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Bang GA, Moto GRB, Ngoumfe JCC, Savom EP, Ngowe MN. Bowel function after anterior rectal resection for cancer: short and long-term prospective evaluation with low anterior rectal syndrome (LARS) score in a cohort of Cameroonian patients. Pan Afr Med J 2024; 47:171. [PMID: 39036021 PMCID: PMC11260046 DOI: 10.11604/pamj.2024.47.171.32287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 03/08/2024] [Indexed: 07/23/2024] Open
Abstract
Introduction bowel dysfunction is the most common and disabling complication after anterior rectal resection (ARR) for cancer. We aimed to evaluate these complications in a cohort of Cameroonian patients, using the low anterior rectal syndrome (LARS) score. Methods we conducted a descriptive and analytical cross-sectional study, in two university hospitals of Yaoundé (Cameroon). Prospectively, we collected the records of all patients aged at least 18 years who had an ARR indicated for rectal cancer from January 2015 to March 2018. Alive patients among them were subsequently received in consultation at 1 and 3 years after surgery, for short and long-term assessment of their digestive function using the LARS score. Results during the study period, 28 patients underwent anterior rectal resection for rectal cancers. Short-term bowel function was evaluated in 23 patients. Their mean age was 48.42 ± 12.2 years and 14 were males. LARS was present in 10 of them (43.47%) and classified as "minor" in the majority of cases (n=6). The commonest bowel dysfunction at this term was splitting of stool (56.53%). Long-term digestive function was evaluated in 11 patients; LARS was found in 3 of them (27,27%) and classified as minor in all cases. Perfect continence was significantly improved (p=0.003) in the long term compared to the short-term status. Continence (p=0.049) and urgency (p=0.048) were better in patients who had a low colorectal anastomosis compared to those who had a colo supra-anal anastomosis. Conclusion after ARR for cancer, there is a high prevalence of LARS in the short term with an improvement in the long term.
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Affiliation(s)
- Guy Aristide Bang
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Surgical Unit, Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | - Georges Roger Bwelle Moto
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Digestive Surgical Unit, Yaoundé Central Hospital, Yaoundé, Cameroon
| | | | - Eric Patrick Savom
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Marcelin Ngowe Ngowe
- Department of Surgery and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
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van Kooten RT, Algie JPA, Tollenaar RAEM, Wouters MWJM, Putter H, Peeters KCMJ, Dekker JWT. The impact on health-related quality of a stoma or poor functional outcomes after rectal cancer surgery in Dutch patients: A prospective cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106914. [PMID: 37105868 DOI: 10.1016/j.ejso.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/01/2023] [Accepted: 04/20/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND As the survival of patients with rectal cancer has improved in recent decades, more and more patients have to live with the consequences of rectal cancer surgery. An influential factor in long-term Health-related Quality of Life (HRQoL) is the presence of a stoma. This study aimed to better understand the long-term consequences of a stoma and poor functional outcomes. METHODS Patients who underwent curative surgery for a primary tumor located in the rectosigmoid and rectum between 2013 and 2020 were identified from the nationwide Prospective Dutch Colorectal Cancer (PLCRC) cohort study. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, and the LARS-score at 12 months, 24 months and 36 months after surgery. RESULTS A total of 1,170 patients were included of whom 751 (64.2%) had no stoma, 122 (10.4%) had a stoma at primary surgery, 45 (3.8%) had a stoma at secondary surgery and 252 (21.5%) patients that underwent abdominoperineal resection (APR). Of all patients without a stoma, 41.4% reported major low-anterior resection syndrome (LARS). Patients without a stoma reported significantly better HRQoL. Moreover, patients without a stoma significantly reported an overall better HRQoL. CONCLUSION The presence of a stoma and poor functional outcomes were both associated with reduced HRQoL. Patients with poor functional outcomes, defined as major LARS, reported a similar level of HRQoL compared to patients with a stoma. In addition, the HRQoL after rectal cancer surgery does not change significantly after the first year after surgery.
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Affiliation(s)
- Robert T van Kooten
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - Jelle P A Algie
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel W J M Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands; Department of Surgery, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Koen C M J Peeters
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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Liao J, Qin H, Wang Z, Meng L, Wang W, Liu J, Mo X. Mesorectal reconstruction with pedicled greater omental transplantation to relieve low anterior resection syndrome following total intersphincteric resection in patients with ultra-low rectal cancer. BMC Surg 2023; 23:236. [PMID: 37573297 PMCID: PMC10423425 DOI: 10.1186/s12893-023-02140-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/04/2023] [Indexed: 08/14/2023] Open
Abstract
BACKGROUND Total intersphincteric resection (ISR) is the ultimate anus-preserving surgery for patients with ultra-low rectal cancer (ULRC), which can result in various degrees of anorectal dysfunction. Known as low anterior resection syndrome (LARS), it seriously affects the postoperative quality of life of patients. The aim of this study was to discuss the value of mesorectal reconstruction with pedicled greater omental transplantation (PGOT) to relieve LARS following total ISR in patients with ULRC, hoping to provide new ideas and strategies for the prevention and improvement of LARS. METHODS We retrospectively analyzed hospitalization data and postoperative anorectal function of 26 ULRC patients, who were met inclusion and exclusion criteria in our center from January 2015 to February 2022. And combined with the results of anorectal manometry and rectal magnetic resonance imaging (MRI) defecography of some patients, we assessed comprehensively anorectal physiological and morphological changes of the patients after surgery, and their correlation with LARS. RESULTS In this study, 26 patients with ULRC were enrolled and divided into observation group (n = 15) and control group (n = 11) according to whether PGOT was performed. There were no significant differences in surgical results such as operative time, intraoperative blood loss and postoperative complications between the two groups (P > 0.05). Postoperative follow-up showed that patients in both groups showed severe LARS within 3 months after surgery, but from the 3rd month after surgery, LARS in both groups gradually began to decrease, especially in the observation group, which showed faster recovery and better recovery, with statistically significant difference (P < 0.001). Through anorectal manometry, the mean rectal resting pressure in the observation group was significantly lower than that in the control group (P = 0.010). In addition, the postoperative thickness of the posterior rectal mesenterium in the observation group was significantly higher than that in the control group (P = 0.001), and also higher than the preoperative level (P = 0.018). Moreover, rectal MRI defecography showed that the neo-rectum had good compliance under the matting of greater omentum, and its intestinal peristalsis was coordinated. CONCLUSIONS ULRC patients, with the help of greater omentum, coordinated their neo-rectum peristalsis after total ISR and recovery of LARS was faster and better. PGOT is expected to be an effective strategy for LARS prevention and treatment of ULRC patients after surgery and is worthy of clinical promotion.
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Affiliation(s)
- Jiankun Liao
- Department of Gastrointestinal Surgery, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, China
- Guangxi Clinical Research Center for Colorectal Cancer, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, The People's Republic of China
| | - Haiquan Qin
- Department of Gastrointestinal Surgery, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, China
- Guangxi Clinical Research Center for Colorectal Cancer, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, The People's Republic of China
| | - Zheng Wang
- Medical Imaging Center, Guangxi Medical University Cancer Hospital, Nanning, 530021, Guangxi Autonomous Region, China
| | - Linghou Meng
- Department of Gastrointestinal Surgery, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, China
- Guangxi Clinical Research Center for Colorectal Cancer, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, The People's Republic of China
| | - Wentao Wang
- Department of Gastrointestinal Surgery, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, China
- Guangxi Clinical Research Center for Colorectal Cancer, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, The People's Republic of China
| | - Jungang Liu
- Department of Gastrointestinal Surgery, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, China
- Guangxi Clinical Research Center for Colorectal Cancer, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, The People's Republic of China
| | - Xianwei Mo
- Department of Gastrointestinal Surgery, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, China.
- Guangxi Clinical Research Center for Colorectal Cancer, Division of Colorectal and Anal, Guangxi Medical University Cancer Hospital, No.71, Hedi Road, Qingxiu District, Nanning, 530021, Guangxi Autonomous Region, The People's Republic of China.
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Couwenberg AM, Varvoglis DN, Grieb BC, Marijnen CA, Ciombor KK, Guillem JG. New Opportunities for Minimizing Toxicity in Rectal Cancer Management. Am Soc Clin Oncol Educ Book 2023; 43:e389558. [PMID: 37307515 PMCID: PMC10450577 DOI: 10.1200/edbk_389558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Advances in multimodal management of locally advanced rectal cancer (LARC), consisting of preoperative chemotherapy and/or radiotherapy followed by surgery with or without adjuvant chemotherapy, have improved local disease control and patient survival but are associated with significant risk for acute and long-term morbidity. Recently published trials, evaluating treatment dose intensification via the addition of preoperative induction or consolidation chemotherapy (total neoadjuvant therapy [TNT]), have demonstrated improved tumor response rates while maintaining acceptable toxicity. In addition, TNT has led to an increased number of patients achieving a clinical complete response and thus eligible to pursue a nonoperative, organ-preserving, watch and wait approach, thereby avoiding toxicities associated with surgery, such as bowel dysfunction and stoma-related complications. Ongoing trials using immune checkpoint inhibitors in patients with mismatch repair-deficient tumors suggest that this subgroup of patients with LARC could potentially be treated with immunotherapy alone, sparing them the toxicity associated with preoperative treatment and surgery. However, the majority of rectal cancers are mismatch repair-proficient and less responsive to immune checkpoint inhibitors and require multimodal management. The synergy noted in preclinical studies between immunotherapy and radiotherapy on immunogenic tumor cell death has led to the design of ongoing clinical trials that explore the benefit of combining radiotherapy, chemotherapy, and immunotherapy (mainly of immune checkpoint inhibitors) and aim to increase the number of patients eligible for organ preservation.
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Affiliation(s)
- Alice M. Couwenberg
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | | | - Brian C. Grieb
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Corrie A.M. Marijnen
- Department of Radiation Oncology, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
| | - Kristen K. Ciombor
- Vanderbilt University Medical Center/Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Jose G. Guillem
- Department of Surgery, Lineberger Comprehensive Cancer Center, University of North Carolina-Chapel Hill, Chapel Hill, NC
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Verkuijl SJ, Hoff C, Furnée EJ, Kelder W, Hess DA, Wit F, Zijlstra RJ, Trzpis M, Broens PM. Anastomotic Height Is a Valuable Indicator of Long-term Bowel Function Following Surgery for Rectal Cancer. Dis Colon Rectum 2023; 66:221-232. [PMID: 35714360 PMCID: PMC9829038 DOI: 10.1097/dcr.0000000000002168] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The exact relation between anastomotic height after rectal cancer surgery and postoperative bowel function problems has not been investigated in the long term, resulting in ineffective treatment. OBJECTIVE The goal of this study was to determine the effect of anastomotic height on long-term bowel function and generic quality of life. DESIGN This was a multicenter, cross-sectional study. SETTINGS Seven hospitals in the north of the Netherlands participated. PATIENTS All patients who underwent rectal cancer surgery between 2009 and 2015 in participating hospitals received the validated Defecation and Fecal Continence and Short-Form 36 questionnaires. Deceased patients, patients with a permanent stoma or an anastomosis >15 cm from the anal verge, patients with intellectual disability, and patients living abroad were excluded. MAIN OUTCOME MEASURES Primary outcomes were constipation (Rome IV), fecal incontinence (Rome IV), and major low anterior resection syndrome. Secondary outcomes were the generic quality of life scores. RESULTS The study population ( n = 630) had a median follow-up of 58.0 months. In multivariable analysis, constipation (OR = 1.08; 95% CI, 1.02-1.15; p = 0.011), fecal incontinence (OR = 0.91; 95% CI, 0.84-0.97; p = 0.006), and major low anterior resection syndrome (OR = 0.93; 95% CI, 0.87-0.99; p = 0.027), were significantly associated with anastomotic height. The curves illustrating the probability of constipation and fecal incontinence crossed at an anastomotic height of 7 cm, with 95% CIs overlapping between 4.5 and 9.5 cm. There was no relation between quality-of-life scores and anastomotic height. LIMITATIONS The study is limited by its cross-sectional design. CONCLUSIONS This study might serve as a guide for the clinician to effectively screen and treat fecal incontinence and constipation during patient follow-up after rectal cancer surgery. More attention should be paid to fecal incontinence in patients with an anastomosis below 4.5 cm and toward constipation in patients with an anastomosis above 9.5 cm. See Video Abstract at http://links.lww.com/DCR/B858 . LA ALTURA ANASTOMTICA ES UN INDICADOR VALIOSO DE LA FUNCIN INTESTINAL A LARGO PLAZO DESPUS DE LA CIRUGA PARA EL CNCER DE RECTO ANTECEDENTES:La relación exacta entre la altura anastomótica después de la cirugía de cáncer de recto y los problemas posoperatorios de la función intestinal no se ha investigado a largo plazo, lo que causa un tratamiento ineficaz.OBJETIVO:Determinar el efecto de la altura anastomótica sobre la función intestinal a largo plazo y la calidad de vida genérica.DISEÑO:Estudio multicéntrico transversal.DISEÑO DEL ESTUDIO:Participaron siete hospitales holandeses en el norte de los Países Bajos.PACIENTES:Todos los pacientes que se sometieron a cirugía de cáncer de recto entre 2009 y 2015 en los hospitales participantes recibieron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36. Se excluyeron pacientes fallecidos, pacientes con estoma permanente o anastomosis > 15 cm del borde anal, discapacidad intelectual o residentes en el extranjero.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron estreñimiento (Roma IV), incontinencia fecal (Roma IV) y síndrome de resección anterior baja mayor. Los resultados secundarios fueron las puntuaciones genéricas de calidad de vida.RESULTADOS:La población de estudio (N = 630) tuvo una mediana de seguimiento de 58.0 meses. En el análisis multivariable el estreñimiento (OR = 1,08, IC del 95%, 1,02-1,15, p = 0,011), incontinencia fecal (OR = 0,91, IC del 95%, 0,84-0,97, p = 0,006) y síndrome de resección anterior baja mayor (OR = 0,93, IC del 95%, 0,87-0,99, p = 0,027) se asociaron significativamente con la altura anastomótica. Las curvas que ilustran la probabilidad de estreñimiento e incontinencia fecal se cruzaron a una altura anastomótica de 7 cm, con IC del 95% superpuestos entre 4,5 y 9,5 cm. No hubo relación entre las puntuaciones de calidad de vida y la altura anastomótica.LIMITACIONES:El estudio está limitado por su diseño transversal.CONCLUSIONES:Este estudio podría servir como una guía para que el médico evalúe y trate eficazmente la incontinencia fecal y el estreñimiento durante el seguimiento de los pacientes después de la cirugía de cáncer de recto. Se debe prestar más atención a la incontinencia fecal en pacientes con anastomosis por debajo de 4,5 cm y al estreñimiento en pacientes con anastomosis por encima de 9,5 cm. Consulte Video Resumen en http://links.lww.com/DCR/B858 . (Traducción-Dr. Yazmin Berrones-Medina ).
