1
|
Nguyen TM, Traeger L, Overall B, Sammour T, Thomas M. Functional outcomes following anterior resection for colorectal cancer: a needs assessment and proposal of a nurse-led remote management algorithm. ANZ J Surg 2024; 94:1590-1597. [PMID: 38680012 DOI: 10.1111/ans.19010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 05/01/2024]
Abstract
AIM With the rise of structured, remote follow-up of colorectal cancers, there is the potential risk of underdiagnosing and undermanaging low anterior resection syndrome (LARS). This cohort study aims to determine the rate of LARS and its patterns of care, with the aim of generating a risk-stratified management algorithm that can be employed for nurse-led follow-up. METHOD Patients who underwent elective anterior resection for the management of colorectal cancer between 1 January 2017 and 31 December 2021 were sent quality-of-life questionnaires (EORTC-QLQ-CR29 and LARS score) and surveyed for LARS symptoms and management utilized. RESULTS Out of 70 patients who completed questionnaires, 71.4% had LARS and 42.9% had major LARS. The international Delphi consensus definition identified more patients (n = 50) with LARS than the LARS score (n = 41). Tumours located <8 cm from the anal verge, ULAR, and temporary stoma were predictive of major LARS on univariate analysis. However, only temporary stoma was predictive for LARS (OR 7.89 (1.15-53.95), P = 0.035) and majors LARS (8.14 (1.79-37.01), P = 0.007) on multivariate analysis. Forty-four percent of patients with LARS did not have input from any health professional for this condition. Consultation with specialist allied health and/or colorectal surgeons ranged from 4% to 22%. CONCLUSIONS Our study highlights that with the current remote follow-up system focused on cancer outcomes a significant proportion of patients with LARS are overlooked, resulting in the underutilization of relevant health professionals and management options. We propose a nurse-led management algorithm to address this issue while still minimizing surgical outpatient load.
Collapse
Affiliation(s)
- Thuy-My Nguyen
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Luke Traeger
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Bronwyn Overall
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Michelle Thomas
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
2
|
Houqiong J, Yuli Y, Yahang L, Tao L, Yang L, Yaxiong L, Dongning L, Taiyuan L. LASSO-based nomogram predicts the risk factors of low anterior resection syndrome for middle and low rectal cancer underwent robotic surgery. Surg Endosc 2024; 38:3378-3387. [PMID: 38714570 DOI: 10.1007/s00464-024-10863-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 04/14/2024] [Indexed: 05/10/2024]
Abstract
BACKGROUND This study aims to analyze the influencing factors of postoperative Low Anterior Resection Syndrome (LARS) in patients with middle and low rectal cancer who underwent robotic surgery. It also seeks to predict the probability of LARS through a visual, quantitative, and graphical nomogram. This approach is expected to lower the risk of postoperative LARS in these patients and improve their quality of life through effective prevention and early intervention. PATIENTS AND METHODS This research involved patients with middle and low rectal cancer who underwent robotic surgery in the Department of Gastrointestinal Surgery at the First Affiliated Hospital of Nanchang University from January 2015 to October 2022. A series of intestinal dysfunction symptoms arising from postoperative rectal cancer were diagnosed and graded using LARS scoring criteria. After the initial screening of all variables related to LARS with Lasso regression, they were included in logistic regression for further univariate and multivariate analysis to identify independent risk factors for LARS. A prediction model was then constructed. RESULTS The study included 358 patients. The parameters identified by Lasso regression included obstruction, BMI, tumor localization, maximum tumor diameter, AJCC stage, stoma, neoadjuvant therapy (NAT), and postoperative adjuvant therapy (AT). Univariate and multivariate analyses indicated that a higher BMI, lower tumor localization, higher AJCC stage, neoadjuvant therapy, and postoperative adjuvant therapy were independent risk factors for total LARS. The AUC of the prediction nomogram was 0.834, with a sensitivity of 0.825 and specificity of 0.741. The calibration curve demonstrated excellent concordance with the nomogram, indicating the prediction curve fit the diagonal well. CONCLUSION Higher BMI, lower tumor localization, higher AJCC stage, neoadjuvant therapy, and adjuvant therapy were identified as independent risk factors for total LARS. A new predictive nomogram for postoperative LARS in patients with middle and low rectal cancer undergoing robotic surgery was developed, proving to be stable and reliable. This tool will assist clinicians in managing the postoperative treatment of these patients, facilitating better clinical decision-making and maximizing patient benefits.
Collapse
Affiliation(s)
- Ju Houqiong
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China
| | - Yuan Yuli
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China
| | - Liang Yahang
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China
| | - Li Tao
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China
| | - Liu Yang
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China
| | - Liu Yaxiong
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China
| | - Liu Dongning
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China.
| | - Li Taiyuan
- Department of General Surgery, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, China.
- Laboratory of Digestive Surgery, Nanchang University, Nanchang, China.
| |
Collapse
|
3
|
Brock H, Lambrineas L, Ong HI, Chen WY, Das A, Edsell A, Proud D, Carrington E, Smart P, Mohan H, Burgess A. Preventative strategies for low anterior resection syndrome. Tech Coloproctol 2023; 28:10. [PMID: 38091118 DOI: 10.1007/s10151-023-02872-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 11/11/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques. METHODS A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed. RESULTS Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically. CONCLUSIONS To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.
Collapse
Affiliation(s)
- H Brock
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Western General, Melbourne, Australia
| | - L Lambrineas
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - H I Ong
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia.
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia.
| | - W Y Chen
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - A Das
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Edsell
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
| | - D Proud
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | | | - P Smart
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - H Mohan
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - A Burgess
- Austin Health, Department of Surgery, University of Melbourne, Melbourne, Australia
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| |
Collapse
|
4
|
Ryoo S. Low anterior resection syndrome. Ann Gastroenterol Surg 2023; 7:719-724. [PMID: 37663958 PMCID: PMC10472409 DOI: 10.1002/ags3.12695] [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] [Received: 12/28/2022] [Revised: 05/02/2023] [Accepted: 05/08/2023] [Indexed: 09/05/2023] Open
Abstract
Low anterior resection syndrome (LARS) is the distressful defecatory functional problem after sphincter-saving surgery for rectal cancer. Although the symptoms of fecal urgency, frequency, and incontinence may develop in most of the patients after surgery, there is no definitive treatments for LARS. Multifactorial etiologies and various risk factors have been identified, but the reduction of storage capacity in the rectum is one of the main reasons for LARS. Anal sphincter muscle or nerve damage during rectoanal resection or anastomosis construction, and intersphincteric resection for low-lying tumors or hand-sewing anastomosis, are the absolute risk factors for LARS. Preoperative radiotherapy, postoperative complications, such as anastomosis leakage, or longer duration of stoma, are also risk factors. The severity of LARS can be confirmed using the LARS score questionnaire. The questionnaire has been translated to numerous language versions including Korean and have been validated. Diverse empirical treatments, such as loperamide, fiber, probiotics, or enema, have been tried, but the safety and efficacy have not been verified yet. The 5-Hydroxytryptamine (5-HT) receptor antagonist, ramosetron, used for diarrhea-dominant irritable bowel syndrome, is one potential drug for relieving the symptoms of major LARS. A randomized-controlled trial suggested the use of ramosetron could be safe and efficacious for patients who have major LARS after sphincter-saving rectal cancer surgery. Novel techniques or drugs for relieving the symptoms of LARS should be developed more and further studies are necessary.
