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Pilkington SA, Bhome R, Gilbert S, Harris S, Richardson C, Dudding TC, Knight JS, King AT, Mirnezami AH, Beck NE, Nichols PH, Nugent KP. Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study. Colorectal Dis 2021; 23:2436-2446. [PMID: 34032359 DOI: 10.1111/codi.15754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 02/08/2023]
Abstract
AIM The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. METHOD Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . RESULTS Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. CONCLUSIONS Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.
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Affiliation(s)
- Sophie A Pilkington
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Rahul Bhome
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Sally Gilbert
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Scott Harris
- Primary Care and Population Studies, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Carl Richardson
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Thomas C Dudding
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - John S Knight
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Andrew T King
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Alex H Mirnezami
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK.,Cancer Sciences, Southampton General Hospital, University of Southampton, Southampton, UK
| | - Nicholas E Beck
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Paul H Nichols
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK
| | - Karen P Nugent
- Colorectal Unit, University Hospitals Southampton NHS Trust, Southampton, UK.,University Surgery, Southampton General Hospital, University of Southampton, Southampton, UK
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Ng KS, Gladman MA. Patient-reported and physician-recorded bowel dysfunction following colorectal resection and radical cystectomy: a prospective, comparative study. Colorectal Dis 2020; 22:1336-1347. [PMID: 32180323 DOI: 10.1111/codi.15041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/18/2020] [Indexed: 02/08/2023]
Abstract
AIM Bowel dysfunction following anterior resection (AR) is termed low anterior resection syndrome. It is unclear whether such dysfunction occurs following other bowel/pelvic operations as well. This study aimed to characterize and compare bowel dysfunction following AR, right hemicolectomy (RH) and radical cystectomy (RC). METHOD A prospective study of consecutive patients undergoing AR, RH and RC (2002-2012) was performed at a tertiary referral centre in Sydney, Australia. Outcome measures included (i) patient-reported satisfaction with bowel function, self-described bowel function and self-reported change in bowel function; (ii) objective assessment of bowel function using validated criteria to identify symptoms and stratify patients into those with constipation and/or faecal incontinence (FI); and (iii) health-related quality of life (SF-36v2 Health Survey). RESULTS Of 743 eligible patients, 70% participated [AR, n = 338, mean age 69.6 years (SD 11.9), 59% men; RH, n = 150, 75.8 years (SD 10.5), 54% men; RC, n = 34, 71.1 years (SD 14.1), 71% men]. AR patients were three times more likely to report change in bowel function post-surgery and self-judged their bowel function as abnormal more frequently (64%) than RH patients (35%) and RC patients (35%) (P < 0.01). AR patients were four times more likely to meet criteria for concomitant constipation and FI. Patients with concomitant constipation and FI had lower physical and mental SF-36v2 scores (P < 0.001). CONCLUSION Bowel dysfunction occurred after RH and RC but rates were higher following AR. This suggests that low anterior resection syndrome occurs due to a direct impact of partial/complete loss of the rectum rather than just due to loss of bowel length and/or the consequence(s) of pelvic dissection.
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Affiliation(s)
- K-S Ng
- Academic Colorectal Unit, Sydney Medical School - Concord, University of Sydney, Sydney, New South Wales, Australia
| | - M A Gladman
- Gastrointestinal and Enteric Neuroscience Research Group, Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Kochi M, Egi H, Adachi T, Takakura Y, Mukai S, Taguchi K, Nakashima I, Sumi Y, Akabane S, Sato K, Yoshinaka H, Hattori M, Ohdan H. Preoperative incremental maximum squeeze pressure as a predictor of fecal incontinence after very low anterior resection for low rectal cancer. Surg Today 2020; 50:516-24. [PMID: 31797125 DOI: 10.1007/s00595-019-01926-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/03/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Very low anterior resection (VLAR) is performed widely, but some patients are left with fecal incontinence (FI), which compromises their quality of life (QOL) severely. This study sought to identify the predictive factors of postoperative FI after VLAR, which remain unclear. METHODS We evaluated the anorectal manometry data of patients who underwent VLAR to identify the risk factors for postoperative FI among the various clinicopathological factors and manometric characteristics. FI and QOL were analyzed using the Wexner score and EORTC QLQ-C30, respectively. RESULTS The subjects of this study were 40 patients who underwent VLAR for low rectal cancer between April, 2015 and May, 2018. There were 11 (27%) patients in the major-FI group and 29 (73%) in the minor-FI group. Multivariate analysis revealed that low preoperative incremental maximum squeeze pressure (iMSP) was an independent risk factor for postoperative major-FI. Postoperative QOL tended to be worse in the major-FI group. CONCLUSIONS Preoperative low iMSP increases the risk of major-FI and impaired QOL after VLAR. This highlights the importance of performing preoperative anorectal manometry to evaluate the patient's anal function as well as to select the most appropriate operative procedure and early multifaceted treatment such as medication, rehabilitation, and biofeedback for postoperative FI.