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Affiliation(s)
- Sanne J. Verkuijl
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Edgar J.B. Furnée
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Wendy Kelder
- Department of Surgery, Martini Hospital, Groningen, the Netherlands
| | - Daniel A. Hess
- Department of Surgery, Antonius Hospital, Sneek, the Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - Ronald J. Zijlstra
- Department of Surgery, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Paul M.A. Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Low anterior resection syndrome following rectal cancer surgery: are incidence and severity lower with long-term follow-up? Tech Coloproctol 2022; 26:981-989. [PMID: 36097205 DOI: 10.1007/s10151-022-02699-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 09/01/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a functional disorder that may follow restorative proctectomy. The aim of this study was to evaluate the long-term incidence and risk factors for LARS following surgery for rectal cancer. METHODS A retrospective study was performed on patients from a prospectively maintained database, who underwent a restorative proctectomy between January 2014 and December 2019 at Hadassah Hebrew University Medical Center. The study cohort was divided into two groups: patients following partial proctectomy with a partial mesorectal excision and a colorectal anastomosis (PME group) and patients following total proctectomy with total mesorectal excision and a coloanal anastomosis (TME group). The incidence and severity of LARS were evaluated using the LARS questionnaire. Risk factors for LARS were also evaluated. RESULTS A total of 240 patients (male: female ratio 134:106, median age 64 years [interquartile range 55-71 years]) were included in the analysis. There were 160 patients in the PME group and 80 patients in the TME group. The overall incidence of LARS was 37.4% (26.5% major LARS and 10.9% minor LARS). Major LARS was observed in 53.8% of patients who underwent TME and in 12.7% of patients who underwent PME (p < 0.001). On multivariate analysis, distance of the anastomosis from the anal verge, TME, and neoadjuvant radiotherapy were independent prognostic factors for LARS. The incidence and severity of LARS were significantly lower in patients with longer follow-up (p = 0.05). CONCLUSIONS Significant improvement in LARS can be expected with longer follow-up. Distance of the anastomosis from the anal verge, TME and neoadjuvant radiotherapy are independent risk factors for LARS.
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MRI measurements predict major low anterior resection syndrome in rectal cancer patients. Int J Colorectal Dis 2022; 37:1239-1249. [PMID: 35503128 DOI: 10.1007/s00384-022-04169-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE Current low anterior resection syndrome (LARS) score is lagging behind and only based on clinical symptoms patient described. Preoperative imaging indicators which can be used to predict LARS is unknown. We proposed preoperative MRI parameters for identifying major LARS. METHODS Patients receiving curative restorative anterior resection from Sept. 2007 to Sept. 2015 were collected to complete LARS score (median 75.7 months since surgery). MRI measurements associated with LARS were tested, and a multivariate logistic model was conducted for predicting LARS. Receiver operating characteristic curve was used to evaluate the model. RESULTS Two hundred fifty-five patients undergoing neoadjuvant chemoradiotherapy and 72 patients undergoing direct surgery were enrolled. The incidence of major LARS in NCRT group was significantly higher (53.3% vs.34.7%, P = 0.005). In patients with neoadjuvant chemoradiotherapy, the thickness of ARJ (TARJ), the distance between the tumor's lower edge and anal rectal joint (DTA), and sex were independent factors for predicting major LARS; ORs were 0.382 (95% CI, 0.198-0.740), 0.653 (95% CI, 0.565-0.756), and 0.935 (95% CI, 0.915-0.955). The AUC of the multivariable model was 0.842 (95% CI, 0.794-0.890). In patients with direct surgery, only DTA was the independent factor for predicting major LARS; OR was 0.958 (95% CI, 0.930-0.988). The AUC was 0.777 (95% CI: 0.630-0.925). CONCLUSIONS Baseline MRI measurements have the potential to predict major LARS in rectal cancer, which will benefit the decision-making and improve patients' life quality.
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Sakamoto Y, Morohashi H, Miura T, Tsutsumi S, Takahashi S, Hirama K, Wakiya T, Hakamada K. A Prospective Multicenter Phase II Study on the Feasibility and Efficacy of S-1 and Oxaliplatin Neoadjuvant Chemotherapy for Locally Advanced Rectal Cancer. Dis Colon Rectum 2022; 65:663-671. [PMID: 33833145 DOI: 10.1097/dcr.0000000000001927] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy and total mesorectal excision compose the standard of care for rectal cancer in multiple guidelines. However, neoadjuvant chemoradiotherapy has not exhibited clear survival benefits but rather has led to an increase in adverse events. Conversely, neoadjuvant chemotherapy is expected to prevent adverse events caused by radiation, yet this treatment is still controversial. OBJECTIVE The purpose of this study was to evaluate the feasibility and efficacy of S-1 and oxaliplatin neoadjuvant chemotherapy together with total mesorectal excision for resectable locally advanced rectal cancer. DESIGN The study was a prospective, single-arm phase II trial. SETTINGS The study was conducted at multiple institutions. PATIENTS Fifty-eight patients with resectable locally advanced rectal cancer were enrolled. INTERVENTION Three cycles of S-1 and oxaliplatin were administered before surgery. S-1 was administered orally at 80 mg/m2 per day for 14 consecutive days, followed by a 7-day resting period. Oxaliplatin was given intravenously on the first day at a dose of 130 mg/m2 per day. The duration of 1 cycle was considered to be 21 days. Total mesorectal excision with bilateral lymph node dissection was carried out after neoadjuvant chemotherapy. MAIN OUTCOME MEASURES The study was designed to detect the feasibility and efficacy of S-1 and oxaliplatin as neoadjuvant chemotherapy. RESULTS The completion rate of 3 courses of S-1 and oxaliplatin as neoadjuvant chemotherapy was 94.8% (55/58). The reasons for discontinuation were thrombocytopenia (3.4%) and liver injury (1.7%). The most common severe (grade ≥3) adverse effect of neoadjuvant chemotherapy was thrombocytopenia (3.4%). There were no severe adverse clinical symptoms. Consequently, R0 resection was achieved in 51 (98.1%) of 52 patients. Pathologic complete response occurred in 10 patients (19.2%). LIMITATIONS This was a single-arm, nonrandomized phase II study. CONCLUSIONS The combination of S-1 and oxaliplatin neoadjuvant chemotherapy and total mesorectal excision is a feasible and promising treatment option for resectable locally advanced rectal cancer. See Video Abstract at http://links.lww.com/DCR/B555. UN ESTUDIO PROSPECTIVO MULTICNTRICO FASE II SOBRE LA FACTIBILIDAD Y EFICACIA DE LA QUIMIOTERAPIA NEOADYUVANTE SCON OXALIPLATINO PARA EL CNCER DE RECTO LOCALMENTE AVANZADO ANTECEDENTES:La quimiorradioterapia neoadyuvante y la escisión mesorrectal total constituyen el estándar de atención para el cáncer de recto en varias guías. Sin embargo, la quimiorradioterapia neoadyuvante no ha mostrado beneficios claros en la sobrevida, pero si ha creado un aumento de eventos adversos. Por otro lado, se espera que la quimioterapia neoadyuvante prevenga los eventos adversos asociados a la radiación, aunque este tratamiento sigue siendo controvertido.OBJETIVO:Evaluar la factibilidad y eficacia de la quimioterapia neoadyuvante S-1 con oxaliplatino en conjunto con la escisión mesorrectal total para el cáncer de recto localmente avanzado resecable.DISEÑO:El estudio fue un ensayo prospectivo fase II de brazo único.AMBITO:Estudio realizado en múltiples instituciones.PACIENTES:Se incluyeron 58 pacientes con cáncer de recto localmente avanzado resecable.INTERVENCIÓN:Se administraron tres ciclos de S-1 con oxaliplatino antes de la cirugía. Se administró S-1 por vía oral a 80 mg / m2 / día durante 14 días consecutivos, seguido de un período de descanso de 7 días. El oxaliplatino se administró por vía intravenosa el primer día a una dosis de 130 mg / m2 / día. Se consideró la duración de un ciclo de 21 días. Posterior a la quimioterapia neoadyuvante se realizó la excisión total mesorrectal con disección ganglionar bilateral.PRINCIPALES VARIABLES EVALUDADAS:El estudio fue diseñado para conocer la factibilidad y eficacia de S-1 con oxaliplatino como quimioterapia neoadyuvante.RESULTADOS:La tasa de conclusión con tres ciclos de S-1 con oxaliplatino como quimioterapia neoadyuvante fue del 94,8% (55/58). Los motivos de interrupción fueron trombocitopenia (3,4%) y daño hepático (1,7%). El efecto adverso grave más común (grado ≥ 3) de la quimioterapia neoadyuvante fue la trombocitopenia (3,4%). No hubo síntomas clínicos adversos graves. Como resultado, la resección R0 se logró en 51 de 52 pacientes (98,1%). Una respuesta patológica completa se obtuvo en 10 pacientes (19,2%).LIMITACIONES:Fue un estudio de fase II no aleatorizado de un solo brazo.CONCLUSIONES:La combinación de S-1 con oxaliplatino como quimioterapia neoadyuvante y escisión mesorrectal total es factible y es una opción de tratamiento prometedora para el cáncer de recto localmente avanzado resecable. Consulte Video Resumen en http://links.lww.com/DCR/B555. (Traducción-Dr Juan Antonio Villanueva-Herrero).
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Affiliation(s)
- Yoshiyuki Sakamoto
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, Japan
| | - Hajime Morohashi
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, Japan
| | - Takuya Miura
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, Japan
| | | | | | | | - Taiichi Wakiya
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, Japan
| | - Kenichi Hakamada
- Department of Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Hirosaki City, Aomori, Japan
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Algie JPA, van Kooten RT, Tollenaar RAEM, Wouters MWJM, Peeters KCMJ, Dekker JWT. Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life. Int J Colorectal Dis 2022; 37:2197-2205. [PMID: 36156128 PMCID: PMC9560940 DOI: 10.1007/s00384-022-04257-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical resection is the mainstay of curative treatment for rectal cancer. Post-operative complications, low anterior resection syndrome (LARS), and the presence of a stoma may influence the quality of life after surgery. This study aimed to gain more insights into the long-term trade-off between stoma and anastomosis. METHODS All patients who underwent sphincter-sparing surgical resection for rectal cancer in the Leiden University Medical Center and the Reinier de Graaf Gasthuis between January 2012 and January 2016 were included. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, EQ-5D-5L, and the LARS score. A comparison was made between patients with a stoma and without a stoma after follow-up. RESULTS Some 210 patients were included of which 149 returned the questionnaires (70.9%), after a mean follow-up of 3.69 years. Overall quality of life was not significantly different in patients with and without stoma after follow-up using the EORTC-QLQ-C30 (p = 0.15) or EQ-5D-5L (p = 0.28). However, after multivariate analysis, a significant difference was found for the presence of a stoma on global health status (p = 0.01) and physical functioning (p < 0.01). Additionally, there was no difference detected in the quality of life between patients with major LARS or a stoma. CONCLUSION This study shows that after correction for possible confounders, a stoma is associated with lower global health status and physical functioning. However, no differences were found in health-related quality of life between patients with major LARS and patients with a stoma. This suggests that the choice between stoma and anastomosis is mainly preferential and that shared decision-making is required.
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Affiliation(s)
- Jelle P. A. Algie
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, J10-71, 2333 ZA Leiden, The Netherlands
| | - Robert T. van Kooten
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, J10-71, 2333 ZA Leiden, The Netherlands
| | - Rob A. E. M. Tollenaar
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, J10-71, 2333 ZA Leiden, The Netherlands
| | - Michel W. J. M. Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands ,Department of Surgery, Netherlands Cancer Institute-Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Koen C. M. J. Peeters
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, J10-71, 2333 ZA Leiden, The Netherlands
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Low Anterior Resection Syndrome in Adults with Rectal Cancer in China: a Case Series Analysis. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02745-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
AbstractLow anterior resection syndrome (LARS) comprises a collection of symptoms affecting patients’ defecation after restorative surgery for rectal cancer. The aim of this work was to study the incidence and risk factors for LARS in China. Rectal cancer patients undergoing total mesorectal excision and colorectal anastomosis between May 2012 and January 2015 were identified from a single center. The patients completed the LARS score questionnaire through telephone. The clinical and pathological factors that may influence the occurrence of LARS were analyzed using univariate and multivariate logistic regression analysis. The influence of postoperative recovery time and pelvic dimensions on the occurrence of LARS was also analyzed. This study included 337 patients, at an average age of 61.03 SD11.32. The mean LARS score of the patients was 14.08 (range 0–41). A total of 126 patients (37.4%) developed LARS after surgery, including 63 (18.7%) severe cases. Compared with the scores within the initial 6 postoperative months, the LARS scores of the patients in 6~18 months after the surgery showed significant reductions (p < 0.01). In multivariate analysis, lower locations of anastomosis, pre-surgery radiotherapy, and shorter postoperative recovery time were significant predisposing factors for LARS. A subgroup analysis revealed that patients suffering from LARS over 18 months after surgery were found to have a significantly shorter interspinous distance than those without LARS (p < 0.05). LARS could improve over time after surgery. Lower anastomotic level and pre-surgery radiotherapy are risk factors for LARS.
