Comparative study of functional outcomes between ultra-low anterior resection and inter-sphincteric resection: a propensity matched analysis

Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors

PURPOSE

Low anterior resection syndrome (LARS) causes devastating symptoms and impairs the quality of life (QOL). This study investigated the incidence and risk factors of LARS and their association with the QOL in patients with lower rectal tumors.

METHODS

Patients who underwent anus-preserving surgery for lower rectal tumors between 2014 and 2019 and who had anal defecation between 2020 and 2021 were surveyed. The LARS score measured severity, and the QOL was evaluated using the Japanese version of the Fecal Incontinence Quality-of-Life Scale (JFIQL). The primary endpoint was the incidence of Major LARS, and the secondary endpoints were risk factors and association with the JFIQL.

RESULTS

Of 107 eligible patients, 82 (76.6%) completed the LARS survey. The incidence of Major LARS was 48%. Independent risk factors included neoadjuvant chemoradiotherapy (CRT) and a short interval (< 24 months after surgery; odds ratio, 4.6; 95% confidence interval: 1.1-19, both). The LARS score was moderately correlated with the JFIQL generic score (correlation coefficient: - 0.54). The JFIQL scores were significantly worse in the Minor and Major LARS groups than in the No LARS group.

CONCLUSIONS

Major LARS was found in 48% of lower rectal tumors, and independent risk factors include neoadjuvant CRT and a short interval. The QOL was significantly impaired in patients with both Minor and Major LARS.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Should anorectal manometry be routine before stoma reversal in patients after an intersphincteric resection?

INTRODUCTION

Anorectal manometry (ARM) is sometimes performed before ostomy reversal in patients with an intersphincteric resection (ISR) to predict bowel function. However, no clinical predictive data exist regarding its utility.

METHODS

The single-centre, retrospective data of ISR patients who had an ARM prior to ostomy reversal, and bowel functional assessment with the low anterior resection syndrome (LARS) and Wexner incontinence scores at least 6 months after reversal, were considered. Correlation statistics were performed with each of the manometric parameters and functional outcome categories.

RESULTS

Eighty-nine patients were included. The median basal and squeeze pressures were 41 and 100 mmHg, respectively. Any LARS (score ≥20) and major incontinence (score ≥11) was observed in 51.7% and 16.9%, respectively. None of the manometric parameters (median basal or maximum squeeze pressure, anal canal length, volume at urge and the ability to expel) correlated with LARS or incontinence.

CONCLUSIONS

Anorectal manometry (ARM) before ostomy reversal to predict bowel function at 6 months or beyond was not helpful in patients with an ISR and diverting stoma. No manometric parameter correlated with the LARS or Wexner incontinence scores.

Functional outcomes after robotic or laparoscopic intersphincteric resection - An inverse probability weighting analysis

BACKGROUND

Functional outcomes after robotic and laparoscopic Intersphincteric resections (ISR) have not been studied adequately. We aimed to compare the bowel functions after robotic or laparoscopic ISR.

METHODS

Single-center, cross-sectional study of minimally invasive ISR. Functional outcomes were assessed on the low anterior resection syndrome (LARS), Wexner incontinence scale, and the Kirwan grading. Baseline characteristics (age, sex, body mass index, T stage, tumour height, preoperative radiation, and anastomotic configuration) in the groups were balanced using inverse probability of treatment weighting (IPTW).

RESULTS

Functional outcomes were assessed for 132 patients, 85 laparoscopic and 47 robotic ISR were performed. After IPTW, baseline characteristics were well balanced (mean deviation <0.1). In the weighted cohorts of laparoscopic and robotic ISR, major LARS was observed in 18.1% and 18.5% (p - 0.182) and major incontinence on the Wexner scale in 18.4% and 22.8% (p - 0.443), respectively. The Kirwan grades of incontinence were also similar between the groups (p - 0.794).

CONCLUSION

No differences in bowel functions on the LARS and incontinence scales between laparoscopic and robotic ISR were found in the present study.

Bowel Functional Outcomes After Long-Course or Short-Course Radiation for Advanced Rectal Cancers: A Propensity-Matched Analysis

BACKGROUND

Despite short-course radiation and chemotherapy gaining popularity because of similar or better oncological outcomes, functional outcomes relative to long-course radiation have not been evaluated.

OBJECTIVE

To compare bowel function outcomes after long-course or short-course radiation and delayed operation for advanced rectal cancers.

DESIGN

Propensity-matched analysis.

SETTINGS

This study was conducted at a single tertiary cancer center. Patients were operated on between 2014 and 2020.

