Factors influencing anterior/low anterior resection syndrome after rectal or sigmoid resections

Low Anterior Resection Syndrome in Total Mesorectal Excision: Risk Factors and Its Relationship with Quality of Life

Background: Low anterior resection syndrome (LARS) is a bowel dysfunction following sphincter-sparing proctectomy. The occurrence of LARS may affect a patient's overall quality of life (QoL) after surgery. Current research was aimed to investigate related factors of LARS and major LARS in total mesorectal excision (TME) and its relationship with QoL. Methods: This study included patients who underwent TME at authors' institutes. LARS was evaluated with an LARS score. QoL was identified using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire, version 3.0. Appropriate statistical methods were used to ascertain risk factors for LARS and major LARS and to analyze the relationships between QoL and LARS. The primary objective was to identify related factors of LARS and major LARS. The secondary objective was to examine the relationships between QoL and LARS. Results: Multivariable analysis identified neoadjuvant chemoradiotherapy (odds ratio [OR] 4.923, 95% confidence interval [CI] 2.335-10.379, P < .001), local anal distance from the lower edge of the tumor (OR 6.199, 95% CI 2.701-14.266, P < .001), and anastomotic leakage (OR 5.624, 95% CI 1.463-21.614, P = .012) as independent predictors for development of LARS. Meanwhile, neoadjuvant chemoradiotherapy (OR 4.693, 95% CI 1.368-16.107, P = .014) and local anal distance from the lower edge of the tumor (OR 4.935, 95% CI 1.332-18.285, P = .017) were dramatically correlated with development of major LARS in a multivariable analysis. In the major LARS group, statistically significant differences (P < .05) were ascertained, include physical functioning, role functioning, emotional functioning, social functioning, and global health. In addition, pain and diarrhea were evidently higher. Conclusions: Neoadjuvant chemoradiotherapy, local anal distance from the lower edge of the tumor, and anastomotic leakage correlated strongly with development of LARS, and neoadjuvant chemoradiotherapy and local anal distance from the lower edge of the tumor correlated strongly with development of major LARS. Meanwhile, the QoL of patients with major LARS was lower than that of patients with no/minor LARS.

Low anterior resection syndrome: Incidence and association with quality of life

Aim

Low anterior resection syndrome (LARS) causes devastating symptoms and impairs quality of life (QOL). Although its incidence and risk factors have been reported, these data are scarce in Japan. This study aimed to elucidate the incidence and risk factors of LARS as well as to evaluate its association with QOL in Japanese patients.

Method

Patients with anal defecation at the time of the survey between November 2020 and April 2021 were included, among those who underwent anus-preserving surgery for rectal tumors between 2014 and 2019 in tertiary referral university hospital. The severity of LARS and QOL were evaluated with the LARS score and the Japanese version of the fecal incontinence quality of life scale (JFIQL), respectively. Primary endpoint was the incidence of major LARS. Secondary endpoints were risk factors and association with JFIQL.

Results

Of 332 eligible patients, 238 (71.7%) answered the LARS survey completely. The incidence of major LARS was 22% overall, and 48% when limited to lower tumors. Independent risk factors included lower tumors (OR: 7.0, 95% CI: 2.1-23.1, p = 0.001) and surgical procedures with lower anastomoses (OR: 4.6, 95% CI: 1.2-18.5, p = 0.03). The JFIQL generic score correlated moderately with the LARS score (correlation coefficient of -0.65). The JFIQL generic score was also significantly lower in lower tumors.

Conclusions

The incidence of major LARS is 22% in Japanese patients, and independent risk factors include lower tumors and surgical procedures with lower anastomoses. More severe LARS is associated with worse QOL which is significantly more impaired in patients with lower tumors.

The impact on health-related quality of a stoma or poor functional outcomes after rectal cancer surgery in Dutch patients: A prospective cohort study

BACKGROUND

As the survival of patients with rectal cancer has improved in recent decades, more and more patients have to live with the consequences of rectal cancer surgery. An influential factor in long-term Health-related Quality of Life (HRQoL) is the presence of a stoma. This study aimed to better understand the long-term consequences of a stoma and poor functional outcomes.