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11
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Troller DR, Meyer DJ, Davies MJ. Defining low anterior resection syndrome (LARS): Scoring tools and patient-reported outcomes. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Kim S, Kang SI, Kim SH, Kim JH. The Effect of Anastomotic Leakage on the Incidence and Severity of Low Anterior Resection Syndrome in Patients Undergoing Proctectomy: A Propensity Score Matching Analysis. Ann Coloproctol 2021; 37:281-290. [PMID: 34098631 PMCID: PMC8566143 DOI: 10.3393/ac.2021.03.15] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
Purpose Proctectomy for the treatment of rectal cancer results in inevitable changes to bowel habits. Symptoms such as fecal incontinence, constipation, and tenesmus are collectively referred to as low anterior resection syndrome (LARS). Among the several risk factors that cause LARS, anastomotic leakage (AL) is a strong risk factor for permanent stoma formation. Therefore, the purpose of this study was to investigate the relationship between the severity of LARS and AL in patients with rectal cancer based on the LARS score and the Memorial Sloan Kettering Cancer Center (MSKCC) defecation symptom questionnaires. Methods We retrospectively analyzed patients who underwent low anterior resection for rectal cancer since January 2010. Patients who completed the questionnaire were classified into the AL group and control group based on medical and imaging records. Major LARS and MSKCC scores were analyzed as primary endpoints. Results Among the 179 patients included in this study, 37 were classified into the AL group. After propensity score matching, there were significant differences in the ratio of major LARS and MSKCC scores of the control group and AL group (ratio of major LARS: 11.1% and 37.8%, P < 0.001; MSKCC score: 67.29±10.4 and 56.49±7.2, respectively, P < 0.001). Univariate and multivariate analyses revealed that AL was an independent factor for major LARS occurrence and MSKCC score. Conclusion This study showed that AL was a significant factor in the occurrence of major LARS and defecation symptoms after proctectomy.
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Affiliation(s)
- Sungjin Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Sung Il Kang
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - So Hyun Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
| | - Jae-Hwang Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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Bakula B, Rašić Ž, Jurčić D, Lucijanić M, Rašić F. CORRELATION BETWEEN THE LEVEL OF COLORECTAL ANASTOMOSIS AND ANORECTAL FUNCTION. Acta Clin Croat 2020; 59:703-711. [PMID: 34285441 PMCID: PMC8253068 DOI: 10.20471/acc.2020.59.04.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/27/2019] [Indexed: 11/24/2022] Open
Abstract
Anterior rectal resection is a standard surgical procedure for treating carcinomas of rectum and distal sigmoid colon. In many cases of anterior rectal resection, postoperatively some level of fecal incontinence may occur. The aim of our study was to evaluate the impact of the colorectal anastomosis level on anorectal functional disorder. In our prospective study, the participants were patients diagnosed with carcinoma of rectum or distal sigmoid colon. All patients underwent standard open or laparoscopic anterior rectal resection. Six months after the surgery, the function of anorectum was evaluated in all participants. Finally, 38 patients were analyzed, including 13/38 (34.2%) patients with high rectal anastomosis, 11/38 (28.9%) with mid rectal anastomosis and 14/38 (36.8%) with low rectal anastomosis. Patients with a lower level of anastomosis had a statistically significantly greater number of stools, higher urgency and discrimination impairment, more pronounced solid, liquid and gas incontinence, and greater need for diapers (p<0.05 all). Therefore, patients with lower anastomosis had a statistically significant impairment of their quality of life and higher Wexner score (p<0.001 for both analyses). Our study results suggested reduced neorectal capacity to be the main pathophysiological factor for the development of postoperative anorectal function impairment.
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Affiliation(s)
| | - Žarko Rašić
- 1Department of Abdominal Surgery, Sveti Duh University Hospital, Zagreb, Croatia; 2Department of Gastroenterology, Sveti Duh University Hospital, Zagreb, Croatia; 3Department of Hematology, Dubrava University Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Dragan Jurčić
- 1Department of Abdominal Surgery, Sveti Duh University Hospital, Zagreb, Croatia; 2Department of Gastroenterology, Sveti Duh University Hospital, Zagreb, Croatia; 3Department of Hematology, Dubrava University Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Marko Lucijanić
- 1Department of Abdominal Surgery, Sveti Duh University Hospital, Zagreb, Croatia; 2Department of Gastroenterology, Sveti Duh University Hospital, Zagreb, Croatia; 3Department of Hematology, Dubrava University Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Fran Rašić
- 1Department of Abdominal Surgery, Sveti Duh University Hospital, Zagreb, Croatia; 2Department of Gastroenterology, Sveti Duh University Hospital, Zagreb, Croatia; 3Department of Hematology, Dubrava University Hospital, Zagreb, Croatia; 4School of Medicine, University of Zagreb, Zagreb, Croatia; 5Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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Randomized Pilot Trial of Percutaneous Posterior Tibial Nerve Stimulation Versus Medical Therapy for the Treatment of Low Anterior Resection Syndrome: One-Year Follow-up. Dis Colon Rectum 2020; 63:1602-1609. [PMID: 33149022 DOI: 10.1097/dcr.0000000000001614] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Low anterior resection syndrome is significantly associated with a deterioration in the quality of life, and its medical treatment is usually ineffective. OBJECTIVE The aim of the present study was to establish the efficacy of percutaneous tibial nerve stimulation in treating this syndrome. DESIGN This is a randomized pilot trial with 1-year follow-up. SETTINGS The study was conducted in a specialized colorectal unit of a tertiary hospital. PATIENTS Patients who underwent neoadjuvant chemoradiotherapy and low anterior rectal resection for cancer with low anterior resection syndrome score ≥21 and ileostomy closed at least 18 months earlier were included. INTERVENTIONS Patients were randomly assigned to receive either percutaneous tibial nerve stimulation plus medical treatment (arm A, n = 6) or medical treatment (arm B, n = 6). Low anterior resection syndrome was assessed using symptom severity and disease-specific quality-of-life scores at baseline, at the end of treatment, and at 1-year follow-up. MAIN OUTCOME MEASURES The primary outcome was a clinical response, defined as a reduction of the low anterior resection syndrome score. RESULTS Only in group A low anterior resection syndrome score, fecal incontinence severity index, and obstructed defecation syndrome score improved significantly with treatment (35.8 ± 2.5 vs 29.0 ± 3.8 (p = 0.03); 36.8 ± 4.3 vs 18.5 ± 8.0 (p = 0.02); 10.3 ± 3.9 vs 8.0 ± 4.9 (p = 0.009)) and changes were observed in all domains of quality-of-life instruments. In both groups the symptom severity and quality-of-life scores at 1-year follow-up did not differ significantly from those recorded at the end of treatment. LIMITATIONS The study had a small number of patients and it was underpowered to detect the within-group effect. CONCLUSIONS Percutaneous tibial nerve stimulation could be an effective treatment for low anterior resection syndrome. Additional studies are warranted to investigate clinical effectiveness in low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B371. ESTUDIO PILOTO ALEATORIO DE ESTIMULACIÓN PERCUTÁNEA DEL NERVIO TIBIAL POSTERIOR VERSUS TERAPIA MÉDICA PARA EL TRATAMIENTO DEL SÍNDROME DE RESECCIÓN ANTERIOR BAJA: UN AÑO DE SEGUIMIENTO: El síndrome de resección anterior baja se asocia con un deterioro significativo en la calidad de vida y su tratamiento médico generalmente es ineficaz.El objetivo del presente estudio fue establecer la eficacia de la estimulación percutánea del nervio tibial en el tratamiento de este síndrome.Este es un estudio piloto aleatorio con 1 año de seguimiento.El estudio se realizó en una unidad colorrectal especializada de un hospital terciario.Se incluyeron pacientes que se sometieron a quimiorradioterapia neoadyuvante y resección rectal anterior baja por cáncer con puntaje de síndrome de resección anterior baja ≥ 21 e ileostomía cerrada al menos 18 meses antes.Los pacientes fueron asignados aleatoriamente para recibir estimulación percutánea del nervio tibial + tratamiento médico (brazo A, n = 6) o tratamiento médico (brazo B, n = 6). El síndrome de resección anterior baja se evaluó utilizando puntajes de la gravedad de los síntomas y de calidad de vida específicos de la enfermedad al inicio, al final del tratamiento y al año de seguimiento.El resultado primario fue una respuesta clínica, definida como una reducción de la puntuación del síndrome de resección anterior baja.Solo en el grupo A, el puntaje del síndrome de resección anterior baja, el índice de severidad de incontinencia fecal y el puntaje del síndrome de defecación obstruida mejoraron significativamente con el tratamiento (35.8 ± 2.5 vs 29 ± 3.8, p = 0.03; 36.8 ± 4.3 vs 18.5 ± 8.0, p = 0.02; 10.3 ± 3.9 vs 8.0 ± 4.9, p = 0.009, respectivamente) y se observaron cambios en todos los dominios de los instrumentos de calidad de vida. En ambos grupos, los puntajes de severidad de los síntomas y de calidad de vida al año de seguimiento no difirieron significativamente de los registrados al final del tratamiento.El estudio tuvo un pequeño número de pacientes y no logró suficiente poder para detectar el efecto dentro de grupo.La estimulación percutánea del nervio tibial podría ser un tratamiento efectivo para el síndrome de resección anterior baja. Se requieren estudios adicionales para investigar la efectividad clínica en el síndrome de resección anterior baja. Consulte Video Resumen http://links.lww.com/DCR/B371.
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Verkuijl SJ, Jonker JE, Trzpis M, Burgerhof JGM, Broens PMA, Furnée EJB. Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis. Eur J Surg Oncol 2020; 47:960-969. [PMID: 33277056 DOI: 10.1016/j.ejso.2020.11.136] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 11/21/2020] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION As survival rates of colon cancer increase, knowledge about functional outcomes is becoming ever more important. The primary aim of this systematic review and meta-analysis was to quantify functional outcomes after surgery for colon cancer. Secondly, we aimed to determine the effect of time to follow-up and type of colectomy on postoperative functional outcomes. MATERIALS AND METHODS A systematic literature search was performed to identify studies reporting bowel function following surgery for colon cancer. Outcome parameters were bowel function scores and/or prevalence of bowel symptoms. Additionally, the effect of time to follow-up and type of resection was analyzed. RESULTS In total 26 studies were included, describing bowel function between 3 to 178 months following right hemicolectomy (n = 4207), left hemicolectomy/sigmoid colon resection (n = 4211), and subtotal/total colectomy (n = 161). In 16 studies (61.5%) a bowel function score was used. Pooled prevalence for liquid and solid stool incontinence was 24.1% and 6.9%, respectively. The most prevalent constipation-associated symptoms were incomplete evacuation and obstructive, difficult emptying (33.3% and 31.4%, respectively). Major Low Anterior Resection Syndrome was present in 21.1%. No differences between time to follow-up or type of colectomy were found. CONCLUSION Bowel function problems following surgery for colon cancer are common, show no improvement over time and do not depend on the type of colectomy. Apart from fecal incontinence, constipation-associated symptoms are also highly prevalent. Therefore, more attention should be paid to all possible aspects of bowel dysfunction following surgery for colon cancer and targeted treatment should commence promptly.
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Affiliation(s)
- Sanne J Verkuijl
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Jara E Jonker
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Paul M A Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Division of Pediatric Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Edgar J B Furnée
- Department of Surgery, Division of Abdominal Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Essangri H, Majbar MA, Benkabbou A, Amrani L, Mohsine R, Souadka A. Validation of the Moroccan arabic version of the low anterior resection syndrome score. BMC Gastroenterol 2020; 20:333. [PMID: 33050906 PMCID: PMC7552529 DOI: 10.1186/s12876-020-01463-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022] Open
Abstract
Background Sphincter sparing surgery is oftentimes associated with bowel dysfunction complaints, namely the low anterior resection syndrome (LARS). The LARS questionnaire is widely used to assess this syndrome. The aim of this observational study is to translate this tool into arabic and test its psychometric properties in rectal cancer patients, in order to ease its use in clinical practice and future research. Methods The LARS questionnaire was translated to arabic and administered to a total of 143 patients. A subgroup of 42 patients took the test twice for test-retest reliability. Internal consistency was examined through cronbach’s alpha. The score results were correlated to the EORTC QLQ-C30 questionnaire for convergent validity assessment, while discriminant validity was established through the ability of the LARS score to differentiate patients with different clinical and pathological criteria. Results The Moroccan Arabic version of the LARS score was completed by 143 patients. The internal consistency was demonstrated through a cronbach alpha score of 0.66. The agreement between the test and retest was established by a Bland Altman plot with 95% limits of agreement. 85.6% of patients remained in the same LARS category. The LARS score showed negative correlation with all five of the QLQ-C30 functional scales as well as positive correlation to the diarrhea symptom scale. The questionnaire score differed between patients according to their tumor location, chemoradiotherapy, type of mesorectal excision and anastomosis. Conclusion The Moroccan Arabic version of the LARS score shows good psychometric properties and can be used for bowel dysfunction assessment in clinical and research settings.
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Affiliation(s)
- Hajar Essangri
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth University in Rabat, Rabat, Morocco
| | - Mohammed Anass Majbar
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth University in Rabat, Rabat, Morocco
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth University in Rabat, Rabat, Morocco
| | - Laila Amrani
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth University in Rabat, Rabat, Morocco
| | - Raouf Mohsine
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth University in Rabat, Rabat, Morocco
| | - Amine Souadka
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth University in Rabat, Rabat, Morocco.
