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Gefen R, Strassmann V, Stefano Hernandez FD, Garoufalia Z, Horesh N, Emile SH, Da Silva G, Wexner S. Risk factors for complications following sacral neuromodulation for faecal incontinence: Long-term follow-up. Colorectal Dis 2024. [PMID: 38997819 DOI: 10.1111/codi.17092] [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: 03/13/2024] [Revised: 06/19/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024]
Abstract
AIM Sacral neuromodulation (SNM) has become a standard surgical treatment for faecal incontinence (FI). Prior studies have reported various adverse events of SNM, including suboptimal therapeutic response, infection, pain, haematoma, and potential need for redo SNM. The aim of this study was to identify the risk factors associated with long-term complications of SNM. METHOD This retrospective cohort reviewed patients who underwent two-stage SNM for FI at our institution between 2011-2021. Preoperative baseline characteristics and follow-up were obtained from the medical record and/or by telephone interview. Management and outcome of each postoperative event were evaluated by univariate and multivariate regression analyses. RESULTS A total of 291 patients (85.2% female) were included in this study. Postoperative complications were recorded in 219 (75.2%) patients and 154 (52.9%) patients required surgical intervention to treat complications. The most common postoperative event was loss of efficacy (46.4%). Other common adverse events were problems at the implant site (pain, infection, etc.) in 16.5% and pain during stimulation in 11.7%. Previous vaginal delivery (OR 2.74, p = 0.003) and anal surgery (OR = 2.46, p = 0.039) were independent predictors for complications. Previous colorectal (OR = 2.04, p = 0.026) and anal (OR = 1.98, p = 0.022) surgery and history of irritable bowel syndrome (IBS) (OR = 3.49, p = 0.003) were independent predictors for loss of efficacy. CONCLUSION Postoperative adverse events are frequently recorded after SNM. Loss of efficacy is the most common. Previous colorectal or anal surgery, vaginal delivery, and IBS are independent risk factors for complications.
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Affiliation(s)
- Rachel Gefen
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of General Surgery, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Victor Strassmann
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Felice De Stefano Hernandez
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Zoe Garoufalia
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Nir Horesh
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Department of Surgery and Transplantation, Sheba Medical Centre, Ramat-Gan, Israel
| | - Sameh Hany Emile
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
- Colorectal Surgery Unit, General Surgery Department, Mansoura University Hospitals, Mansoura, Egypt
| | - Giovanna Da Silva
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
| | - Steven Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Centre, Cleveland Clinic Florida, Weston, Florida, USA
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Pires M, Severo M, Lopes A, Neves S, Matzel K, Povo A. Sacral neuromodulation for low anterior resection syndrome: current status-a systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:189. [PMID: 37428256 DOI: 10.1007/s00384-023-04485-8] [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] [Accepted: 06/30/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION It is estimated that approximately 70% of patients with rectal cancer who undergo surgery will suffer from Low Anterior Resection Syndrome (LARS). In the last decades, sacral neuromodulation (SNM) has been widely used in urinary dysfunction and in faecal incontinence refractory to medical treatment. Its application in LARS has been investigated and has shown promising results. The paper's aim is to present a systematic review and meta-analysis of the available literature and evaluate the therapeutic success of SNM in patients with LARS. METHODS A systematic search was performed in international health-related databases: Cochrane Library, EMBASE, PubMed and SciELO. No restrictions on year of publication or language were applied. Retrieved articles were screened and selected according to set inclusion criteria. Data items were collected and processed for each included article and a meta-analysis was done according to the PRISMA guidelines. The primary outcome was the number of successful definitive SNM implants. Further outcomes included changes in bowel habits, incontinence scores, quality of life scores, anorectal manometry data and complications. RESULTS A total of 18 studies were included, with 164 patients being submitted to percutaneous nerve evaluation (PNE) with 91% responding successfully. During follow-up of therapeutic SNM some devices were explanted. The final clinical success rate was 77% after permanent implant. Other outcomes, such as the frequency of incontinent episodes, faecal incontinence scores, quality of life scores were overall improved after SNM. The meta-analysis showed a decrease in 10.11 incontinent episodes/week; a decrease of 9.86 points in the Wexner score and an increase in quality of life of 1.56 (pooled estimate). Changes in anorectal manometry were inconsistent. Local infection was the most common post-operative complication, followed by pain, mechanical issues, loss of efficacy and haematoma. DISCUSSION/CONCLUSION This is the largest systematic review and meta-analysis concerning the use of SNM in LARS patients. The findings support the available evidence that sacral neuromodulation can be effective in the treatment of LARS, with significant improvement in total incontinent episodes and patients´ quality of life.