METHODS

Patients who underwent curative surgery for a primary tumor located in the rectosigmoid and rectum between 2013 and 2020 were identified from the nationwide Prospective Dutch Colorectal Cancer (PLCRC) cohort study. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, and the LARS-score at 12 months, 24 months and 36 months after surgery.

RESULTS

A total of 1,170 patients were included of whom 751 (64.2%) had no stoma, 122 (10.4%) had a stoma at primary surgery, 45 (3.8%) had a stoma at secondary surgery and 252 (21.5%) patients that underwent abdominoperineal resection (APR). Of all patients without a stoma, 41.4% reported major low-anterior resection syndrome (LARS). Patients without a stoma reported significantly better HRQoL. Moreover, patients without a stoma significantly reported an overall better HRQoL.

CONCLUSION

The presence of a stoma and poor functional outcomes were both associated with reduced HRQoL. Patients with poor functional outcomes, defined as major LARS, reported a similar level of HRQoL compared to patients with a stoma. In addition, the HRQoL after rectal cancer surgery does not change significantly after the first year after surgery.

Development of prediction model of low anterior resection syndrome for colorectal cancer patients after surgery based on machine-learning technique

BACKGROUND

Low anterior resection syndrome (LARS) is a common postoperative complication in patients with colorectal cancer, which seriously affects their postoperative quality of life. At present, the aetiology of LARS is still unclear, but some risk factors have been studied. Accurate prediction and early management of medical intervention are keys to improving the quality of life of such high-risk patients.

OBJECTIVES

Based on machine-learning methods, this study used the follow-up results of postoperative patients with colorectal cancer to develop prediction models for LARS and conducted a comparative analysis between the different models.

METHODS

A total of 382 patients diagnosed with colorectal cancer and undergoing surgery at West China Hospital from April 2017 to December 2020 were retrospectively selected as the development cohort. Logistic regression, support vector machine, decision tree, random forest and artificial neural network algorithms were used to construct the prediction models of the obtained dataset. The models were internally validated using cross-validation. The area under the curve and Brier score measures were used to evaluate and compare the differentiation and calibration degrees of the models. The sensitivity, specificity, positive predictive value and negative predictive value of the different models were described for clinical use.

RESULTS

A total of 342 patients were included, the incidence of LARS being 47.4% (162/342) during the six-month follow-up. After feature selection, the factors influencing the occurrence of LARS were found to be location, distance, diverting stoma, exsufflation and surgical type. The prediction models based on five machine-learning methods all showed acceptable performance.

CONCLUSIONS

The five models developed based on the machine-learning methods showed good prediction performance. However, considering the simplicity of clinical use of the model results, the logistic regression model is most recommended. The clinical applicability of these models will also need to be evaluated with external cohort data.

Validation of the Vietnamese version of the low anterior resection syndrome score questionnaire

Purpose

The aim of this study was to validate the low anterior resection syndrome (LARS) score questionnaire in the Vietnamese language among Vietnamese patients who underwent sphincter-preserving surgery for rectal cancer.

Methods

The LARS score questionnaire was translated from English into Vietnamese and then back-translated as recommended internationally. From January 2018 to December 2020, 93 patients who underwent sphincter-preserving surgery completed the Vietnamese version of the LARS score questionnaire together with an anchored question assessing the influence of bowel function on quality of life (QoL). To validate test-retest reliability, patients were requested to answer the LARS score questionnaire twice.

Results

Ninety-three patients completed the LARS score questionnaire, of whom 89 responded twice. The patients who responded twice were included in the analysis of test-retest reliability. Fifty-eight patients had a "major" LARS score. The LARS score was able to discriminate between patients who were obese and those who were not (P<0.001) and between the low anterior resection and anterior resection procedures (P<0.001). Age and sex were not associated with higher LARS scores (P=0.975). There was a perfect fit between the QoL category question and the LARS score in 56.2% of cases, and a moderate fit was found in 42.7% of cases, showing reasonable convergent validity. The test-retest reliability of 89 patients showed a high intraclass correlation coefficient.

Conclusion

The Vietnamese version of the LARS score questionnaire is a valid tool for measuring LARS.

The risk factors of low anterior resection syndrome after colorectal cancer surgery: A retrospective study of 566 patients in a single institution in China

PURPOSE

This study aims to identify the independent risk factors in the low anterior resection syndrome (LARS) after surgery for colorectal cancer (CRC).

