Functional outcome of low rectal resection evaluated by anorectal manometry

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of low anterior resection syndrome on quality of life in colorectal cancer patients: A retrospective observational study

BACKGROUND

Low anterior resection syndrome (LARS) is a common complication of anus-preserving surgery in patients with colorectal cancer, which significantly affects patients' quality of life.

AIM

To determine the relationship between the incidence of LARS and patient quality of life after colorectal cancer surgery and to establish a LARS prediction model to allow perioperative precision nursing.

METHODS

We reviewed the data from patients who underwent elective radical resection for colorectal cancer at our institution from April 2013 to June 2020 and completed the LARS score questionnaire and the European Organization for Research and Treatment of Cancer Core Quality of Life and Colorectal Cancer Module questionnaires. According to the LARS score results, the patients were divided into no LARS, mild LARS, and severe LARS groups. The incidence of LARS and the effects of this condition on patient quality of life were determined. Univariate and multivariate analyses were performed to identify independent risk factors for the occurrence of LARS. Based on these factors, we established a risk prediction model for LARS and evaluated its performance.

RESULTS

Among the 223 patients included, 51 did not develop LARS and 171 had mild or severe LARS. The following quality of life indicators showed significant differences between patients without LARS and those with mild or severe LARS: Physical, role, emotional, and cognitive function, total health status, fatigue, pain, shortness of breath, insomnia, constipation, and diarrhea. Tumor size, partial/total mesorectal excision, colostomy, preoperative radiotherapy, and neoadjuvant chemotherapy were identified to be independent risk factors for LARS. A LARS prediction model was successfully established, which demonstrated an accuracy of 0.808 for predicting the occurrence of LARS.

CONCLUSION

The quality of life of patients with LARS after colorectal cancer surgery is significantly reduced.

Optimizing the Utility of Anorectal Manometry for Diagnosis and Therapy: A Roundtable Review and Recommendations

BACKGROUND & AIMS

Anorectal manometry (ARM) is a comprehensive diagnostic tool for evaluating patients with constipation, fecal incontinence, or anorectal pain; however, it is not widely utilized for reasons that remain unclear. The aim of this roundtable discussion was to critically examine the current clinical practices of ARM and biofeedback therapy by physicians and surgeons in both academic and community settings.

METHODS

Leaders in medical and surgical gastroenterology and physical therapy with interest in anorectal disorders were surveyed regarding practice patterns and utilization of these technologies. Subsequently, a roundtable was held to discuss survey results, explore current diagnostic and therapeutic challenges with these technologies, review the literature, and generate consensus-based recommendations.

RESULTS

ARM identifies key pathophysiological abnormalities such as dyssynergic defecation, anal sphincter weakness, or rectal sensory dysfunction, and is a critical component of biofeedback therapy, an evidence-based treatment for patients with dyssynergic defecation and fecal incontinence. Additionally, ARM has the potential to enhance health-related quality of life and reduce healthcare costs. However, it has significant barriers that include a lack of education and training of healthcare providers regarding the utility and availability of ARM and biofeedback procedures, as well as challenges with condition-specific testing protocols and interpretation. Additional barriers include understanding when to perform, where to refer, and how to use these technologies, and confusion over billing practices.

CONCLUSIONS

Overcoming these challenges with appropriate education, training, collaborative research, and evidence-based guidelines for ARM testing and biofeedback therapy could significantly enhance patient care of anorectal disorders.

Functional Outcome of Laparoscopic-Assisted Resection Versus Open Resection of Rectal Cancer: A Secondary Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial

BACKGROUND

Low anterior resection syndrome has a significant impact on the quality of life in rectal cancer survivors. Previous studies comparing laparoscopic to open rectal resection have neglected bowel function outcomes.

OBJECTIVE

This study aimed to assess whether there is a difference in the functional outcome between patients undergoing laparoscopic versus open resection for rectal adenocarcinoma.

DESIGN

Cross-sectional prevalence of low anterior resection syndrome was assessed in a secondary analysis of the multicenter phase 3 randomized clinical trial, Australasian Laparoscopic Cancer of the Rectum Trial (ACTRN12609000663257).

SETTING

There were 7 study subsites across New Zealand and Australia.

PATIENTS

Participants were adults with rectal cancer who underwent anterior resection and had bowel continuity.