Collapse
Affiliation(s)
- Seung‐Bum Ryoo
- Division of Colorectal Surgery, Department of SurgerySeoul National University Hospital, Seoul National University College of MedicineSeoulKorea
- Colorectal Cancer CenterSeoul National University Cancer HospitalSeoulKorea
| |
Collapse
|
5
|
Liu F, Guo P, Wang Q, Chen F, Wu W, Su X, Wang G, Yu Z, Jiang J, Liang F, Diao D, Chen Z, Liu Y, Meng F, Ning N, Ye Y. Excessive bowel volume loss during anus-preserving surgery for rectal cancer affects the bowel function after operation: A prospective observational cohort study (Bas-1611). Heliyon 2023; 9:e17630. [PMID: 37483691 PMCID: PMC10362271 DOI: 10.1016/j.heliyon.2023.e17630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 06/21/2023] [Accepted: 06/23/2023] [Indexed: 07/25/2023] Open
Abstract
Background Bowel volume loss during anus-preserving surgery (APS) may result in low anterior resection syndrome (LARS). We conducted this prospective observational cohort study to measure the incidence of LARS after surgery and evaluate the relationship between bowel volume loss and bowel function. Methods Patients with R0 resectable rectal cancer who consented to several bowel function surveys through telephone interviews after the operation were included. Enrolled patients underwent standard APS for rectal cancer, and three length indexes, viz. length of excised bowel, length of the distal margin and length of the proximal margin (LPM) of fresh bowel specimens, were measured in vitro. Results The three measured variables of the specimens showed a positively skewed distribution. Patient interviews revealed a trend of gradual improvement in bowel function. Univariate analyses revealed that longer LPM was associated with a significantly negative impact on bowel function at all time points. In multivariate analysis, LPM was found to be a significant risk factorstatistically significant, but its impact was not as strong as that of radiotherapy and low-middle tumour. Furthermore, there was no significant difference in the lymph node detection rate between <10-cm and ≥10-cm LPM groups. Conclusion In APS for rectal cancer, bowel volume loss is an important factor causing postoperative bowel dysfunction. Controlling LPM to <10 cm may help improve postoperative bowel function.
Collapse
Affiliation(s)
- Fan Liu
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China
| | - Peng Guo
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China
| | - Quan Wang
- Department of Gastrointestinal Surgery, The First Hospital of Jilin University, Changchun, China
| | - Fujun Chen
- Department of Colorectal Surgery, The First Affiliated Hospital of Jiamusi Medical University, Jiamusi, China
| | - Wenyong Wu
- Department of General Surgery, Anhui No. 2 Provincial People's Hospital, Hefei, China
| | - Xiangqian Su
- Department of Gastrointestinal Surgery IV, Peking University Cancer Hospital, Beijing, China
- Key Laboratory of Carcinogenesis and Translational Research, Peking University Cancer Hospital, Beijing, China
| | - Guiying Wang
- Department of General Surgery, 3rd Hospital of Hebei Medical University, Shijiazhuang, China
- 2nd Department of General Surgery, 4th Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhouman Yu
- Department of Gastroenterological Surgery, Qilu Hospital of Shandong University (Qingdao), Qingdao, China
| | - Jianlong Jiang
- Department of General Surgery, Changshu Hospital Affiliated to Soochow University, First People's Hospital of Changshu City, Changshu, China
| | - Feng Liang
- Department of General Surgery, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Dechang Diao
- Department of Gastrointestinal (Tumor) Surgery, Guangdong Province Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhikang Chen
- Department of Colorectal and Anal Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Yuanting Liu
- Department of Gastroenterological Surgery, Tangshan People's Hospital, Tangshan, China
| | - Fanqiang Meng
- Department of General Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Ning Ning
- Department of Gastrointestinal Surgery, Peking University International Hospital, Beijing, China
| | - Yingjiang Ye
- Department of Gastroenterological Surgery, Peking University People's Hospital, Beijing, China
| |
Collapse
|
6
|
Liu FF, Zhuo GZ, Zhao YJ, Zhang B, Zhao Y, Ding JH. Advances in diagnosis and treatment of low anterior resection syndrome. Shijie Huaren Xiaohua Zazhi 2023; 31:178-183. [DOI: 10.11569/wcjd.v31.i5.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Rectal cancer is one of the most common cancers. As much as 90% of patients with low rectal cancer complain of increased frequency of defecation, fecal incontinence, and evacuation problems after surgery, which is termed as low anterior resection syndrome (LARS). LARS detrimentally affects the quality of life for patients with rectal cancer. In this paper, we review the pathogenesis, risk factors, assessment tools, and treatment strategies for LARS.
Collapse
Affiliation(s)
- Fei-Fan Liu
- Jinzhou Medical University Joint PLA Rocket Force Characteristic Medical Center Training Base, Beijing 100088, China
| | - Guang-Zuan Zhuo
- Department of Colorectal Surgery, PLA Rocket Force Characteristic Medical Center, PLA Characteristic Anorectal Medical Center, Beijing 100088, China
| | - Yu-Juan Zhao
- Department of Colorectal Surgery, PLA Rocket Force Characteristic Medical Center, PLA Characteristic Anorectal Medical Center, Beijing 100088, China
| | - Bin Zhang
- Department of Colorectal Surgery, PLA Rocket Force Characteristic Medical Center, PLA Characteristic Anorectal Medical Center, Beijing 100088, China
| | - Yong Zhao
- Department of Colorectal Surgery, PLA Rocket Force Characteristic Medical Center, PLA Characteristic Anorectal Medical Center, Beijing 100088, China
| | - Jian-Hua Ding
- Department of Colorectal Surgery, PLA Rocket Force Characteristic Medical Center, PLA Characteristic Anorectal Medical Center, Beijing 100088, China
| |
Collapse
|
7
|
Asnong A, Tack J, Devoogdt N, De Groef A, Geraerts I, D'Hoore A. Exploring the pathophysiology of LARS after low anterior resection for rectal cancer with high-resolution colon manometry. Neurogastroenterol Motil 2022; 34:e14432. [PMID: 35866548 DOI: 10.1111/nmo.14432] [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: 02/17/2022] [Revised: 05/16/2022] [Accepted: 06/10/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND A total mesorectal excision for rectal cancer-although nerve- and sphincter-sparing-can give rise to significant bowel symptoms, commonly referred to as low anterior resection syndrome (LARS). The exact pathophysiology of this syndrome still remains largely unknown, and the impact of radical surgery on colonic motility has only been scarcely investigated. METHODS High-resolution colon manometry was performed in patients, 12-24 months after restoration of transit. Patients were divided into two groups: patients with major LARS and no/minor LARS, according to the LARS-score. Colonic motor patterns were compared, and the relationship of these patterns with the LARS-scores was investigated. KEY RESULTS Data were analyzed in 18 patients (9 no/minor LARS, 9 major LARS). Cyclic short antegrade motor patterns did occur more in patients with major LARS (total: p = 0.022; post-bisacodyl: p = 0.004) and were strongly correlated to LARS-scores after administering bisacodyl (p < 0.001). High amplitude propagating contractions (HAPC's) that started in the proximal colon and ended in the mid-section of the colon occurred significantly less in patients with major LARS compared with patients with no/minor LARS (p = 0.015). CONCLUSIONS AND INFERENCES The occurrence of more cyclic short antegrade motor patterns and less HAPC's (from the proximal to the mid-colon) is more prevalent in patients with major LARS. These findings help to understand the differences in pathophysiology in patients developing major versus no/minor bowel complaints after TME for rectal cancer.
