0.001) used more antidiarrheal medications constantly. The urgency and sensation of incomplete evacuation favoured CJP in the short term. TCP was associated with a higher risk of anastomotic leakage (OR 12.85; P < 0.001) and stricture (OR 3.21; P = 0.012).

CONCLUSION

Because of its better functional outcomes, CJP should be the reconstruction technique of choice. TCP showed increased anastomotic leak and stricture rates, warranting judicious use.

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.

'He's a surgeon, like I'm not going to waste his time': interviews to determine healthcare needs of people with low anterior resection syndrome after rectal cancer surgery

AIM

The aim of this study was to determine the views of people on their healthcare needs when managing their bowel symptoms following an anterior resection.

METHOD

One-to-one, semi-structured interviews were undertaken, after consent and completion of three questionnaires. Results were analysed using a modified framework analysis and presented narratively.

RESULTS

Twenty three participants aged 38-75 years were interviewed; 10 were men. Most had low anterior resection syndrome (LARS) scores indicating 'major LARS', Bowel Function Index scores ranged from 28 to 65. The two most bothersome symptoms were faecal incontinence and unpredictable bowel function. Data were grouped into three broad themes: 'treatment consequences', 'strategies and compromises' and 'healthcare needs.' Each theme had four subthemes, such as 'bowel dysfunction' in the theme 'treatment consequences'. Bowel symptoms were common and persistent. Symptom management often required multiple interventions. Expressed healthcare needs included managing expectations through clinician-led information. Participants needed knowledgeable clinicians to enquire about and assess symptoms, provide and reiterate information as well as making an onward referral to enable symptom management. Peers improved the adaptation process through support and advice. Our findings indicate that participants' needs are not being fully met.

CONCLUSION

People with LARS have unmet healthcare requirements needed to meet their individual goals. We propose these are addressed by using the acronym 'LARS': a Learned clinician who Asks and assesses bowel symptoms, Revisiting the topic to address new or persisting symptoms as well as Signposting, advising or referring onwards as needed.

A Randomized Controlled Clinical Trial of Transanal Irrigation Versus Conservative Treatment in Patients With Low Anterior Resection Syndrome After Rectal Cancer Surgery

OBJECTIVE

The aim of the study was to evaluate transanal irrigation (TAI) as a treatment for low anterior resection syndrome (LARS).

BACKGROUND

LARS is a bowel disorder that is common after sphincter preserving rectal cancer surgery. Despite symptomatic medical treatment of LARS many patients still experience bowel symptoms that may have a negative impact on quality of life (QoL). TAI is a treatment strategy, of which the clinical experience is promising but scientific evidence is limited.

MATERIALS AND METHODS

A multicenter randomized trial comparing TAI (intervention) with conservative treatment (control) was performed. Inclusion criteria were major LARS, age above 18 years, low anterior resection with anastomosis and a defunctioning stoma as primary surgery, >6 months since stoma reversal, anastomosis without signs of leakage or stricture, and no signs of recurrence at 1-year follow-up. The primary endpoint was differences in bowel function at 12-month follow-up measured by LARS score, Cleveland Clinic Florida Fecal Incontinence Score, and 4 study-specific questions. The secondary outcome was QoL.

RESULTS

A total of 45 patients were included, 22 in the TAI group and 23 in the control group. Follow-up was available for 16 and 22 patients, respectively. At 12 months, patients in the TAI group reported significantly lower LARS scores (22.9 vs 32.4; P =0.002) and Cleveland Clinic Florida Fecal Incontinence Score (6.4 vs 9.2; P =0.050). In addition, patients in the TAI group also scored significantly higher QoL [8 of 16 European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) QoL aspects] compared with the control group.

CONCLUSIONS

The results confirm our clinical experience that TAI reduces symptoms included in LARS and improves QoL.

Does the Low Anterior Resection Syndrome Score Accurately Represent the Impact of Bowel Dysfunction on Health-Related Quality of Life?