MAIN OUTCOME MEASURES

Postoperative bowel function was evaluated using the validated low anterior resection syndrome score and Bowel Function Instrument.

RESULTS

The Australasian Laparoscopic Cancer of the Rectum Trial randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. A total of 257 participants were eligible for, and invited to, participate in additional follow-up; 163 (63%) completed functional follow-up. Overall cross-sectional prevalence of major low anterior resection syndrome was 49% (minor low anterior resection syndrome 27%). There were no differences in median overall Bowel Function Instrument score nor low anterior resection syndrome score between participants undergoing laparoscopic versus open surgery (66 vs 67, p = 0.52; 31 vs 27, p = 0.24) at a median follow-up of 69 months.

LIMITATIONS

The major limitations are a result of conducting a secondary analysis; the likelihood of an insufficient sample size to detect a difference in prevalence between the groups and the possibility of selection bias as a subset of the randomized population was analyzed.

CONCLUSIONS

Bowel dysfunction affects a majority of rectal cancer patients for a significant time after the operation. In this secondary analysis of a randomized trial, surgical approach does not appear to influence the likelihood or severity of low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B794.

RESULTADO FUNCIONAL DE LA RESECCIN ASISTIDA POR LAPAROSCOPIA VERSUS RESECCIN ABIERTA EN CNCER DE RECTO ANLISIS SECUNDARIO DEL ESTUDIO DE CNCER DE RECTO LAPAROSCPICO DE AUSTRALASIA

ANTECEDENTES:El síndrome de resección anterior baja tiene un impacto significativo en la calidad de vida de los supervivientes de cáncer de recto. Los estudios anteriores que compararon la resección rectal laparoscópica con la abierta no han presentado resultados de la función intestinal.OBJETIVO:Evaluar si existe una diferencia en el resultado funcional entre los pacientes sometidos a resección laparoscópica versus resección abierta por adenocarcinoma de recto.DISEÑO:La prevalencia transversal del síndrome de resección anterior baja se evaluó en un análisis secundario del ensayo clínico aleatorizado multicéntrico de fase 3, Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia (Australasian Laparoscopic Cancer of the Rectum Trial, ACTRN12609000663257).AJUSTE:Siete subsitios de estudio en Nueva Zelanda y Australia.PACIENTES:Los participantes eran adultos con cáncer de recto que se sometieron a resección anterior con anastomosis.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal posoperatoria se evaluó utilizando el previamente validado puntaje LARS y el Instrumento de Función Intestinal.RESULTADOS:El Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia asignó al azar a 475 pacientes con adenocarcinoma rectal T1-T3 a menos de 15 cm del borde anal. 257 participantes fueron elegibles e invitados a participar en un seguimiento adicional. 163 (63%) completaron el seguimiento funcional. La prevalencia transversal general de LARS mayor fue del 49% (LARS menor 27%). No hubo diferencias en la puntuación media general del Instrumento de Función Intestinal ni en la puntuación LARS entre los participantes sometidos a cirugía laparoscópica versus cirugía abierta (66 frente a 67, p = 0,52; 31 frente a 27, p = 0,24) en una mediana de seguimiento de 69 meses.LIMITACIONES:Las principales limitaciones son el resultado de realizar un análisis secundario; se analizó la probabilidad de un tamaño de muestra insuficiente para detectar una diferencia en la prevalencia entre los grupos y la posibilidad de sesgo de selección como un subconjunto de la población aleatorizada.CONCLUSIONES:La disfunción intestinal afecta a la mayoría de los pacientes con cáncer de recto durante un tiempo significativo después de la operación. En este análisis secundario de un ensayo aleatorizado, el abordaje quirúrgico no parece influir en la probabilidad o gravedad del síndrome de resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B794. (Traducción-Dr. Felipe Bellolio).

Functional anorectal studies in patients with low anterior resection syndrome

BACKGROUND

Most patients who have undergone low anterior resection suffer from bowel dysfunction postoperatively. This condition is referred to as low anterior resection syndrome (LARS). The aim was to study defecatory patterns in LARS patients compared to a primary control group of fecal incontinence (FI) patients and normal subjects (NS) with the Fecobionics device.