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Ng KS, Gladman MA. Patient-reported and physician-recorded bowel dysfunction following colorectal resection and radical cystectomy: a prospective, comparative study. Colorectal Dis 2020; 22:1336-1347. [PMID: 32180323 DOI: 10.1111/codi.15041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
AIM Bowel dysfunction following anterior resection (AR) is termed low anterior resection syndrome. It is unclear whether such dysfunction occurs following other bowel/pelvic operations as well. This study aimed to characterize and compare bowel dysfunction following AR, right hemicolectomy (RH) and radical cystectomy (RC). METHOD A prospective study of consecutive patients undergoing AR, RH and RC (2002-2012) was performed at a tertiary referral centre in Sydney, Australia. Outcome measures included (i) patient-reported satisfaction with bowel function, self-described bowel function and self-reported change in bowel function; (ii) objective assessment of bowel function using validated criteria to identify symptoms and stratify patients into those with constipation and/or faecal incontinence (FI); and (iii) health-related quality of life (SF-36v2 Health Survey). RESULTS Of 743 eligible patients, 70% participated [AR, n = 338, mean age 69.6 years (SD 11.9), 59% men; RH, n = 150, 75.8 years (SD 10.5), 54% men; RC, n = 34, 71.1 years (SD 14.1), 71% men]. AR patients were three times more likely to report change in bowel function post-surgery and self-judged their bowel function as abnormal more frequently (64%) than RH patients (35%) and RC patients (35%) (P < 0.01). AR patients were four times more likely to meet criteria for concomitant constipation and FI. Patients with concomitant constipation and FI had lower physical and mental SF-36v2 scores (P < 0.001). CONCLUSION Bowel dysfunction occurred after RH and RC but rates were higher following AR. This suggests that low anterior resection syndrome occurs due to a direct impact of partial/complete loss of the rectum rather than just due to loss of bowel length and/or the consequence(s) of pelvic dissection.
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Affiliation(s)
- K-S Ng
- Academic Colorectal Unit, Sydney Medical School - Concord, University of Sydney, Sydney, New South Wales, Australia
| | - M A Gladman
- Gastrointestinal and Enteric Neuroscience Research Group, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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18
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Ivatury SJ, Kang R, Goldwag JL, Wilson MZ. Restorative reconstruction after total mesorectal excision for rectal cancer is associated with significant bowel dysfunction from initial presentation. Surg Open Sci 2020; 3:29-33. [PMID: 33554098 PMCID: PMC7848764 DOI: 10.1016/j.sopen.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background Patients often desire restorative reconstruction following total mesorectal excision. Reconstruction has become synonymous with providing high-quality rectal cancer care. However, the bowel functional outcomes of restoration from presentation are unknown. We aimed to evaluate the bowel functional effects of rectal cancer treatment from presentation through surveillance. Methods This was a retrospective cohort study from 2014 to 2019 using prospectively collected data. Patients underwent treatment for rectal adenocarcinoma including restorative reconstruction. Patients completed the validated Colorectal Functional Outcome questionnaire during clinic visits (1) at presentation, (2) after neoadjuvant therapy, (3) after restoration of continuity, and (4) at surveillance. Scores range from 0 to 100 with a higher score indicating worse bowel function. Results Sixty-eight patients (age: 62 ± 12 years, 40% female) were included. The mean tumor height was 7 ± 4 cm with 85% symptomatic. Bowel function did not worsen from presentation to after neoadjuvant therapy in Total Colorectal Functional Outcome and most domain scores; there was improvement in frequency and stool-related aspects. Bowel function worsened in all scores from after neoadjuvant to restoration of continuity (mean anastomotic height: 5 ± 2 cm); there were similar findings between presentation and restoration of continuity. At surveillance, there was improvement in most domains compared with restoration of continuity. There remained significant worsening of incontinence, social impact, and need for medication scores at surveillance compared with presentation. Conclusion Restorative reconstruction after total mesorectal excision is associated with significant bowel dysfunction. For some patients, restorative reconstruction may not be high-quality rectal cancer care.
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Affiliation(s)
- Srinivas J Ivatury
- Dartmouth-Hitchcock Medical Center, Lebanon, NH.,Geisel School of Medicine, Hanover, NH
| | - Ravinder Kang
- Dartmouth-Hitchcock Medical Center, Lebanon, NH.,Geisel School of Medicine, Hanover, NH
| | - Jenaya L Goldwag
- Dartmouth-Hitchcock Medical Center, Lebanon, NH.,Geisel School of Medicine, Hanover, NH
| | - Matthew Z Wilson
- Dartmouth-Hitchcock Medical Center, Lebanon, NH.,Geisel School of Medicine, Hanover, NH
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19
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De Meyere C, Nuytens F, Parmentier I, D'Hondt M. Five-year single center experience of sacral neuromodulation for isolated fecal incontinence or fecal incontinence combined with low anterior resection syndrome. Tech Coloproctol 2020; 24:947-958. [PMID: 32556866 DOI: 10.1007/s10151-020-02245-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 05/15/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Sacral neuromodulation (SNM) has proven to be a safe and effective treatment for fecal incontinence (FI). For low anterior resection syndrome (LARS), however, SNM efficacy is still poorly documented. The primary aim of this study was to report on efficacy of SNM therapy for patients with isolated FI or LARS. Furthermore, we evaluated the safety of the procedure and the relevance of adequate follow-up. METHODS A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for isolated FI or LARS between January 2014 and January 2019. The Wexner and LARS scores were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50% improvement of the Wexner score or a reduction to minor or no LARS. RESULTS Out of 89 patients with isolated FI or LARS who had a SNM test phase, 62 patients were eligible for implantation of the permanent SNM device. At baseline, 3 weeks, and 1, 2, 3, 4 and 5 years after definitive implantation the median Wexner score of all patients was 18, 2, 4.5, 5, 5, 4 and 4.5, respectively, and 18, 4, 5.5, 5, 4, 3 and 4, respectively, for patients with FI and LARS. Patients with LARS more frequently required changes in program settings. CONCLUSIONS SNM therapy is a safe and effective treatment for patients with isolated FI and patients with FI and LARS. Adequate follow-up is essential to ensure long-term effectivity, especially for LARS patients.
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Affiliation(s)
- C De Meyere
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - F Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - I Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, Kortrijk, Belgium
| | - M D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium.
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20
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Valadão M, Dias JA, Araújo R, Cesar D. Do We Have to Treat All T3 Rectal Cancer the Same Way? Clin Colorectal Cancer 2020; 19:231-235. [PMID: 32839078 DOI: 10.1016/j.clcc.2020.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/20/2020] [Accepted: 07/20/2020] [Indexed: 12/29/2022]
Abstract
Chemoradiotherapy (CRT) followed by surgery is the recommended approach in the last years for stage II and III rectal cancer with the intention to decrease the risk of local recurrence. However, fewer patients benefit from this strategy in terms of overall survival and long-term adverse outcomes because T3 rectal cancer has a broad range of prognosis, as shown by recent publications. Many patients with cT3 rectal cancer have a substantial risk of overtreatment with long-term toxicity related to radiotherapy that could be avoided in a subset group of cT3 tumors with good prognosis. These findings raised the question of whether all cT3 rectal cancer should receive preoperative radiotherapy and if a selected cT3 subgroup could be treated by surgery alone. This review addresses the rationale of selecting good prognosis cT3 rectal cancer for surgery alone and analyzes the data to support this recommendation.
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Affiliation(s)
- Marcus Valadão
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | - José Antônio Dias
- Department of Colorectal Surgery, Universidade Federal Fluminense (UFF), Niterói, Brazil
| | - Rodrigo Araújo
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
| | - Daniel Cesar
- Department of Abdomino-Pelvic Surgery, Instituto Nacional de Câncer (INCA), Rio de Janeiro, Brazil
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21
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Keane C, O'Grady G, Bissett I, Woodfield J. Comparison of bowel dysfunction between colorectal cancer survivors and a non-operative non-cancer control group. Colorectal Dis 2020; 22:806-813. [PMID: 31943637 DOI: 10.1111/codi.14966] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 12/15/2019] [Indexed: 02/08/2023]
Abstract
AIM Low anterior resection syndrome (LARS) detrimentally affects quality of life in colorectal cancer survivors. This study assessed the prevalence for LARS in colorectal cancer survivors and the same symptoms in a matched control group. METHOD Validated instruments, the LARS score and Short Form Survey 12, used to collect functional and quality of life outcomes from patients who had undergone distal colorectal resection at Auckland Hospital (2008-2015) or Dunedin Hospital (2008-2017). A matched non-operative control group was drawn from patients undergoing surveillance colonoscopy. RESULTS The response rate was 79%. Cross-sectional prevalence of major LARS in rectal cancer patients was 52% at a median follow-up of 52 months. Major LARS prevalence in the sigmoid cancer resection and non-cancer control groups was similar (25% vs 26%, P = 0.6). On univariate analysis anastomotic height [risk ratio (RR) for low anterior resection 4.6, P < 0.001; ultralow anterior resection RR = 15.5, P < 0.001], radiotherapy (RR = 2.6; P = 0.009), stoma (RR = 3.6; P = 0.001) and J pouch reconstruction (vs straight anastomosis, RR = 4.6; P = 0.008) were associated with major LARS for rectal cancer patients. These factors were not significant when the analysis was stratified for anastomotic height. Despite correlation between LARS and Short Form Survey 12 outcomes (physical ρ = -0.2; mental ρ = -0.2) there was no difference in quality of life outcomes between the groups. CONCLUSION Bowel dysfunction after low anterior resection affects the majority of rectal cancer patients. The high background rate of bowel dysfunction must be considered when assessing the prevalence of LARS.
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Affiliation(s)
- C Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Whangarei Hospital, Whangarei, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - I Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - J Woodfield
- Department of Surgery, Dunedin Hospital, Dunedin, New Zealand.,Department of Surgical Sciences, University of Otago, Auckland, New Zealand
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22
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Xu G, Xiao Q, Lei H, Fu Y, Kong J, Zheng Q, Zhao L, Liang F. Effectiveness and safety of acupuncture and moxibustion for defecation dysfunction after sphincter-preserving surgery for rectal cancer: protocol for systematic review and meta-analysis. BMJ Open 2020; 10:e034152. [PMID: 32381535 PMCID: PMC7223156 DOI: 10.1136/bmjopen-2019-034152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Defecation dysfunction (DD) is one of the most common complications following sphincter-preserving surgery for rectal cancer. And there is no effective treatment of DD after sphincter-preserving surgery for rectal cancer. Although some studies suggested that acupuncture and moxibustion (AM) is effective and safe for DD after sphincter-preserving surgery for rectal cancer, lacking strong evidence, for instance, the relevant systematic review, meta-analysis and randomised controlled trial (RCT) of a large, multicentre sample, makes the effects and safety remain uncertain. The present protocol is described for a systematic review and meta-analysis to investigate the effectiveness and safety of AM for DD after sphincter-preserving surgery for rectal cancer. METHODS AND ANALYSIS We will search nine online databases from inception to 1 October 2019; the language of included trials will not be restricted. This study will include RCTs that performed AM as the main method of the experimental group for patients with DD after sphincter-preserving surgery for rectal cancer. Two of the researchers will independently select the studies, conduct risk of bias assessment and extract the data. We will use the fixed-effects model or random-effects model of RevMan V.5.2 software to analyse data synthesis. The risk ratios with 95% CIs and weighted mean differences or standardised mean differences with 95% CIs will be used to present the data synthesis outcome of dichotomous data respectively and the continuous data. Evidence quality of outcome will be assessed by using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. ETHICS AND DISSEMINATION Ethical approval is not required in this secondary research evidence, and we will publish the results of this study in a journal or concerned conferences. TRIAL REGISTRATION NUMBER CRD42019140097.
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Affiliation(s)
- Guixing Xu
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qiwei Xiao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Hanzhou Lei
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yanan Fu
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Jing Kong
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Qianhua Zheng
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Ling Zhao
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Fanrong Liang
- Acupuncture and Tuina School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
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23
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Ram E, Meyer R, Carter D, Gutman M, Rosin D, Horesh N. The efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome: a systematic review and meta-analysis. Tech Coloproctol 2020; 24:803-815. [PMID: 32350733 DOI: 10.1007/s10151-020-02231-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/22/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sacral neuromodulation (SNM) has become one of the main treatment options in patients with fecal incontinence. The aim of this study was to determine the efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome (LARS). METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was conducted using the Pubmed, Embase, Ovid, and Cochrane databases, restricted to the English language and to articles published from 2000 to November 2018. RESULTS A total of 434 articles on the efficacy of SNM in the treatment of LARS were retrieved, and 13 studies were included in the final analysis, with a total of 114 patients treated with SNM for LARS The overall success rate excluding study heterogeneity was 83.30% [95% CI (71.33-95.25%)]. Improvement in anal continence was seen in several clinical and functional parameters, including the Wexner Score [10.78 points, 95% CI (8.55-13.02), p < 0.0001], manometric maximum resting pressure [mean improvement of 6.37 mm/Hg, 95% CI (2.67-10.07), p = 0.0007], maximum squeeze pressure [mean improvement of 17.99 mm/Hg, 95% CI (17.42-18.56), p < 0.0001] and maximum tolerated volume [mean improvement of 22.74 ml, 95% CI (10.65-34.83), p = 0.0002]. Quality of life questionnaires also demonstrated significant improvement in patients' quality of life, but were reported only in a small group of included patients. CONCLUSIONS SNM significantly improves symptoms and quality of life in patients suffering from fecal incontinence following low anterior resection.
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Affiliation(s)
- E Ram
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel.
- Tel Aviv University, Tel Aviv, Israel.
| | - R Meyer
- Tel Aviv University, Tel Aviv, Israel
- Department of Gynecology and Obstetrics, Sheba Medical Centre, Tel Hashomer, Israel
| | - D Carter
- Tel Aviv University, Tel Aviv, Israel
- Department of Gastroenterology, Sheba Medical Centre, Tel Hashomer, Israel
| | - M Gutman
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - D Rosin
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - N Horesh
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
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24
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Haas S, Faaborg PM, Gram M, Lundby L, Brock C, Drewes AM, Laurberg S, Krogh K, Christensen P. Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy. Tech Coloproctol 2020; 24:721-730. [PMID: 32323098 DOI: 10.1007/s10151-020-02210-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers. METHODS Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing. RESULTS Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers. CONCLUSIONS Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.
