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Ofluoglu CB, Aydin IC, Altuntas YE, Cetin K, Inan R, Ilhan N, Mulkut F, Kucuk HF. Impact of pelvic floor muscle training on sphincter function and quality-of-life in patients who underwent low anterior resection: A comparative evaluation. North Clin Istanb 2024; 11:336-342. [PMID: 39165708 PMCID: PMC11331206 DOI: 10.14744/nci.2024.37786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 06/25/2024] [Indexed: 08/22/2024] Open
Abstract
OBJECTIVE Our study aimed to determine the impact of pelvic floor muscle training (PFMT) on sphincter function and overall well-being in patients who underwent low anterior resection (LAR) and diverting ileostomy due to rectal cancer. For this purpose, anal electromyography (aEMG), low anterior resection syndrome (LARS) score, and the European Organization for Research and Treatment of Cancer quality-of-life questionnaires (EORTC-QLQ)-C30 (generic for cancer) and CR29 (specific to colorectal cancer) were used. The primary endpoint of our study is to determine the effect of PFMT on sphincter function by aEMG, the secondary endpoint is to evaluate the effect on quality-of-life using the LARS score, EORTC-QLQ-C30 and CR-29 questionnaires. METHODS Conducted between January 2017 and April 2018 at a tertiary hospital's general surgery clinic, the study included 32 patients between the ages of 18 and 75 who underwent low anterior resection and diverting ileostomy surgery. The patients were divided into two: the Study Group (SG), which started PFMT after surgery, and the Control Group (CG), which was not subjected to additional exercises. Six months after closure of the diverting ileostomy, both groups were evaluated with aEMG, LARS scores, and EORTC-QLQ-C30 and CR-29. RESULTS aEMG duration values were significantly lower in the SG (17.6 m/sec vs. 19.9 m/sec; p=0.001). Additionally, a significant decrease in SG, major LARS rates (12.5% vs. 62.5%; p=0.004) and LARS scores (23.1 vs. 30.0; p=0.003) was observed. While there was no significant difference between the groups in EORTC-QLQ C30, increased sexual interest and decreased fecal incontinence were observed in SG in EORTC-QLQ-CR29. CONCLUSION PFMT significantly improves LARS scores, quality-of-life questionnaires and aEMG parameters, positioning PFMT as an accessible, non-invasive, easy-to-use first-line treatment option in the treatment of LARS.
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Affiliation(s)
- Cem Batuhan Ofluoglu
- Department of General Surgery, University of Health Sciences, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkiye
| | - Isa Caner Aydin
- Department of Gastroenterology Surgery, University of Health Sciences, Kartal Kosuyolu Higher Specialty Training and Research Hospital, Istanbul, Turkiye
| | - Yunus Emre Altuntas
- Department of General Surgery, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkiye
| | - Kenan Cetin
- Department of General Surgery, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkiye
| | - Rahsan Inan
- Department of Neurology, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkiye
| | - Noyan Ilhan
- Department of General Surgery, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkiye
| | - Firat Mulkut
- Department of General Surgery, University of Health Sciences, Sancaktepe Sehit Prof. Dr. Ilhan Varank Training and Research Hospital, Istanbul, Turkiye
| | - Hasan Fehmi Kucuk
- Department of General Surgery, University of Health Sciences, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkiye
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Zhou L, Zhang Z, Wang L. Treatment of anterior resection syndrome: A systematic review and network meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108336. [PMID: 38626589 DOI: 10.1016/j.ejso.2024.108336] [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: 10/19/2023] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION There has been a lack of research comparing the efficacy of various treatments for low anterior resection syndrome (LARS). METHODS We conducted a comprehensive search across six electronic databases and a paired meta-analysis was undertaken to assess the effectiveness of the interventions. Furthermore, a network meta-analysis was utilized to compare the efficacy of different treatments for LARS. RESULTS This study encompassed nine randomized controlled trials, involving a total of 450 patients. Compared to routine care, 5-HT3 receptor antagonists (follow-up<3 months) and percutaneous tibial nerve stimulation (3 months ≤ follow-up <6 months) were effective in reducing the LARS score. Pelvic floor rehabilitation (follow-up≤3 months) was effective in decreasing daily number of bowel movements when compared to routine care. The network meta-analysis indicated that 5-HT3 receptor antagonists (follow-up<3 months) were the most effective in reducing both the LARS score and the daily number of bowel movements. Transanal irrigation (3 months ≤ follow-up ≤ 12 months) was most effective in reducing the LARS score. Additionally, 5-HT3 receptor antagonists demonstrated relative efficacy in improving patients' quality of life (follow-up ≤ 1 month). CONCLUSIONS This review indicates that 5-HT3 receptor antagonists and anal irrigation show significant promise in the treatment of LARS. Nevertheless, the contributions of percutaneous tibial nerve stimulation and pelvic floor rehabilitation to LARS treatment should not be overlooked. Given the clinical heterogeneity observed among the studies, the results should be interpreted with caution.
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Affiliation(s)
- Lu Zhou
- Department of Nursing, Peking University People's Hospital, Beijing, China; School of Nursing, Peking University, Beijing, China
| | - Zhengyang Zhang
- Department of Nursing, Peking University People's Hospital, Beijing, China; School of Nursing, Peking University, Beijing, China
| | - Ling Wang
- Department of Nursing, Peking University People's Hospital, Beijing, China.
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Lambrineas LJ, Brock HG, Ong HI, Tisseverasinghe S, Carrington E, Heriot A, Burgess A, Proud D, Mohan H. Challenges in evaluating pelvic floor physiotherapy based strategies in low anterior resection syndrome: a systematic review and qualitative analysis. Colorectal Dis 2024; 26:258-271. [PMID: 38173138 DOI: 10.1111/codi.16839] [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: 05/26/2023] [Revised: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 01/05/2024]
Abstract
AIM Physiotherapy is an established treatment strategy for low anterior resection syndrome (LARS). However, data on its efficacy are limited. This is in part due to the inherent challenges in study design in this context. This systematic review aims to analyse the methodology of studies using pelvic floor physiotherapy for treatment of LARS to elucidate the challenges and limitations faced, which may inform the design of future prospective trials. METHODOLOGY A systematic review of the literature was undertaken through MEDLINE, Embase and Cochrane Library, yielding 345 unique records for screening. Five studies were identified for review. Content thematic analysis of study limitations was carried out using the Braun and Clarke method. Line-by-line coding was used to organize implicit and explicit challenges and limitations under broad organizing categories. RESULTS Key challenges fell into five overarching categories: patient-related issues, cancer-related issues, adequate symptomatic control, intervention-related issues and measurement of outcomes. Adherence, attrition and randomization contributed to potential bias within these studies, with imbalance in the baseline patient characteristics, particularly gender and baseline pelvic floor function scores. Outcome measurements consisted of patient-reported measures and quality of life measures, where significant improvements in bowel function according to patient-reported outcome measures were not reflected in the quality of life scores. CONCLUSION Upcoming trial design in the area of pelvic floor physiotherapy for faecal incontinence related to rectal cancer surgery can be cognisant of and design around the challenges identified in this systematic review, including the reduction of bias, exclusion of the placebo effect and the potential cultural differences in attitude towards a sensitive intervention.
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Affiliation(s)
- Lauren J Lambrineas
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Henry G Brock
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
| | - Hwa Ian Ong
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | | | | | - Alexander Heriot
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Adele Burgess
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - David Proud
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Helen Mohan
- Department of Colorectal Surgery, Austin Health, Melbourne, Australia
- Department of Surgery, University of Melbourne, Melbourne, Australia
- Peter MacCallum Cancer Centre, Melbourne, Australia
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Verkuijl SJ, Jonker JE, Furnée EJ, Kelder W, Hoff C, Hess DA, Wit F, Zijlstra RJ, Trzpis M, Broens PM. The Effect of a Temporary Stoma on Long-term Functional Outcomes Following Surgery for Rectal Cancer. Dis Colon Rectum 2024; 67:291-301. [PMID: 38127585 PMCID: PMC10769172 DOI: 10.1097/dcr.0000000000003009] [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] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients with rectal cancer may undergo surgical resection with or without a temporary stoma. OBJECTIVE This study primarily aimed to compare long-term functional outcomes between patients with and without a temporary stoma after surgery for rectal cancer. The secondary aim was to investigate the effect of time to stoma reversal on functional outcomes. DESIGN This was a multicenter, cross-sectional study. SETTINGS This study was conducted at 7 Dutch hospitals. PATIENTS Included were patients who had undergone rectal cancer surgery (2009-2015). Excluded were deceased patients, who were deceased, had a permanent stoma, or had intellectual disability. MAIN OUTCOME MEASURES Functional outcomes were measured using the Rome IV criteria for constipation and fecal incontinence and the low anterior resection syndrome score. RESULTS Of 656 patients, 32% received a temporary ileostomy and 20% a temporary colostomy (86% response). Follow-up was at 56 (interquartile range, 38.5-79) months. Patients who had a temporary ileostomy experienced less constipation, more fecal incontinence, and more major low anterior resection syndrome than those without a temporary stoma. Patients who had a temporary colostomy experienced more major low anterior resection syndrome than those without a temporary stoma. A temporary ileostomy or colostomy was not associated with constipation or fecal incontinence after correction for confounding factors (eg, anastomotic height, anastomotic leakage, radiotherapy). Time to stoma reversal was not associated with constipation, fecal incontinence, or major low anterior resection syndrome. LIMITATIONS Cross-sectional design. CONCLUSIONS Although patients with a temporary ileostomy or colostomy have worse functional outcomes in the long term, it seems that the reason for creating a temporary stoma, rather than the stoma itself, underlies this phenomenon. Time to reversal of a temporary stoma does not influence functional outcomes. See Video Abstract . EL EFECTO DEL ESTOMA TEMPORAL SOBRE LOS RESULTADOS FUNCIONALES A LARGO PLAZO DESPUS DE LA CIRUGA POR CNCER DE RECTO ANTECEDENTES:Los pacientes con cáncer de recto pueden someterse a resección quirúrgica con o sin un estoma temporal.OBJETIVO:El objetivo principal de este estudio fue comparar los resultados funcionales a largo plazo entre pacientes con y sin estoma temporal después de cirugía por cáncer de recto. El objetivo secundario fue investigar el efecto del tiempo transcurrido hasta la reversión del estoma sobre los resultados funcionales.DISEÑO:Este fue un estudio transversal multicéntrico.ESCENARIO:Este estudio se llevó a cabo en siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a cirugía de cáncer de recto (2009-2015). Se excluyeron pacientes fallecidos, pacientes con estoma permanente o discapacidad intelectual.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados funcionales se midieron utilizando los criterios de Roma IV para el estreñimiento y la incontinencia fecal y la puntuación del síndrome de resección anterior baja (LARS).RESULTADOS:De 656 pacientes, el 32% recibió una ileostomía temporal y el 20% una colostomía temporal (respuesta del 86%). El seguimiento fue de 56.0 (RIQ 38.5-79.0) meses. Los pacientes a los que se les realizó una ileostomía temporal experimentaron menos estreñimiento, más incontinencia fecal y más LARS mayor que los pacientes sin un estoma temporal. Los pacientes que tuvieron una colostomía temporal experimentaron más LARS mayor que los pacientes sin un estoma temporal. Una ileostomía o colostomía temporal no se asoció con estreñimiento o incontinencia fecal después de la corrección de factores de confusión (p. ej., altura anastomótica, fuga anastomótica, radioterapia). El tiempo hasta la reversión del estoma no se asoció con estreñimiento, incontinencia fecal o LARS mayor.LIMITACIONES:El presente estudio está limitado por su diseño transversal.CONCLUSIONES:Aunque los pacientes con una ileostomía o colostomía temporal tienen peores resultados funcionales a largo plazo, parece que la razón para crear un estoma temporal, más que el estoma en sí, se asocia a este fenómeno. El tiempo hasta la reversión de un estoma temporal no influye en los resultados funcionales. (Traducción-Dr. Jorge Silva Velazco ).