METHODS

Fecobionics expulsion parameters were assessed in an interventional study design. The Fecobionics probe contained pressure sensors at the front, rear, and inside the bag. The bag was distended until urge sensation in rectum in 11 LARS patients (5F/6M, 63.2 ± 2.9 years), 11 FI subjects (7F/4M, 64.4 ± 2.5 years), and 11 NS (7F/4M, 63.6 ± 3.0 years). Defecation indices were computed from the Fecobionics data. All subjects had high-resolution anorectal manometry (ARM) and balloon expulsion test (BET) done. Symptoms were evaluated with LARS and Wexner scores.

KEY RESULTS

The LARS score in the LARS patients was 39.0 ± 0.6. The Wexner score in the LARS, FI, and NS groups was 14.2 ± 0.7, 10.1±1.0, and 0.0 ± 0.0 (p < 0.01). The resting anal pressure and squeeze pressure were lowest in LARS patients (p < 0.05). The urge volume was 11.8 ± 4.2, 59.6 ± 6.4, and 41.6 ± 6.4 ml in the LARS, FI, and NS groups, respectively (p < 0.001). The expulsion duration did not differ between groups. Defecation indices were lowest in the LARS patients (p < 0.05). ARM-BET confirmed the low urge volume in LARS patients whereas anal pressures did not differ between groups.

CONCLUSIONS AND INFERENCES

The LARS patients had low anal pressures and urge volume. Most Defecation Indices differed between the LARS group and the other groups.

A randomized clinical trial of technical modifications of appendix stump closure during laparoscopic appendectomy for uncomplicated acute appendicitis

Background

Closure of the appendix stump presents the most critical part of laparoscopic appendectomy. The aim of the present study was to compare the medical outcomes and cost analysis of laparoscopic appendectomy with respect to the different methods of stump closure.

Methods

This was a prospective randomized clinical trial conducted in a single institution (University Hospital Ostrava) within a 2-year study period. All included patients were randomized into one of three trial arms (endoloop, hem-o-lok clips or endostapler).

Results

In total, 180 patients (60 patients in each arm) were enrolled into the study. The mean length of hospital stay (3.6 ± 1.7 days) was comparable in all study arms. The shortest operative time was noted in the hem-o-lok subgroup of patients (37.9 ± 12.5 min). Superficial surgical site infection was detected in 4.4% of study patients; deep surgical site infection was noted in 1.7% of the patients. The frequency of surgical site infections was comparable in all study arms (p = 0.7173). The mean direct costs of laparoscopic appendectomy were significantly the lowest in the hem-o-lok subgroup of patients. Laparoscopic appendectomy is not a profit-making procedure in our institution (mean profit of made from the study patients was—104.3 ± 579.2 Euro). Closure of the appendix stump by means of endostapler presents the most expensive and the highest loss-incurring technique (p = 0.0072).

Conclusions

The present study indicates that all technical modifications of appendix stump closure are comparable with regards to postoperative complications. The stapler technique is significantly the most expensive. We concluded that hem-o-lok clips have the potential for becoming the preferred method of securing the appendix base during laparoscopic appendectomy. Trial registration NCT03750032 (http://www.clinicaltrials.gov).

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients’ quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.

[Low anterior resection syndrome-Causes and treatment approaches]

BACKGROUND

With improvement of the oncological prognosis and more sphincter-preserving procedures for rectal cancer of the lower third, the functional sequelae of anterior rectal resection become more and more predominant and are summarized under the term low anterior resection syndrome (LARS).

MATERIAL AND METHODS

In this narrative review the causes, associated factors, prevalence, diagnostics and treatment strategies are presented based on an evaluation of the international literature.

RESULTS

The central role of the rectum in the physiology of defecation and continence explains the frequency of symptoms following anterior rectal resection. In an unselected patient population a major LARS is to be expected in approximately 40% and a minor LARS in approximately 20%. The most important factor is the length of the remaining rectal stump. The diagnosis of LARS is made clinically and can be quantified by scores, especially by the LARS score. Treatment options range from patient counselling to stoma construction and a symptom-related, stepwise approach is generally accepted.

CONCLUSION

While the evidence for the causes, the quantification and determination of associated factors of LARS is good, the treatment options are based either on experience or on only few studies.