BACKGROUND

Bowel dysfunction after rectal cancer surgery is common, but its effect on health-related quality of life (HRQOL) is complex. Objective measures of bowel function may not be a good representation on the actual impact on HRQOL. Therefore, the objective of this study is to determine whether there are differences between patient-reported bowel-related impairment versus a standardized measure of bowel dysfunction on HRQOL.

METHODS

A prospective database starting in September 2018 of adult patients who had undergone sphincter preserving rectal cancer surgery up to October 2021 was queried. Patients were excluded if they had local recurrence, metastasis, persistent stoma, or had less than 1-year follow-up. Patients were administered the study instruments at their standard surveillance visit: patient-reported bowel-related quality of life(BQOL) impairment, HRQOL using the Short Form-36 (SF-36), and bowel dysfunction using the low anterior resection syndrome(LARS) score.

RESULTS

Overall, 136 patients were included. There were 43% with no LARS, 22% with minor LARS, and 35% with major LARS. For the BQOL, 26% of subjects reported no impairment, 57% minor impairment, and 17% major impairment. There was a high proportion of discordance between BQOL and LARS, with 23% minor or major LARS in patients with no BQOL impairment, and 32% with no or minor LARS with major BQOL impairment. The BQOL was associated with more changes in SF-36 scores compared to the LARS score.

CONCLUSIONS

The patient-reported BQOL is likely to be a more relevant outcome of interest to patients than the objective LARS score. This has important implications for shared decision-making for rectal cancer treatments.

The Effectiveness of a Self-management Program of Bowel Dysfunction in Patients With Mid and Low Rectal Cancer After Sphincter-Preserving Surgery: A Pilot Randomized Controlled Trial

BACKGROUND

Most patients with mid and low rectal cancer passively react to bowel symptoms after sphincter-preserving surgery (SPS), and their self-management behaviors are scarce in the Chinese patient population.

OBJECTIVE

The aim of this study was to evaluate the effect of a self-management program for bowel symptoms in patients with mid and low rectal cancer after SPS.

METHODS

A convenient sampling method was used to recruit patients with mid and low rectal cancer after SPS in gastric wards from 2 tertiary hospitals in Beijing, China. Ninety-five patients (intervention, n = 47; control, n = 48) were recruited. The intervention group received a predetermined self-management program plus routine postoperative care; the control group received only routine care in the ward. Data on patients' bowel symptoms, quality of life, and bowel symptom self-management behaviors were collected at baseline and at 3 and 6 months postoperatively using questionnaires. A generalized estimating equation was adopted to examine group effect and time effect.

RESULTS

Bowel symptoms and quality of life in both the intervention and control groups of patients improved significantly 6 months after SPS compared with baseline (time effect, P < .001). The total score of patients' bowel symptom self-management behaviors and the score of the therapeutic domain increased significantly in the intervention group compared with those in the control group (group effect, P = .009).

CONCLUSIONS

Self-management programs could help prompt patients' self-management behaviors, but the extent to which they impact patients' bowel symptoms requires further investigation.

IMPLICATIONS FOR PRACTICE

The bowel dysfunction self-management program could alter the behavior of patients. It also effectively improves self-management strategies for bowel symptoms.

Coloanal Anastomosis

The furthest extent of restorative proctectomy involves a colon to anal anastomosis in the deep pelvis. While the anastomosis can be challenging, it can allow the patient to avoid a permanent ostomy. Patient and surgeon preparation can improve patient outcomes. This article will describe the options, technical challenges, and anecdotal tips for coloanal anastomosis.

Bowel dysfunction following pelvic organ cancer: a prospective study on the treatment effect in nurse-led late sequelae clinics

BACKGROUND

Bowel dysfunction following treatment of pelvic organ cancer is prevalent and impacts the quality of life (QoL). The present study aimed to evaluate the feasibility and effects of treating bowel dysfunction in two nurse-led late sequelae clinics.

MATERIAL AND METHODS

Treatment effects were monitored prospectively by patient-reported outcome measures collected at baseline and discharge. Change in bowel function was evaluated by 15 bowel symptoms, the St. Mark's Incontinence Score, the Patients Assessment of Constipation-Symptoms (PAC-SYM) score and self-rated bowel function. QoL was evaluated by the EuroQol 5-dimension 5-level (EQ-5D-5L) utility score and by measuring the impact of bowel function on QoL.