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Affiliation(s)
- Sanne J. Verkuijl
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jara E. Jonker
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Edgar J.B. Furnée
- Division of Abdominal Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wendy Kelder
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | - Christiaan Hoff
- Department of Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Daniel A. Hess
- Department of Surgery, Antonius Hospital, Sneek, The Netherlands
| | - Fennie Wit
- Department of Surgery, Tjongerschans Hospital, Heerenveen, The Netherlands
| | - Ronald J. Zijlstra
- Department of Surgery, Nij Smellinghe Hospital, Drachten, The Netherlands
| | - Monika Trzpis
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul M.A. Broens
- Department of Surgery, Anorectal Physiology Laboratory, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Division of Pediatric Surgery, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Pun MY, Leung PH, Chan TC, Pang C, Chan KH, Kannan P. The effectiveness of physiotherapy interventions on fecal incontinence and quality of life following colorectal surgery: a systematic review and meta-analysis of randomized controlled trials. Support Care Cancer 2024; 32:103. [PMID: 38217744 PMCID: PMC10787910 DOI: 10.1007/s00520-023-08294-1] [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: 08/03/2023] [Accepted: 12/27/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE To investigate the effectiveness of physiotherapy interventions compared to control conditions on fecal incontinence (FI) and quality of life (QoL) following colorectal surgery. METHODS Electronic searches in English-language (Scopus, Web of Science, Embase, AMED, CENTRAL, CINAHL, MEDLINE, Ovid, and PEDro) and Chinese-language (CNKI, Wanfang Data) databases were conducted. Trials comparing physiotherapy interventions against control conditions and assessing FI and QoL outcomes were included in the review. RESULTS Ten trials were included. Meta-analysis revealed statistically significant improvements in lifestyle (0.54; 95% CI 0.03, 1.05; p = 0.04), coping behavior (MD 1.136; 95% CI 0.24, 2.04; p = 0.01), and embarrassment (0.417; 95% CI 0.14, 0.70; p = 0.00) components of QoL among individuals receiving pelvic floor muscle training (PFMT) compared with those receiving usual care (UC). Meta-analysis showed biofeedback to be significantly more effective than UC in enhancing anal resting pressure (ARP; 9.551; 95% CI 2.60, 16.51; p = 0.007), maximum squeeze pressure (MSP; 25.29; 95% CI 4.08, 48.50; p = 0.02), and rectal resting pressure (RRP; 0.51; 95% CI 0.10, 0.9; p = 0.02). Meta-analysis also found PFMT combined with biofeedback to be significantly more effective than PFMT alone for ARP (3.00; 95% CI 0.40, 5.60; p = 0.02), MSP (9.35, 95% CI 0.17, 18.53; p = 0.05), and RRP (1.54; 95% CI 0.60, 2.47; p = 0.00). CONCLUSIONS PFMT combined with biofeedback was more effective than PFMT alone, but both interventions delivered alone were superior to UC. Future studies remain necessary to optimize and standardize the PFMT parameters for improving QoL among individuals who experience FI following CRC surgery. REVIEW REGISTRATION This systematic review is registered in the PROSPERO registry (Ref: CRD42022337084).
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Affiliation(s)
- Ming Yan Pun
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Pak Ho Leung
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Tsz Ching Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Chunn Pang
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Kin Hei Chan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
| | - Priya Kannan
- Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong.
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Zhang R, Luo W, Qiu Y, Chen F, Luo D, Yang Y, He W, Li Q, Li X. Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment. Cancers (Basel) 2023; 15:5011. [PMID: 37894378 PMCID: PMC10605930 DOI: 10.3390/cancers15205011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed. OBJECTIVE AND METHODS To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer. RESULTS The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy. CONCLUSIONS In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.
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Affiliation(s)
- Ruijia Zhang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Wenqin Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yulin Qiu
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Fan Chen
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Dakui Luo
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Yufei Yang
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Weijing He
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Qingguo Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xinxiang Li
- Department of Colorectal Surgery, Fudan University Shanghai Cancer Center, Shanghai 200032, China; (R.Z.); (W.L.); (Y.Q.); (F.C.); (D.L.); (Y.Y.); (W.H.)
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
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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.
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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
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Haas S, Mikkelsen AH, Kronborg CJS, Oggesen BT, Møller PF, Fassov J, Frederiksen NA, Krogsgaard M, Graugaard-Jensen C, Ventzel L, Christensen P, Emmertsen KJ. Management of treatment-related sequelae following colorectal cancer. Colorectal Dis 2023; 25:458-488. [PMID: 35969031 DOI: 10.1111/codi.16299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/15/2022] [Accepted: 07/21/2022] [Indexed: 02/08/2023]
Abstract
AIM Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment. METHOD A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included. RESULTS Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units. CONCLUSION Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.
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Affiliation(s)
- Susanne Haas
- Department of Surgery, Danish Cancer Society National Research Center for Survivorship and Late Adverse Effects Following Pelvic Organ Cancer, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
| | | | | | | | - Pia F Møller
- Department of Surgery, Vejle Hospital, Vejle, Denmark
| | - Janne Fassov
- Department of Surgery, Danish Cancer Society National Research Center for Survivorship and Late Adverse Effects Following Pelvic Organ Cancer, Aarhus University Hospital, Aarhus, Denmark
- Department of Gastroenterology and Hepatology, Aarhus University Hospital, Aarhus, Denmark
| | | | | | | | - Lise Ventzel
- Department of Oncology, University Hospital of Southern Denmark, Vejle, Denmark
| | - Peter Christensen
- Department of Surgery, Danish Cancer Society National Research Center for Survivorship and Late Adverse Effects Following Pelvic Organ Cancer, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Katrine Jøssing Emmertsen
- Department of Surgery, Danish Cancer Society National Research Center for Survivorship and Late Adverse Effects Following Pelvic Organ Cancer, Aarhus University Hospital, Aarhus, Denmark
- Department of Surgery, Randers Regional Hospital, Randers, Denmark
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Kim YM, Oh EG. Effectiveness of Pelvic Floor Muscle Training for Patients Following Low Anterior Resection: A Systematic Review and Meta-analysis. J Wound Ostomy Continence Nurs 2023; 50:142-150. [PMID: 36867038 DOI: 10.1097/won.0000000000000958] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE The purpose of this systematic review was to identify the effects of pelvic floor muscle training (PFMT) on bowel function and health-related quality of life among patients who have undergone low anterior resection. METHODS A systematic review and meta-analysis of pooled findings was conducted according to PRISMA guidelines. SEARCH STRATEGY A literature search was completed using PubMed, EMBASE, Cochrane, and CINAHL electronic databases; we searched studies published in English and Korean languages. Two reviewers independently selected relevant studies, evaluated their methodological quality, and extracted data. Meta-analysis was conducted of pooled findings. FINDINGS Thirty-six of 453 articles retrieved were read in full and 12 articles were included in the systematic review. In addition, pooled findings from 5 studies were selected for meta-analysis. Analysis revealed that PFMT reduced bowel dysfunction (mean difference [MD] -2.39, 95% confidence interval [CI] -3.79 to -0.99) and improved several domains of health-related quality of life: lifestyle (MD 0.49, 95% CI 0.15 to 0.82), coping (MD 0.36, 95% CI 0.04 to 0.67), depression (MD 0.46, 95% CI 0.23 to 0.70), and embarrassment (MD 0.24, 95% CI 0.01 to 0.46). IMPLICATIONS Findings suggested PFMT is effective for improving bowel function and enhancing multiple domains of health-related quality of life after low anterior resection. Further well-designed studies are required to confirm our conclusions and provide stronger evidence for the effects of this intervention.