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De Nardi P, Testoni SGG, Corsetti M, Andreoletti H, Giollo P, Passaretti S, Testoni PA. Manometric evaluation of anorectal function in patients treated with neoadjuvant chemoradiotherapy and total mesorectal excision for rectal cancer. Dig Liver Dis 2017; 49:91-97. [PMID: 27720700 DOI: 10.1016/j.dld.2016.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 08/22/2016] [Accepted: 09/14/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND An altered anorectal function is reported after chemoradiotherapy (CRT) and surgery for rectal cancer. AIM The aim of this study was to clarify the relative contribution of neoadjuvant chemoradiation and surgical resection on the impairment of anorectal function as evaluated by anorectal manometry. METHODS Thirty-nine patients with rectal cancer, who underwent neoadjuvant CRT and laparoscopic rectal resection, were evaluated with the Pescatori Faecal Incontinence score, and with anorectal manometry: before neoadjuvant therapy (T0), after neoadjuvant therapy and before surgery (T1), 12 months after stoma closure (T2). RESULTS Resting and/or maximum squeeze pressure and/or volume thresholds for urgency were below the normal values in 12 (30%) patients at baseline. After CRT the mean resting pressure significantly decreased (p=0.007). Surgery determined a significantly decrease of the resting pressure (p=0.001), of the maximum squeeze pressure (p=0.001) and of the volume threshold for urgency (p=0.001). Impairment of continence was reported by 5, 11 and 18 patients at T0, T1 and T2, with a mean incontinence score of 3, 3.8 and 3.9 respectively. CONCLUSIONS CRT is detrimental to the function of the internal anal sphincter. Rectal resection significantly affects both internal and external anal sphincter function and the maximum tolerated volume of the neo-rectum, particularly in patients with low rectal cancer, significantly impairing anal continence.
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Affiliation(s)
- Paola De Nardi
- Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy.
| | | | - Maura Corsetti
- National Institute for Health Research, Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottingham, UK
| | - Hulda Andreoletti
- Service de Anesthésiologie,Etablissements Hospitaliers du Nord Vaudois, Yverdon-les-Bain, Switzerland
| | - Patrizia Giollo
- Gastroenterology Division, San Raffaele Scientific Institute, Milan, Italy
| | - Sandro Passaretti
- Gastroenterology Division, San Raffaele Scientific Institute, Milan, Italy
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How P, Evans J, Moran B, Swift I, Brown G. Preoperative MRI sphincter morphology and anal manometry: can they be markers of functional outcome following anterior resection for rectal cancer? Colorectal Dis 2012; 14:e339-45. [PMID: 22251438 DOI: 10.1111/j.1463-1318.2012.02942.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM Good functional outcome following anterior resection (AR) for rectal cancer is an important clinical goal, but its prediction has proven difficult. Assessments such as anal manometry have been advocated as a potential tool but functional anatomy as depicted on MRI has not been investigated. This study looked at whether sphincter complex measurements recorded from preoperative staging MRIs and preoperative anal manometry have any correlation with functional outcome. METHOD Consecutive patients with rectal adenocarcinoma underwent preoperative manometric assessment and MRI staging. MRIs were assessed with regard to anorectal angle, puborectalis thickness, canal length and external and internal anal sphincter thickness. Functional outcome was categorized into three groups according to the number of adverse postoperative symptoms (frequency, urgency, leakage, diarrhoea, use of pads, use of antidiarrhoeal medication): 0, 1 and ≥ 2. This was evaluated 1 year following surgery and 6 months following stoma reversal where applicable. Univariate analysis of an ordinal regression model was performed with significance at the 5% level. RESULTS Thirty patients were assessed. No single preoperative manometric parameter proved significant (P > 0.05). Only puborectalis thickness showed a significant (P = 0.01) relationship with the number of adverse symptoms suffered postoperatively. On receiver operating characteristics analysis, a cut-off value of 3.5 mm gave an optimal sensitivity of 0.5 (95% CI, 0.17-0.83) and specificity of 0.86 (95% CI, 0.64-0.96). CONCLUSIONS Measurements of the puborectalis thickness on preoperative staging MRIs for rectal cancer may help predict functional outcome following AR. Prospective assessment of larger numbers with a fully validated continence score are required to evaluate these findings further.