Collapse
Affiliation(s)
- Anne Asnong
- Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven, Belgium
| | - Jan Tack
- Department of Chronic Diseases, Metabolism and Ageing, Faculty of Medicine, Leuven, Belgium.,Department of Translational Research in Gastrointestinal Disorders, University Hospitals Leuven, Leuven, Belgium
| | - Nele Devoogdt
- Center for lymphedema, University Hospitals Leuven, Leuven, Belgium.,Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - An De Groef
- Department of Rehabilitation Sciences, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Rehabilitation Sciences, University of Antwerp, Antwerp, Belgium.,International Research Group Pain in Motion, Leuven, Belgium
| | - Inge Geraerts
- Department of Rehabilitation Sciences, Faculty of Movement and Rehabilitation Sciences, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, University Hospitals Leuven
| | - André D'Hoore
- Department of Oncology, Faculty of Medicine, Leuven, Belgium.,Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
8
|
Anterior Resection Syndrome and Quality of Life With Long-term Follow-up After Rectal Cancer Resection. Dis Colon Rectum 2022; 65:1251-1263. [PMID: 34840295 DOI: 10.1097/dcr.0000000000002107] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality of life remain unclear. OBJECTIVE The purpose of this study was to assess the impact of anterior resection and reversal of ileostomy on long-term health-related quality of life and low anterior resection syndrome. DESIGN Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires. SETTING Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at 2 high-volume centers in the United Kingdom were identified, excluding those experiencing anastomotic leakage. PATIENTS Among 478 eligible patients, 311 (65.1%) participated at a mean of 6.5 ± 0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar ( p > 0.05) between participants and nonparticipants. RESULTS The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). Health-related quality-of-life functional domain scores improved in the years after reversal of ileostomy, with significant changes in constipation ( p = 0.01), social function ( p = 0.03), and emotional scores ( p = 0.02), as well as a reduction in the prevalence of major low anterior resection syndrome ( p = 0.003). LIMITATIONS The main limitation of this study was that the data collected were cross-sectional rather than longitudinal, and that nonresponders may have had worse cancer symptoms. CONCLUSIONS In this first large-scale study assessing long-term function after anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825 . SEGUIMIENTO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA Y LA CALIDAD DE VIDA POR CNCER DE RECTO ANTECEDENTES:Los tratamientos tanto quirúrgicos como sistémicos continúan evolucionando día a día, así éstos permiten resecciones restaurativas por cáncer de recto distal. Estas operaciones están asociadas con el síndrome de resección anterior baja. Estudios recientes con limitaciones tanto metodológicas como de talla han estudiado la incidencia del síndrome de resección anterior bajo post-quirúrgico. Sin embargo, la evolución a largo plazo del síndrome de resección anterior baja y su acción sobre la calidad de vida relacionadas con la salud siguen sin estar claros.OBJETIVO:Evaluar el impacto de la resección anterior baja y el cierre de la ileostomía en la calidad de vida relacionadas con la salud a largo plazo y el síndrome post-resección anterior.AJUSTE:Se incluyeron todos los pacientes sometidos a una reseccción anterior baja de recto por cáncer asociada a una ileostomía de protección entre 2003 y 2016 en dos centros de gran volumen en el Reino Unido, se excluyeron los pacientes que presentaron fuga anastomótica.DISEÑO:Se revisaron los datos demográficos de todos los pacientes que presentaban el síndrome de resección anterior baja, se revisaron las puntuaciones de la calidad de vida relacionadas con el estado general de salud (EORTC-QLQ-C30) obtenidas a través de cuestionarios transversales enviados por correo.PACIENTES:478 pacientes fueron escogidos, 311 (65,1%) participaron del estudio en una media de 6,5 ± 0,2 años después de la resección anterior. Las tasas demográficas y de radio-quimioterapia neoadyuvante fueron similares (p > 0,05) entre los participantes y los no participantes.RESULTADOS:El porcentaje de pacientes que experimentaron síndrome de resección anterior baja mayor fue del 53,4% (166/311).PRINCIPALES MEDIDAS DE RESULTADO:Las puntuaciones funcionales en la calidad de vida relacionadas con estado general de salud mejoraron en los años posteriores al cierre de la ileostomía de protección, los cambios fueron significativos con relación al estreñimiento (p = 0,01), con relación a la actividad social (p = 0,03) y con las puntuaciones emocionales (p = 0,02), así como con la reducción de la prevalencia del síndrome de resección anterior baja mayor (p = 0,003).LIMITACIONES:La principal limitación del presente estudio mostró que los datos recopilados fueron transversales y no longitudinales, y que los pacientes no respondedores pueden haber tenido peores síntomas relacionados con el cáncer.CONCLUSIONES:Este primer estudio a gran escala, evalúa la función a largo plazo después de la resección anterior baja y el cierre de la ileostomía, demuestra una mejoría lineal en el síndrome de resección anterior baja de grado importante, más allá de los 6 años, asociado con la mejoría en las medidas clave de calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B825 . (Traducción-Dr. Xavier Delgadillo ).
Collapse
|
9
|
Varghese C, Wells CI, Bissett IP, O'Grady G, Keane C. The role of colonic motility in low anterior resection syndrome. Front Oncol 2022; 12:975386. [PMID: 36185226 PMCID: PMC9523793 DOI: 10.3389/fonc.2022.975386] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Low anterior resection syndrome (LARS) describes the symptoms and experiences of bowel dysfunction experienced by patients after rectal cancer surgery. LARS is a complex and multifactorial syndrome exacerbated by factors such as low anastomotic height, defunctioning of the colon and neorectum, and radiotherapy. There has recently been growing awareness and understanding regarding the role of colonic motility as a contributing mechanism for LARS. It is well established that rectosigmoid motility serves an important role in coordinating rectal filling and maintaining continence. Resection of the rectosigmoid may therefore contribute to LARS through altered distal colonic and neorectal motility. This review evaluates the role of colonic motility within the broader pathophysiology of LARS and outlines future directions of research needed to enable targeted therapy for specific LARS phenotypes.
Collapse
Affiliation(s)
- Chris Varghese
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Cameron I Wells
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of General Surgery, Counties Manukau District Health Board, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Celia Keane
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Department of Surgery, Whangārei Hospital, Whangarei, New Zealand
| |
Collapse
|
10
|
Pi YN, Xiao Y, Wang ZF, Lin GL, Qiu HZ, Fang XC. Anorectal dysfunction in patients with mid-low rectal cancer after surgery: A pilot study with three-dimensional high-resolution manometry. World J Clin Cases 2022; 10:3754-3763. [PMID: 35647175 PMCID: PMC9100741 DOI: 10.12998/wjcc.v10.i12.3754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/08/2022] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The quality of life in patients who develop low anterior resection syndrome (LARS) after surgery for mid-low rectal cancer is seriously impaired. The underlying pathophysiological mechanism of LARS has not been fully investigated.
AIM To assess anorectal function of mid-low rectal cancer patients developing LARS perioperatively.
METHODS Patients diagnosed with mid-low rectal cancer were included. The LARS score was used to evaluate defecation symptoms 3 and 6 mo after anterior resection or a stoma reversal procedure. Anorectal functions were assessed by three-dimensional high resolution anorectal manometry preoperatively and 3-6 mo after surgery.
RESULTS The study population consisted of 24 patients. The total LARS score was decreased at 6 mo compared with 3 mo after surgery (P < 0.05), but 58.3% (14/24) lasted as major LARS at 6 mo after surgery. The length of the high-pressure zone of the anal sphincter was significantly shorter, the mean resting pressure and maximal squeeze pressure of the anus were significantly lower than those before surgery in all patients (P < 0.05), especially in the neoadjuvant therapy group after surgery (n = 18). The focal pressure defects of the anal canal were detected in 70.8% of patients, and those patients had higher LARS scores at 3 mo postoperatively than those without focal pressure defects (P < 0.05). Spastic peristaltic contractions from the new rectum to anus were detected in 45.8% of patients, which were associated with a higher LARS score at 3 mo postoperatively (P < 0.05).
CONCLUSION The LARS score decreases over time after surgery in the majority of patients with mid-low rectal cancer. Anorectal dysfunctions, especially focal pressure defects of the anal canal and spastic peristaltic contractions from the new rectum to anus postoperatively, might be the major pathophysiological mechanisms of LARS.
Collapse
Affiliation(s)
- Yan-Na Pi
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Yi Xiao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Zhi-Feng Wang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Guo-Le Lin
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Hui-Zhong Qiu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiu-Cai Fang
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| |
Collapse
|
11
|
Garfinkle R, Boutros M. Low Anterior Resection Syndrome: Predisposing Factors and Treatment. Surg Oncol 2021; 43:101691. [PMID: 34863592 DOI: 10.1016/j.suronc.2021.101691] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/24/2021] [Indexed: 12/15/2022]
Abstract
Bowel dysfunction after restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long-term sequela of rectal cancer treatment that has a significant impact on quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause is likely multifactorial, and there are numerous patient, tumor, and treatment-level factors associated with its development. In accordance with these risk factors, several strategies have been proposed to mitigate LARS postoperatively, including modifications in the technical approach to restorative proctectomy and advancements in the multidisciplinary care of rectal cancer. Furthermore, a clinically applicable pre-operative nomogram has been developed to estimate the risk of LARS postoperatively, which may help in counseling patients before surgery. The management of LARS begins with identifying those who manifest symptoms, as postoperative bowel dysfunction often goes unrecognized. This goal is best achieved with the systematic screening of patients using validated Patient-Reported Outcome Measures. Once a patient with LARS is identified, conservative management strategies should be implemented. When available, a dedicated LARS nurse and/or multidisciplinary team can be an invaluable resource in engaging patients and educating them regarding LARS self-care. If symptoms of LARS persist or worsen over time despite conservative measures, second-line interventions, such as transanal irrigation or pelvic floor rehabilitation, can be initiated. A small proportion of patients will ultimately require an intervention such as sacral neuromodulation or permanent colostomy for refractory, major LARS symptoms.