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Affiliation(s)
- Marco Pires
- Serviço de Cirurgia Geral, Departamento de Cirurgia, Porto, CHUdSA, Portugal.
| | - Milton Severo
- ICBAS-UP-School of Medicine and Biomedical Sciences, Porto, Portugal
- Academic Clinical Center ICBAS-CHUdSA, Porto, Portugal
| | - Ana Lopes
- Serviço de Urologia, Departamento de Cirurgia, Porto, CHUdSA, Portugal
| | - Sílvia Neves
- ICBAS-UP-School of Medicine and Biomedical Sciences, Porto, Portugal
- Serviço de Cirurgia Geral de Ambulatório, Departamento de Cirurgia, Porto, CHUdSA, Portugal
| | - Klaus Matzel
- Section of Coloproctology, Department of Surgery, University of Erlangen, Erlangen, Germany
| | - Ana Povo
- ICBAS-UP-School of Medicine and Biomedical Sciences, Porto, Portugal
- Academic Clinical Center ICBAS-CHUdSA, Porto, Portugal
- Serviço de Cirurgia Geral de Ambulatório, Departamento de Cirurgia, Porto, CHUdSA, Portugal
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Emile SH, Garoufalia Z, Barsom S, Horesh N, Gefen R, Zhou P, Wexner SD. Systematic review and meta-analysis of randomized clinical trials on the treatment of low anterior resection syndrome. Surgery 2023; 173:1352-1358. [PMID: 37012144 DOI: 10.1016/j.surg.2023.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND We conducted a systematic review of randomized clinical trials on treating low anterior resection syndrome to help inform current practice. METHODS This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials involved different treatments for low anterior resection syndrome. The risk of bias 2 tool was used to assess the risk of bias. The main outcomes were improvement in low anterior resection syndrome after treatment assessed by change in low anterior resection syndrome, fecal incontinence scores, and adverse treatment effects. RESULTS After an initial screening of 1,286 studies, 7 randomized clinical trials were included. Sample sizes ranged between 12 to 104 patients. Posterior tibial nerve stimulation was the most frequently assessed treatment in 3 randomized clinical trials. The weighted mean difference between posterior tibial nerve stimulation and medical treatment or sham therapy in follow-up low anterior resection syndrome score (-3.31, P = .157) was insignificant. Transanal irrigation reduced major low anterior resection syndrome symptoms by 61.5% compared with 28.6% after posterior tibial nerve stimulation with a significantly lower 6-month follow-up low anterior resection syndrome score. Pelvic floor training achieved better improvement in low anterior resection syndrome than standard care (47.8% vs 21.3%) at 6 months, but this was not maintained at 12 months (40.0% vs 34.9%). Ramosetron was associated with a greater short-term improvement in major low anterior resection syndrome (23% vs 8%) and a lower low anterior resection syndrome score (29.5 vs 34.6) at 4-weeks follow-up than Kegels or Sitz baths. No significant improvement in bowel function was noted after probiotics use as probiotics and placebo had similar follow-up low anterior resection syndrome scores (33.3 vs 36). CONCLUSION Transanal irrigation was associated with improvement in low anterior resection syndrome according to 2 trials, and ramosetron showed promising short-term results in one trial. Posterior tibial nerve stimulation had a marginal benefit compared with standard care. In contrast, pelvic floor training was associated with short-term symptomatic improvement, and probiotics showed no tangible improvement in low anterior resection syndrome symptoms. Firm conclusions cannot be drawn due to the small number of trials published.
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Vettoretto N, Foglia E, Ferrario L, Gerardi C, Molteni B, Nocco U, Lettieri E, Molfino S, Baiocchi GL, Elmore U, Rosati R, Currò G, Cassinotti E, Boni L, Cirocchi R, Marano A, Petz WL, Arezzo A, Bonino MA, Davini F, Biondi A, Anania G, Agresta F, Silecchia G. Could fluorescence-guided surgery be an efficient and sustainable option? A SICE (Italian Society of Endoscopic Surgery) health technology assessment summary. Surg Endosc 2021; 34:3270-3284. [PMID: 32274626 DOI: 10.1007/s00464-020-07542-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. METHODS A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. RESULTS From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. CONCLUSION The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.