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Affiliation(s)
- P How
- Pelican Cancer Foundation, Dinwoodie Drive, Basingstoke, UK.
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Abstract
AIM Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. METHOD Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. RESULTS Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC-curve was 0.84 (P < 0.001; 95% confidence interval, 0.80-0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. CONCLUSION Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.
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Affiliation(s)
- T J Lam
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam, the Netherlands.
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Barisic G, Markovic V, Popovic M, Dimitrijevic I, Gavrilovic P, Krivokapic Z. Function after intersphincteric resection for low rectal cancer and its influence on quality of life. Colorectal Dis 2011; 13:638-43. [PMID: 20184636 DOI: 10.1111/j.1463-1318.2010.02244.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM The aim of the study was to investigate function and quality of life after different types of intersphincteric resection (ISR). METHOD Between January 2006 and February 2008, 45 patients (34 men and 11 women) with distal third rectal cancer underwent curative ISR. Function was evaluated using the Memorial Sloan Kettering Cancer Center bowel function questionnaire and Wexner score, anal manometry and measurements of rectal capacity were also performed. Quality of life was assessed using the Serbian version of the European Organisation for Research and Treatment of Cancer, quality of life questionnaire (EORTC QLQ-C30) and the translated version of the fecal incontinence quality of life scale (FIQL). RESULTS There were no postoperative deaths. Partial ISR was performed in 22 (48.9%) patients, subtotal ISR was performed in 19 (42.2%) patients and total ISR was performed in four (8.9%) patients. Anastomotic leakage occurred in nine (20%) patients. Five (11.1%) of 45 patients had major (complete) incontinence and a further six (13.3%) patients had continuing frequent faecal leakage 12 months after ileostomy reversal. There was no significant difference in quality of life between the groups in the EORTC QLQ-C30 scale, but this was significantly altered by internal anal sphincter resection in two of the FIQL scales (coping/behaviour and depression/self-perception). CONCLUSION Although ISR does not affect quality of life in general, the extent of internal anal sphincter resection has a negative impact on symptom-specific quality of life owing to faecal incontinence.
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Affiliation(s)
- G Barisic
- First Surgical Clinic, Clinical Centre of Serbia, Belgrade, Serbia College for Sport and Health, Belgrade, Serbia
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8
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Lee TG, Kang SB, Heo SC, Jeong SY, Park KJ. Risk Factors for Persistent Anal Incontinence After Restorative Proctectomy in Rectal Cancer Patients with Anal Incontinence: Prospective Cohort Study. World J Surg 2011; 35:1918-24. [PMID: 21519972 DOI: 10.1007/s00268-011-1116-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Taek-Gu Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam, Gyeonggi-do 463-707, Republic of Korea
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Abstract
PURPOSE Intersphincteric resection has been performed as an alternative to abdominoperineal resection for low rectal cancer. The purpose of this study was to assess the long-term results after intersphincteric resection in terms of the morbidity, oncologic safety, and defecatory function. METHODS Between 1994 and 2006, 107 consecutive patients with low rectal cancer had curative intersphincteric resection, categorized as total, subtotal, or partial resection of the internal anal sphincter. RESULTS There were no mortalities. Neorectal mucosal prolapse in patients with total intersphincteric resection and coloanal anastomotic stenosis in patients with subtotal or partial intersphincteric resection were observed as characteristic late complications. The five-year disease-free survival rates classified according to the TNM stage were 100 percent for stage I, 83.5 percent for stage II, and 72.0 percent for stage III cases. The five-year cumulative local recurrence rate after intersphincteric resection was 2.5 percent. Defecatory function, which was evaluated by bowel movement in a 24-hour period, and continence after intersphincteric resection were objectively good. The results of the multivariate analysis revealed that age was the only factor associated with a risk of fecal incontinence. CONCLUSION Provided strict selection criteria are used, intersphincteric resection may be the optimal sphincter-preserving surgery for low rectal cancer.