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Affiliation(s)
- Young Man Kim
- Young Man Kim, PhD, RN , College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju-si, South Korea
- Eui Geum Oh, PhD, RN, FAAN , Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, and Yonsei Evidence Based Nursing Center of Korea: A Joanna Briggs Institute Affiliated Group, Seoul, South Korea
| | - Eui Geum Oh
- Young Man Kim, PhD, RN , College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju-si, South Korea
- Eui Geum Oh, PhD, RN, FAAN , Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, and Yonsei Evidence Based Nursing Center of Korea: A Joanna Briggs Institute Affiliated Group, Seoul, South Korea
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10
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Pieniowski EHA, Bergström CM, Nordenvall CAM, Westberg KS, Johar AM, Tumlin Ekelund SF, Larsson KR, Pekkari KJ, Jansson Palmer GC, Lagergren P, Abraham-Nordling M. A Randomized Controlled Clinical Trial of Transanal Irrigation Versus Conservative Treatment in Patients With Low Anterior Resection Syndrome After Rectal Cancer Surgery. Ann Surg 2023; 277:30-37. [PMID: 35797618 DOI: 10.1097/sla.0000000000005482] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate transanal irrigation (TAI) as a treatment for low anterior resection syndrome (LARS). BACKGROUND LARS is a bowel disorder that is common after sphincter preserving rectal cancer surgery. Despite symptomatic medical treatment of LARS many patients still experience bowel symptoms that may have a negative impact on quality of life (QoL). TAI is a treatment strategy, of which the clinical experience is promising but scientific evidence is limited. MATERIALS AND METHODS A multicenter randomized trial comparing TAI (intervention) with conservative treatment (control) was performed. Inclusion criteria were major LARS, age above 18 years, low anterior resection with anastomosis and a defunctioning stoma as primary surgery, >6 months since stoma reversal, anastomosis without signs of leakage or stricture, and no signs of recurrence at 1-year follow-up. The primary endpoint was differences in bowel function at 12-month follow-up measured by LARS score, Cleveland Clinic Florida Fecal Incontinence Score, and 4 study-specific questions. The secondary outcome was QoL. RESULTS A total of 45 patients were included, 22 in the TAI group and 23 in the control group. Follow-up was available for 16 and 22 patients, respectively. At 12 months, patients in the TAI group reported significantly lower LARS scores (22.9 vs 32.4; P =0.002) and Cleveland Clinic Florida Fecal Incontinence Score (6.4 vs 9.2; P =0.050). In addition, patients in the TAI group also scored significantly higher QoL [8 of 16 European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) QoL aspects] compared with the control group. CONCLUSIONS The results confirm our clinical experience that TAI reduces symptoms included in LARS and improves QoL.
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Affiliation(s)
- Emil H A Pieniowski
- Department of Surgery, South General Hospital (Södersjukhuset), Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Charlotta M Bergström
- Department of Surgery, Danderyd Hospital, Stockholm, Sweden
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Caroline A M Nordenvall
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Colorectal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Karin S Westberg
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery, Danderyd Hospital, Stockholm, Sweden
| | - Asif M Johar
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Susanne F Tumlin Ekelund
- Department of Surgery, South General Hospital (Södersjukhuset), Stockholm, Sweden
- Department of Clinical Science and Education, Karolinska Institute, Södersjukhuset, Stockholm, Sweden
| | - Kristina R Larsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Klas J Pekkari
- Department of Surgery, Danderyd Hospital, Stockholm, Sweden
- Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Gabriella C Jansson Palmer
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Colorectal Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Mirna Abraham-Nordling
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Colorectal Cancer, Karolinska University Hospital, Stockholm, Sweden
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11
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Morino M, Nicotera A. Low Anterior Resection Syndrome. ANAL INCONTINENCE 2023:171-178. [DOI: 10.1007/978-3-031-08392-1_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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12
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The Effectiveness of a Self-management Program of Bowel Dysfunction in Patients With Mid and Low Rectal Cancer After Sphincter-Preserving Surgery: A Pilot Randomized Controlled Trial. Cancer Nurs 2023; 46:67-76. [PMID: 35089874 DOI: 10.1097/ncc.0000000000001065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Most patients with mid and low rectal cancer passively react to bowel symptoms after sphincter-preserving surgery (SPS), and their self-management behaviors are scarce in the Chinese patient population. OBJECTIVE The aim of this study was to evaluate the effect of a self-management program for bowel symptoms in patients with mid and low rectal cancer after SPS. METHODS A convenient sampling method was used to recruit patients with mid and low rectal cancer after SPS in gastric wards from 2 tertiary hospitals in Beijing, China. Ninety-five patients (intervention, n = 47; control, n = 48) were recruited. The intervention group received a predetermined self-management program plus routine postoperative care; the control group received only routine care in the ward. Data on patients' bowel symptoms, quality of life, and bowel symptom self-management behaviors were collected at baseline and at 3 and 6 months postoperatively using questionnaires. A generalized estimating equation was adopted to examine group effect and time effect. RESULTS Bowel symptoms and quality of life in both the intervention and control groups of patients improved significantly 6 months after SPS compared with baseline (time effect, P < .001). The total score of patients' bowel symptom self-management behaviors and the score of the therapeutic domain increased significantly in the intervention group compared with those in the control group (group effect, P = .009). CONCLUSIONS Self-management programs could help prompt patients' self-management behaviors, but the extent to which they impact patients' bowel symptoms requires further investigation. IMPLICATIONS FOR PRACTICE The bowel dysfunction self-management program could alter the behavior of patients. It also effectively improves self-management strategies for bowel symptoms.
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13
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Marinello F, Pellino G, Espín-Basany E. Low anterior resection syndrome: An unavoidable price to pay to preserve the rectum? Front Oncol 2022; 12:994720. [PMID: 36313684 PMCID: PMC9614064 DOI: 10.3389/fonc.2022.994720] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Franco Marinello
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Franco Marinello,
| | - Gianluca Pellino
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania “Luigi Vanvitelli”, Naples, Italy
| | - Eloy Espín-Basany
- Colorectal Surgery Unit – Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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14
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Pelvic Floor Rehabilitation After Rectal Cancer Surgery: A Multicenter Randomized Clinical Trial (FORCE Trial). Ann Surg 2022; 276:38-45. [PMID: 34966064 DOI: 10.1097/sla.0000000000005353] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the effects of PFR after LAR compared to usual care without PFR. SUMMARY OF BACKGROUND DATA Functional complaints, including fecal incontinence, often occur after LAR for rectal cancer. Controversy exists about the effectiveness of PFR in improving such postoperative functional outcomes. METHODS This was a multicenter, randomized controlled trial involving 17 Dutch centers. Patients after LAR for rectal cancer were randomly assigned (1:1) to usual care or PFR and stratified by sex and administration of neoadjuvant therapy. Selection was not based on severity of complaints at baseline. Baseline measurements were taken 3 months after surgery without temporary stoma construction or 6 weeks after stoma closure. The primary outcome measure was the change in Wexner incontinence scores 3 months after randomization. Secondary outcomes were fecal incontinence-related quality of life, colorectal-specific quality of life, and the LARS scores. RESULTS Between October 2017 and March 2020, 128 patients were enrolled and 106 randomly assigned (PFR n = 51, control n = 55); 95 patients (PFR n = 44, control n = 51) were assessable for final analysis. PFR did not lead to larger changes in Wexner incontinence scores in nonselected patients after LAR compared to usual care [PFR: -2.3, 95% confidence interval (CI) -3.3 to -1.4, control: -1.3, 95% CI -2.2 to -0.4, P = 0.13]. However, PFR was associated with less urgency at follow-up (odds ratio 0.22, 95% CI 0.06-0.86). Patients without near-complete incontinence reported larger Wexner score improvements after PFR (PFR: -2.1, 95% CI -3.1 to -1.1, control: -0.7, 95% CI -1.6 to 0.2, P = 0.045). For patients with at least moderate incontinence PFR resulted in relevant improvements in all fecal incontinence-related quality of life domains, while the control group deteriorated. These improvements were even larger when patients with near-complete incontinence were excluded. No serious adverse PFR-related events occurred. CONCLUSION No benefit was found of PFR in all patients but several subgroups were identified that did benefit from PFR, such as patients with urgency or with at least moderate incontinence and no near-complete incontinence. A selective referral policy (65%-85% of all patients) is suggested to improve postoperative functional outcomes for patients after LAR for rectal cancer. TRIAL REGISTRATION Netherlands Trial Registration, NTR5469, registered on 3 September 2015.
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15
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Tazhikova A, Makishev A, Bekisheva A, Dmitriyeva M, Toleubayev M, Sabitova A. Efficacy of Tibial Nerve Stimulation on Fecal Incontinence in Patients With Low Anterior Resection Syndrome Following Surgery for Colorectal Cancer. Ann Rehabil Med 2022; 46:142-153. [PMID: 35793903 PMCID: PMC9263329 DOI: 10.5535/arm.22025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/16/2022] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To systematically review the available literature on the efficacy of tibial nerve stimulation on faecal incontinence and quality of life in adult patients with low anterior resection syndrome following surgery for colorectal cancer. METHODS A primary search of electronic databases was conducted adopting a combination of search terms related to the following areas of interest: "efficacy", "tibial nerve stimulation" and "low anterior resection syndrome". A secondary search of the grey literature was performed in addition to checking the reference list of included studies and review papers. The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A descriptive analysis was used to integrate the review findings. RESULTS Five distinct studies involving 116 patients met the inclusion criteria for the review. The included studies suggest that tibial nerve stimulation may have a positive effect on faecal incontinence and quality of life in some patients with low anterior resection syndrome and might be considered as an additional treatment option. CONCLUSION There were a limited number of studies and a great degree of heterogeneity of evidence due to differences in participants' baseline characteristics, dropout rates, and follow-up periods. Further research adopting validated, consistent, and complex outcome assessment methods is recommended to determine the efficacy of tibial nerve stimulation for treatment of patients with low anterior resection syndrome.