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Affiliation(s)
- N Vettoretto
- Chirurgia Montichiari, Azienda Socio Sanitaria Territoriale Degli Spedali Civili, V.le Ciotti 154, Montichiari, 25018, Brescia, Italy.
| | - E Foglia
- LIUC - Università Cattaneo, Castellanza, VA, Italy
| | - L Ferrario
- LIUC - Università Cattaneo, Castellanza, VA, Italy
| | - C Gerardi
- Centro di Politiche Regolatorie, Istituto di Ricerche Farmacologiche "Mario Negri" IRCCS, Milan, Italy
| | - B Molteni
- Department of Clinical and Experimental Surgery, University of Brescia, Brescia, Italy
| | - U Nocco
- Ingegneria Clinica, Azienda Socio Sanitaria Territoriale dei Sette Laghi, Varese, Italy
| | - E Lettieri
- School of Management, Department of Management, Economics and Industrial Engineering, Politecnico, Milano, Italy
| | - S Molfino
- Department of Clinical and Experimental Surgery, University of Brescia, Brescia, Italy
| | - G L Baiocchi
- Department of Clinical and Experimental Surgery, University of Brescia, Brescia, Italy
| | - U Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - R Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - G Currò
- Department of Human Pathology of Adult and Evolutive Age, University Hospital of Messina, Messina, Italy
| | - E Cassinotti
- Chirurgia Generale, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico - University of Milan, Milan, Italy
| | - L Boni
- Chirurgia Generale, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico - University of Milan, Milan, Italy
| | - R Cirocchi
- Department of Surgical Sciences, University of Perugia, Perugia, Italy
| | - A Marano
- Chirurgia Generale ed Oncologica, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy
| | - W L Petz
- Chirurgia, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - A Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - M A Bonino
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - F Davini
- Centro multidisciplinare Chirurgia Robotica, Chirurgia Toracica mini-invasiva e Robotica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - A Biondi
- Chirurgia Generale, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - G Anania
- Chirurgia Generale, University of Ferrara, Ferrara, Italy
| | - F Agresta
- Chirurgia Generale, Azienda ULSS 5 "Polesana", Hospital of Adria, Adria, RO, Italy
| | - G Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome-Polo Pontino, Rome, Italy
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Rubio-Perez I, Saavedra J, Marijuan JL, Pascual-Miguelañez I. Optimizing sacral neuromodulation for low anterior resection syndrome: learning from our experience. Colorectal Dis 2020; 22:2146-2154. [PMID: 32657528 DOI: 10.1111/codi.15261] [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: 04/11/2020] [Accepted: 06/30/2020] [Indexed: 12/12/2022]
Abstract
AIM The aim of this work was to review our institutional series of patients treated with sacral neuromodulation (SNM) for low anterior resection syndrome (LARS) and evaluate possible factors associated with therapeutic success. METHOD Twenty-five patients were treated with SNM for LARS between 2008 and 2019. SNM was performed as per our institutional protocol. Patients were evaluated with Wexner and LARS scores before and after SNM treatment. A visual analogue scale (1-10) was used to evaluate overall patient satisfaction with SNM. RESULTS There were significant differences between the mean LARS score values before (37.82) and after (29) SNM therapy (P < 0.004). The mean Wexner score was higher (16.24) before SNM treatment than afterwards (11.13) (P < 0.004). There was a direct relationship between the height of anastomosis and LARS score (P = 0.035): there were big changes in LARS scoring (pre-/post-SNM therapy) in patients with higher anastomoses, and vice versa. Patients who received radiotherapy scored lower in mean satisfaction (6.38) than patients without previous radiotherapy (8.22) (P = 0.008). There was an important positive association between Wexner score and patient satisfaction (P = 0.001): relevant changes in Wexner scoring after SNM therapy were associated with high patient satisfaction, and vice versa. CONCLUSION Our study showed a relationship between changes in Wexner and LARS scores before and after SNM and overall patient satisfaction with SNM therapy. These findings also suggest patients with previous radiotherapy may have worse results with SNM (based on lower overall satisfaction), and that higher anastomoses have a greater impact on the post-SNM LARS score.