Long-Term Anorectal Manometry Outcomes After Laparoscopic and Transanal Total Mesorectal Excision

Background: During transanal total mesorectal excision (TaTME), sustained dilation of the anal canal occurs, which can cause anatomical and functional damage to the sphincter complex. This study aimed to analyze the impact of laparoscopic total mesorectal excision (LaTME) and TaTME in anorectal sphincter function. Materials and Methods: An observational study was conducted comparing two cohorts of patients who underwent LaTME or TaTME for rectal cancer. The two groups were paired for comparison based on age, gender, and distance of the neoplasm to the anal margin. The anorectal function was assessed by manometry before surgery and at least 6 months after primary intervention or stoma closure. The intestinal function was assessed using the low anterior resection syndrome (LARS) score. Results: Twenty-two patients were included. There were no significant differences in baseline characteristics between groups except for the time between surgery and testing. A decrease in the mean resting and squeeze pressures between pre- and postoperative manometry was observed in both the treatment groups, the difference being only significant in the squeeze pressure values (TaTME P = .003; LaTME P = .004). After surgery, squeeze pressure reduction correlated with a worsening of the LARS point count (rho 0.587; P = .004). The time elapsed since surgery was negatively correlated with the LARS point count (rho -0.696; P = .001) and the difference between pre- and postoperative mean squeeze pressures (rho -0.499; P = .018). Conclusion: Manometric findings after TME are comparable between the laparoscopic and the transanal approach. Deterioration of both anal sphincter function and LARS improves with time after surgery.

Altered anal slow-wave pressure activity in low anterior resection syndrome: short case series in two independent specialist centres provide new mechanistic insights

AIM

Conventional parameters (anal resting and squeeze pressures) measured with anorectal manometry (ARM) fail to identify anal sphincter dysfunction in many patients with low anterior resection syndrome (LARS). We aimed to assess whether there are differences in anal canal slow-wave pressure activity in LARS patients and healthy individuals.

METHOD

High-resolution ARM (HR-ARM) traces of 21 consecutive male LARS patients referred to the Royal London Hospital, UK (n = 12) and Aarhus University Hospital, Denmark (n = 9) were compared with HR-ARM data from 37 healthy men.

RESULTS

Qualitatively (by visual inspection of HR-ARM recordings), the frequency of slow-wave pressure activity was strikingly different in 11/21 (52.4%) LARS patients from that observed in all the healthy individuals. Quantitative analysis showed that peaks of the mean spectrum in these 11 LARS patients occurred at approximately 6-7 cycles per minute (cpm), without activity at higher frequencies. An equivalent pattern was found in only 2/37 (5.4%) healthy individuals (P < 0.0001). Peaks of the mean spectrum in healthy individuals were concentrated at 16 cpm and 3-4 cpm.

CONCLUSION

Over half of the male LARS patients studied had altered anal slow-wave pressure activity based on analysis of HR-ARM recordings. Further studies could investigate the relative contributions of sex, human baseline variance and neoadjuvant/surgical therapies on anal slow waves, and correlate the presence of abnormal activity with symptom severity.

Altered colonic motility is associated with low anterior resection syndrome

AIM

Patients frequently suffer from low anterior resection syndrome (LARS) after distal colorectal resection. The pathophysiology of LARS has not been clearly elucidated. We hypothesized that rectosigmoid resection could impair motility patterns in the distal colon, such as the rectosigmoid brake, which contribute to control of stool form and frequency.

METHOD

High-resolution colonic manometry was performed in patients who had previously undergone distal colorectal resection (mean 6.8 years after resection) and non-operative controls before and after a standardized meal. Symptoms were assessed using the LARS score. Propagating contractions were compared between patients with and without LARS, and controls.

RESULTS

Data were analysed from 23 patients (11 no-LARS; 12 LARS) and nine controls. All groups demonstrated a significant meal response. LARS patients had fewer post-prandial antegrade propagating contractions than controls (P = 0.028), and fewer retrograde propagating contractions both pre- (P = 0.005) and post-prandially (P = 0.004). Post-prandially, the LARS group had a significantly lower percentage of propagating contractions that met the criteria for the cyclic motor pattern compared to the control group (26% vs. 58%; P = 0.009). There were significant differences in antegrade and retrograde amplitude (P = 0.049; P = 0.018) and distance of propagation (P = 0.003; P = 0.002) post-prandially between LARS patients and controls.