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Affiliation(s)
- S Haas
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark. .,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark.
| | - P M Faaborg
- Department of Surgery, Vejle Hospital, Vejle, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - M Gram
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - L Lundby
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - C Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Clinical Institute, Aalborg University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aalborg, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
| | - P Christensen
- Department of Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd 99, 8200, Århus N, Denmark.,Danish Cancer Society Centre for Research and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus and Aalborg University Hospitals, Aalborg, Denmark
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25
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Eid Y, Bouvier V, Dejardin O, Menahem B, Chaillot F, Chene Y, Dutheil JJ, Juul T, Morello R, Alves A. 'French LARS score': validation of the French version of the low anterior resection syndrome (LARS) score for measuring bowel dysfunction after sphincter-preserving surgery among rectal cancer patients: a study protocol. BMJ Open 2020; 10:e034251. [PMID: 32152168 PMCID: PMC7064062 DOI: 10.1136/bmjopen-2019-034251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Many bowel problems following low anterior resection (LAR) for rectal cancer considerably impair the quality of life (QoL) of patients. The LAR syndrome (LARS) scale is a self-report questionnaire to identify and assess bowel dysfunction after rectal cancer surgery. It has been translated and validated in several languages but not in French (metropolitan French). The primary objective is to adapt the LARS scale to the French language (called French-LARS score) and to assess its psychometric properties. Secondary objectives are to assess both the prevalence and severity of LARS and to measure their impact on QoL. METHODS AND ANALYSIS A French multicentre observational cohort study has been designed. The validation study will include translation of the LARS scale following the current international recommendations, assessment of its reliability, convergent and discriminant validities, sensitivity, internal consistency, internal validity and confirmatory analyses. One thousand patients will be enrolled for the analyses. The questionnaire will be initially administered to the first 100 patients to verify the adequacy and degree of comprehension of the questions. Then reproducibility will be investigated by a test-retest procedure in the following 400 patients.An analysis will be conducted to determine the correlation between the LARS score and the Quality of Life Questionnaire (QLQ; European Organization for Treatment and Research of Cancer's QLQ-C30, QLQ-CR29). Risk factors linked to QoL deterioration will be identified and their impact will be measured. This study will meet the need for a validated tool to improve patient care and QoL. ETHICS AND DISSEMINATION The institutional review board of the University Hospital of Caen and the ethics committee (CPP Nord Ouest I, 25 January 2019) approved the study. TRIAL REGISTRATION NUMBER NCT03569488.
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Affiliation(s)
- Yassine Eid
- Department of digestive surgery, University Hospital of Caen, Caen, France
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Department of research, University Hospital of Caen, Normandy, France
| | - Véronique Bouvier
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Digestive Cancer Registry of Calvados, University Hospital of Caen, Caen cedex, France
| | - Olivier Dejardin
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Department of research, University Hospital of Caen, Normandy, France
| | - Benjamin Menahem
- Department of digestive surgery, University Hospital of Caen, Caen, France
| | - Fabien Chaillot
- Department of research, University Hospital of Caen, Normandy, France
| | - Yannick Chene
- Department of research, University Hospital of Caen, Normandy, France
| | | | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Rémy Morello
- Department of research, University Hospital of Caen, Normandy, France
- Department of biostatistics and clinical research, University Hospital of Caen, Caen cedex, France
| | - Arnaud Alves
- Department of digestive surgery, University Hospital of Caen, Caen, France
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Department of research, University Hospital of Caen, Normandy, France
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26
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Keane C, Fearnhead NS, Bordeianou LG, Christensen P, Basany EE, Laurberg S, Mellgren A, Messick C, Orangio GR, Verjee A, Wing K, Bissett I. International Consensus Definition of Low Anterior Resection Syndrome. Dis Colon Rectum 2020; 63:274-284. [PMID: 32032141 PMCID: PMC7034376 DOI: 10.1097/dcr.0000000000001583] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Low anterior resection syndrome is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The low anterior resection syndrome score was designed as a simple tool for clinical evaluation of low anterior resection syndrome. Although the low anterior resection syndrome score has good clinical utility, it may not capture all important aspects that patients may experience. OBJECTIVE The aim of this collaboration was to develop an international consensus definition of low anterior resection syndrome that encompasses all aspects of the condition and is informed by all stakeholders. DESIGN This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. PARTICIPANTS Three expert groups participated: patients, surgeons, and other health professionals from 5 regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in 3 languages (English, Spanish, and Danish). MAIN OUTCOME MEASURE The primary outcome measured was the priorities for the definition of low anterior resection syndrome. RESULTS Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96%, and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to 8 symptoms and 8 consequences that capture essential aspects of the syndrome. LIMITATIONS Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSIONS This is the first definition of low anterior resection syndrome developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of low anterior resection syndrome. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in low anterior resection syndrome over time and with intervention.
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Affiliation(s)
- Celia Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Nicola S. Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Liliana G. Bordeianou
- Colorectal Surgery Centre/Department of Surgery at the Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Peter Christensen
- Danish Cancer Society National Research Centre for Survivorship and Late Side Effect to Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Eloy Espin Basany
- Colon and Recto Unit, Department of General Surgery, Vall de Hebron Hospital, Universitat Autonoma de Barcelona, Spain
| | - Søren Laurberg
- Danish Cancer Society National Research Centre for Survivorship and Late Side Effect to Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Mellgren
- Division of Colon & Rectal Surgery, Department of Surgery, University of Illinois at Chicago, Illinois
| | - Craig Messick
- Department of Surgical Oncology, Section of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston and Sugar Land, Texas
| | - Guy R. Orangio
- Department of Surgery/School of Medicine, Louisiana State University, New Orleans, Louisiana
| | - Azmina Verjee
- Bowel Disease Research Foundation, London, England, United Kingdom
| | - Kirsty Wing
- Otago Community Hospice, Dunedin, New Zealand
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
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Keane C, Fearnhead NS, Bordeianou L, Christensen P, Espin Basany E, Laurberg S, Mellgren A, Messick C, Orangio GR, Verjee A, Wing K, Bissett I. International consensus definition of low anterior resection syndrome. Colorectal Dis 2020; 22:331-341. [PMID: 32037685 DOI: 10.1111/codi.14957] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 08/23/2019] [Indexed: 12/13/2022]
Abstract
AIM Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. METHOD This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. RESULTS Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSION This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.
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Affiliation(s)
- C Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - N S Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - L Bordeianou
- Colorectal Surgery Centre/Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Christensen
- Danish Cancer Society National Research Centre for Survivorship and Late Side Effect to Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - E Espin Basany
- Colon and Recto Unit, Department of General Surgery, Vall de Hebron Hospital, Universitat Autonoma de Barcelona, Spain
| | - S Laurberg
- Danish Cancer Society National Research Centre for Survivorship and Late Side Effect to Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - A Mellgren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - C Messick
- Department of Surgical Oncology, Section of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - G R Orangio
- Department of Surgery/School of Medicine, Louisiana State University, New Orleans, Louisiana, USA
| | - A Verjee
- Bowel Disease Research Foundation, London, UK
| | - K Wing
- Otago Community Hospice, Dunedin, New Zealand
| | - I Bissett
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
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Keane C, Fearnhead NS, Bordeianou LG, Christensen P, Espin Basany E, Laurberg S, Mellgren A, Messick C, Orangio GR, Verjee A, Wing K, Bissett IP. International consensus definition of low anterior resection syndrome. ANZ J Surg 2020; 90:300-307. [PMID: 32040983 DOI: 10.1111/ans.15421] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/28/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. METHODS This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish and Danish). The primary outcome measured was the priorities for the definition of LARS. RESULTS Three hundred and twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSIONS This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.
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Affiliation(s)
- Celia Keane
- Department of Surgery, The University of Auckland, Auckland, New Zealand
| | - Nicola S Fearnhead
- Department of Colorectal Surgery, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Liliana G Bordeianou
- Colorectal Surgery Centre/Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Christensen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Eloy Espin Basany
- Colon and Recto Unit, Department of General Surgery, Vall d'Hebron Hospital, The Autonomous University of Barcelona, Barcelona, Spain
| | - Søren Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Mellgren
- Division of Colon and Rectal Surgery, Department of Surgery, University of Illinois, Chicago, Illinois, USA
| | - Craig Messick
- Department of Surgical Oncology, Section of Colon and Rectal Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guy R Orangio
- Department of Surgery/School of Medicine, Louisiana State University, New Orleans, Louisiana, USA
| | | | - Kirsty Wing
- Otago Community Hospice, Dunedin, New Zealand
| | - Ian P Bissett
- Department of Surgery, The University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
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Fernández-Martínez D, Rodríguez-Infante A, Otero-Díez JL, Baldonedo-Cernuda RF, Mosteiro-Díaz MP, García-Flórez LJ. Is my life going to change?-a review of quality of life after rectal resection. J Gastrointest Oncol 2020; 11:91-101. [PMID: 32175110 DOI: 10.21037/jgo.2019.10.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Rectal resection is a common practice for colorectal surgeons. The causes of this procedure are varied. The most frequent is cancer, but also inflammatory bowel disease, endometriosis, and rectovaginal or rectourethral fistulas. The loss of the normal rectal reservoir function, urinary problems, sexual dysfunction or pelvic pain are frequently reported in patients after rectal surgery and these disorders markedly affect the overall quality of life (QoL). In the last decades, rectal surgery has radically changed, with the development of surgical techniques, and it has progressed from abdominoperineal resection (APR) with a permanent colostomy to sphincter-saving procedures. Nowadays, the use of sphincter-preserving surgery has increased, but all these surgical techniques can have important sequels that modify the QoL of the patients. Historically, surgical outcomes, such as complications, survival and recurrences, have been widely studied by surgeons. In the present day, surgical outcomes have improved, rectal cancer recurrence rate has decreased and survival has increased. For these reasons, it has begun to gain importance in aspects of the QoL of patients, such as body image, fecal continence and sexuality or urinary function. Therefore, physicians should know the influence of different techniques and approaches on functional outcomes and QoL, to be able to inform patients of the treatment benefits and risk of postoperative dysfunctions. The aim of our study is to review the current literature to determine to what degree the QoL of patients who underwent a rectal resection decreases, which domains are the most affected and, in addition, to establish the influence of different surgical techniques and approaches on functional outcomes.
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Affiliation(s)
- Daniel Fernández-Martínez
- Coloproctology Section, Department of General and Digestive Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | | | - Jorge Luis Otero-Díez
- Coloproctology Section, Department of General and Digestive Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Ricardo Felipe Baldonedo-Cernuda
- Coloproctology Section, Department of General and Digestive Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | | | - Luis Joaquin García-Flórez
- Coloproctology Section, Department of General and Digestive Surgery, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
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Miacci FLC, Guetter CR, Moreira PH, Sartor MC, Savio MC, Baldin Júnior A, Nóbrega NL. Predictive factors of low anterior resection syndrome following anterior resection of the rectum. ACTA ACUST UNITED AC 2020; 46:e20192361. [PMID: 32022113 DOI: 10.1590/0100-6991e-20192361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 10/22/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE to identify predictors of low anterior resection syndrome (LARS) that can contribute to its early diagnosis and treatment. METHODS we conducted a retrospective cohort study of patients undergoing anterior resection of the rectum between 2007 and 2017 in the Coloproctology Service of the Federal University of Parana Clinics Hospital. We performed Receiver Operating Characteristic Curve (ROC) analysis to identify LARS predictive factors. RESULTS we included 64 patients with complete data. The men's age was 60.1±11.4 years and 37.10% were male. Twenty patients (32.26%) had LARS. The most reported symptoms were incomplete evacuation (60%) and urgency (55%). In the univariate analysis, the distance from the anastomosis to the anal margin (p<0.001), neoadjuvant therapy (p=0.0014) and ileostomy at the time of resection (p=0.0023) were predictive of LARS. The ROC curve analysis showed a 6.5cm cut-off distance from the anastomosis to the anal margin as a predictor of LARS. CONCLUSION distance between the anastomosis and the anal margin, neoadjuvant therapy history and preparation of stoma are conditions that can help predict the development of LARS. Guidance and involvement in patient education, as well as early management, can potentially reduce the impact of these symptoms on patients' quality of life.
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Affiliation(s)
| | - Camila Roginski Guetter
- Universidade Federal do Paraná, Centro de Ciências da Saúde, Curso de Medicina, Curitiba, PR, Brasil
| | - Paula Heroso Moreira
- Universidade Federal do Paraná, Centro de Ciências da Saúde, Curso de Medicina, Curitiba, PR, Brasil
| | - Maria Cristina Sartor
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Serviço de Coloproctologia, Curitiba, PR, Brasil
| | - Mariane Christina Savio
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Serviço de Coloproctologia, Curitiba, PR, Brasil
| | - Antonio Baldin Júnior
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Serviço de Coloproctologia, Curitiba, PR, Brasil
| | - Norton Luiz Nóbrega
- Universidade Federal do Paraná, Complexo Hospital de Clínicas, Serviço de Coloproctologia, Curitiba, PR, Brasil
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Kauff DW, Roth YDS, Bettzieche RS, Kneist W. Fecal incontinence after total mesorectal excision for rectal cancer-impact of potential risk factors and pelvic intraoperative neuromonitoring. World J Surg Oncol 2020; 18:12. [PMID: 31941505 PMCID: PMC6961229 DOI: 10.1186/s12957-020-1782-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 12/31/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Fecal incontinence frequently occurs after total mesorectal excision for rectal cancer. This prospective study analyzed predictive factors and the impact of pelvic intraoperative neuromonitoring at different follow-up intervals. METHODS Fifty-two patients were included undergoing total mesorectal excision for rectal cancer, and 29 under control of pelvic intraoperative neuromonitoring. Fecal incontinence was assessed using the Wexner Score at 3 and 6 months after stoma closure (follow-ups 1 and 2) as well as 1 and 2 years after surgery (follow-ups 3 and 4). Risk factors were identified by means of logistic regression. RESULTS New onset of fecal incontinence was significantly lower in the neuromonitoring group at each follow-up (follow-up 1: 2 of 29 patients (7%) vs. 8 of 23 (35%), (p = 0.014); follow-up 2: 3 of 29 (10%) vs. 9 of 23 (39%), (p = 0.017); follow-up 3: 5 of 29 (17%) vs. 11 of 23 (48%), p = 0.019; follow-up 4: 6 of 28 (21%) vs. 11 of 22 (50%), p = 0.035). Non-performance of neuromonitoring was found to be an independent predictor for fecal incontinence throughout the survey. Neoadjuvant chemoradiotherapy was an independent predictor in the further course 1 and 2 years after surgery. CONCLUSIONS Performance of pelvic intraoperative neuromonitoring is associated with significantly lower rates of fecal incontinence. Neoadjuvant chemoradiotherapy was found to have negative late effects. This became evident 1 year after surgery.