RESULTS

From June 2018 to December 2021, 380 cancer survivors (46% rectal, 15% gynaecological, 13% anal, 12% colon, 12% prostate, and 2% other cancers) completed a baseline questionnaire and started treatment for bowel dysfunction. At referral, 96% of patients were multisymptomatic. The most frequent symptoms were faecal urgency (95%), fragmented defaecation (93%), emptying difficulties (92%), flatus/faecal incontinence (flatus 89%, liquid 59%, solid 33%), and obstructed defaecation (79%). In total, 169 patients were discharged from the clinics in the follow-up period. At discharge, 69% received conservative treatment only and 24% also received transanal irrigation; 4% were surgically treated; 3% discontinued treatment. Improvements were seen in all 15 bowel symptoms (p < 0.001), the mean St. Mark's Incontinence Score (12.0 to 9.9, p < 0.001), the mean PAC-SYM score (1.04 to 0.84, p < 0.001) and the mean EQ-5D-5L utility score (0.78 to 0.84, p < 0.001). Self-rated bowel function improved in 56% (p < 0.001) of cases and the impact of bowel function on QoL improved in 46% (p < 0.001).

CONCLUSION

Treatment of bowel dysfunction in nurse-led late sequelae clinics is feasible and significantly improved bowel function and QoL.

Pelvic floor muscle exercises alleviate symptoms and improve mental health and rectal function in patients with low anterior resection syndrome

Background

Pelvic floor rehabilitation has been reported to be effective in improving fecal incontinence. The aim of this study was to prospectively evaluate the effectiveness of combined pelvic floor muscle exercises (PFMEs) and loperamide treatment on rectal function and mental health for low anterior resection syndrome (LARS) patients after sphincter-saving operation (SSO) for rectal cancer.

Methods

A total of 60 inpatients diagnosed with LARS were enrolled and randomly assigned to one of two groups: patients in Group A (n = 30) were treated with a PFME intervention and those in Group B (n = 30) with a control intervention for 4 weeks. High-resolution anorectal manometry (HRAM) was performed for all LARS patients. Demographic information was collected for all patients, and they subsequently also completed several questionnaires, including the Hospital Anxiety and Depression Scale (HADS), a measure of Wexner score, a measure of stool frequency per day, and the Bristol Stool Form Scale (BSFS).

Results

No significant differences between the groups were observed in baseline data. With regard to rectal function, we found significant improvements at week 4 in maximal resting pressure (MRP) (39.93 ± 5.02 vs. 28.70 ± 5.40 mmH₂O, p < 0.001) and maximal squeeze pressure (MSP) (132.43 ± 8.16 mmH₂O vs. 113.33 ± 9.87 mmH₂O, p < 0.001) among Group A patients compared to Group B patients. Additionally, Wexner scores were significantly lower in Group A than in Group B at week 4 (8.10 ± 1.24 vs. 9.87 ± 1.29 ml, p = 0.018), as were stool frequency (6.47 ± 0.90 vs. 7.83 ± 0.93, p < 0.001) and BSFS scores (5.17 ± 0.65 vs. 6.10 ± 0.80, p = 0.020). Notably, HADS scores were also significantly lower in Group A than in Group B at week 4 (8.25 ± 2.36 vs. 10.48 ± 3.01, p < 0.001). Additionally, both anxiety scores (4.16 ± 1.38 vs. 5.33 ± 1.69, p < 0.001) and depression scores (4.09 ± 1.56 vs. 5.15 ± 1.89, p < 0.001) were significantly lower in Group A than in Group B at week 4.

Conclusion

Pelvic floor muscle exercises are an effective treatment that can alleviate symptoms and improve rectal function and mental health in patients with low anterior resection syndrome.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Experiences of bowel symptoms in patients with rectal cancer after sphincter-preserving surgery: a qualitative meta-synthesis

PURPOSE

This study is to identify and synthesize the available evidence of bowel symptom experiences of patients with rectal cancer after sphincter-preserving surgery (SPS).