Collapse
Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, QC, Canada.
| |
Collapse
|
12
|
He S, Liu Z, Li L, Zhang J, Shi L, Song Y, Lin H, Sun W, Wang J, Deng Y, Wang H, Kang L, Dou R. Improvement of low anterior resection syndrome beyond 2 years after total mesorectal excision. J Surg Oncol 2021; 125:448-456. [PMID: 34689328 DOI: 10.1002/jso.26729] [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: 09/11/2021] [Accepted: 10/15/2021] [Indexed: 11/07/2022]
Abstract
AIM Bowel dysfunction after sphincter-preserving proctectomy, also known as low anterior resection syndrome (LARS), has significant impact on survivors of rectal cancer. This study aimed to assess the temporal change of LARS beyond 2 years after proctectomy, which has not been fully studied. METHODS We longitudinally enrolled consecutive patients who had received total mesorectal excision in a tertiary academic medical center, with preoperative neoadjuvant therapy if indicated. LARS score was longitudinally assessed by two serial follow-ups, with a fixed interval of 18 months. RESULTS Overall, 107 patients responded for the first follow-up after a median of q20 months, 96 of whom responded for the second follow-up after a median of 38 months. At the first follow-up, 48 patients (44.9%) reported major LARS, compared with 23 (24.0%) at the second follow-up (p < 0.001). Mean LARS score improved from 27.3 to 18.6, mostly from "urgency" (12.2 vs. 6.2, p < 0.001) and "clustering of stools" (9.7 vs. 7.7, p = 0.001). Anastomosis less than 3 cm from the anal verge was independently associated with LARS improvement. CONCLUSION Bowel dysfunction continues to improve 2 years after total mesorectal excision, with most symptom relief in urgency and stool clustering, especially in patients with lower anastomosis.
Collapse
Affiliation(s)
- Siqi He
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Zhanzhen Liu
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Li Li
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Pelvic Floor Center, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Jinquan Zhang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Lishuo Shi
- Clinical Research Center, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Yuntao Song
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Hongcheng Lin
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Department of Anorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Weipeng Sun
- Department of Colorectal Surgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, PR China
| | - Jianping Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Yanhong Deng
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Department of Medical Oncology, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Hui Wang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Liang Kang
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| | - Ruoxu Dou
- Department of Colorectal Surgery, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, the Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, PR China
| |
Collapse
|
13
|
Pilkington SA, Bhome R, Gilbert S, Harris S, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study. Colorectal Dis 2021; 23:2436-2446. [PMID: 34032359 DOI: 10.1111/codi.15754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. METHOD Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . RESULTS Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. CONCLUSIONS Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.
Collapse
Affiliation(s)
- Sophie A Pilkington
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Rahul Bhome
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Sally Gilbert
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Scott Harris
- Primary Care and Population Studies, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Carl Richardson
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Thomas C Dudding
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - John S Knight
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Andrew T King
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Alex H Mirnezami
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Nicholas E Beck
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Paul H Nichols
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Karen P Nugent
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK
| |
Collapse
|
14
|
De Bono JA, Larach JT, Singh P, Kong JC, Smart PJ, Heriot AG, Warrier SK. Anastomosis following low anterior resection: does one size fit all? ANZ J Surg 2021; 91:775-778. [PMID: 33999534 DOI: 10.1111/ans.16442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 01/01/2023]
Affiliation(s)
- Joshua A De Bono
- Department of Surgery, Epworth Healthcare, Melbourne, Victoria, Australia
| | - José T Larach
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Digestive Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Primal Singh
- Department of Surgery, Alfred Health, Melbourne, Victoria, Australia
| | - Joseph C Kong
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - Philip J Smart
- Department of Surgery, Epworth Healthcare, Melbourne, Victoria, Australia.,Department of Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Alexander G Heriot
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| | - Satish K Warrier
- Department of Surgery, Epworth Healthcare, Melbourne, Victoria, Australia.,Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Surgery, Alfred Health, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, Parkville, Victoria, Australia
| |
Collapse
|
15
|
Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chin Med J (Engl) 2021; 133:1824-1833. [PMID: 32604174 PMCID: PMC7469998 DOI: 10.1097/cm9.0000000000000852] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
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.
Collapse
|
16
|
The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surveillance and Survivorship Care of Patients After Curative Treatment of Colon and Rectal Cancer. Dis Colon Rectum 2021; 64:517-533. [PMID: 33591043 DOI: 10.1097/dcr.0000000000001984] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
17
|
Stelzner S, Kupsch J, Mees ST. [Low anterior resection syndrome-Causes and treatment approaches]. Chirurg 2021; 92:612-620. [PMID: 33877394 DOI: 10.1007/s00104-021-01398-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
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.
Collapse
Affiliation(s)
- Sigmar Stelzner
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Friedrichstr. 41, 01067, Dresden, Deutschland.
| | - Juliane Kupsch
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Friedrichstr. 41, 01067, Dresden, Deutschland
| | - Sören Torge Mees
- Klinik für Allgemein- und Viszeralchirurgie, Städtisches Klinikum Dresden-Friedrichstadt, Friedrichstr. 41, 01067, Dresden, Deutschland
| |
Collapse
|
18
|
Abstract
Abstract
Introduction With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving resection many patients suffer from severe bowel dysfunction with an impact on quality of life (QoL) – referred to as low anterior resection syndrome (LARS).
Study objective To provide an overview of the current knowledge of LARS regarding symptomatology, occurrence, risk factors, pathophysiology, evaluation instruments and treatment options.
Results LARS is characterized by urgency, frequent bowel movements, emptying difficulties and incontinence, and occurs in up to 50-75% of patients on a long-term basis. Known risk factors are low anastomosis, use of radiotherapy, direct nerve injury and straight anastomosis. The pathophysiology seems to be multifactorial, with elements of anatomical, sensory and motility dysfunction. Use of validated instruments for evaluation of LARS is essential. Currently, there is a lack of evidence for treatment of LARS. Yet, transanal irrigation and sacral nerve stimulation are promising.
Conclusion LARS is a common problem following sphincter-preserving resection. All patients should be informed about the risk of LARS before surgery, and routinely be screened for LARS postoperatively. Patients with severe LARS should be offered treatment in order to improve QoL. Future focus should be on the possibilities of non-resectional treatment in order to prevent LARS.
Collapse
|
19
|
Keane C, Paskaranandavadivel N, Vather R, Rowbotham D, Arkwright J, Dinning P, Bissett I, O'Grady G. Altered colonic motility is associated with low anterior resection syndrome. Colorectal Dis 2021; 23:415-423. [PMID: 33253472 DOI: 10.1111/codi.15465] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 10/13/2020] [Accepted: 11/17/2020] [Indexed: 12/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Celia Keane
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | | | - Ryash Vather
- Colorectal Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David Rowbotham
- Department of Gastroenterology, Auckland City Hospital, Auckland, New Zealand
| | - John Arkwright
- College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
| | - Phil Dinning
- Department of Surgery and Gastroenterology, Flinders Medical Centre, Flinders University, Adelaide, South Australia, Australia
| | - Ian Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| |
Collapse
|
20
|
Christensen P, IM Baeten C, Espín‐Basany E, Martellucci J, Nugent KP, Zerbib F, Pellino G, Rosen H. Management guidelines for low anterior resection syndrome - the MANUEL project. Colorectal Dis 2021; 23:461-475. [PMID: 33411977 PMCID: PMC7986060 DOI: 10.1111/codi.15517] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023]
Abstract
AIM Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS. METHOD The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project. RESULTS The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts. CONCLUSIONS The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.