CONCLUSION

Rectosigmoid resection alters the meal response following anterior resection, including impairment of the rectosigmoid brake cyclic motor pattern. These findings help to quantify the impaired functional motility after rectosigmoid resection and offer new insights into the mechanisms of LARS.

Low Anterior Resection Syndrome

PURPOSE OF REVIEW

Low anterior resection syndrome is a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life. In this review, we summarize the major features and pathophysiology of this syndrome and discuss treatment approaches.

RECENT FINDINGS

Quality of life correlates significantly with severity of low anterior resection syndrome. Prompt assessment and initiation of therapy are essential to rehabilitating damaged mechanical and neural structures. Anorectal manometry demonstrates a global decrease in sphincteric function postoperatively, though in many patients, function does recover. Transanal irrigation, pelvic floor rehabilitation, and biofeedback are the mainstays of the treatment of major LARS. Definitive stoma can be considered in therapy refractory LARS > 2 years. The development of low anterior resection syndrome likely involves an interplay between mechanical and neural pathways. Clinically, patients present at varying levels of severity, and scoring systems are available to help assess patient symptoms and guide therapy. Treatment approaches range from conservative therapies to biofeedback and sacral nerve stimulation. Future randomized controlled trials aimed at risk stratification of patients and development of severity-based treatment algorithms are warranted.

Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy

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.

Is my life going to change?-a review of quality of life after rectal resection

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.

Postoperative Bowel Function After Anal Sphincter-Preserving Rectal Cancer Surgery: Risks Factors, Diagnostic Modalities, and Management

Low anterior resection syndrome (LARS) refers to a disturbance of bowel function that commonly manifests within 1 month after rectal cancer surgery. A low level of anastomosis and chemoradiotherapy have been consistently found to be risk factors for developing LARS. Thorough history taking and physical examination with adjunctive procedures are essential when evaluating patients with LARS. Anorectal manometry, fecoflowmetry, and validated questionnaires are important tools for assessing the quality of life of patients with LARS. Conservative management (medical, physiotherapy, transanal irrigation), invasive procedures (neuromodulation), and multimodal therapy are the mainstay of treatment for patients with LARS. A stoma could be considered when other treatment modalities have failed. An initial meticulous surgical procedure for rectal cancer, creation of a neorectal reservoir during anastomosis, and proper exercise of the anal sphincter muscle (Kegel’s maneuver) are essential to combat LARS. Pretreatment counseling is a crucial step for patients who have risk factors for developing LARS.

Resting vector volume measured before ileostomy reversal may be a predictor of major fecal incontinence in patients with mid or low rectal cancer: a longitudinal cohort study using a prospective clinical database

PURPOSE

Despite a high incidence of fecal incontinence following sphincter-preservation surgery (SPS), there are no definitive factors measured before ileostomy reversal that predict fecal incontinence. We investigated whether vector volume anorectal manometry before ileostomy reversal predicts major fecal incontinence following SPS in patients with mid or low rectal cancer.

METHODS

This longitudinal prospective cohort study comprised 173 patients who underwent vector volume anorectal manometry before ileostomy reversal. The Fecal Incontinence Severity Index was measured 1 year after the primary SPS and classified as major incontinence (FISI score ≥ 25) or continent/minor incontinence (FISI score < 25). Multivariable logistic regression analysis was used to identify predictors of major incontinence.

RESULTS

Ninety-two patients (53.1%) had major incontinence. Although tumor stage, location, and neoadjuvant chemoradiotherapy were comparable, the major incontinence group had lower resting pressure (28.4 vs. 34.3 mmHg, P = 0.027), greater asymmetry at rest (39.1% vs. 34.1%, P = 0.002) and squeezing (34.2% vs. 31.4%, P = 0.046), shorter sphincter length (3.3 vs. 3.7 cm, P = 0.034), and lower resting vector volume (143,601 vs. 278,922 mmHg² mm, P < 0.001) compared with the continent/minor incontinence group. Resting vector volume was the only independent predictor of major incontinence (odds ratio = 0.675 per 100,000 mmHg² mm, 95% confidence interval, 0.532-0.823; P = 0.006).

CONCLUSIONS

This study revealed that resting vector volume before ileostomy reversal may predict major fecal incontinence. We suggest that the physiology of the anorectum should be discussed with patients before ileostomy reversal in patients at high risk of fecal incontinence.