METHODS

This qualitative meta-synthesis was conducted following the Joanna Briggs Institute (JBI) qualitative systematic review methodology and reported following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) guidelines. Seven databases were searched on 22 December 2021. The selected studies were reviewed by two independent reviewers, and disagreements were resolved by discussion or with a third reviewer.

RESULTS

Seven qualitative articles were included in the meta-synthesis with 192 total rectal cancer patients. The review summarized 53 qualitative findings into three synthesized findings: (a) Patients experienced bowel symptoms and triggered additional physiological problems, and they underestimated bowel symptoms; (b) patients had many negative emotions, and their daily life and social interaction were disturbed; and (c) patients adopted strategies to adapt or control their bowel symptoms. According to the ConQual evidence grading approach, the confidence of the synthesized findings was rated as moderate to low.

CONCLUSIONS

The bowel symptoms of patients with rectal cancer after SPS have troubled their lives. Timely acquisition of symptom-related knowledge and enhancement of their coping abilities are important for the control and management of bowel symptoms. Healthcare professionals should clearly understand the bowel symptoms that patients may experience after SPS and provide supportive care for patients to improve patients' self-management abilities and quality of life.

TRIAL REGISTRATION

PROSPERO: CRD42021242610.

A predictive nomogram model for low anterior resection syndrome after rectal cancer resection

BACKGROUND

The aim of this study was to identify risk factors associated with the low anterior resection syndrome (LARS) and to construct a nomogram capable of predicting the risk of LARS in patients who undergo rectal cancer resection.

METHODS

About 538 patients who had undergone anterior resection were recruited as a development set. In addition, 114 patients with rectal cancer were analysed as a validation set to test the new nomogram. Patients in the development set were grouped into two separate cohorts: those with major LARS and those with minor or no LARS. Multiple logistic regression was conducted to detect risk factors for major LARS.

RESULTS

The prevalence of major LARS was 40.7%, of minor LARS was 28.6% and the proportion with no LARS was 30.7% in the development set. In multivariate analysis, female gender, preoperative chemoradiation, low tumour height, diverting ileostomy, postoperative anastomotic leakage were shown to be independently associated with major LARS occurring in patients after rectal cancer resection. The area under the curve (AUC) values of the nomogram were 0.726 (95% CI: 0.682-0.769) and 0.750 (95% CI: 0.655-0.845) in the development and validation sets, respectively. The calibration curves and Hosmer-Lemeshow goodness of fit tests showed that the model was acceptably accurate.

CONCLUSION

A nomogram model based on risk factors could be valuable as a predictor of the probability of major LARS after rectal cancer surgery, and provides a guide that clinical staff can use to take preventive measures for high-risk patients.

Coping strategies and considerations regarding low anterior resection syndrome and quality of life among patients with rectal cancer; a qualitative interview study

Introduction

Low anterior resection syndrome (LARS) is defined as disordered bowel function following rectal resection, which is detrimental to quality of life (QoL). A recent international consensus definition of LARS stresses the importance of focusing on both the symptoms and the consequences that the symptoms have for the individual patient as studies indicate that LARS has a negative impact on patients’ QoL. However, an ongoing PROM study investigating late sequelae after rectal cancer finds that a minor proportion of patients scoring major LARS experience none or only little impact on quality of life

Aim

The aim of this study was to identify patients’ considerations and coping strategies to establish why the burden caused by major LARS had little or no influence on their QoL.

Materials and methods

This was a qualitative interview study based on 21 semi-structured individual telephone interviews with patients treated for rectal cancer. Data were analysed using a hermeneutic inspired thematic analysis.

Results and conclusion

Three themes emerged from the analysis; Adapting new life situation, Altering life perception and the Importance of relationships. Major LARS and its consequences following rectal cancer may be managed or altered by adopting problem-focused and emotion-focused coping strategies. Maintaining a positive attitude and having a good network of family and friends constitute a surplus, allowing patients to cope with the need for changed behaviour and appreciate the life that they have been given. Accepting that major LARS and its consequences cause limitations in life allowed patients to change their normality threshold over time.