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Affiliation(s)
- Aigul Tazhikova
- Departments of Oncology, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Abay Makishev
- Departments of Oncology, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Aizhan Bekisheva
- Departments of Oncology, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Mariya Dmitriyeva
- Departments of Plastic Surgery, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Medet Toleubayev
- Departments of Plastic Surgery, Astana Medical University, Nur-Sultan, Kazakhstan
| | - Alina Sabitova
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
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16
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Bradshaw E. Colorectal nursing and low anterior resection syndrome. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:194-198. [PMID: 35220732 DOI: 10.12968/bjon.2022.31.4.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Ellie Bradshaw
- Colorectal and Biofeedback Nurse Specialist, Princess Grace Hospital, London
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17
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Shipton DA, Dennett AM, Sayner AM, Tang CY. A national survey of oncology physiotherapy services for cancer survivors in Australia. Asia Pac J Clin Oncol 2022; 18:e404-e413. [PMID: 35098664 DOI: 10.1111/ajco.13739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 10/25/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Cancer is a leading cause of illness globally. Advancements in screening and treatment have led to improved survivorship. Physiotherapy is integral in improving survivorship for people with cancer, with strong evidence supporting the use of various physiotherapy services. However, the scope and extent of these services within clinical practice in Australia is unknown. AIM Identify and describe physiotherapy service provision for cancer survivors in Australia and describe the scope of physiotherapy services provided to cancer survivors. METHODS This cross-sectional study recruited physiotherapists and their respective managers involved in cancer service/s provision across Australia. Physiotherapy departments of tertiary hospitals and known oncology rehabilitation programs were contacted through a government directory and snowball sampling. The online survey included questions related to the extent and scope of service provision of physiotherapy for cancer survivors. Quantitative data were descriptively analyzed whereas open-ended responses were analyzed and presented narratively. RESULTS Seventy-nine physiotherapy services were identified from 159 hospitals and/or health networks. Of the 55 (70%) responses received, 87% were from metropolitan areas, whereas 13% were regionally/rurally based services. Prehabilitation services mostly offered individual programs whereas rehabilitation programs had a mix of individual and group-based programs. The service content between prehabilitation and rehabilitation were similar, comprising primarily exercise-based interventions, followed by education and impairment-based therapies. CONCLUSION Few designated physiotherapy services for cancer survivors exist in Australia. There is also disparity between service provision between metropolitan and regional/rural areas highlighting a need for clinicians, managers, and policy makers to invest more resources in establishing oncology physiotherapy services.
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Affiliation(s)
- Daniel A Shipton
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Amy M Dennett
- School of Allied Health, La Trobe University and Allied Health Clinical Research Office, Eastern Health, Melbourne, Victoria, Australia
| | - Alesha M Sayner
- Western Health, Physiotherapy Department/Chronic and Complex Care, Melbourne, Victoria, Australia
| | - Clarice Y Tang
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
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18
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Park EJ, Baik SH. Functional outcomes after sphincter-preserving surgeries for low-lying rectal cancer: A review. PRECISION AND FUTURE MEDICINE 2021. [DOI: 10.23838/pfm.2021.00142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Sphincter preservation and organ restoration during rectal cancer surgery avoids permanent stoma creation and diminishes psychosocial damages. However, decreased rectal volumes and sphincter dysfunction—including pelvic nerve damage—results in low anterior resection syndrome, as well as urinary and sexual dysfunction after rectal resection. Bowel habit changes such as fecal incontinence, fecal urgency, frequent bowel movements, clustered stools, and difficulties in bowel emptying can be treated using medications, pelvic floor rehabilitation, sacral neuromodulation, or neorectal reservoir reconstruction. Pelvic nerve damage resulting from superior and inferior hypogastric plexi during sphincter-preserving rectal cancer surgery can induce urologic and sexual dysfunctions. Preoperative voiding difficulty, perioperative blood loss, and autonomic nerve injury are considered independent risk factors for postoperative urinary dysfunction. Retrograde ejaculation and erectile dysfunction, female dyspareunia, and vaginal dryness are manifestations of sexual dysfunction resulting from autonomic nerve injury during rectal cancer surgery. Multifactorial causes for functional outcomes after sphincter- preserving surgeries are considered to improve patient’s quality of life with acceptable oncologic outcomes in the treatment of rectal cancer patients.
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19
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Ng KS, Gladman MA. LARS: A review of therapeutic options and their efficacy. SEMINARS IN COLON AND RECTAL SURGERY 2021. [DOI: 10.1016/j.scrs.2021.100849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Annicchiarico A, Martellucci J, Solari S, Scheiterle M, Bergamini C, Prosperi P. Low anterior resection syndrome: can it be prevented? Int J Colorectal Dis 2021; 36:2535-2552. [PMID: 34409501 DOI: 10.1007/s00384-021-04008-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 02/04/2023]
Abstract
Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.
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Affiliation(s)
| | | | - Stefano Solari
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | | | - Carlo Bergamini
- Emergency Surgery, Careggi University Hospital, Florence, Italy
| | - Paolo Prosperi
- Emergency Surgery, Careggi University Hospital, Florence, Italy
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21
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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.
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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.
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22
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Cho HM, Kim H, Yoo R, Kim G, Kye BH. Effect of Biofeedback Therapy during Temporary Stoma Period in Rectal Cancer Patients: A Prospective Randomized Trial. J Clin Med 2021; 10:5172. [PMID: 34768692 PMCID: PMC8584867 DOI: 10.3390/jcm10215172] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/30/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This prospective randomized controlled study was designed to evaluate the effect of biofeedback therapy (BFT) during temporary stoma period to prevent defecation dysfunction after sphincter-preserving surgery (SPS). METHODS Following SPS with temporary stoma, patients were divided according to whether (BFT group) or not (Control group) they received BFT. BFT was performed once or twice a week during the temporary stoma period. Kegel exercise were advised to all the patients. Subjective defecation symptoms were evaluated according to Cleveland Clinic Incontinence Score (CCIS) as primary outcome at 12 months postoperatively. Manometric data of five time-points were also analyzed. RESULTS Twenty-one patients in the BFT group and 23 patients in the control group received anorectal physiologic testing. The incidence of CCIS of more than 9 points, which is the primary end point in this study, was not statistically different between BFT group and control group (p = 1.000). The liquid stool incontinence in the BFT group showed a better tendency (p = 0.06) at 12 months post-SPS. Time-dependent serial changes in maximal sensory threshold (Max RST) was significantly different between the BFT and control groups (p = 0.048). Also, the change of mean resting pressure (MRP) tended to be more stable in the BFT group (p = 0.074). CONCLUSIONS The BFT in the period of temporary stoma may be related to liquid stool incontinence at 12 months post-SPS and lead to stable MRP and better Max RST. Therefore, BFT during temporary stoma might be helpful for preventing and minimizing defecation dysfunction in high risk patients after SPS, NCT01661829).
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Affiliation(s)
- Hyeon-Min Cho
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
| | - Hyungjin Kim
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - RiNa Yoo
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
| | - Gun Kim
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
| | - Bong-Hyeon Kye
- Department of Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon 16247, Korea; (H.-M.C.); (R.Y.); (G.K.)
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23
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Harji D, Fernandez B, Boissieras L, Berger A, Capdepont M, Zerbib F, Rullier E, Denost Q. A novel bowel rehabilitation programme after total mesorectal excision for rectal cancer: the BOREAL pilot study. Colorectal Dis 2021; 23:2619-2626. [PMID: 34264005 DOI: 10.1111/codi.15812] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/18/2021] [Accepted: 07/06/2021] [Indexed: 12/13/2022]
Abstract
AIM Low anterior resection syndrome (LARS) following sphincter-preserving surgery for rectal cancer has a high prevalence, with an impact on long-term bowel dysfunction and quality of life. We designed the bowel rehabilitation programme (BOREAL) as a proactive strategy to assess and treat patients with LARS. The BOREAL programme consists of a stepwise approach of escalating treatments: medical management (steps 0-1), pelvic floor physiotherapy, biofeedback and transanal irrigation (step 2), sacral nerve neuromodulation (step 3), percutaneous endoscopic caecostomy and anterograde enema (step 4) and definitive colostomy (step 5). METHODS A pilot study was undertaken to assess the feasibility of collecting LARS data routinely with the parallel implementation of the BOREAL programme. All patients who underwent total mesorectal excision for rectal cancer between February 2017 and March 2019 were included. LARS was assessed using the LARS score and the Wexner Faecal Incontinence score at 30 days and 3, 6, 9 and 12 months postoperatively. A good functional result was considered to be a combined LARS score <20 and/or a Wexner score <4. RESULTS In all, 137 patients were included. Overall compliance with the BOREAL programme was 72.9%. Major LARS decreased from 48% at 30 days postoperatively to 12% at 12 months, with a concomitant improvement in overall good function from 33% to 77%, P < 0.001. The majority of patients (n = 106, 77%) required medical management of their LARS. CONCLUSION The BOREAL programme demonstrates the acceptability, feasibility and effectiveness of implementing a responsive, stepwise programme for detecting and treating LARS.