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Affiliation(s)
- Daniel W Kauff
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Yvonne D S Roth
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Rika S Bettzieche
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Werner Kneist
- Department of General, Visceral and Transplant Surgery, University Medicine of the Johannes Gutenberg University Mainz, Mainz, Germany. .,Department of General and Visceral Surgery, St. Georg Hospital Eisenach gGmbH, Mühlhäuser Straße 94, 99817, Eisenach, Germany.
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Stijns RCH, de Graaf EJR, Punt CJA, Nagtegaal ID, Nuyttens JJME, van Meerten E, Tanis PJ, de Hingh IHJT, van der Schelling GP, Acherman Y, Leijtens JWA, Bremers AJA, Beets GL, Hoff C, Verhoef C, Marijnen CAM, de Wilt JHW. Long-term Oncological and Functional Outcomes of Chemoradiotherapy Followed by Organ-Sparing Transanal Endoscopic Microsurgery for Distal Rectal Cancer: The CARTS Study. JAMA Surg 2019; 154:47-54. [PMID: 30304338 DOI: 10.1001/jamasurg.2018.3752] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Treatment of rectal cancer is shifting toward organ preservation aiming to reduce surgery-related morbidity. Short-term outcomes of organ-preserving strategies are promising, but long-term outcomes are scarce in the literature. Objective To explore long-term oncological outcomes and health-related quality of life (HRQL) in patients with cT1-3N0M0 rectal cancer who underwent neoadjuvant chemoradiotherapy (CRT) followed by transanal endoscopic microsurgery (TEM). Design, Setting, and Participants In this multicenter phase II feasibility study, patients with cT1-3N0M0 rectal cancer admitted to referral centers for rectal cancer throughout the Netherlands between February 2011 and September 2012 were prospectively included. These patients were to be treated with neoadjuvant CRT followed by TEM in case of good response. An intensive follow-up scheme was used to detect local recurrences and/or distant metastases. Data from validated HRQL questionnaires and low anterior resection syndrome questionnaires were collected. Data were analyzed from February 2011 to April 2017. Main Outcomes and Measures The primary study outcome of the study was the number of ypT0-1 specimens by performing TEM. Secondary outcome parameters were locoregional recurrences and HRQL. Results Of the 55 included patients, 30 (55%) were male, and the mean (SD) age was 64 (39-82) years. Patients were followed up for a median (interquartile range) period of 53 (39-57) months. Two patients (4%) died during CRT, 1 (2%) stopped CRT, and 1 (2%) was lost to follow-up. Following CRT, 47 patients (85%) underwent TEM, of whom 35 (74%) were successfully treated with local excision alone. Total mesorectal excision was performed in 16 patients (4 with inadequate responses, 8 with completion after TEM, and 4 with salvage for local recurrence). The actuarial 5-year local recurrence rate was 7.7%, with 5-year disease-free and overall survival rates of 81.6% and 82.8%, respectively. Health-related quality of life during follow-up was equal to baseline, with improved emotional well-being in patients treated with local excision (mean score at baseline, 72.0; 95% CI, 67.1-80.1; mean score at follow-up, 86.9; 95% CI, 79.2-94.7; P = .001). Major, minor, and no low anterior resection syndrome was experienced in 50%, 28%, and 22%, respectively, of patients with successful organ preservation. Conclusions and Relevance In early-stage rectal cancer (cT1-3N0M0), CRT enables organ preservation with additional TEM surgery in approximately two-thirds of patients with good long-term oncological outcome and HRQL. This multimodality treatment triggers a certain degree of bowel dysfunction, and one-third of patients still undergo radical surgery and are overtreated by CRT.
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Affiliation(s)
- Rutger C H Stijns
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Cornelis J A Punt
- Department of Medical Oncology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Iris D Nagtegaal
- Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joost J M E Nuyttens
- Department of Radiation Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Esther van Meerten
- Department of Oncology, Erasmus Medical Centre Cancer Institute, Rotterdam, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Academic Medical Centre, Amsterdam, the Netherlands
| | | | | | - Yair Acherman
- Department of Surgery, Medical Centre Slotervaart, Amsterdam, the Netherlands
| | | | - Andreas J A Bremers
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Geerard L Beets
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Corrie A M Marijnen
- Department of Radiotherapy, Leiden University Medical Centre, Leiden, the Netherlands
| | - Johannes H W de Wilt
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
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Quezada-Diaz F, Jimenez-Rodriguez RM, Pappou EP, Joshua Smith J, Patil S, Wei I, Guillem JG, Paty PB, Nash GM, Weiser MR, Garcia-Aguilar J. Effect of Neoadjuvant Systemic Chemotherapy With or Without Chemoradiation on Bowel Function in Rectal Cancer Patients Treated With Total Mesorectal Excision. J Gastrointest Surg 2019; 23:800-807. [PMID: 30350191 PMCID: PMC6430650 DOI: 10.1007/s11605-018-4003-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 10/05/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neoadjuvant chemoradiation (CRT) impairs bowel function in patients with rectal cancer treated with total mesorectal excision (TME). The impact of other forms of neoadjuvant therapy such as neoadjuvant chemotherapy alone (NC) and induction chemotherapy followed by CRT (total neoadjuvant therapy or TNT) on postoperative bowel function has not been investigated. METHODS We conducted a retrospective review of 176 rectal cancer patients treated between November 1, 2011, and August 31, 2017. All patients completed the MSKCC Bowel Function Instrument (BFI), a validated bowel function questionnaire, at least 6 months after TME and/or ileostomy reversal. Differences in BFI scores were compared across four groups (surgery alone, CRT, NC, and TNT) and also according to exposure to neoadjuvant RT and neoadjuvant chemotherapy. A multivariable linear regression model was used to evaluate the independent relationship between exposure to neoadjuvant RT or chemotherapy and BFI. RESULTS BFI total scores were significantly different between the four groups (p = 0.008). Exposure to RT correlated with worse BFI total scores (p = 0.002), and no differences were found in BFI total score after exposure to neoadjuvant chemotherapy (p = 0.92). In a linear regression model, only exposure to RT (β = - 5.1; 95% CI - 8.9 to - 1.3; p = 0.008) and tumor distance from the anal verge (β = 1.23; 95% CI 0.48 to 1.97; p = 0.001) were significantly correlated with BFI total score. CONCLUSION NC, whether administered alone or added to CRT, does not seem to impair bowel function. These data should be used to counsel rectal cancer patients when discussing neoadjuvant therapy options.
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Affiliation(s)
- Felipe Quezada-Diaz
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Rosa M. Jimenez-Rodriguez
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Emmanouil P. Pappou
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - J. Joshua Smith
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Iris Wei
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Jose G. Guillem
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Philip B. Paty
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Garrett M. Nash
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Martin R. Weiser
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Julio Garcia-Aguilar
- Colorectal Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Quality of life after rectal cancer surgery: differences between laparoscopic and transanal total mesorectal excision. Surg Endosc 2019; 33:79-87. [PMID: 29967994 PMCID: PMC6336756 DOI: 10.1007/s00464-018-6276-z] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/18/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Transanal total mesorectal excision (TaTME) is a safe alternative to laparoscopic TME for mid and low rectal cancer. TaTME allows improved visualization of the surgical planes and margins, and may potentially improve oncological outcomes. However, functional results after total mesorectal excision (TME) are variable and there are currently only a few published studies that include functional data related to the outcomes of TaTME. METHODS Fifty-four consecutive patients were included in this study: one group included 27 patients who underwent laparoscopic low anterior and the other included 27 patients who underwent TaTME. All patients were asked to complete five questionnaires related to quality of life (QOL) and function [EQ-5D-3L, EORTC-QLQ C30, EORTC-QLQ C29, Low Anterior Resection Syndrome score (LARS), and International Prostate Symptom Score IPSS]. All TaTME patients were operated on at The Gelderse Vallei Hospital by a single surgeon and had a follow-up of at least 6.6 months. RESULTS The EORTC-QLQ C30 and EQ-5D-3L questionnaires showed comparable outcomes in terms of QOL between the two groups. Almost all items evaluated by the EORTC-QLQ C29, including sexual outcomes, were similar between the two groups. One item concerning fecal incontinence, however, was scored worse for TaTME. There were no significant differences between the groups in terms of LARS symptoms or urinary function. CONCLUSIONS Patients undergoing laparoscopic or transanal TME showed comparable functional and QOL outcomes. Although the TaTME technique is still evolving, this study indicates that this technique is a safe alternative to laparoscopic surgery in terms of functional outcomes for mid and low rectal cancers.
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Abstract
Multidisciplinary management of infra-peritoneal rectal cancer has pushed back the frontiers of sphincter preservation, without impairment of carcinological outcome. However, functional intestinal sequelae, grouping together several symptoms known under the name of anterior resection syndrome (ARS), have emerged and become an increasingly frequent concern for both patients and physicians. The pathophysiology is complex: ARS is a combination in various degrees of stool frequency, incontinence for flatus and/or stools, urgency, and disorders in discrimination and evacuation. The "Low Anterior Resection Score" (LARS), validated in 2012, is currently used to evaluate the severity of ARS and its impact on quality of life. While ARS can show improvement over the first two years, symptoms persist for longer than two years in nearly 60% of patients and in half of these patients, ARS is considered severe. The most frequently reported independent risk factors of severe ARS include neo-adjuvant radiation therapy, the extent of resection (total mesorectal excision that includes inter-sphincteric resection), absence of colonic pouch and anastomotic leak. In the absence of surgical complications and/or local recurrence, physicians can draw from a wide therapeutic armamentarium in order to improve the functional outcome of patients, including diet and lifestyle modifications, gut motility regulators, multimodal rehabilitation (biofeedback, electro-stimulation) and sacral nerve modulation. Permanent colostomy is an alternative of last resort, proposed only when all other solutions fail. A better understanding of the natural history of ARS, its risk factors as well as the array of therapeutic alternatives should provide better patient information and optimize management.
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Utility Scores and Preferences for Surgical and Organ-Sparing Approaches for Treatment of Intermediate and High-Risk Rectal Cancer. Dis Colon Rectum 2018; 61:911-919. [PMID: 29697477 DOI: 10.1097/dcr.0000000000001029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Organ-sparing approaches, including wait-and-see and local excision, are increasingly being offered to patients with rectal cancer following a good response to neoadjuvant therapy. Preferences regarding these treatment strategies are yet unknown. OBJECTIVE This study aimed to determine the preferences and utility scores for rectal cancer treatment approaches. DESIGN This is a cross-sectional study. SETTING This study was conducted at the Radiation-Oncology Department of the University Medical Center Utrecht. PATIENTS Fifty-seven patients with a history of rectal cancer and 38 volunteers were included. MAIN OUTCOME MEASURES Participants assessed 6 hypothetical treatment-outcome scenarios, including short-course radiotherapy or chemoradiation followed by abdominoperineal resection, low anterior resection, local excision, or a wait-and-see approach. The hierarchy in preferences between scenarios was assessed by using ranking. Utilities were estimated with a visual analog scale and time trade-off. RESULTS Organ-sparing approaches were ranked as the first preferred treatment option by 51% of the participants. Among all scenarios, wait-and-see was most often ranked highest by patients and volunteers (36% and 50%). Meanwhile, a substantial proportion ranked wait-and-see as their lowest preference (38% in patients and 35% in volunteers). Utility scores differed significantly between scenarios. Wait-and-see received a significantly higher score on the visual analog scale than the scenarios including abdominoperineal resection and the scenario including chemoradiation with low anterior resection, and a score similar to the scenarios including local excision and short-course radiotherapy with low anterior resection. LIMITATIONS The study population consisted of patients with a history of rectal cancer treatment and volunteers related to patients. This may have influenced preferences. CONCLUSIONS This study suggests that there is a wide disparity in preferences concerning organ-sparing approaches for rectal cancer in both patients with a history of rectal cancer and volunteers. Wait-and-see is often the highest preferred treatment, but it is also among the least preferred treatment options. These findings give insights into how patients may value the current rectal cancer treatment options. See Video Abstract at http://links.lww.com/DCR/A521.