Collapse
Affiliation(s)
- Peter Christensen
- Department of SurgeryDanish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic OrgansAarhus University HospitalAarhusDenmark
| | - Coen IM Baeten
- Department of SurgeryGroene Hart ZiekenhuisGoudaThe Netherlands
| | | | | | | | - Frank Zerbib
- Gastroenterology DepartmentCHU de BordeauxCentre Medico‐Chirurgical MagellanHôpital Haut‐LévêqueUniversité de BordeauxBordeauxFrance
| | - Gianluca Pellino
- Colorectal SurgeryVall d'Hebron University HospitalBarcelonaSpain
- Department of Advanced Medical and Surgical SciencesUniversitá degli Studi della Campania ‘Luigi Vanvitelli’NaplesItaly
| | - Harald Rosen
- Department of Surgical OncologySigmund Freud UniversityViennaAustria
| | | |
Collapse
|
21
|
McDermott FD. Altered colonic motility is associated with low anterior resection syndrome, by Keane et al. Colorectal Dis 2021; 23:338. [PMID: 33638906 DOI: 10.1111/codi.15547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
22
|
Afshari K, Smedh K, Wagner P, Chabok A, Nikberg M. Risk factors for developing anorectal dysfunction after anterior resection. Int J Colorectal Dis 2021; 36:2697-2705. [PMID: 34471965 PMCID: PMC8589768 DOI: 10.1007/s00384-021-04024-3] [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: 08/26/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR. METHODS This is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996-2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I-III rectal cancer patients had AR whereof 412 were included in this study. RESULTS Clustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63-0.90; p < 0.001) and clustering (OR 0.78; CI 0.67-0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08-3.31; p = 0.03), incontinence (OR 2.48; 1.29-4.77; p < 0.01), and urgency (OR 4.61; CI 2.02-10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis. CONCLUSION The part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.
Collapse
Affiliation(s)
- Kevin Afshari
- grid.413653.60000 0004 0584 1036Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland’s Hospital Västerås, 72189 Västerås, Sweden
| | - Kenneth Smedh
- grid.413653.60000 0004 0584 1036Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland’s Hospital Västerås, 72189 Västerås, Sweden
| | - Philippe Wagner
- grid.8993.b0000 0004 1936 9457Centre for Clinical Research, Uppsala University, Hospital of Vastmanland Västerås, Västerås, Sweden
| | - Abbas Chabok
- grid.413653.60000 0004 0584 1036Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland’s Hospital Västerås, 72189 Västerås, Sweden
| | - Maziar Nikberg
- grid.413653.60000 0004 0584 1036Colorectal Unit, Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland’s Hospital Västerås, 72189 Västerås, Sweden
| |
Collapse
|
23
|
Abstract
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.
Collapse
Affiliation(s)
- Theresa H Nguyen
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Ave., Ste. 8B, BCM 901, Houston, TX, 77030, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Reena V Chokshi
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, 7200 Cambridge Ave., Ste. 8B, BCM 901, Houston, TX, 77030, USA.
| |
Collapse
|
24
|
Thyø A, Laurberg S, Emmertsen KJ. Impact of bowel and stoma dysfunction on female sexuality after treatment for rectal cancer. Colorectal Dis 2020; 22:894-905. [PMID: 31985130 DOI: 10.1111/codi.14987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 01/14/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to measure the impact of bowel dysfunction and a poorly functioning stoma on the risk of sexual inactivity and sexual dysfunction in female patients. METHOD In a population-based cross-sectional study, Danish rectal cancer patients diagnosed between 2001 and 2014 were invited to answer a comprehensive questionnaire regarding cancer- and treatment-related late side effects after rectal cancer treatment. Bowel function was assessed using the Low Anterior Resection score and stoma function using the Colostomy Impact score. Female sexuality was measured by sexual activity, overall sexual dysfunction (the Rectal Cancer Female Sexuality score) and by different domains of sexual dysfunction (Sexual Vaginal Changes questionnaire). RESULTS Eight-hundred and thirteen female patients completed the questionnaire (response rate 49.2%). Major bowel dysfunction did not significantly increase the risk of sexual inactivity (OR 1.39, 95% CI 0.93-2.07) but clearly increased the risk of sexual dysfunction (OR 3.03, 95% CI 1.67-5.51). The most distinct problems were dyspareunia and inability to complete intercourse. On the contrary, poor stoma function increased the risk sexual inactivity (OR 2.26, 95% CI 1.16-4.40) but not the risk of sexual dysfunction (OR 0.74, 95% CI 0.27-1.99). The most distinct problem was dissatisfaction with own physical appearance. CONCLUSIONS Both bowel dysfunction and stoma dysfunction negatively, but differently, affect sexuality. After restorative surgery, bowel dysfunction was primarily associated with sexual dysfunction while poor stoma function after abdominoperineal excision was associated with sexual inactivity.
Collapse
Affiliation(s)
- A Thyø
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - K J Emmertsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, Randers Regional Hospital, Randers, Denmark
| |
Collapse
|
25
|
Nocera F, Angehrn F, von Flüe M, Steinemann DC. Optimising functional outcomes in rectal cancer surgery. Langenbecks Arch Surg 2020; 406:233-250. [PMID: 32712705 PMCID: PMC7936967 DOI: 10.1007/s00423-020-01937-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/07/2023]
Abstract
Background By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention. Purpose This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted. Conclusion Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.
Collapse
Affiliation(s)
- Fabio Nocera
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Fiorenzo Angehrn
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Markus von Flüe
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland
| | - Daniel C Steinemann
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Disease, St Clara Hospital and University Hospital, Kleinriehenstrasse 30, 4058, Basel, Switzerland.
- Department of Surgery, University Hospital Basel, Spitalstrasse 23, 4031, Basel, Switzerland.
| |
Collapse
|
26
|
Fassov J, Liao D, Brock C, Lundby L, Laurberg S, Krogh K. Sacral Nerve Modulation Has No Effect on the Postprandial Response in Irritable Bowel Syndrome. Clin Exp Gastroenterol 2020; 13:235-244. [PMID: 32636665 PMCID: PMC7335277 DOI: 10.2147/ceg.s245209] [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] [Received: 01/08/2020] [Accepted: 05/22/2020] [Indexed: 11/24/2022] Open
Abstract
Purpose Irritable bowel syndrome is a common gastrointestinal disorder with a global prevalence of approximately 11%. Onset or worsening of symptoms following digestion is one of the characteristics of the condition. The present study aimed at evaluating the postprandial sensory and motor response before and after treatment with sacral nerve modulation. Patients and Methods Twenty-one irritable bowel syndrome patients, 12 diarrhea-predominant and 9 mixed, were eligible for a 6-week sacral nerve modulation test period. Patients were investigated with multimodal impedance planimetry including a standardized meal at baseline and at the end of 2 weeks of suprasensory stimulation embedded in the 6-week sacral nerve modulation period. Results There was no statistical significant difference in the sensory response to heat or cold before and after sacral nerve modulation, p>0.05. At baseline, wall tension increased after the meal (mean 124.79 [range 82.5 to 237.3] mmHg.mm before the meal, mean 207.76 [range, 143.5 to 429] mmHg.mm after the meal), p=0.048 indicating a postprandial response. During sacral nerve modulation, the postprandial increase in wall tension did not reach statistical significance (mean 86.79 [range 28.8 to 204.5] mmHg.mm before the meal, mean 159.71 [range 71.3 to 270.8] mmHg.mm after the meal), p=0.277. However, there was no statistically significant difference between the postprandial wall tension at baseline and during sacral nerve modulation, p=0.489. Likewise, we found no difference between pressure or stretch ratio at baseline and during sacral nerve modulation, p>0.05. Conclusion Sacral nerve modulation does not exert its positive treatments effects in diarrhea-predominant and mixed irritable bowel syndrome through a modulation of the postprandial response.
Collapse
Affiliation(s)
- Janne Fassov
- Department Of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Donghua Liao
- GIOME Academia, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital and Clinical Institute, Faculty of Health Sciences Aalborg University, Aalborg, Denmark
| | - Lilli Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Department Of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
27
|
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.
Collapse
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
| |
Collapse
|
28
|
van Heinsbergen M, den Haan N, Maaskant-Braat AJ, Melenhorst J, Belgers EH, Leijtens JW, Bloemen JG, Rutten HJ, Bouvy ND, Janssen-Heijnen ML, Konsten JL. Functional bowel complaints and quality of life after surgery for colon cancer: prevalence and predictive factors. Colorectal Dis 2020; 22:136-145. [PMID: 31397962 DOI: 10.1111/codi.14818] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/09/2019] [Indexed: 12/13/2022]
Abstract
AIM Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS-like symptoms and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery. METHOD All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ-C30 and QLQ-CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories. RESULTS A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392-2.528) and a previous diverting stoma (OR 1.84, CI 1.14-2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains. CONCLUSION The results of this study highlight the presence of LARS-like symptoms after surgery for colonic cancer. Patients suffering from major LARS-like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients.