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Affiliation(s)
- Deena Harji
- Colorectal Unit, Department of Digestive Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Benjamin Fernandez
- Colorectal Unit, Department of Digestive Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Lara Boissieras
- Colorectal Unit, Department of Digestive Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Arthur Berger
- Gastroenterology Department, CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, INSERM CIC 1401, Université de Bordeaux, Bordeaux, France
| | - Maylis Capdepont
- Colorectal Unit, Department of Digestive Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Frank Zerbib
- Gastroenterology Department, CHU de Bordeaux, Centre Medico-chirurgical Magellan, Hôpital Haut-Lévêque, INSERM CIC 1401, Université de Bordeaux, Bordeaux, France
| | - Eric Rullier
- Colorectal Unit, Department of Digestive Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
| | - Quentin Denost
- Colorectal Unit, Department of Digestive Surgery, Haut-Lévêque Hospital, Bordeaux University Hospital, Pessac, France
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Sacomori C, Lorca LA, Martinez-Mardones M, Salas-Ocaranza RI, Reyes-Reyes GP, Pizarro-Hinojosa MN, Plasser-Troncoso J. A randomized clinical trial to assess the effectiveness of pre- and post-surgical pelvic floor physiotherapy for bowel symptoms, pelvic floor function, and quality of life of patients with rectal cancer: CARRET protocol. Trials 2021; 22:448. [PMID: 34256795 PMCID: PMC8276537 DOI: 10.1186/s13063-021-05396-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/24/2021] [Indexed: 01/22/2023] Open
Abstract
Background There is scarcity of trials about preventative strategies for low anterior resection syndrome (LARS) in rectal cancer patients. The aim of this study is to evaluate the effectiveness of a pre- and post-surgical pelvic floor rehabilitation program on the bowel symptoms, pelvic floor function, and quality of life of rectal cancer patients. Methods A randomized controlled trial with parallel groups (pelvic floor rehabilitation versus control group), with a blinded evaluator. Participants and setting: 56 stage I to III rectal cancer patients aged from 18 to 80 years old undergoing sphincter preservation surgery at Hospital del Salvador and who have a sufficient knowledge of Spanish. Main outcome measures: ICIQ-B questionnaire for intestinal symptoms, high-resolution anorectal manometry (Alacer Multiplex 24-channel manometry equipment) for anorectal function, pelvic floor muscle strength test with Oxford Modified Scale, and a quality of life test with the EORTC QLQ C30 questionnaire. The evaluations will be carried out at five stages: before surgery, before and after the pelvic floor rehabilitation, and during a 3-month and 1-year follow-up. Interventions: one pre-rehabilitation session and 9 to 12 sessions of pelvic floor rehabilitation, including patient education, pelvic floor muscle exercises, pelvic floor electromyography biofeedback, and capacitive and sensory rectal training with a balloon probe. Rehabilitation will begin 3–5 weeks before the ileostomy is removed (four sessions) and around 3 weeks after stoma removal (5–8 sessions). Discussion We expect the program to improve the bowel symptoms, pelvic floor function, and quality of life of rectal cancer patients. Trial registration Australian New Zealand Clinical Trials Register ACTRN12620000040965. Registered on 21 January 2020.
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Affiliation(s)
- Cinara Sacomori
- Universidad Bernardo O'Higgins, Escuela de Kinesiología, Santiago, Chile.
| | - Luz Alejandra Lorca
- Hospital del Salvador, Servicio de Medicina Física y Rehabilitación, Santiago, Chile
| | - Mónica Martinez-Mardones
- Hospital del Salvador, Servicio de Cirugía y Servicio de Coloproctologia, Santiago, Chile.,Universidad Finnis Terrae, Escuela de Medicina, Santiago, Chile
| | | | | | | | - Jorge Plasser-Troncoso
- Hospital del Salvador, Servicio de Cirugía y Servicio de Coloproctologia, Santiago, Chile.,Fundación Arturo López Pérez, Santiago, Chile
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Garfinkle R, Ky A, Singh A, Morin N, Ghitulescu G, Faria J, Vasilevsky CA, Boutros M. Financial and occupational impact of low anterior resection syndrome in rectal cancer survivors. Colorectal Dis 2021; 23:1777-1784. [PMID: 33724620 DOI: 10.1111/codi.15633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 02/19/2021] [Accepted: 03/09/2021] [Indexed: 12/12/2022]
Abstract
AIM The aim of this study was to assess bowel-related financial stress and strain and to evaluate its association with global quality of life. METHOD This was a retrospective cohort study with cross-sectional follow-up including consecutive patients who underwent restorative proctectomy for neoplastic disease of the rectum at a single university-affiliated hospital in Montreal, Quebec, Canada. Bowel-related financial impact and occupational impact were compared between patients with major low anterior resection syndrome (LARS) and those with minor/no LARS. The association between LARS, bowel-related financial impact and global quality of life (QoL) was then assessed in a multiple logistic regression model. RESULTS Of 180 eligible rectal cancer survivors who were contacted, 154 completed the questionnaires (response rate 47.1%) at a median follow-up of 57.5 months (interquartile range 34.1-98.1) after proctectomy. Individuals with major LARS reported a higher prevalence of bowel-related financial stress (53.2% vs 5.6%, p < 0.001) and strain (42.2% vs 5.6%, p < 0.001) compared with those with minor/no LARS. Among those who were working preoperatively (n = 100), the majority of participants with major LARS reported an impact of their new bowel function on their ability to work (70.6%), including delayed return to work (44.1%), the need to change schedules (35.3%) or roles (20.6%), and complete long-term medical absence from work (14.7%). On multiple logistic regression, major LARS with financial impact (OR 4.50, 95% CI 1.57-13.77) was associated with low global QoL compared with minor/no LARS. CONCLUSION Major LARS was associated with considerable financial stress and strain and difficulties in returning to work.
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Affiliation(s)
- Richard Garfinkle
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Aurelie Ky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Aashiyan Singh
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Nancy Morin
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Gabriela Ghitulescu
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Julio Faria
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Carol-Ann Vasilevsky
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
| | - Marylise Boutros
- Division of Colon and Rectal Surgery, Jewish General Hospital, Montreal, Quebec, Canada
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26
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Vogel I, Reeves N, Tanis PJ, Bemelman WA, Torkington J, Hompes R, Cornish JA. Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 2021; 25:751-760. [PMID: 33792822 PMCID: PMC8187190 DOI: 10.1007/s10151-021-02436-5] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 03/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Impaired bowel function after low anterior resection (LAR) for rectal cancer is a frequent problem with a major impact on quality of life. The aim of this study was to assess the impact of a defunctioning ileostomy, and time to ileostomy closure on bowel function after LAR for rectal cancer. METHODS We performed a systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Comprehensive literature searches were conducted using PubMed, Embase and Cochrane databases for articles published from 1989 up to August 2019. Analysis was performed using Review Manager (version 5.3) using a random-effects model. RESULTS The search yielded 11 studies (1400 patients) that reported on functional outcome after LAR with at least 1 year follow-up, except for one study. Five scales were used: the Low Anterior Resection Syndrome (LARS) score, the Wexner score, the Memorial Sloan Kettering Cancer Centre Bowel Function Instrument, the Fecal Incontinence Quality of Life scale, and the Hallbook questionnaire. Based on seven studies, major LARS occurred more often in the ileostomy group (OR 2.84, 95% CI, 1.70-4.75, p < 0.0001: I2 = 60%, X2 = 0.02). Based on six studies, a longer time to stoma closure increased the risk of major LARS with a mean difference in time to closure of 2.39 months (95% CI, 1.28-3.51, p < 0.0001: I2 = 21%, X2 = 0.28) in the major vs. no LARS group. Other scoring systems could not be pooled, but presence of an ileostomy predicted poorer bowel function except with the Hallbook questionnaire. CONCLUSIONS The risk of developing major LARS seems higher with a defunctioning ileostomy. A prolonged time to ileostomy closure seems to reinforce the negative effect on bowel function; therefore, early reversal should be an important part of the patient pathway.
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Affiliation(s)
- I Vogel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK.
| | - N Reeves
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - P J Tanis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - W A Bemelman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J Torkington
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
| | - R Hompes
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J A Cornish
- Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
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27
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Ryoo SB, Park JW, Lee DW, Lee MA, Kwon YH, Kim MJ, Moon SH, Jeong SY, Park KJ. Anterior resection syndrome: a randomized clinical trial of a 5-HT3 receptor antagonist (ramosetron) in male patients with rectal cancer. Br J Surg 2021; 108:644-651. [PMID: 33982068 DOI: 10.1093/bjs/znab071] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 01/31/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND No effective treatment exists for anterior resection syndrome (ARS) following sphincter-saving surgery for rectal cancer. This RCT assessed the safety and efficacy of a 5-HT3 receptor antagonist, ramosetron, for ARS. METHODS A single-centre, randomized, controlled, open-label, parallel group trial was conducted. Male patients with ARS 1 month after rectal cancer surgery or ileostomy reversal were enrolled and randomly assigned (1 : 1) to 5 μg of ramosetron (Irribow®) daily or conservative treatment for 4 weeks. Low ARS (LARS) score was calculated after randomization and 4 weeks after treatment. The study was designed as a superiority test with a primary endpoint of the proportion of patients with major LARS between the groups. Primary outcome analysis was based on the modified intention-to-treat population. Safety was assessed by monitoring adverse events during the study. RESULTS : A total of 100 patients were randomized to the ramosetron (49 patients) or conservative treatment group (51 patients). Two patients were excluded, and 48 and 50 patients were analysed in the ramosetron and control groups, respectively. The proportion of major LARS after 4 weeks was 58 per cent (28 of 48 patients) in the ramosetron group versus 82 per cent (41 of 50 patients) in the control group, with a difference of 23.7 per cent (95 per cent c.i. 5.58 to 39.98, P = 0.011). There were minor adverse events in five patients, which were hard stool, frequent stool or anal pain. These were not different between the two groups. There were no serious adverse events. CONCLUSION : Ramosetron could be safe and feasible for male patients with ARS. TRIAL REGISTRATION NUMBER NCT02869984 (http://www.clinicaltrials.gov).
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Affiliation(s)
- S-B Ryoo
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - J W Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - D W Lee
- Centre for Colorectal Cancer, Research Institute and Hospital, National Cancer Centre, Goyang, Korea
| | - M A Lee
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Y-H Kwon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - M J Kim
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - S H Moon
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
| | - S-Y Jeong
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - K J Park
- Division of Colorectal Surgery, Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
- Colorectal Cancer Centre, Seoul National University Cancer Hospital, Seoul, Korea
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A study on the clinical application of greater omental pedicle flap transplantation to correct anterior resection syndrome in patients with low rectal cancer. Regen Ther 2021; 18:146-151. [PMID: 34222567 PMCID: PMC8220312 DOI: 10.1016/j.reth.2021.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 05/06/2021] [Accepted: 05/15/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction Low anterior resection syndrome (LARS) is the most common complication after total mesorectal excision (TME) in patients with low rectal cancer and has been a challenge in colorectal surgery that severely impacts the quality of life of patients. This study aimed to introduce a revised surgical procedure which could effectively maintain rectal compliance and significantly improve LARS after the operation. Methods We performed mesorectal reconstruction after routine Dixon TME using greater omental pedicle flap transplantation in 11 patients with low rectal cancer (5 cases of preoperative neoadjuvant chemoradiotherapy, 5 cases of preoperative neoadjuvant chemotherapy, and 1 case of postoperative adjuvant chemotherapy), thereby simulating the initial anatomical structure of the mesorectum and significantly reducing the postoperative anterior resection syndrome. The lars precision syndrome assessment scale (LARSS) was used to access the LARS. Results At 12 weeks after the 11 patients recovered from the anal defecation function, the average score on the LARS questionnaire was 25.5 ± 1.5 (minor). The average time at which anal function began to recover was 6.2 ± 2.6 weeks after surgery. The recovery was rapid, as the rectal and anal function of all patients generally returned to normal levels within 12 weeks, and the quality of life was close to that before surgery. Conclusion Greater omental flap transplantation can significantly improve LARS after Dixon TME in patients with low rectal cancer. Omental pedicle flap transplantation is a revised and promising surgical procedure. The procedure reconstructing the mesorectum could maintain rectal compliance. The procedure can significantly improve low anterior resection syndrome.