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Affiliation(s)
- I Rubio-Perez
- Colorectal Surgery Unit, Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - J Saavedra
- Colorectal Surgery Unit, Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - J L Marijuan
- Colorectal Surgery Unit, Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
| | - I Pascual-Miguelañez
- Colorectal Surgery Unit, Department of General Surgery, Hospital Universitario La Paz, Madrid, Spain
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Randomized Pilot Trial of Percutaneous Posterior Tibial Nerve Stimulation Versus Medical Therapy for the Treatment of Low Anterior Resection Syndrome: One-Year Follow-up. Dis Colon Rectum 2020; 63:1602-1609. [PMID: 33149022 DOI: 10.1097/dcr.0000000000001614] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Low anterior resection syndrome is significantly associated with a deterioration in the quality of life, and its medical treatment is usually ineffective. OBJECTIVE The aim of the present study was to establish the efficacy of percutaneous tibial nerve stimulation in treating this syndrome. DESIGN This is a randomized pilot trial with 1-year follow-up. SETTINGS The study was conducted in a specialized colorectal unit of a tertiary hospital. PATIENTS Patients who underwent neoadjuvant chemoradiotherapy and low anterior rectal resection for cancer with low anterior resection syndrome score ≥21 and ileostomy closed at least 18 months earlier were included. INTERVENTIONS Patients were randomly assigned to receive either percutaneous tibial nerve stimulation plus medical treatment (arm A, n = 6) or medical treatment (arm B, n = 6). Low anterior resection syndrome was assessed using symptom severity and disease-specific quality-of-life scores at baseline, at the end of treatment, and at 1-year follow-up. MAIN OUTCOME MEASURES The primary outcome was a clinical response, defined as a reduction of the low anterior resection syndrome score. RESULTS Only in group A low anterior resection syndrome score, fecal incontinence severity index, and obstructed defecation syndrome score improved significantly with treatment (35.8 ± 2.5 vs 29.0 ± 3.8 (p = 0.03); 36.8 ± 4.3 vs 18.5 ± 8.0 (p = 0.02); 10.3 ± 3.9 vs 8.0 ± 4.9 (p = 0.009)) and changes were observed in all domains of quality-of-life instruments. In both groups the symptom severity and quality-of-life scores at 1-year follow-up did not differ significantly from those recorded at the end of treatment. LIMITATIONS The study had a small number of patients and it was underpowered to detect the within-group effect. CONCLUSIONS Percutaneous tibial nerve stimulation could be an effective treatment for low anterior resection syndrome. Additional studies are warranted to investigate clinical effectiveness in low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B371. ESTUDIO PILOTO ALEATORIO DE ESTIMULACIÓN PERCUTÁNEA DEL NERVIO TIBIAL POSTERIOR VERSUS TERAPIA MÉDICA PARA EL TRATAMIENTO DEL SÍNDROME DE RESECCIÓN ANTERIOR BAJA: UN AÑO DE SEGUIMIENTO: El síndrome de resección anterior baja se asocia con un deterioro significativo en la calidad de vida y su tratamiento médico generalmente es ineficaz.El objetivo del presente estudio fue establecer la eficacia de la estimulación percutánea del nervio tibial en el tratamiento de este síndrome.Este es un estudio piloto aleatorio con 1 año de seguimiento.El estudio se realizó en una unidad colorrectal especializada de un hospital terciario.Se incluyeron pacientes que se sometieron a quimiorradioterapia neoadyuvante y resección rectal anterior baja por cáncer con puntaje de síndrome de resección anterior baja ≥ 21 e ileostomía cerrada al menos 18 meses antes.Los pacientes fueron asignados aleatoriamente para recibir estimulación percutánea del nervio tibial + tratamiento médico (brazo A, n = 6) o tratamiento médico (brazo B, n = 6). El síndrome de resección anterior baja se evaluó utilizando puntajes de la gravedad de los síntomas y de calidad de vida específicos de la enfermedad al inicio, al final del tratamiento y al año de seguimiento.El resultado primario fue una respuesta clínica, definida como una reducción de la puntuación del síndrome de resección anterior baja.Solo en el grupo A, el puntaje del síndrome de resección anterior baja, el índice de severidad de incontinencia fecal y el puntaje del síndrome de defecación obstruida mejoraron significativamente con el tratamiento (35.8 ± 2.5 vs 29 ± 3.8, p = 0.03; 36.8 ± 4.3 vs 18.5 ± 8.0, p = 0.02; 10.3 ± 3.9 vs 8.0 ± 4.9, p = 0.009, respectivamente) y se observaron cambios en todos los dominios de los instrumentos de calidad de vida. En ambos grupos, los puntajes de severidad de los síntomas y de calidad de vida al año de seguimiento no difirieron significativamente de los registrados al final del tratamiento.El estudio tuvo un pequeño número de pacientes y no logró suficiente poder para detectar el efecto dentro de grupo.La estimulación percutánea del nervio tibial podría ser un tratamiento efectivo para el síndrome de resección anterior baja. Se requieren estudios adicionales para investigar la efectividad clínica en el síndrome de resección anterior baja. Consulte Video Resumen http://links.lww.com/DCR/B371.