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Akizuki E, Matsuno H, Satoyoshi T, Ishii M, Usui A, Ueki T, Nishidate T, Okita K, Mizushima T, Mori M, Takemasa I. Validation of the Japanese Version of the Low Anterior Resection Syndrome Score. World J Surg 2018; 42:2660-2667. [PMID: 29450698 PMCID: PMC6060820 DOI: 10.1007/s00268-018-4519-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The low anterior resection syndrome (LARS) score is a patient-reported outcome measure to evaluate the severity of bowel dysfunction after rectal cancer surgery by scoring the major symptoms of LARS. The aim of this study was to translate the English version of the LARS score into Japanese and to investigate the validity and reliability of the LARS score. METHODS The LARS score was translated in Japanese following current international recommendations. A total of 149 rectal cancer patients completed the LARS score questionnaire and were also asked a single question assessing the impact of bowel function on quality of life (QoL). A total of 136 patients answered the LARS score questionnaire twice. RESULTS The Japanese LARS score showed high convergent validity, based on its good correlation between the LARS score and QoL (p < 0.001). The LARS score was able to discriminate between patients according to the tumor distance to anal verge (p < 0.001), type of surgery (p < 0.001), and time since surgery (p = 0.001). Patients after ultra-low anterior resection and intersphincteric resection showed especially high scores. The score also had high test-retest reliability (intraclass correlation coefficient: 0.87). CONCLUSION The Japanese LARS score is a valid and reliable tool for measuring LARS. The LARS score is appropriate for assessments in postoperative bowel function and international comparison. Using this score, patient-reported outcome measures of LARS in Japanese patients can be shared internationally. Additional validation reports from non-English speaking countries can support the LARS score as a worldwide assessment tool for postoperative bowel dysfunction.
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Affiliation(s)
- Emi Akizuki
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Hiroshi Matsuno
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tetsuta Satoyoshi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Masayuki Ishii
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Akihiro Usui
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Tomomi Ueki
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Toshihiko Nishidate
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Kenji Okita
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ichiro Takemasa
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan.
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Yin L, Fan L, Tan R, Yang G, Jiang F, Zhang C, Ma J, Yan Y, Zou Y, Zhang Y, Wang Y, Zhang G. Bowel symptoms and self-care strategies of survivors in the process of restoration after low anterior resection of rectal cancer. BMC Surg 2018; 18:35. [PMID: 29866087 PMCID: PMC5987619 DOI: 10.1186/s12893-018-0368-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/24/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The purpose of this research is to identify the bowel symptoms and self-care strategies for rectal cancer survivors during the recovery process following low anterior resection surgery. METHODS A total of 100 participants were investigated under the structured interview guide based on the dimensions of "symptom management theory". RESULTS 92% of participants reported changes in bowel habits, the most common being the frequent bowel movements and narrower stools, which we named it finger-shaped consistency stools. The 6 most frequently reported bowel symptoms were excessive flatus (93%), clustering (86%), urgency (77%), straining (62%), bowel frequency (57%) and anal pendant expansion (53%). Periodic bowel movements occurred in 19% participants. For a group of 79 participants at 6 to 24 months post-operation, 86.1% reported a significant improvement of bowel symptoms. Among 68 participants of this subgroup with significant improvements, 70.5% participants reported the length of time it took was at least 6 months. Self-care strategies adopted by participants included diet, bowel medications, practice management and exercise. CONCLUSIONS It is necessary to educate patients on the symptoms experienced following low anterior resection surgery. Through the process of trial and error, participants have acquired self-care strategies. Healthcare professionals should learn knowledge of such strategies and help them build effective interventions.
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Affiliation(s)
- Lishi Yin
- Department of Hepatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Ling Fan
- Department of Hepatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Renfu Tan
- Medical University of Chongqing, Chongqing City, 400000 China
| | - Guangjing Yang
- Nursing Department, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Fenglin Jiang
- Department of Cardiovascular, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Chao Zhang
- Department of Nephrology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Jun Ma
- Department of Hepatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Yang Yan
- Department of Hepatology, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Yanhong Zou
- Science and Education Department, Chongqing Hospital of Traditional Chinese Medicine, Chongqing City, 400000 China
| | - Yaowen Zhang
- Department of Emergency and the Intensive Care Unit, Chongqing Hospital of Traditional Chinese Medicine, No. 6 Road Panxi seven branch, Chongqing City, 400000 China
| | - Yamei Wang
- Department of Emergency and the Intensive Care Unit, Chongqing Hospital of Traditional Chinese Medicine, No. 6 Road Panxi seven branch, Chongqing City, 400000 China
| | - Guifang Zhang
- Department of Emergency and the Intensive Care Unit, Chongqing Hospital of Traditional Chinese Medicine, No. 6 Road Panxi seven branch, Chongqing City, 400000 China
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Functional Outcomes After Rectal Resection for Deep Infiltrating Pelvic Endometriosis: Long-term Results. Dis Colon Rectum 2018; 61:733-742. [PMID: 29664797 DOI: 10.1097/dcr.0000000000001047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Curative management of deep infiltrating endometriosis requires complete removal of all endometriotic implants. Surgical approach to rectal involvement has become a topic of debate given potential postoperative bowel dysfunction and complications. OBJECTIVE This study aims to assess long-term postoperative evacuation and incontinence outcomes after laparoscopic segmental rectal resection for deep infiltrating endometriosis involving the rectal wall. DESIGN This is a retrospective study of prospectively collected data. SETTINGS This single-center study was conducted at the University Hospital of Bern, Switzerland. PATIENTS Patients with deep infiltrating endometriosis involving the rectum undergoing rectal resection from June 2002 to May 2011 with at least 24 months follow-up were included. MAIN OUTCOME MEASURES Aside from endometriosis-related symptoms, detailed symptoms on evacuation (points: 0 (best) to 21 (worst)) and incontinence (0-24) were evaluated by using a standardized questionnaire before and at least 24 months after surgery. RESULTS Of 66 women who underwent rectal resection, 51 were available for analyses with a median follow-up period of 86 months (range: 26-168). Forty-eight patients (94%) underwent laparoscopic resection (4% converted, 2% primary open), with end-to-end anastomosis in 41 patients (82%). Two patients (4%) had an anastomotic insufficiency; 1 case was complicated by rectovaginal fistula. Dysmenorrhea, nonmenstrual pain, and dyspareunia substantially improved (p < 0.001 for all comparisons). Overall evacuation score increased from a median of 0 (range: 0-11) to 2 points (0-15), p = 0.002. Overall incontinence also increased from 0 (range: 0-9) to 2 points (0-9), p = 0.003. LIMITATIONS This study was limited by its retrospective nature and moderate number of patients. CONCLUSIONS Laparoscopic segmental rectal resection for the treatment of deep infiltrating endometriosis including the rectal wall is associated with good results in endometriotic-related symptoms, although patients should be informed about possible postoperative impairments in evacuation and incontinence. However, its clinical impact does not outweigh the benefit that can be achieved through this approach. See Video Abstract at http://links.lww.com/DCR/A547.
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Couwenberg AM, Burbach JPM, van Grevenstein WMU, Smits AB, Consten ECJ, Schiphorst AHW, Wijffels NAT, Heikens JT, Intven MPW, Verkooijen HM. Effect of Neoadjuvant Therapy and Rectal Surgery on Health-related Quality of Life in Patients With Rectal Cancer During the First 2 Years After Diagnosis. Clin Colorectal Cancer 2018; 17:e499-e512. [PMID: 29678514 DOI: 10.1016/j.clcc.2018.03.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Rectal cancer surgery with neoadjuvant therapy is associated with substantial morbidity. The present study describes the course of quality of life (QOL) in rectal cancer patients in the first 2 years after the start of treatment. PATIENTS AND METHODS We performed a prospective study within a colorectal cancer cohort including rectal cancer patients who were referred for neoadjuvant chemoradiation or short-course radiotherapy and underwent rectal surgery. QOL was assessed using the European Organization for Research and Treatment of Cancer core questionnaire (EORTC QLQ-C30) and colorectal cancer questionnaire (EORTC QLQ-CR29) before treatment and after 3, 6, 12, 18, and 24 months. The outcomes were compared with the QOL scores from the Dutch general population and stratified by low anterior resection and abdominoperineal resection. Postoperative bowel dysfunction after low anterior resection was measured using the low anterior resection syndrome score. RESULTS Of the 324 patients, 272 (84%) responded to at least 2 questionnaires and were included in the present study. Compared with pretreatment levels, the strongest decline was observed in physical, role, and social functioning at 3 and 6 months after the start of treatment. Global health and cognitive functioning declined to a lesser extend, and emotional functioning gradually improved over the time. Within 24 months, the QOL scores had recovered toward the pretreatment levels in most patients. Compared with the general population, physical, role, social, and cognitive functioning and symptoms of fatigue and insomnia remained significantly worse in patients on longer-term. After low anterior resection, major bowel dysfunction was reported by 44% to 60% of the patients. Increasing urinary incontinence and severe complaints of impotence were observed in patients who had undergone abdominoperineal resection. CONCLUSION Rectal cancer treatment is associated with a significant decline in QOL during the first 6 months after the diagnosis. Within 2 years, most patients return toward pretreatment functioning but could still experience poorer functioning and treatment-related symptoms compared with the general population. These findings support shared decision-making and emphasize the need for postoperative supportive care and novel treatment approaches.
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Affiliation(s)
- Alice M Couwenberg
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Johannes P M Burbach
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Anke B Smits
- Department of Surgery, St Antonius Ziekenhuis, Nieuwegein, The Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Niels A T Wijffels
- Department of Surgery, Zuwe Hofpoort Ziekenhuis, Woerden, The Netherlands
| | - Joost T Heikens
- Department of Surgery, Ziekenhuis Rivierenland, Tiel, The Netherlands
| | - Martijn P W Intven
- Department of Radiation-Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Helena M Verkooijen
- Imaging Division, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; University of Utrecht, Utrecht, The Netherlands
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Lin KY, Denehy L, Frawley HC, Wilson L, Granger CL. Pelvic floor symptoms, physical, and psychological outcomes of patients following surgery for colorectal cancer. Physiother Theory Pract 2018; 34:442-452. [PMID: 29308963 DOI: 10.1080/09593985.2017.1422165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little has been published regarding general and pelvic floor-related health status in patients who have undergone surgery for colorectal cancer (CRC). OBJECTIVE The objective of the study was to assess changes in pelvic floor symptoms, physical activity levels, psychological status, and health-related quality of life (HRQoL) in patients with CRC from pre- to 6 months postoperatively. METHODS Pelvic floor symptoms, physical activity levels, anxiety and depression, and HRQoL of 30 participants who were undergoing surgery for stages I-III CRC were evaluated pre- and 6 months postoperatively. RESULTS Six months postoperatively, there were no significant changes in severity of pelvic floor symptoms, or other secondary outcomes (physical activity levels, depression, global HRQoL) compared to preoperative levels (p > 0.05). However, fecal incontinence (p = 0.03) and hair loss (p = 0.003) measured with the HRQoL instrument were significantly worse. Participants were engaged in low levels of physical activity before (42.3%) and after surgery (47.4%). CONCLUSION The findings of a high percentage of participants with persistent low physical activity levels and worse bowel symptoms after CRC surgery compared to preoperative levels suggest the need for health-care professionals to provide information about the benefits of physical activity and bowel management at postoperative follow-ups. Further investigation in larger studies is warranted.
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Affiliation(s)
- Kuan-Yin Lin
- a Department of Physiotherapy, School of Health Sciences , University of Melbourne , Melbourne , Australia.,b Department of Physiotherapy , Royal Melbourne Hospital , Melbourne , Australia.,c Centre for Allied Health Research and Education, Cabrini Health , Melbourne , Australia
| | - Linda Denehy
- a Department of Physiotherapy, School of Health Sciences , University of Melbourne , Melbourne , Australia.,e Institute for Breathing and Sleep , Melbourne , Victoria , Australia
| | - Helena C Frawley
- c Centre for Allied Health Research and Education, Cabrini Health , Melbourne , Australia.,d Physiotherapy, School of Allied Health , La Trobe University , Melbourne , Australia
| | - Lisa Wilson
- f Department of General Surgery , The Royal Melbourne Hospital , Melbourne , Victoria , Australia
| | - Catherine L Granger
- a Department of Physiotherapy, School of Health Sciences , University of Melbourne , Melbourne , Australia.,b Department of Physiotherapy , Royal Melbourne Hospital , Melbourne , Australia.,e Institute for Breathing and Sleep , Melbourne , Victoria , Australia
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Lawler M, Alsina D, Adams RA, Anderson AS, Brown G, Fearnhead NS, Fenwick SW, Halloran SP, Hochhauser D, Hull MA, Koelzer VH, McNair AGK, Monahan KJ, Näthke I, Norton C, Novelli MR, Steele RJC, Thomas AL, Wilde LM, Wilson RH, Tomlinson I. Critical research gaps and recommendations to inform research prioritisation for more effective prevention and improved outcomes in colorectal cancer. Gut 2018; 67:179-193. [PMID: 29233930 PMCID: PMC5754857 DOI: 10.1136/gutjnl-2017-315333] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Colorectal cancer (CRC) leads to significant morbidity/mortality worldwide. Defining critical research gaps (RG), their prioritisation and resolution, could improve patient outcomes. DESIGN RG analysis was conducted by a multidisciplinary panel of patients, clinicians and researchers (n=71). Eight working groups (WG) were constituted: discovery science; risk; prevention; early diagnosis and screening; pathology; curative treatment; stage IV disease; and living with and beyond CRC. A series of discussions led to development of draft papers by each WG, which were evaluated by a 20-strong patient panel. A final list of RGs and research recommendations (RR) was endorsed by all participants. RESULTS Fifteen critical RGs are summarised below: RG1: Lack of realistic models that recapitulate tumour/tumour micro/macroenvironment; RG2: Insufficient evidence on precise contributions of genetic/environmental/lifestyle factors to CRC risk; RG3: Pressing need for prevention trials; RG4: Lack of integration of different prevention approaches; RG5: Lack of optimal strategies for CRC screening; RG6: Lack of effective triage systems for invasive investigations; RG7: Imprecise pathological assessment of CRC; RG8: Lack of qualified personnel in genomics, data sciences and digital pathology; RG9: Inadequate assessment/communication of risk, benefit and uncertainty of treatment choices; RG10: Need for novel technologies/interventions to improve curative outcomes; RG11: Lack of approaches that recognise molecular interplay between metastasising tumours and their microenvironment; RG12: Lack of reliable biomarkers to guide stage IV treatment; RG13: Need to increase understanding of health related quality of life (HRQOL) and promote residual symptom resolution; RG14: Lack of coordination of CRC research/funding; RG15: Lack of effective communication between relevant stakeholders. CONCLUSION Prioritising research activity and funding could have a significant impact on reducing CRC disease burden over the next 5 years.