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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.
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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
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Dalsgaard P, Emmertsen KJ, Mekhael M, Laurberg S, Christensen P. Nurse-led standardized intervention for low anterior resection syndrome. A population-based pilot study. Colorectal Dis 2021; 23:434-443. [PMID: 33340218 DOI: 10.1111/codi.15497] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/12/2020] [Accepted: 11/29/2020] [Indexed: 01/13/2023]
Abstract
AIM Our aim was to study the implementation of the low anterior resection syndrome (LARS) score in a clinical setting and to evaluate a nurse-led standardized intervention for bowel dysfunction following rectal cancer surgery. METHOD All patients who underwent curatively intended, restorative rectal cancer resection in a single centre between 2012 and 2016 were screened using the LARS score. At clinical follow-up, patients with major LARS were offered treatment in a nurse-led clinic. Data were retrospectively collected from patients' electronic medical records. RESULTS In total, 190 out of 286 (66%) patients were screened with the LARS score of whom 89 had major LARS. A total of 86 patients requested treatment for their bowel dysfunction and the majority obtained acceptable function after nurse-led optimized conservative treatment. Seventeen patients went on to transanal irrigation, and seven patients were treated with biofeedback. Five patients were referred for surgery, three for gastroenterological evaluation. After treatment in the clinic, patients achieved a statistically significant decrease in median LARS score from 37 (interquartile range 34-39) to 31 (interquartile range 23-34) (P < 0.001), and the prevalence of major LARS fell from 95% to 53% (P < 0.001). CONCLUSION Screening for LARS was not optimal as one-third of patients were not screened. The majority of patients with major LARS requested treatment for their symptoms and could be successfully treated with standardized interventions managed in a nurse-led setting.
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Affiliation(s)
- Peter Dalsgaard
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Surgery, Regional Hospital West Jutland, Herning, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus, Denmark
| | - Katrine Jøssing Emmertsen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus, Denmark.,Department of Surgery, Regional Hospital Randers, Randers, Denmark
| | - Mira Mekhael
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus, Denmark
| | - Peter Christensen
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark.,Danish Cancer Society Centre for Research on Survivorship and Late Adverse Effects after Cancer in the Pelvic Organs, Aarhus, Denmark
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Asnong A, D'Hoore A, Van Kampen M, Devoogdt N, De Groef A, Sterckx K, Lemkens H, Wolthuis A, Van Molhem Y, Van Geluwe B, Debrun L, Geraerts I. Randomised controlled trial to assess efficacy of pelvic floor muscle training on bowel symptoms after low anterior resection for rectal cancer: study protocol. BMJ Open 2021; 11:e041797. [PMID: 33483444 PMCID: PMC7831707 DOI: 10.1136/bmjopen-2020-041797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Radical surgery after a total mesorectal excision (TME) for rectal cancer often results in a significant decrease in the patient's quality of life, due to functional problems such as bowel, urinary and sexual dysfunction. The effect of pelvic floor muscle training (PFMT) on these symptoms has been scarcely investigated. We hypothesise that the proportion of successful patients will be significantly higher in the intervention group, receiving 12 weeks of PFMT, compared with the control group without treatment. The primary outcome of this trial is the severity of bowel symptoms, measured through the Low Anterior Resection Syndrome questionnaire, 4 months after TME or stoma closure. Secondary outcomes are related to other bowel and urinary symptoms, sexual function, physical activity and quality of life. METHODS AND ANALYSIS This research protocol describes a multicentre single blind prospective, randomised controlled trial. Since January 2017, patients treated for rectal cancer (n=120) are recruited after TME in three Belgian centres. One month following surgery or, in case of a temporary ileostomy, 1 month after stoma closure, patients are randomly assigned to the intervention group (n=60) or to the control group (n=60). The assessments concern the preoperative period and 1, 4, 6, 12 and 24 months postoperatively. ETHICS AND DISSEMINATION The study will be conducted in accordance with the Declaration of Helsinki. Ethics approval was granted by the local Ethical Committee of the University Hospitals Leuven (s59761) and positive advice from the others centres has been obtained. Dissemination of the results will be accomplished via guidelines and (non-)scientific literature for professionals as well as organisation of patient symposia. TRIAL REGISTRATION NUMBER NTR6383.
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Affiliation(s)
- Anne Asnong
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
- Department of Oncology, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Marijke Van Kampen
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Nele Devoogdt
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - An De Groef
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Kim Sterckx
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Hilde Lemkens
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
- Department of Oncology, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Yves Van Molhem
- Department of Abdominal Surgery, OLVZ, Aalst, Oost-Vlaanderen, Belgium
| | - Bart Van Geluwe
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
- Department of Abdominal Surgery, AZ Groeninge - Campus Kennedylaan, Kortrijk, West-Vlaanderen, Belgium
| | - Lynn Debrun
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
| | - Inge Geraerts
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
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32
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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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Lam D, Jones O. Changes to gastrointestinal function after surgery for colorectal cancer. Best Pract Res Clin Gastroenterol 2020; 48-49:101705. [PMID: 33317788 DOI: 10.1016/j.bpg.2020.101705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/19/2020] [Accepted: 11/05/2020] [Indexed: 01/31/2023]
Abstract
Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.
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Affiliation(s)
- David Lam
- Senior Clinical Fellow in Colorectal Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - Oliver Jones
- Consultant Colorectal Surgeon and Clinical Director of Surgery, Oxford University Hospitals NHS Foundation Trust, Department of Colorectal Surgery, Churchill Hospital, Old Road, Headington, Oxford, OX3 7LE, UK.
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Chan KYC, Suen M, Coulson S, Vardy JL. Efficacy of pelvic floor rehabilitation for bowel dysfunction after anterior resection for colorectal cancer: a systematic review. Support Care Cancer 2020; 29:1795-1809. [PMID: 33111180 DOI: 10.1007/s00520-020-05832-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 10/13/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Bowel dysfunction is common after anterior resection for colorectal cancer (CRC). Pelvic floor rehabilitation (PFR) may improve functional outcomes after surgery. This review aimed to evaluate the efficacy of PFR for patients with bowel symptoms after anterior resection. METHODS MEDLINE, CINHAL, PUBMED, EMBASE, Scopus, PsycINFO, Web of Science, PEDRO and Cochrane Library were searched from inception to June 2019. A final search was performed on 11 July 2020. Randomised controlled trials (RCTs), cohort studies, case-control studies and case series of bowel dysfunction after CRC surgery and PFR were eligible for review. Outcome measures were bowel function changes measured by patient-reported outcomes and manometric measurement. Risk of bias assessments using Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle Ottawa Scale (NOS) were conducted. RESULTS Eleven trials met eligibility criteria: four retrospective studies and seven prospective, non-randomised controlled studies. A total of 516 participants were included, of which 455 received PFR. Functional outcomes were measured by bowel functional outcome questionnaires, patient diary, anorectal manometry and three studies measured quality of life. Faecal incontinence was improved in seven studies, and bowel frequency also decreased in five studies. The mean MINORS score was 10 (8-13) out of 16 in non-comparative groups and 18 (16-22) out of 24 in comparative groups; the NOS was 4.2 (3-7) out of 9. The overall risk of bias was high in most studies. CONCLUSIONS PFR appears to be beneficial for improving bowel function after anterior resection for CRC. However, the studies included had methodological limitations, so further investigation on the effectiveness of PFR is warranted.
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Affiliation(s)
- K Y C Chan
- Concord Cancer Centre, Concord Repatriation & General Hospital, Hospital Road, Sydney, NSW, 2139, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - M Suen
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Colorectal Surgery, Concord Repatriation & General Hospital, Concord, NSW, 2139, Australia
| | - S Coulson
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Janette L Vardy
- Concord Cancer Centre, Concord Repatriation & General Hospital, Hospital Road, Sydney, NSW, 2139, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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Sandberg S, Asplund D, Bisgaard T, Bock D, González E, Karlsson L, Matthiessen P, Ohlsson B, Park J, Rosenberg J, Skullman S, Sörensson M, Angenete E. Low anterior resection syndrome in a Scandinavian population of patients with rectal cancer: a longitudinal follow-up within the QoLiRECT study. Colorectal Dis 2020; 22:1367-1378. [PMID: 32346917 DOI: 10.1111/codi.15095] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/25/2020] [Indexed: 12/12/2022]
Abstract
AIM Low anterior resection syndrome (LARS) is common after low anterior resection. Our aim was to evaluate the prevalence and 'bother' (subjective, symptom-associated distress) of major LARS after 1 and 2 years, identify possible risk factors and relate the bowel function to a reference population. METHOD The QoLiRECT (Quality of Life in RECTal cancer) study is a Scandinavian prospective multicentre study including 1248 patients with rectal cancer, of whom 552 had an anterior resection. Patient questionnaires were distributed at diagnosis and after 1, 2 and 5 years. Data from the baseline and at 1- and 2-year follow-up were included in this study. RESULTS The LARS score was calculated for 309 patients at 1 year and 334 patients at 2 years. Prevalence was assessed by a generalized linear mixed effects model. Major LARS was found in 63% at 1 year and 56% at 2 years. Bother was evident in 55% at 1 year, decreasing to 46% at 2 years. Major LARS was most common among younger women (69%). Among younger patients, only marginal improvement was seen over time (63-59%), for older patients there was more improvement (62-52%). In the reference population, the highest prevalence of major LARS-like symptoms was noted in older women (12%). Preoperative radiotherapy, defunctioning stoma and tumour height were found to be associated with major LARS. CONCLUSION Major LARS is common and possibly persistent over time. Younger patients, especially women, are more affected, and perhaps these patients should be prioritized for early stoma closure to improve the chance of a more normal bowel function.