Collapse
Affiliation(s)
- M van Heinsbergen
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - N den Haan
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | - A J Maaskant-Braat
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - E H Belgers
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - J W Leijtens
- Department of Surgery, Laurentius Medical Centre, Roermond, The Netherlands
| | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - H J Rutten
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - M L Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J L Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| |
Collapse
|
29
|
van Heinsbergen M, Van der Heijden JAG, Stassen LP, Melenhorst J, de Witte E, Belgers EH, Maaskant-Braat AJG, Bloemen JG, Bouvy ND, Janssen-Heijnen ML, Konsten JL. The low anterior resection syndrome in a reference population: prevalence and predictive factors in the Netherlands. Colorectal Dis 2020; 22:46-52. [PMID: 31344293 DOI: 10.1111/codi.14790] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/15/2019] [Indexed: 02/08/2023]
Abstract
AIM The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after colorectal cancer surgery. There are no data about these complaints and the association with QoL in a reference population. The aim of this study was to assess LARS and the association with QoL in a reference population. METHODS Six hundred patients who visited the outpatient clinic because of general or trauma surgical indications were asked to participate in this study. They received an invitation letter containing three validated questionnaires to assess LARS (assessed with the LARS score) and both general [European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30] and colorectal-specific (EORTC QLQ-CR29) QoL. RESULTS Five hundred and one respondents could be included for the analyses. The median age at inclusion was 68 years and 47.3% were men. Major LARS was observed in 15% of patients (11.4% in men and 18.9% in women, P = 0.021). Women reported more urgency (P = 0.070) and incontinence for both flatus (P < 0.001) and stool (P = 0.063) compared to men. In univariate analyses, women reported major LARS significantly more often than men (OR 1.82; 95% CI 1.10-3.01). Patients with major LARS scored significantly worse in most QoL domains compared to patients with no/minor LARS. CONCLUSION This is the first study demonstrating major LARS and the association with QoL in a reference population of patients without colorectal cancer. Our data can assist in the interpretation of LARS in past and future research about abdominal complaints after colorectal cancer surgery.
Collapse
Affiliation(s)
- M van Heinsbergen
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| | | | - L P Stassen
- Department of Surgery, Maastricht University Medical Centre+/Uniklinik Aachen, Maastricht, The Netherlands
| | - J Melenhorst
- Department of Surgery, Maastricht University Medical Centre+/Uniklinik Aachen, Maastricht, The Netherlands
| | - E de Witte
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | - E H Belgers
- Department of Surgery, Zuyderland Medical Centre, Sittard-Geleen, The Netherlands
| | | | - J G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - N D Bouvy
- Department of Surgery, Maastricht University Medical Centre+/Uniklinik Aachen, Maastricht, The Netherlands
| | - M L Janssen-Heijnen
- Department of Clinical Epidemiology, VieCuri Medical Centre, Venlo, The Netherlands.,Department of Epidemiology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - J L Konsten
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
| |
Collapse
|
30
|
Etiology and management of low anterior resection syndrome based on the normal defecation mechanism. Surg Today 2019; 49:803-808. [PMID: 30937634 DOI: 10.1007/s00595-019-01795-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/07/2019] [Indexed: 12/27/2022]
Abstract
Low anterior resection syndrome (LARS) commonly develops after an anal sphincter-preserving operation (SPO). The etiology of LARS is not well understood, as the anatomical components and physiological function of normal defecation, which may be damaged during the SPO, are not well established. SPOs may damage components of the anal canal (such as the internal anal sphincter, longitudinal conjoint muscle, or hiatal ligament), either mechanically or via injury to the nerves that supply these organs. The function of the rectum is substantially impaired by resection of the rectum, division of the rectococcygeus muscle, and/or injury of the nervous supply. When the remnant rectum is small and does not function properly, an important functional role may be played by the neorectum, which is usually constructed from the left side of the colon. Hypermotility of the remnant colon may affect the manifestation of urge fecal incontinence. To develop an SPO that minimizes the risk of LARS, the anatomy and physiology of the structures involved in normal defecation need to be understood better. LARS is managed similarly to fecal incontinence. In particular, management should focus on reducing colonic motility when urge fecal incontinence is the dominant symptom.
Collapse
|
31
|
Elfeki H, Larsen HM, Emmertsen KJ, Christensen P, Youssef M, Khafagy W, Omar W, Laurberg S. Bowel dysfunction after sigmoid resection for cancer and its impact on quality of life. Br J Surg 2018; 106:142-151. [PMID: 30211443 DOI: 10.1002/bjs.10979] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/12/2018] [Accepted: 07/13/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Several studies have explored functional outcomes after rectal cancer surgery, but bowel dysfunction after sigmoid resection for cancer has hardly been considered. The aim of this study was to identify the prevalence and pattern of bowel dysfunction after resection for sigmoid cancer, and the impact of bowel function on quality of life (QoL) by comparison with patients who had polypectomy for cancer. METHODS This was a national cross-sectional study. Data were collected from the Danish Colorectal Cancer Group database, and a questionnaire regarding bowel function and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 QoL questionnaire was sent to all Danish colonic cancer survivors treated with sigmoid resection or polypectomy between 2001 and 2014. RESULTS A total of 3295 patients (3061 sigmoid resection, 234 polypectomy) responded to the questionnaire (response rate 63·8 per cent). Twelve bowel symptoms were more prevalent after sigmoid resection, including: excessive straining, fragmentation, bloating, nocturnal defaecation, bowel false alarm, liquid stool incontinence, incomplete evacuation and sense of outlet obstruction. QoL impairment owing to bowel symptoms was reported in 16·6 per cent of patients in the resection group and 10·1 per cent after polypectomy (P = 0·008). Obstructed defaecation symptoms (ODS) were encountered significantly more often after sigmoid resection than following polypectomy (17·9 versus 7·3 per cent; P < 0·001). In the resection group, patients with ODS had substantial impairment on most aspects of QoL assessed by the EORTC QLQ-C30. CONCLUSION Sigmoid resection for cancer is associated with an increased risk of long-term bowel dysfunction; obstructed defaecation is prevalent and associated with substantial impairment of QoL.
Collapse
Affiliation(s)
- H Elfeki
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark.,Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - H M Larsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - K J Emmertsen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, Regional Hospital Randers, Randers, Denmark
| | - P Christensen
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| | - M Youssef
- Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - W Khafagy
- Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - W Omar
- Colorectal Surgery Unit, Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | - S Laurberg
- Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects After Cancer in the Pelvic Organs, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
32
|
Bowel dysfunction after sigmoid resection underestimated: Multicentre study on quality of life after surgery for carcinoma of the rectum and sigmoid. Eur J Surg Oncol 2018; 44:1261-1267. [DOI: 10.1016/j.ejso.2018.05.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 02/21/2018] [Accepted: 05/03/2018] [Indexed: 01/11/2023] Open
|
33
|
Nuytens F, Develtere D, Sergeant G, Parmentier I, D'Hoore A, D'Hondt M. Perioperative radiotherapy is an independent risk factor for major LARS: a cross-sectional observational study. Int J Colorectal Dis 2018; 33:1063-1069. [PMID: 29696348 DOI: 10.1007/s00384-018-3043-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Sphincter-preserving surgery for rectal cancer is often associated with low anterior resection syndrome (LARS). The aim of our study was to determine the prevalence of LARS in our institution and identify possible risk factors for LARS. Furthermore, we evaluated which of the LARS symptoms was considered most disabling by patients and whether or not there is an adaptation of the LARS score over time. METHODS This study includes a prospective database of 100 patients who underwent total or partial mesorectal excision between January 2009 and September 2014. Patients were contacted after a median postoperative time of 38 (5-45) months to determine the LARS score and to identify LARS symptoms that were considered most disabling. Uni- and multivariate regression analysis was performed to identify risk factors for LARS and major LARS. Finally, the LARS score was evaluated over time after restoration of bowel continuity. RESULTS Out of the 100 patients, 16 had minor LARS (score 21-29) and 51 patients had major LARS (score 30-42). Radiotherapy was an independent risk factor for major LARS (p = 0.04). For the majority of patients with major LARS (22%), fragmentation was considered the most disabling complaint. There was no correlation between interval after restoration of bowel continuity and the severity of the LARS score. CONCLUSIONS Perioperative radiotherapy is an independent risk factor for major LARS. Fragmentation is considered the most disabling complaint in the majority of patients with major LARS. There is no significant adaptation of the LARS score over time.