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Arezzo A, Bonino MA, Ris F, Boni L, Cassinotti E, Foo DCC, Shum NF, Brolese A, Ciarleglio F, Keller DS, Rosati R, De Nardi P, Elmore U, Fumagalli Romario U, Jafari MD, Pigazzi A, Rybakov E, Alekseev M, Watanabe J, Vettoretto N, Cirocchi R, Passera R, Forcignanò E, Morino M. Intraoperative use of fluorescence with indocyanine green reduces anastomotic leak rates in rectal cancer surgery: an individual participant data analysis. Surg Endosc 2020; 34:4281-4290. [PMID: 32556696 DOI: 10.1007/s00464-020-07735-w] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 06/09/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fluorescence imaging by means of Indocyanine green (ICG) has been applied to intraoperatively determine the perfusion of the anastomosis. The purpose of this Individual Participant Database meta-analysis was to assess the effectiveness in decreasing the incidence of anastomotic leak (AL) after rectal cancer surgery. METHODS We searched PubMed, Embase, Cochrane Library and ClinicalTrial.gov, EU Clinical Trials and ISRCTN registries on September 1st, 2019. We considered eligible those studies comparing the assessment of anastomotic perfusion during rectal cancer surgery by intraoperative use of ICG fluorescence compared with standard practice. We defined as primary outcome the incidence of AL at 30 days after surgery. The studies were assessed for quality by means of the ROBINS-I and the Cochrane risk tools. We calculated odds ratios (ORs) using the Individual patient data analysis, restricted to rectal lesions, according to original treatment allocation. RESULTS The review of the literature and international registries produced 15 published studies and 5 ongoing trials, for 9 of which the authors accepted to share individual participant data. 314 patients from two randomized trials, 452 from three prospective series and 564 from 4 non-randomized studies were included. Fluorescence imaging significantly reduced the incidence of AL (OR 0.341; 95% CI 0.220-0.530; p < 0.001), independent of age, gender, BMI, tumour and anastomotic distance from the anal verge and neoadjuvant therapy. Also, overall morbidity and reintervention rate were positively influenced by the use of ICG. CONCLUSIONS The incidence of AL may be reduced when ICG fluorescence imaging is used to assess the perfusion of a colorectal anastomosis. Limitations relate to the consistent number of non-randomized studies included and their heterogeneity in defining and assessing AL. Ongoing large randomized studies will help to determine the exact role of routine ICG fluorescence imaging may decrease the incidence of AL in surgery for rectal cancer.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy.
| | - Marco Augusto Bonino
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and medical school, Geneva, Switzerland
| | - Frédéric Ris
- Department of Surgery, Service of Visceral Surgery, Geneva University Hospitals and medical school, Geneva, Switzerland
| | - Luigi Boni
- Department of Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Elisa Cassinotti
- Department of Surgery, Fondazione IRCCS - Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Nga Fan Shum
- Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | | | | | - Deborah S Keller
- Department of Surgery, New York Presbyterian Hospital, Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY, USA
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola De Nardi
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ugo Elmore
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Mehraneh Dorna Jafari
- Colon and Rectal Surgery, General Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Alessio Pigazzi
- Colon and Rectal Surgery, General Surgery, UC Irvine Medical Center, Orange, CA, USA
| | - Evgeny Rybakov
- Surgical Department of Oncoproctology - State Scientific Centre of Coloproctology, Moscow, Russian Federation
| | - Mikhail Alekseev
- Surgical Department of Oncoproctology - State Scientific Centre of Coloproctology, Moscow, Russian Federation
| | - Jun Watanabe
- Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Nereo Vettoretto
- General Surgery, Montichiari Hospital, ASST Spedali Civili Brescia, Brescia, Italy
| | - Roberto Cirocchi
- Department of General Surgery and Surgical Oncology, Hospital of Terni, University of Perugia, Terni, Italy
| | - Roberto Passera
- Department of Medical Sciences, University of Torino, Torino, Italy
| | - Edoardo Forcignanò
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Corso Dogliotti 14, 10126, Torino, Italy