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Affiliation(s)
- S Sandberg
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - D Asplund
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - T Bisgaard
- Department of Surgery, Centre for Surgical Science, University Hospital of Zealand, Køge, Denmark
| | - D Bock
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E González
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - L Karlsson
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - P Matthiessen
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - B Ohlsson
- Department of Surgery, Blekinge Hospital, Karlshamn, Sweden
| | - J Park
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
| | - J Rosenberg
- Department of Surgery, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark
| | - S Skullman
- Department of Surgery, Skaraborgs Hospital Skövde, Skövde, Sweden
| | - M Sörensson
- Department of Surgery, Karlstad Hospital, Karlstad, Sweden
| | - E Angenete
- Department of Surgery, SSORG - Scandinavian Surgical Outcomes Research Group, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
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Abstract
Defecatory disorders can include structural, neurological, and functional disorders in addition to concomitant symptoms of fecal incontinence, functional anorectal pain, and pelvic floor dyssynergia. These disorders greatly affect quality of life and healthcare costs. Treatment for pelvic floor disorders can include medications, botulinum toxin, surgery, physical therapy, and biofeedback. Pelvic floor muscle training for pelvic floor disorders aims to enhance strength, speed, and/or endurance or coordination of voluntary anal sphincter and pelvic floor muscle contractions. Biofeedback therapy builds on physical therapy by incorporating the use of equipment to record or amplify activities of the body and feed the information back to the patients. Biofeedback has demonstrated efficacy in the treatment of chronic constipation with dyssynergic defecation, fecal incontinence, and low anterior resection syndrome. Evidence for the use of biofeedback in levator ani syndrome is conflicting. In comparing biofeedback to pelvic floor muscle training alone, studies suggest that biofeedback is superior therapy.
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Affiliation(s)
- Melissa Hite
- Department of Surgery, Division of Colon and Rectal Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Thomas Curran
- Department of Surgery, Division of Colon and Rectal Surgery, Medical University of South Carolina, Charleston, South Carolina
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De Meyere C, Nuytens F, Parmentier I, D'Hondt M. Five-year single center experience of sacral neuromodulation for isolated fecal incontinence or fecal incontinence combined with low anterior resection syndrome. Tech Coloproctol 2020; 24:947-958. [PMID: 32556866 DOI: 10.1007/s10151-020-02245-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 05/15/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE Sacral neuromodulation (SNM) has proven to be a safe and effective treatment for fecal incontinence (FI). For low anterior resection syndrome (LARS), however, SNM efficacy is still poorly documented. The primary aim of this study was to report on efficacy of SNM therapy for patients with isolated FI or LARS. Furthermore, we evaluated the safety of the procedure and the relevance of adequate follow-up. METHODS A retrospective analysis was performed upon a prospectively maintained database of all patients who underwent SNM therapy for isolated FI or LARS between January 2014 and January 2019. The Wexner and LARS scores were evaluated at baseline, during test phase, after definitive implantation and annually during follow-up. Treatment success was defined as at least 50% improvement of the Wexner score or a reduction to minor or no LARS. RESULTS Out of 89 patients with isolated FI or LARS who had a SNM test phase, 62 patients were eligible for implantation of the permanent SNM device. At baseline, 3 weeks, and 1, 2, 3, 4 and 5 years after definitive implantation the median Wexner score of all patients was 18, 2, 4.5, 5, 5, 4 and 4.5, respectively, and 18, 4, 5.5, 5, 4, 3 and 4, respectively, for patients with FI and LARS. Patients with LARS more frequently required changes in program settings. CONCLUSIONS SNM therapy is a safe and effective treatment for patients with isolated FI and patients with FI and LARS. Adequate follow-up is essential to ensure long-term effectivity, especially for LARS patients.
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Affiliation(s)
- C De Meyere
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - F Nuytens
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium
| | - I Parmentier
- Department of Oncology and Statistics, Groeninge Hospital, Kortrijk, Belgium
| | - M D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, President Kennedylaan 4, 8500, Kortrijk, Belgium.
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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.
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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.
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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.
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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.
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Eid Y, Bouvier V, Dejardin O, Menahem B, Chaillot F, Chene Y, Dutheil JJ, Juul T, Morello R, Alves A. 'French LARS score': validation of the French version of the low anterior resection syndrome (LARS) score for measuring bowel dysfunction after sphincter-preserving surgery among rectal cancer patients: a study protocol. BMJ Open 2020; 10:e034251. [PMID: 32152168 PMCID: PMC7064062 DOI: 10.1136/bmjopen-2019-034251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Many bowel problems following low anterior resection (LAR) for rectal cancer considerably impair the quality of life (QoL) of patients. The LAR syndrome (LARS) scale is a self-report questionnaire to identify and assess bowel dysfunction after rectal cancer surgery. It has been translated and validated in several languages but not in French (metropolitan French). The primary objective is to adapt the LARS scale to the French language (called French-LARS score) and to assess its psychometric properties. Secondary objectives are to assess both the prevalence and severity of LARS and to measure their impact on QoL. METHODS AND ANALYSIS A French multicentre observational cohort study has been designed. The validation study will include translation of the LARS scale following the current international recommendations, assessment of its reliability, convergent and discriminant validities, sensitivity, internal consistency, internal validity and confirmatory analyses. One thousand patients will be enrolled for the analyses. The questionnaire will be initially administered to the first 100 patients to verify the adequacy and degree of comprehension of the questions. Then reproducibility will be investigated by a test-retest procedure in the following 400 patients.An analysis will be conducted to determine the correlation between the LARS score and the Quality of Life Questionnaire (QLQ; European Organization for Treatment and Research of Cancer's QLQ-C30, QLQ-CR29). Risk factors linked to QoL deterioration will be identified and their impact will be measured. This study will meet the need for a validated tool to improve patient care and QoL. ETHICS AND DISSEMINATION The institutional review board of the University Hospital of Caen and the ethics committee (CPP Nord Ouest I, 25 January 2019) approved the study. TRIAL REGISTRATION NUMBER NCT03569488.
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Affiliation(s)
- Yassine Eid
- Department of digestive surgery, University Hospital of Caen, Caen, France
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Department of research, University Hospital of Caen, Normandy, France
| | - Véronique Bouvier
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Digestive Cancer Registry of Calvados, University Hospital of Caen, Caen cedex, France
| | - Olivier Dejardin
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Department of research, University Hospital of Caen, Normandy, France
| | - Benjamin Menahem
- Department of digestive surgery, University Hospital of Caen, Caen, France
| | - Fabien Chaillot
- Department of research, University Hospital of Caen, Normandy, France
| | - Yannick Chene
- Department of research, University Hospital of Caen, Normandy, France
| | | | - Therese Juul
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Rémy Morello
- Department of research, University Hospital of Caen, Normandy, France
- Department of biostatistics and clinical research, University Hospital of Caen, Caen cedex, France
| | - Arnaud Alves
- Department of digestive surgery, University Hospital of Caen, Caen, France
- ANTICIPE" U1086 INSERM-University of Caen Normandy, Team « Ligue contre le Cancer », Centre François Baclesse, Caen, France
- Department of research, University Hospital of Caen, Normandy, France
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Whitehead WE, Simren M, Busby-Whitehead J, Heymen S, van Tilburg MAL, Sperber AD, Palsson OS. Fecal Incontinence Diagnosed by the Rome IV Criteria in the United States, Canada, and the United Kingdom. Clin Gastroenterol Hepatol 2020; 18:385-391. [PMID: 31154029 DOI: 10.1016/j.cgh.2019.05.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/06/2019] [Accepted: 05/19/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS The diagnostic criteria for fecal incontinence (FI) were made more restrictive in the Rome IV revision. We aimed to determine the characteristics of FI patients defined by the Rome IV criteria, assess how FI frequency and amount affect quality of life, identify risk factors, and compare prevalence values among countries. METHODS We performed an internet-based survey of 5931 subjects in the United States, Canada, and the United Kingdom, from September to December 2015. Subjects were stratified by country, sex, and age. Responders answered questions about diagnosis, health care use, and risk factors. We performed multivariate linear regression analysis to identify risk factors for FI. RESULTS FI was reported by 957 subjects (16.1%) but only 196 (3.3%) fulfilled the Rome IV criteria. Frequency of FI was less than twice a month for 672/957 subjects (70.2%) and duration was less than 6 months for 285/957 subjects (29.8%). Quality of life was significantly impaired in all subjects with FI compared to subjects with fecal continence. The strongest risk factors for FI were diarrhea, urgency to defecate, and abdominal pain. FI was more prevalent in the United States than in the United Kingdom. Between-country differences were due to less diarrhea and urgency in the United Kingdom. CONCLUSIONS Rome IV FI prevalence is lower than previous estimates because the new criteria exclude many individuals with less frequent or short duration FI. These excluded patients have impaired quality of life. It might be appropriate to make a diagnosis of FI for all patients with FI ≥2 times in 3 months and to provide additional information on frequency, duration, and amount of stool lost to assist clinicians in treatment selection.
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Affiliation(s)
- William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina.
| | - Magnus Simren
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Busby-Whitehead
- Center for Aging and Health, Division of Geriatric Medicine, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Steve Heymen
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Miranda A L van Tilburg
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina; Department of Clinical Research, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, North Carolina; School of Social Work, University of Washington, Seattle, Washington
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Olafur S Palsson
- Center for Functional Gastrointestinal and Motility Disorders, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Kalkdijk-Dijkstra A, van der Heijden J, van Westreenen H, Broens P, Trzpis M, Pierie J, Klarenbeek B. Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial). Trials 2020; 21:112. [PMID: 31992358 PMCID: PMC6988240 DOI: 10.1186/s13063-019-4043-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 12/30/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment. METHODS The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes. DISCUSSION The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial. TRIAL REGISTRATION Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.