METHOD

This was a retrospective, single-institution study in the Second Affiliation Hospital of Dalian Medical University, China. Patients underwent sphincter-preserving low anterior resection with total or partial mesorectal resection (with or without protective ileostomy) and completed a self-filled questionnaire over the phone to assess postoperative bowel dysfunction from January 2017 to December 2019. The predictors of LAR were evaluated using univariate and multivariate analyses.

RESULT

The study population was 566 patients, 264 (46.64%), 224 (39.58%), and 78 (13.78%) patients with no, minor, and major LARS, respectively. In the univariate analysis, independent factors such as tumor location and size, anastomotic height, protective ileostomy, post-operation chemoradiotherapy, tumor T stage, lymphatic nodal metastasis classification, surgery duration, and time interval for closure of stoma were significantly associated with LARS points while we found the tumor T stage and lymphatic nodal metastasis classification as the new independent risk factors compared with the last decade studies. In the multivariate analysis, factors such as low and middle tumor location and protective ileostomy, and post operation treatment, nodal metastasis classification were the independent risk factors for major LARS.

CONCLUSION

The new independence risk factors were tumor T stage and lymphatic nodal metastasis status in univariate analysis in our study, with anastomotic height, low and middle tumor location, protective ileostomy, post-operation chemoradiotherapy, nodal metastasis status increasing LARS point in multivariate analysis after surgery for CRC.

Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life

BACKGROUND

Surgical resection is the mainstay of curative treatment for rectal cancer. Post-operative complications, low anterior resection syndrome (LARS), and the presence of a stoma may influence the quality of life after surgery. This study aimed to gain more insights into the long-term trade-off between stoma and anastomosis.

METHODS

All patients who underwent sphincter-sparing surgical resection for rectal cancer in the Leiden University Medical Center and the Reinier de Graaf Gasthuis between January 2012 and January 2016 were included. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, EQ-5D-5L, and the LARS score. A comparison was made between patients with a stoma and without a stoma after follow-up.

RESULTS

Some 210 patients were included of which 149 returned the questionnaires (70.9%), after a mean follow-up of 3.69 years. Overall quality of life was not significantly different in patients with and without stoma after follow-up using the EORTC-QLQ-C30 (p = 0.15) or EQ-5D-5L (p = 0.28). However, after multivariate analysis, a significant difference was found for the presence of a stoma on global health status (p = 0.01) and physical functioning (p < 0.01). Additionally, there was no difference detected in the quality of life between patients with major LARS or a stoma.

CONCLUSION

This study shows that after correction for possible confounders, a stoma is associated with lower global health status and physical functioning. However, no differences were found in health-related quality of life between patients with major LARS and patients with a stoma. This suggests that the choice between stoma and anastomosis is mainly preferential and that shared decision-making is required.

Risk factors of postoperative low anterior resection syndrome for colorectal cancer: A meta-analysis

The prevalence of postoperative low anterior resection syndrome (LARS) in patients with colorectal cancer is high, which seriously affects the quality of life after operation. The purpose of this meta-analysis is to systematically evaluate the related factors of LARS in patients with colorectal cancer and provide reference for clinicians when making reasoned decisions. A systematic electronic search of PubMed, Embase, The Cochrane Library, WANFANG and CNKI was performed from 2012 to Dec 2020. We analyzed the risk factors of LARS by extracting baseline data and clinical results. The odds ratio (OR) was used to analyze binary variables. A total of 5102 patients were included in 21 literatures, of which the prevalence of LARS was 49.7% (2538/5102). Meta-analysis showed that there was no significant difference in the influence of age (P = 0.48) and sex (P = 0.68) on LARS, but low tumor height (P < 0.001), low anastomotic height (P < 0.001), radiotherapy and chemotherapy (P < 0.001) and postoperative anastomotic leakage (P < 0.001), disfunction stoma (P < 0.001) are high risk factors for the prevalence of LARS. Low tumor height, low anastomotic height, radiotherapy and chemotherapy, anastomotic leakage and disfunction stoma are risk factors for postoperative LARS in patients with colorectal cancer. Clinicians should pay attention to these indicators of patients to provide better clinical intervention for patients and improve their quality of life after operation.