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Affiliation(s)
- Mark Lawler
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | | | | | - Annie S Anderson
- Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Gina Brown
- Department of Radiology, Royal Marsden Hospital, Sutton, UK
| | | | - Stephen W Fenwick
- Hepatobiliary Surgery Unit, Aintree University Hospital, Liverpool, UK
| | - Stephen P Halloran
- Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Daniel Hochhauser
- Department of Oncology, University College London Cancer Institute, London, UK
| | - Mark A Hull
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Viktor H Koelzer
- Molecular and Population Genetics Laboratory, University of Oxford, Oxford, UK
| | - Angus G K McNair
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Kevin J Monahan
- Family History of Bowel Cancer Clinic, Imperial College London, London, UK
| | - Inke Näthke
- School of Life Sciences, University of Dundee, Dundee, UK
| | - Christine Norton
- Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, London, UK
| | - Marco R Novelli
- Research Department of Pathology, University College London Medical School, London, UK
| | - Robert J C Steele
- Research into Cancer Prevention and Screening, University of Dundee, Dundee, UK
| | - Anne L Thomas
- Leicester Cancer Research Centre, University of Leicester, Leicester, UK
| | - Lisa M Wilde
- Bowel Cancer UK, London, UK
- Atticus Consultants Ltd, Croydon, UK
| | - Richard H Wilson
- Centre for Cancer Research and Cell Biology, Queen’s University Belfast, Belfast, UK
| | - Ian Tomlinson
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
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Eftaiha SM, Nordenstam JF. Sacral neuromodulation and the low anterior resection syndrome. SEMINARS IN COLON AND RECTAL SURGERY 2017. [DOI: 10.1053/j.scrs.2017.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Eftaiha SM, Balachandran B, Marecik SJ, Mellgren A, Nordenstam J, Melich G, Prasad LM, Park JJ. Sacral nerve stimulation can be an effective treatment for low anterior resection syndrome. Colorectal Dis 2017; 19:927-933. [PMID: 28477435 DOI: 10.1111/codi.13701] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/05/2017] [Indexed: 02/08/2023]
Abstract
AIM Sacral nerve stimulation has become a preferred method for the treatment of faecal incontinence in patients who fail conservative (non-operative) therapy. In previous small studies, sacral nerve stimulation has demonstrated improvement of faecal incontinence and quality of life in a majority of patients with low anterior resection syndrome. We evaluated the efficacy of sacral nerve stimulation in the treatment of low anterior resection syndrome using a recently developed and validated low anterior resection syndrome instrument to quantify symptoms. METHOD A retrospective review of consecutive patients undergoing sacral nerve stimulation for the treatment of low anterior resection syndrome was performed. Procedures took place in the Division of Colon and Rectal Surgery at two academic tertiary medical centres. Pre- and post-treatment Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores were assessed. RESULTS Twelve patients (50% men) suffering from low anterior resection syndrome with a mean age of 67.8 (±10.8) years underwent sacral nerve test stimulation. Ten patients (83%) proceeded to permanent implantation. Median time from anterior resection to stimulator implant was 16 (range 5-108) months. At a median follow-up of 19.5 (range 4-42) months, there were significant improvements in Cleveland Clinic Incontinence Scores and Low Anterior Resection Syndrome scores (P < 0.001). CONCLUSION Sacral nerve stimulation improved symptoms in patients suffering from low anterior resection syndrome and may therefore be a viable treatment option.
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Affiliation(s)
- S M Eftaiha
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - B Balachandran
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - S J Marecik
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA.,Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.,Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - A Mellgren
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - J Nordenstam
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA
| | - G Melich
- Department of General Surgery, Royal Columbian Hospital, University of British Columbia, New Westminster, BC, Canada
| | - L M Prasad
- Division of Colon and Rectal Surgery, University of Illinois, Chicago, Illinois, USA.,Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - J J Park
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA.,Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
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Keane C, Wells C, O'Grady G, Bissett IP. Defining low anterior resection syndrome: a systematic review of the literature. Colorectal Dis 2017; 19:713-722. [PMID: 28612460 DOI: 10.1111/codi.13767] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/29/2017] [Indexed: 12/13/2022]
Abstract
AIM There is increasing awareness of the poor functional outcome suffered by many patients after sphincter-preserving rectal resection, termed 'low anterior resection syndrome' (LARS). There is no consensus definition of LARS and varying instruments have been employed to measure functional outcome, complicating research into prevalence, contributing factors and potential therapies. We therefore aimed to describe the instruments and outcome measures used in studies of bowel dysfunction after low anterior resection and identify major themes used in the assessment of LARS. METHOD A systematic review of the literature was performed for studies published between 1986 and 2016. The instruments and outcome measures used to report bowel function after low anterior resection were extracted and their frequency of use calculated. RESULTS The search revealed 128 eligible studies. These employed 18 instruments, over 30 symptoms, and follow-up time periods from 4 weeks to 14.6 years. The most frequent follow-up period was 12 months (48%). The most frequently reported outcomes were incontinence (97%), stool frequency (80%), urgency (67%), evacuatory dysfunction (47%), gas-stool discrimination (34%) and a measure of quality of life (80%). Faecal incontinence scoring systems were used frequently. The LARS score and the Bowel Function Instrument (BFI) were used in only nine studies. CONCLUSION LARS is common, but there is substantial variation in the reporting of functional outcomes after low anterior resection. Most studies have focused on incontinence, omitting other symptoms that correlate with patients' quality of life. To improve and standardize research into LARS, a consensus definition should be developed, and these findings should inform this goal.
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Affiliation(s)
- C Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - C Wells
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - I P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
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Bowel dysfunction after anastomotic leakage in laparoscopic sphincter-saving operative intervention for rectal cancer: A case-matched study in 46 patients using the Low Anterior Resection Score. Surgery 2017; 161:1028-1039. [DOI: 10.1016/j.surg.2016.09.037] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2016] [Revised: 08/31/2016] [Accepted: 09/07/2016] [Indexed: 12/31/2022]
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47
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Ribas Y, Aguilar F, Jovell-Fernández E, Cayetano L, Navarro-Luna A, Muñoz-Duyos A. Clinical application of the LARS score: results from a pilot study. Int J Colorectal Dis 2017; 32:409-418. [PMID: 27796496 DOI: 10.1007/s00384-016-2690-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE The impact of the low anterior resection syndrome (LARS) on quality of life has underscored the importance of measuring functional outcomes after treatment for rectal cancer. The aim of this study was to evaluate whether the LARS score as a single questionnaire was useful enough in the clinical setting. METHODS Patients treated by curative anterior resection for rectal cancer were sent the LARS score and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 questionnaires by post. Patients classified as "minor" and "major" LARS according to the LARS score were visited. Assessment included several scores (Vaizey score, Altomare Obstructed Defecation Syndrome score, Bristol scale). Patients with urgency/faecal incontinence also filled in a bowel diary and the FIQL score. RESULTS Seventy patients returned the questionnaires, 49 of whom ("major LARS" and "minor LARS") were visited and 19 ("no LARS") were assessed by phone. Four different clinical patterns were identified. The group with urgency/faecal incontinence was the largest (33.8 %), whereas 17.7 % referred evacuatory dysfunction. The LARS score did not correctly evaluate 18 patients: 5 who were classified as no LARS but had severe evacuatory dysfunction and 13 patients categorized as LARS but without significant bowel dysfunction, 9 of whom were classified as major LARS. CONCLUSION The LARS score may overestimate the impact on quality of life in some patients and may underestimate the impact of severe evacuatory dysfunction. Due to the complexity of the LARS, the LARS score as a single questionnaire might not be enough to assess bowel function. A complete clinical evaluation and additional questionnaires might be required.
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Affiliation(s)
- Yolanda Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Ctra. de Torrebonica s/n, 080227, Terrassa, Barcelona, Spain.
| | - Francesc Aguilar
- Department of Surgery, Consorci Sanitari de Terrassa, Ctra. de Torrebonica s/n, 080227, Terrassa, Barcelona, Spain
| | | | - Ladislao Cayetano
- Department of Surgery, Consorci Sanitari de Terrassa, Ctra. de Torrebonica s/n, 080227, Terrassa, Barcelona, Spain
| | - Albert Navarro-Luna
- Department of Surgery, Hospital Universitari Mútua Terrassa, Terrassa, Spain
| | - Arantxa Muñoz-Duyos
- Department of Surgery, Hospital Universitari Mútua Terrassa, Terrassa, Spain
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A Cross-Sectional Review of Reporting Variation in Postoperative Bowel Dysfunction After Rectal Cancer Surgery. Dis Colon Rectum 2017; 60:240-247. [PMID: 28059921 DOI: 10.1097/dcr.0000000000000649] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Postoperative bowel dysfunction affects quality of life after sphincter-preserving rectal cancer surgery, but the extent of the problem is not clearly defined because of inconsistent outcome measures used to characterize the condition. OBJECTIVE The purpose of this study was to assess variation in the reporting of postoperative bowel dysfunction and to make recommendations for standardization in future studies. If possible, a quantitative synthesis of bowel dysfunction symptoms was planned. DATA SOURCES MEDLINE and EMBASE databases, as well as the Cochrane Library, were queried systematically between 2004 and 2015. STUDY SELECTION The studies selected reported at least 1 component of bowel dysfunction after resection of rectal cancer. MAIN OUTCOME MEASURES The main outcome measures were reporting, measurement, and definition of postoperative bowel dysfunction. RESULTS Of 5428 studies identified, 234 met inclusion criteria. Widely reported components of bowel dysfunction were incontinence to stool (227/234 (97.0%)), frequency (168/234 (71.8%)), and incontinence to flatus (158/234 (67.5%)). Urgency and stool clustering were reported less commonly, with rates of 106 (45.3%) of 234 and 61 (26.1%) of 234. Bowel dysfunction measured as a primary outcome was associated with better reporting (OR = 3.49 (95% CI, 1.99-6.23); p < 0.001). Less than half of the outcomes were assessed using a dedicated research tool (337/720 (46.8%)), and the remaining descriptive measures were infrequently defined (56/383 (14.6%)). LIMITATIONS Heterogeneity in the reporting, measurement, and definition of postoperative bowel dysfunction precluded pooling of results and limited interpretation. CONCLUSIONS Considerable variation exists in the reporting, measurement, and definition of postoperative bowel dysfunction. These inconsistencies preclude reliable estimates of incidence and meta-analysis. A broadly accepted outcome measure may address this deficit in future studies.
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De Nardi P, Testoni SGG, Corsetti M, Andreoletti H, Giollo P, Passaretti S, Testoni PA. Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer. Dig Liver Dis 2017; 49:91-97. [PMID: 27720700 DOI: 10.1016/j.dld.2016.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 08/22/2016] [Accepted: 09/14/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer. AIM The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry. METHODS Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2). RESULTS Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p=0.007). Surgery determined a significantly decrease of the resting pressure (p=0.001), of the maximum squeeze pressure (p=0.001) and of the volume threshold for urgency (p=0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively. CONCLUSIONS CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.
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Affiliation(s)
- Paola De Nardi
- Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy.
| | | | - Maura Corsetti
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Hulda Andreoletti
- Service de Anesthésiologie,Etablissements Hospitaliers du Nord Vaudois, Yverdon-les-Bain, Switzerland
| | - Patrizia Giollo
- Gastroenterology Division, San Raffaele Scientific Institute, Milan, Italy
| | - Sandro Passaretti
- Gastroenterology Division, San Raffaele Scientific Institute, Milan, Italy
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50
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Sturiale A, Martellucci J, Zurli L, Vaccaro C, Brusciano L, Limongelli P, Docimo L, Valeri A. Long-term functional follow-up after anterior rectal resection for cancer. Int J Colorectal Dis 2017; 32:83-88. [PMID: 27695976 DOI: 10.1007/s00384-016-2659-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE This is a retrospective analysis including all of the patients that have undergone anterior resection for rectal cancer from January 1998 to December 2005 in two tertiary referral centers. The study aims to evaluate the long term functional results after low anterior resection and to identify the risk factors of postoperative bowel disorders. METHOD Data were collected from the clinical records, and then the low anterior resection syndrome score which is a specific questionnaire to investigate the symptoms after surgery was submitted to the selected patients. Exclusion criteria were intra-abdominal rectal cancer, partial mesorectal excision, permanent stoma, recurrent local disease, and patients who declined the questionnaire. RESULTS A total of 93 patients were included in the analysis with a median age at the diagnosis of 66 years. The median follow-up was 13.7 years, and low anterior resection syndrome was reported in 44 patients (47.5 %), with major manifestations in 19 patients (20.5 %), and minor symptoms in 25 patients (27 %). Age more than 70 years, tumor distance from the external anal verge, neoadjuvant treatment, and interval time of closing stoma are independent prognostic factors of functional disorders after surgery. CONCLUSIONS Because of its great impact on the quality of life of these patients, it is necessary to early identify the syndrome trying to reduce its manifestations. Moreover, the symptoms seem to remain stable 1 year after surgery; hence, it is important to have an exhaustive, preoperative counseling and an integrated post-operative functional and rehabilitational follow-up in association with the oncologic pathway.
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Affiliation(s)
- Alessandro Sturiale
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy.
| | - Jacopo Martellucci
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Letizia Zurli
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Carla Vaccaro
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
| | - Luigi Brusciano
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Paolo Limongelli
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Ludovico Docimo
- XI Division of General and Obesity Surgery, Second University of Naples, Aversa (CE), Naples, Italy
| | - Andrea Valeri
- General, Emergency and Mini-invasive Surgery, Careggi University Hospital, Largo Brambilla 3, Florence, Italy
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