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Affiliation(s)
| | | | | | - P.M.A. Broens
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - M. Trzpis
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - J.P.E.N. Pierie
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
- Department of PGSoM, University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - B.R. Klarenbeek
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Lee KH, Kim JS, Kim JY. Efficacy of biofeedback therapy for objective improvement of pelvic function in low anterior resection syndrome. Ann Surg Treat Res 2019; 97:194-201. [PMID: 31620393 PMCID: PMC6779952 DOI: 10.4174/astr.2019.97.4.194] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/22/2019] [Accepted: 08/13/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose There is no established treatment of choice for low anterior resection syndrome (LARS). To evaluate the efficacy of biofeedback therapy for objective improvement of pelvic function in LARS, we performed the present study. Methods The primary endpoint was the change of Wexner score. Consenting patients between 20 and 80 years old with major LARS at least 2 months after sphincter preserving proctectomy for rectal cancer were enrolled. After recommendation of biofeedback therapy, patients who accept it were enrolled in the biofeedback group and patients who refuse were enrolled in the control group. Initial and follow-up evaluations were performed and analyzed. Results Fifteen and sixteen patients were evaluated in the control group and the biofeedback group, respectively. There was no statistically significant difference of LARS score between both groups. Decrease in Wexner score and increase in rectal capacity were significantly higher in the biofeedback group (odds ratio [OR], 5.386; 95% confidence interval [CI], 1.194–24.287; P = 0.028 and OR, 1.061; 95% CI, 1.002–1.123; P = 0.042). Conclusion Biofeedback therapy was superior for objective improvement of pelvic function to observation in LARS. It can be considered to induce more rapid improvement of major LARS.
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Affiliation(s)
- Kyung Ha Lee
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jin Soo Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
| | - Ji Yeon Kim
- Department of Surgery, Chungnam National University College of Medicine, Daejeon, Korea
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Implementation of a Postoperative Screening and Treatment Guidance for the Low Anterior Resection Syndrome: Preliminary Results. Dis Colon Rectum 2019; 62:1033-1042. [PMID: 31318775 DOI: 10.1097/dcr.0000000000001428] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Even years after a low anterior resection, many patients experience persisting bowel complaints. This is referred to as low anterior resection syndrome and has a severe adverse effect on quality of life. Its diverse nature makes it difficult to find a gold-standard therapy for this syndrome. However, most importantly, postoperative guidance appears to be suboptimal. OBJECTIVE The purpose of this study was to describe and evaluate the implementation of a multimodel guidance with structured screening and treatment options. DESIGN A retrospective, comparative, cross-sectional study was conducted. Data of patients treated before protocol implementation were compared with a cohort after implementation. SETTINGS This was a single-center study. PATIENTS Patients seen after low anterior resection or sigmoid resection between 2010 and 2017 for colorectal malignancy were included. INTERVENTION This included implementation of a postoperative guidance protocol. MAIN OUTCOME MEASURES Bowel dysfunction was assessed by the low anterior resection score, whereas the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires (C30 and CR29) assessed general and colorectal-specific quality of life. RESULTS A total of 243 patients were included; 195 were guided before and 48 after protocol implementation. Patients who underwent low anterior resection after protocol implementation showed significantly lower median low anterior resection scores (31 vs 18; p = 0.02) and less major low anterior resection syndrome (51.9% vs 26.3%; p = 0.045). Patients who underwent sigmoid resection did not present with similar changes. Multiple quality-of-life domains showed clinically significant positive changes since our postoperative protocol was implemented. LIMITATIONS Patient characteristics are not comparable between groups, which makes it difficult to draw firm conclusions. CONCLUSIONS We recommend that others reconsider their current postoperative management for patients with rectal cancer and suggest a change to a comparable noninvasive, patient-driven postoperative guidance to enhance patient coping mechanisms and self-management and therefore improve their quality of life. See Video Abstract at http://links.lww.com/DCR/A970. IMPLEMENTACIÓN DE UNA GUÍA POSTOPERATORIA DE DETECCIÓN Y TRATAMIENTO PARA EL SÍNDROME DE RESECCIÓN ANTERIOR BAJA: RESULTADOS PRELIMINARES: Incluso años después de una resección anterior baja, muchos pacientes experimentan quejas intestinales persistentes. Esto se conoce como síndrome de resección anterior baja y tiene un efecto adverso grave en la calidad de vida. Su naturaleza diversa hace que sea difícil encontrar una terapia patrón de oro para este síndrome. Pero lo más importante, la guía postoperatoria parece ser subóptima. OBJETIVO Describir y evaluar la implementación de una guía de múltiples modelos con opciones estructuradas de selección y tratamiento. DISENO Se realizó un estudio retrospectivo de corte transversal comparativo. Los datos de los pacientes tratados antes de la implementación del protocolo se compararon con una cohorte después de la implementación. MARCO Centro de estudio único. PACIENTES Pacientes después de resección anterior baja o resección sigmoidea entre 2010-2017 por neoplasia colorectal. INTERVENCIÓN:: La implementación de un protocolo de guía postoperatoria. PRINCIPALES MEDIDAS DE RESULTADO La disfunción intestinal se evaluó mediante la puntuación de resección anterior baja, mientras que la Organización Europea para la Investigación y Tratamiento de Cuestionarios de Calidad de Vida del Cáncer (C30 y CR29) evaluó la calidad de vida general y específicamente colorectal. RESULTADOS Se incluyeron 243 pacientes, 195 fueron guiados antes y 48 después de la implementación del protocolo. Los pacientes que se sometieron a una resección anterior baja después de la implementación del protocolo mostraron puntuaciones de resección anterior bajas medias significativamente más bajas (31 frente a 18; p = 0,02) y menos puntuaciones de síndrome de resección anterior baja (51,9% frente a 26,3%; p = 0,045). Los pacientes sometidos a resección sigmoidea no presentaron cambios similares. Los múltiples dominios de calidad de vida mostraron cambios positivos clínicamente significativos desde que se implementó nuestro protocolo postoperatorio. LIMITACIONES Las características de los pacientes no son comparables entre los grupos, lo que dificulta sacar conclusiones firmes. CONCLUSIÓNES:: Recomendamos a otros que reconsideren su manejo postoperatorio actual para pacientes con cáncer de recto y sugerimos un cambio a una guía postoperatoria impulsada por el paciente no invasiva comparable para mejorar los mecanismos de afrontamiento y el autocontrol de los pacientes y, por lo tanto, mejorar su calidad de vida. Vea el Video del Resumen en http://links.lww.com/DCR/A970.
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Cura Pales CG, An S, Cruz JP, Kim K, Kim Y. Postoperative Bowel Function After Anal Sphincter-Preserving Rectal Cancer Surgery: Risks Factors, Diagnostic Modalities, and Management. Ann Coloproctol 2019; 35:160-166. [PMID: 31487762 PMCID: PMC6732333 DOI: 10.3393/ac.2019.08.10] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/10/2019] [Indexed: 02/06/2023] Open
Abstract
Low anterior resection syndrome (LARS) refers to a disturbance of bowel function that commonly manifests within 1 month after rectal cancer surgery. A low level of anastomosis and chemoradiotherapy have been consistently found to be risk factors for developing LARS. Thorough history taking and physical examination with adjunctive procedures are essential when evaluating patients with LARS. Anorectal manometry, fecoflowmetry, and validated questionnaires are important tools for assessing the quality of life of patients with LARS. Conservative management (medical, physiotherapy, transanal irrigation), invasive procedures (neuromodulation), and multimodal therapy are the mainstay of treatment for patients with LARS. A stoma could be considered when other treatment modalities have failed. An initial meticulous surgical procedure for rectal cancer, creation of a neorectal reservoir during anastomosis, and proper exercise of the anal sphincter muscle (Kegel’s maneuver) are essential to combat LARS. Pretreatment counseling is a crucial step for patients who have risk factors for developing LARS.
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Affiliation(s)
- Chris George Cura Pales
- Section of Colon and Rectal Surgery, Department of Surgery, Southern Philippines Medical Center, Davao City, The Philippines
| | - Sanghyun An
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jan Paolo Cruz
- Section of Colorectal Surgery, Department of Surgery, Rizal Medical Center, Pasig City, The Philippines.,Department of Surgery, Clinica Antipolo Hospital and Wellness Center, Antipolo City, The Philippines
| | - Kwangmin Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea.,Department of Surgery, Saidabad Clinic, Dhaka, Bangladesh
| | - Youngwan Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Abstract
PURPOSE OF REVIEW Health-related quality of life (HRQoL) is a topic of great importance among older patients with cancer. Here we review the literature on HRQoL in older patients with colon and rectal cancer. RECENT FINDINGS HRQoL in older cancer patients with colon and rectal cancer can be impacted by care delivery model, use of selected treatments (i.e., chemotherapy), and the trajectory of the patient after surgery for colorectal cancer (CRC). HRQoL is an important outcome for older cancer patients. Greater numbers of older patients are undergoing treatment for CRC and may experience wide variations in quality of life during and after treatment. Trials should be developed with HRQoL as a primary outcome, and interventions need to be developed to maintain or improve HRQoL in older patients with cancer.
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Affiliation(s)
- Evan Lapinsky
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, 925 Chestnut St., 4th Floor, Philadelphia, PA, 19107, USA
| | - Lillian C Man
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, 925 Chestnut St., 4th Floor, Philadelphia, PA, 19107, USA
| | - Amy R MacKenzie
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, 925 Chestnut St., 4th Floor, Philadelphia, PA, 19107, USA.
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Simard J, Kamath S, Kircher S. Survivorship Guidance for Patients with Colorectal Cancer. Curr Treat Options Oncol 2019; 20:38. [DOI: 10.1007/s11864-019-0635-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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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.
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