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Shelygin YA, Vorobiev GI, Pikunov DY, Markova EV, Djhanaev YA, Fomenko OY. Intersphincteric resection with partial removal of external anal sphincter for low rectal cancer. ACTA ACUST UNITED AC. 2008;55:45-53. [PMID: 19069692 DOI: 10.2298/ACI0803045S] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abdominoperineal resection (APR) remains the standard procedure for rectal cancer located within 0.5 cm from dentate line (DL). In this study, we present a new type of restorative surgery: intersphincteric resection with partial removal of external anal sphincter (EAS) and anorectal reconstruction for-ultra low rectal cancer. Between March 2003 and May 2008 fifty patients (28 males, aged between 39 and 71) were operated on for ultra low rectal cancer uT2-3N0M0 with partial preservation of EAS and total anorectal reconstruction (smooth-muscle neosphincter and colonic pouch). A protective stoma was performed in all cases. Functional outcome and quality of life were recorded at 3, 6, 12, 18, 24 months after stoma closure using Wexner score and FIQL respectively. Anal manometry, vectrum volumetry and myography data were taken as well. Results. Postoperative complications developed in 2 patients, but no secondary surgery was required. Carcinomas were staged as pT2 (n = 14) and pT3 (n = 36). The distal clearance was 2.00.4 (range 1.5-2.8) cm, lateral clearance was 0.80.3 (range 0.2-1.4) cm. After a median follow-up of 24 (range 2-61) months, 2 local recurrences were occurred and salvaged by APR. Contractive activity of saved elements of EAS improved with a course of time and squeezing anal pressure increased as well. Perfect functional outcome was achieved in 25 of 34 patients at 12 months after stoma closure, and all the patients were satisfied with procedure. Good functional results of suggested surgery seems to be an acceptable alternative to APR with permanent stoma in selected patients.
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Abstract
BACKGROUND Intersphincteric resection (ISR) is the ultimate sphincter-preserving operation for very low rectal cancer. The aim of this study was to assess defaecatory function after ISR in relation to the degree of resection of the internal anal sphincter. METHODS Between 2001 and 2003, 35 consecutive patients with low rectal cancer had curative ISR, categorized as total, subtotal or partial resection of the internal anal sphincter. Defaecatory function was assessed in terms of frequency of bowel movements and continence. Sphincter function was evaluated by manometric study and anorectal sensation testing before surgery and 3, 6 and 12 months afterwards. RESULTS Defaecatory function was satisfactory after ISR; 34 of 35 patients were grossly continent. The maximum resting anal canal pressure fell after all three procedures. Patients who had total ISR had reduced anal canal sensation at 3 months, but this had improved by 12 months after surgery. CONCLUSION These functional results suggest that ISR should be considered as an alternative to abdominoperineal resection for low rectal cancer. However, as the outcome for continence is worse after total ISR than subtotal or partial ISR, the indication for total ISR should strictly take into account the preoperative sphincter function.