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Ram E, Meyer R, Carter D, Gutman M, Rosin D, Horesh N. The efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome: a systematic review and meta-analysis. Tech Coloproctol 2020; 24:803-815. [PMID: 32350733 DOI: 10.1007/s10151-020-02231-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/22/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Sacral neuromodulation (SNM) has become one of the main treatment options in patients with fecal incontinence. The aim of this study was to determine the efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome (LARS). METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was conducted using the Pubmed, Embase, Ovid, and Cochrane databases, restricted to the English language and to articles published from 2000 to November 2018. RESULTS A total of 434 articles on the efficacy of SNM in the treatment of LARS were retrieved, and 13 studies were included in the final analysis, with a total of 114 patients treated with SNM for LARS The overall success rate excluding study heterogeneity was 83.30% [95% CI (71.33-95.25%)]. Improvement in anal continence was seen in several clinical and functional parameters, including the Wexner Score [10.78 points, 95% CI (8.55-13.02), p < 0.0001], manometric maximum resting pressure [mean improvement of 6.37 mm/Hg, 95% CI (2.67-10.07), p = 0.0007], maximum squeeze pressure [mean improvement of 17.99 mm/Hg, 95% CI (17.42-18.56), p < 0.0001] and maximum tolerated volume [mean improvement of 22.74 ml, 95% CI (10.65-34.83), p = 0.0002]. Quality of life questionnaires also demonstrated significant improvement in patients' quality of life, but were reported only in a small group of included patients. CONCLUSIONS SNM significantly improves symptoms and quality of life in patients suffering from fecal incontinence following low anterior resection.
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Affiliation(s)
- E Ram
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel.
- Tel Aviv University, Tel Aviv, Israel.
| | - R Meyer
- Tel Aviv University, Tel Aviv, Israel
- Department of Gynecology and Obstetrics, Sheba Medical Centre, Tel Hashomer, Israel
| | - D Carter
- Tel Aviv University, Tel Aviv, Israel
- Department of Gastroenterology, Sheba Medical Centre, Tel Hashomer, Israel
| | - M Gutman
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - D Rosin
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - N Horesh
- Department of Surgery B, Sheba Medical Centre, Tel Hashomer, Israel
- Tel Aviv University, Tel Aviv, Israel
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Antegrade Enema After Total Mesorectal Excision for Rectal Cancer: The Last Chance to Avoid Definitive Colostomy for Refractory Low Anterior Resection Syndrome and Fecal Incontinence. Dis Colon Rectum 2018; 61:667-672. [PMID: 29722725 DOI: 10.1097/dcr.0000000000001089] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Total mesorectal excision and preoperative radiotherapy in mid and low rectal cancer allow us to achieve very good oncological results. However, major and refractory low anterior resection syndrome and fecal incontinence alter the quality of life of patients with a long expected life span. OBJECTIVE We assessed the functional results of patients treated by antegrade enema for refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision. DESIGN This is a prospective monocentric study from 2012 to 2016. PATIENTS Patients who underwent percutaneous endoscopic cecostomy for refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision were prospectively analyzed. MAIN OUTCOME MEASURES We assessed the morbidity of the procedure and compared low anterior resection syndrome score, Wexner score, and Gastrointestinal Quality of Life Index before and after the use of antegrade enema. RESULTS Of 25 patients treated by antegrade enema over the study period, 6 (24%) had a low anterior resection, 18 (72%) had a coloanal anastomosis, and 1 (4%) had a perineal colostomy. Postoperatively, the rate of local abscess was 8%, all treated by antibiotics. Low anterior resection syndrome score (33 vs 4, p < 0.001), Wexner score (16 vs 4, p <0.001), and Gastrointestinal Quality of Life Index (73 vs 104, p < 0.001) were all significantly improved after antegrade enema. The 2 main symptoms reported by patients were sweating (28%) and local pain (36%). At the end of the follow-up, 16% (n = 4) catheters were removed, and the rate of definitive colostomy was 12% (n = 3). LIMITATIONS The main limitations of this study are the monocentric features and the sample size. CONCLUSION Antegrade enema for major and refractory low anterior resection syndrome and fecal incontinence after total mesorectal excision appears to be a promising treatment to avoid definitive colostomy. See Video Abstract at http://links.lww.com/DCR/A608.
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