PATIENTS

The study included patients with locally advanced, nonmetastatic, mid, and low rectal cancers who underwent low anterior resection with stapled anastomosis and diverting ostomy. Extended or beyond total mesorectal excisions and lateral node dissections were excluded.

INTERVENTIONS

Long-course radiation delivered as a radiation dose of 50 Gy in 25 fractions or short-course radiation (5 Gy in 5 fractions) and delayed surgery after 4 to 6 weeks with or without chemotherapy.

MAIN OUTCOME MEASURES

One-time assessment of low anterior resections syndrome and Wexner incontinence scores at least 6 months after stoma reversal.

RESULTS

After matching 124 patients in the 1:2 ratio between short- and long-course radiations, 93 patients were included for analysis. Any low anterior resection syndrome was found in 90.3% of short-course patients compared to 54.8% after long-course radiation (p < 0.001). Major incontinence was detected in 6.5% after short-course radiation as opposed to 8.1% of patients after long-course radiation (p = 0.781). On multivariate logistic regression, short-course radiation predicted the development of any low anterior resection syndrome with an OR of 4.4.

LIMITATIONS

Selection and misclassification biases from retrospective recruitment.

CONCLUSIONS

For patients with locally advanced, nonmetastatic, mid, and low rectal cancers who underwent preoperative radiation followed by stapled low anterior resection, short-course radiation had higher probability of developing low anterior resection syndrome than long-course radiation. See Video Abstract at http://links.lww.com/DCR/C37.

RESULTADOS DE LA FUNCIN INTESTINAL DESPUS DE LA RADIACIN DE CICLO LARGO O CORTO EN CNCER DE RECTO AVANZADO UN ANLISIS EMPAREJADO DE PROPENSIN

ANTECEDENTES:A pesar de que la radiación de corta duración y la quimioterapia están ganando popularidad debido a resultados oncológicos similares o mejores, los resultados funcionales en relación con la radiación de larga duración no han sido evaluado.OBJETIVO:Comparar resultados de la función intestinal después de la radiación de ciclo largo o corto y cirugía diferida para los en cáncer de recto avanzado.DISEÑO:Análisis emparejado de propensión.ENTORNO CLINICO:Centro único de cáncer terciario. Pacientes operados entre 2014 y 2020.PACIENTES:Cánceres de recto medio y bajo localmente avanzados, no metastásicos, que se sometieron a resección anterior baja con anastomosis grapada y ostomía de derivación. Se excluyeron las escisiones total de mesorecto extendidas o más allá del plano y las disecciones de los ganglios laterales.INTERVENCIONES:Radiación de ciclo largo administrada como 50 Gy en 25 fracciones o radiación de ciclo corto (5 Gy en 5 fracciones) y cirugía diferida después de 4 a 6 semanas con o sin quimioterapia.PRINCIPALES MEDIDAS DE RESULTADO:Evaluación única del síndrome de reseccion anterior baja y escala de Wexner de incontinencia al menos seis meses después de la restitución del tránsito intestinal.RESULTADOS:Después de emparejar 124 pacientes en la proporción 1:2 entre radiación de ciclo corto y largo, se incluyeron 93 pacientes para el análisis. Se encontró cualquier síndrome de resección anterior baja en el 90,3% de los pacientes de ciclo corto en comparación con el 54,8% después de la radiación de ciclo largo (p < 0,001). Se detectó incontinencia grave en el 6,5% después de un tratamiento de corta duración frente al 8,1% de los pacientes que recibieron un tratamiento de radiación de larga duración (p = 0,781). En la regresión logística multivariable, la radiación de corta duración predijo el desarrollo de cualquier síndrome de resección anterior baja con una probabilidad de 4,4.LIMITACIONES:Sesgos de selección y clasificación errónea de reclutamiento retrospectivo.CONCLUSIONES:Para los cánceres de recto medio e inferior localmente avanzados, no metastásicos, que se sometieron a radiación preoperatoria seguida de resección anterior baja con grapas, curso corto tuvo una mayor probabilidad de desarrollar síndrome de resección anterior baja en comparación con radiación de curso largo. Consulte Video Resumen en http://links.lww.com/DCR/C37. (Traducción- Dr. Francisco M. Abarca-Rendon).

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group’s practical consensus statements for surgical management of localized and locally advanced rectal cancer

Introduction

There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings.

Methods

Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement.

Results

Using the results of the review of the literature and experts’ opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as “strong or weak”, based on the GRADE framework.

Conclusion

The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons’ community in India.