Collapse
Affiliation(s)
- Frederiek Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Gregory Sergeant
- Department of Abdominal and Hepatobiliary Surgery, Jessa Hospital, Hasselt, Belgium
| | - Isabelle Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, Kortrijk, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium.
| |
Collapse
|
34
|
A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors. Int J Surg 2018; 56:234-241. [PMID: 29936195 DOI: 10.1016/j.ijsu.2018.06.031] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/10/2018] [Accepted: 06/20/2018] [Indexed: 12/16/2022]
Abstract
AIM To summarize the reported prevalence and causative factors of Low Anterior Resection Syndrome (LARS) from studies using the LARS score. METHODS A systematic literature search was conducted using Pubmed, Ovid Medline and the Cochrane database. Searches were performed using a combination of MeSH (medical subject headings) terms and key terms. Studies that were included used the LARS score as their primary collection tool. Studies were excluded if initial surgery was not for malignancy, or if the majority of LARS scores were from patients less than 1 year post initial surgery or closure of diverting stoma. Eligible studies were assessed with a validated quality assessment tool prior to performing a meta-analysis with quality effects model. Meta-analysis was conducted with prevalence estimates that had been transformed using the double arcsine method. RESULTS Following the initial search and implementation of inclusion and exclusion criteria 11 studies were deemed suitable for meta-analysis. Meta-analysis found the estimated prevalence of major LARS was 41% (95% CI 34 -48). Where possible outlier studies were excluded, the prevalence was 42% (95%CI 35-48). Radiotherapy and tumour height were the most consistently assessed variables, both showing a consistent negative effect on bowel function. Defunctioning ileostomy was found to have a statically significant negative impact on bowel function in 4 of 11 studies. The majority of reported data has been produced by groups in Denmark and the United Kingdom with limited numbers provided by other locations. Available data is heterogenous with some variables having limited numbers, making meta-analysis of certain variables impossible. CONCLUSIONS There is significant prevalence of Low Anterior Resection Syndrome following oncological rectal resection. A low anastomotic height or history of radiotherapy are major risk factors.
Collapse
|
35
|
Lin AY, Dinning PG, Milne T, Bissett IP, O'Grady G. The "rectosigmoid brake": Review of an emerging neuromodulation target for colorectal functional disorders. Clin Exp Pharmacol Physiol 2018; 44:719-728. [PMID: 28419527 DOI: 10.1111/1440-1681.12760] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/09/2017] [Accepted: 03/27/2017] [Indexed: 12/11/2022]
Abstract
The regulation of gastrointestinal motility encompasses several overlapping mechanisms including highly regulated and coordinated neurohormonal circuits. Various feedback mechanisms or "brakes" have been proposed. While duodenal, jejunal, and ileal brakes are well described, a putative distal colonic brake is less well defined. Despite the high prevalence of colonic motility disorders, there is little knowledge of colonic motility owing to difficulties with organ access and technical difficulties in recording detailed motor patterns along its entire length. The motility of the colon is not under voluntary control. A wide range of motor patterns is seen, with long intervals of intestinal quiescence between them. In addition, the use of traditional manometric catheters to record contractile activity of the colon has been limited by the low number of widely spaced sensors, which has resulted in the misinterpretation of colonic motor patterns. The recent advent of high-resolution (HR) manometry is revolutionising the understanding of gastrointestinal motor patterns. It has now been observed that the most common motor patterns in the colon are repetitive two to six cycles per minute (cpm) propagating events in the distal colon. These motor patterns are prominent soon after a meal, originate most frequently in the rectosigmoid region, and travel in the retrograde direction. The distal prominence and the origin of these motor patterns raise the possibility of them serving as a braking mechanism, or the "rectosigmoid brake," to limit rectal filling. This review aims to describe what is known about the "rectosigmoid brake," including its physiological and clinical significance and potential therapeutic applications.
Collapse
Affiliation(s)
- Anthony Y Lin
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Phil G Dinning
- Department of Gastroenterology and Surgery, Flinders Medical Centre, and the Discipline of Human Physiology, Flinders University, Bedford Park, South Australia, Australia
| | - Tony Milne
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Ian P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Gregory O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Department of Surgery, Auckland City Hospital, Auckland, New Zealand
| |
Collapse
|
36
|
Altomare DF, Picciariello A, Ferrara C, Digennaro R, Ribas Y, De Fazio M. Short-term outcome of percutaneous tibial nerve stimulation for low anterior resection syndrome: results of a pilot study. Colorectal Dis 2017; 19:851-856. [PMID: 28371160 DOI: 10.1111/codi.13669] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022]
Abstract
AIM Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive procedure which has been demonstrated to be effective in faecal/urinary incontinence but has never been tested in low anterior resection syndrome (LARS). The severity of LARS may be evaluated by the LARS score, but rectal cancer treatments may also affect urinary and sexual function, which are not explored by the LARS score. The Three Axial Perineal Evaluation (TAPE) score is a new validated index addressing the overall pelvic floor functions. This study aims to assess the efficacy of PTNS in LARS patients and to evaluate the results by the LARS and TAPE scores. METHODS Twenty-one patients operated on for rectal cancer between 2009 and 2014 complaining of LARS underwent PTNS (12 sessions of 30 min each). Six patients reported urinary incontinence and all except two (men) were sexually inactive. The LARS score and the TAPE score questionnaires were administered at baseline and after 6 months of follow-up. RESULTS At 6 months' follow-up, nine patients reported a significant improvement of faecal incontinence and 3/6 an improvement of urinary incontinence after PTNS. Median LARS score significantly decreased from 32 to 27 (P = 0.009), while the median TAPE score improved significantly from 55 to 58 (P = 0.004). CONCLUSIONS PTNS may be a further option in the treatment of selected patients with LARS and in addition may improve associated urinary incontinence. The severity of LARS can be detected by the LARS score; however, the adoption of the TAPE score is preferred in the case of concomitant urinary and/or sexual problems not explored by the LARS score.
Collapse
Affiliation(s)
- D F Altomare
- Department of Emergency and Organ Transplantation and Inter-department Research Center for Pelvic Floor Diseases (CIRPAP), University 'Aldo Moro' of Bari, Bari, Italy
| | - A Picciariello
- Department of Emergency and Organ Transplantation and Inter-department Research Center for Pelvic Floor Diseases (CIRPAP), University 'Aldo Moro' of Bari, Bari, Italy
| | - C Ferrara
- Department of Emergency and Organ Transplantation and Inter-department Research Center for Pelvic Floor Diseases (CIRPAP), University 'Aldo Moro' of Bari, Bari, Italy
| | - R Digennaro
- Department of Emergency and Organ Transplantation and Inter-department Research Center for Pelvic Floor Diseases (CIRPAP), University 'Aldo Moro' of Bari, Bari, Italy
| | - Y Ribas
- Department of Surgery, Consorci Sanitari de Terrassa, Terrassa (Barcelona), Spain
| | - M De Fazio
- Department of Emergency and Organ Transplantation and Inter-department Research Center for Pelvic Floor Diseases (CIRPAP), University 'Aldo Moro' of Bari, Bari, Italy
| |
Collapse
|
37
|
D'Hondt M, Nuytens F, Kinget L, Decaestecker M, Borgers B, Parmentier I. Sacral neurostimulation for low anterior resection syndrome after radical resection for rectal cancer: evaluation of treatment with the LARS score. Tech Coloproctol 2017; 21:301-307. [PMID: 28451766 DOI: 10.1007/s10151-017-1612-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 02/16/2017] [Indexed: 01/22/2023]
Abstract
PURPOSE Sacral neurostimulation (SNS) has proven to be an effective treatment modality for low anterior resection syndrome (LARS). The primary aim of this study is to investigate the impact of SNS on all symptoms of LARS, not merely on fecal incontinence. Furthermore, we wanted to evaluate whether the LARS score could be useful as a tool to evaluate SNS treatment. METHODS All patients diagnosed with minor or major LARS, unresponsive to conservative therapy for fecal incontinence, who underwent sacral neuromodulation for LARS at Groeninge Hospital, Kortrijk, Belgium, were prospectively enrolled in the study. The primary endpoint was the reduction in the severity of LARS. This was assessed by validated questionnaires: the LARS score and the Wexner score. RESULTS Eleven patients underwent definite implantation of the SNS device. All patients showed a substantial decrease in their Wexner scores: The mean score was reduced from 17.7 to 4.6 (Z: 2.93; p: 0.0033). Additionally, the mean LARS score dropped from 36.9 to 11.4 (Z: 2.93; p: 0.0033). Furthermore, there was a significant amelioration of all symptoms of LARS. CONCLUSIONS Our study shows that SNS is effective for all symptoms of LARS. The authors believe that in patients who receive SNS for LARS, it could be useful to determine the LARS score to evaluate the complexity of the symptoms and their response to treatment.