Defecation Dysfunction and Exercise Habits among Survivors of Rectal Cancer: A Pilot Qualitative Study

This pilot qualitative study aimed to investigate exercise habits and assess defecatory dysfunction among adult survivors of rectal cancer with and without stomas. Patients were eligible for the study if they had stage I-IV rectal cancer, and less than 5 years had elapsed since surgery. We conducted semi-structured interviews with outpatients visiting two general hospitals in Japan and inquired about their diets, defecation, and exercise habits. The interview data were transcribed verbatim, interpreted, and abstracted to generate coding units; we divided the responses into categories and subcategories. Eleven patients had stomas inserted after surgery while six did not. Content analysis identified four categories common to patients with and without stomas: [diet control], [coping with defecation dysfunction], [compromising with defecation dysfunctions], and [maintenance of exercise habits]. Our results suggest the need for intervening among rectal cancer survivors to address eating habits to alleviate defecation dysfunction and exercise habits to maintain physical function. In clinical practice, symptom relief and exercise instruction may improve the well-being of cancer survivors with bowel dysfunction.

Prospective Evaluation of the Quality of Life of Patients after Surgical Treatment of Rectal Cancer: A 12-Month Cohort Observation

This study constitutes a prospective, three-stage evaluation of quality of life among patients receiving surgical treatment for colorectal cancer depending on the type of surgery performed (open anterior resection, laparoscopic anterior resection, abdominoperineal resection, or Hartmann’s procedure). The study included 82 patients treated at the Surgical Oncology Outpatient Department of the Oncology Center in Bydgoszcz from June 2019 to August 2021. The study tools consisted of diagnostic surveys and analyses of medical records. The standardized study tools were the surveys EORTC QLQ-C30 and QLQ-CR29. In addition, a proprietary questionnaire was developed to collect demographic data. Quality of life was measured at three time-points: the day before the surgery and 6 and 12 months post-surgery. Statistically significant differences (p < 0.05) were observed in the domains of role functioning (III, p = 0.030), body image (II, p < 0.001; III, p < 0.001), sexual functioning (II, p = 0.037), buttocks/anal area/rectum pain (III, p = 0.031), and embarrassment (II, p = 0.022; III, p = 0.010). Statistically significant differences in the functional and symptom scale scores were also observed within each group at different stages of cancer treatment. As shown by our study, the quality of life of patients treated for colorectal cancer is determined not only by the operating technique but also by sociodemographic and clinical factors. The use of minimally invasive surgical techniques enables patients to return to their social roles more quickly and improves their self-assessment of body image.

Turnbull-Cutait abdominoperineal pull-through operation: The Cleveland Clinic experience in the 21st century

AIM

The Turnbull-Cutait pull-through procedure (TCO) restores intestinal continuity in the setting of chronic pelvic sepsis, colorectal anastomotic leak, complex pelvic fistulas and technical challenges related to complicated rectal cancer. The aim of this study was to evaluate the outcomes of the TCO for salvaging complex pelvic conditions and to compare it to hand-sewn immediate coloanal anastomosis (CAA).

METHODS

This is a retrospective single-institution study where we searched a prospectively maintained database to identify patients who underwent the TCO. Patient demographics, operative indications and outcomes were analysed. TCO success was defined as maintenance of intestinal continuity and being stoma-free. Kaplan-Meier analysis was employed for stoma-free survival analysis.

RESULTS

A total of 81 patients with TCO and 129 patients with CAA were included. The TCO success rate was 69% at a median of 1.4 years' follow-up with 25 (31%) patients ending up with a permanent stoma compared to 22 (17%) in the CAA group with a median follow-up of 4 years (P = 0.03). The Kaplan-Meier cumulative incidence of TCO success at 1, 3 and 5 years was 79%, 60% and 51%, respectively, compared to 91%, 81% and 73% after CAA.

CONCLUSION

The TCO has a high success rate for patients with complex pelvic conditions who may be facing a permanent stoma as their only option.

Endoscopic Treatment Options for Gastrointestinal Leaks

Background

Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients.

Methods

We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022.

Results

The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting.

Conclusion

Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.