Collapse
Affiliation(s)
- M D'Hondt
- 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
| | - L Kinget
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | | | - B Borgers
- Faculty of Medicine and Health Sciences, UGent, De Pintelaan 135, 9000, Ghent, Belgium
| | - I Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Gregersen T, Brock C, Haase AM, Laurberg S, Drewes AM, Grønbæk H, Krogh K. Rectal Mechano-sensory Function in Patients with Carcinoid Diarrhea. J Neurogastroenterol Motil 2016; 22:264-71. [PMID: 26690884 PMCID: PMC4819865 DOI: 10.5056/jnm15113] [Citation(s) in RCA: 4] [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: 06/29/2015] [Revised: 11/21/2015] [Accepted: 12/01/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/AIMS In patients with neuroendocrine tumors, excessive production of serotonin and other amines may cause the carcinoid syndrome,which is mainly characterized by diarrhea and flushing. Little is known about the pathophysiology of carcinoid diarrhea. In severalother groups of patients, diarrhea may be associated with rectal hypersensitivity and increased rectal tone. Therefore, the aim of thepresent study was to compare rectal sensitivity and compliance in patients with carcinoid diarrhea and in healthy subjects. METHODS Twelve patients (6 males, aged 54-78 years, median 65 years), with carcinoid diarrhea and 19 healthy subjects (7 males, aged 50-78 years, median 61 years) were included. Rectal mechanical and heat stimulation was used for assessment of rectal mechano-sensory properties. RESULTS Overall, 5.3% higher temperatures were needed to elicit sensory responses in patients with carcinoid diarrhea than in healthy subjects (P = 0.015). Posthoc analyses revealed that the sensory threshold to heat was 48.1 ± 3.1°C in patients vs 44.7 ± 4.7°C in healthy subjects (P = 0.041). In contrast, patients and healthy subjects showed no overall differences in rectal sensory response to mechanical distension (P = 0.731) or rectal compliance (P = 0.990). CONCLUSIONS Patients with carcinoid diarrhea have higher sensory thresholds to heat stimulation in comparison to healthy subjects, but normalrectal sensation to mechanical distension and normal compliance. Therefore, treatment of carcinoid diarrhea should aim at prolonging gastrointestinal transit and decreasing secretion, rather than modifying rectal mechano-sensory function.
Collapse
Affiliation(s)
- Tine Gregersen
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christina Brock
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Anne-Mette Haase
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - Asbjørn M Drewes
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Henning Grønbæk
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
40
|
Bondeven P, Emmertsen KJ, Laurberg S, Pedersen BG. Neoadjuvant therapy abolishes the functional benefits of a larger rectal remnant, as measured by magnetic resonance imaging after restorative rectal cancer surgery. Eur J Surg Oncol 2015. [PMID: 26219852 DOI: 10.1016/j.ejso.2015.07.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The combination of advances in surgical technique and neoadjuvant therapy for rectal cancer has resulted in more patients undergoing sphincter-preserving surgery. Unfortunately, numerous patients subsequently experience bowel dysfunction, and may suffer from lifelong severe disability with major impact on their quality of life. The aim of the present study was to investigate whether the risk of severe LARS in patients was associated with the length of remnant rectum. METHODS A total of 125 patients who underwent sphincter-preserving surgery for rectal cancer were included. Postoperative bowel function was assessed using the low anterior resection syndrome (LARS) score a minimum of one year following surgery. The length of remnant rectum was measured on postoperative MRI of the pelvis and was correlated with the risk of having major LARS. RESULTS Overall, major LARS was observed in 38 per cent of patients. In the patients who underwent surgery alone, major LARS was reported by 27 per cent, and a larger remnant rectum was associated with a better functional outcome. In contrast, 80 per cent of patients who underwent combined preoperative chemoradiotherapy and surgery reported having major LARS. No association between the length of remnant rectum and the risk of major LARS was observed in patients treated with combined neoadjuvant therapy and surgery. CONCLUSION Both the length of remnant rectum and preoperative chemoradiotherapy had a major impact on the severity of bowel dysfunction after restorative rectal cancer surgery. No functional benefit from an irradiated rectal remnant was observed.
Collapse
Affiliation(s)
- P Bondeven
- Aarhus University Hospital, Department of Surgery P, Tage-Hansensgade 2, 8000 Aarhus, Denmark; Aarhus University Hospital, Department of Radiology, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark.
| | - K J Emmertsen
- Aarhus University Hospital, Department of Surgery P, Tage-Hansensgade 2, 8000 Aarhus, Denmark
| | - S Laurberg
- Aarhus University Hospital, Department of Surgery P, Tage-Hansensgade 2, 8000 Aarhus, Denmark
| | - B G Pedersen
- Aarhus University Hospital, Department of Radiology, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| |
Collapse
|
41
|
Bregendahl S, Emmertsen KJ, Lindegaard JC, Laurberg S. Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study. Colorectal Dis 2015; 17:26-37. [PMID: 25156386 DOI: 10.1111/codi.12758] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Revised: 06/29/2014] [Accepted: 07/15/2014] [Indexed: 02/08/2023]
Abstract
AIM Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction. METHOD All living female patients who underwent abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ-FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009. RESULTS Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties (OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions (OR = 4.77, 95% CI 1.97-11.55), dyspareunia (OR = 2.76, 95% CI 1.12-6.79), lack of desire (OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity (OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia (OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties (OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence (OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire (OR = 2.69, 95% CI 1.21-5.98), sexual inactivity (OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction (OR = 0.40, 95% CI 0.20-0.82). CONCLUSION Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction.
Collapse
Affiliation(s)
- S Bregendahl
- Surgical Research Unit, Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | |
Collapse
|
42
|
Petersen SE, Bentzen L, Emmertsen KJ, Laurberg S, Lundby L, Høyer M. Development and validation of a scoring system for late anorectal side-effects in patients treated with radiotherapy for prostate cancer. Radiother Oncol 2014; 111:94-9. [DOI: 10.1016/j.radonc.2014.01.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 01/29/2014] [Accepted: 01/31/2014] [Indexed: 12/20/2022]
|
43
|
Neorectal hyposensitivity after neoadjuvant therapy for rectal cancer. Radiother Oncol 2013; 108:331-6. [PMID: 23932153 DOI: 10.1016/j.radonc.2013.07.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 06/11/2013] [Accepted: 07/14/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Preoperative radiotherapy for rectal cancer has a detrimental effect on long-term anorectal function and quality of life, additional to that observed after rectal resection. The exact physiological mechanisms for the excess impairment remain unknown. We aimed to investigate neorectal and anal sphincter properties in patients treated with neoadjuvant therapy (NT) prior to total mesorectal excision (TME). MATERIAL AND METHODS Sixteen patients (NT+ patients) were examined by multimodal neorectal stimulation and standard anorectal physiological testing. Data were compared to the results of 23 patients, who underwent TME without NT (NT- patients). RESULTS NT+ patients had elevated sensory thresholds to heat (median temperature, 60 vs. 55 °C; p<0.01) and mechanical distension (median tension, 2513 vs. 1521 mmHg mm; p=0.05) in the fasting state, and altered perception of the sensory response to heat (p=0.01) and cold (p=0.01) compared to NT- patients. No differences in the biomechanical properties of the neorectal wall were detected. Anal resting pressure was lower in NT+ patients compared to NT- patients (median pressure, 31 vs. 45 cm H2O; p=0.05). CONCLUSIONS Pelvic radiotherapy causes neorectal hyposensitivity to mechanical and thermal stimuli in patients receiving NT prior to TME surgery for rectal cancer, possibly due to impaired afferent nerve function.
Collapse
|