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Affiliation(s)
- K Yamada
- Coloproctology Centre, Takano Hospital, 4-2-88 Obiyama, Kumamoto 862-0924, Japan
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Matsuoka H, Masaki T, Sugiyama M, Atomi Y. Impact of lateral pelvic lymph node dissection on evacuatory and urinary functions following low anterior resection for advanced rectal carcinoma. Langenbecks Arch Surg 2005; 390:517-22. [PMID: 16133268 DOI: 10.1007/s00423-005-0577-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2005] [Accepted: 07/14/2005] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Lateral pelvic lymph node dissection (LPLD) has been reported to be beneficial in terms of survival for locally advanced low rectal carcinoma. However, the impact of LPLD on bowel function has not yet been determined by means of anorectal physiologic investigation. PATIENTS AND METHODS Fifty-seven rectal cancer patients who underwent low anterior resection were evaluated with clinical and physiologic parameters. Of these, 15 patients had LPLD. The postoperative bowel and urinary function were evaluated with patients' questionnaire and anorectal manometry before and after the operation. RESULTS The proportion of patients who had pouch reconstruction, adjuvant radiation therapy, and autonomic nerve dissection were significantly higher in the LPLD group. The incidence of evacuatory dysfunction was significantly higher (80% vs 45%) postoperatively in the LPLD group. There was no significant difference in anal sphincter pressures, sensory threshold, and neorectal volumes between the groups postoperatively. In terms of urinary function, use of medication for urination was significantly frequent in the LPLD group. Multivariate analysis identified the level of anastomosis as an independent affecting factor for evacuatory dysfunction and LPLD for urinary dysfunction. CONCLUSION Although LPLD affected urinary dysfunction, it did not impair postoperative evacuatory function in the early postoperative period.
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Affiliation(s)
- Hiroyoshi Matsuoka
- The Department of Surgery, School of Medicine, Kyorin University, Tokyo, Japan.
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Affiliation(s)
- Victor W Fazio
- Department of Colorectal Surgery, Cleveland Clinic Foundation, OH 44118, USA.
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15
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Vorobiev GI, Odaryuk TS, Tsarkov PV, Talalakin AI, Rybakov EG. Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma. Br J Surg 2004; 91:1506-12. [PMID: 15455363 DOI: 10.1002/bjs.4330] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Intersphincteric resection can provide tumour-free margins for rectal tumours located 0-1 cm above the dentate line. However, the internal anal sphincter (IAS) is partially or totally resected and some degree of anal incontinence may develop. A novel technique of smooth muscle plasty of the IAS and colonic pouch construction is described, along with an assessment of morbidity, oncological results and functional outcome. PATIENTS AND METHODS Between 1997 and 2002, 27 patients (16 men; median age 55 (range 26-75) years) were operated on for T2-3 N0-1 M0 rectal carcinoma located a median of 1.0 (range 0.5-1.5) cm from the dentate line. Resection of the IAS was performed transanally. A smooth muscle cuff, fashioned from the muscular layer of colon, and a colonic pouch were used for anorectal reconstruction. RESULTS There were no perioperative deaths. Anastomotic leakage developed in two patients. After a median follow-up of 38 (range 14-66) months no local recurrence was detected. Distant metastases occurred in three patients, two of whom died. Perfect functional outcome was achieved in 22 of 26 patients. At 6 months after surgery the mean(s.d.) resting anal pressure was 49(8) mmHg. CONCLUSION In selected patients intersphincteric resection does not compromise the oncological result. The suggested anorectal reconstruction may improve the functional outcome.
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Affiliation(s)
- G I Vorobiev
- Department of Rectal Cancer Surgery, State Research Centre of Coloproctology, Salyam Adyl street 2, 123154 Moscow, Russia
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Bittorf B, Stadelmaier U, Göhl J, Hohenberger W, Matzel KE. Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer. Eur J Surg Oncol 2004; 30:260-5. [PMID: 15028306 DOI: 10.1016/j.ejso.2003.11.011] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2003] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVES Anterior rectal resection with partial removal of the internal sphincter is an option for low rectal cancer. The objective of this study was to evaluate the functional outcome after this intersphincteric rectal resection. METHODS Anal continence was evaluated by anorectal manometry and a standardized questionnaire (Wexner Score) in 33 patients 28+/-15 weeks and 100+/-45 weeks, respectively, after intersphincteric resection. Nineteen of the 33 patients were reconstructed with a straight anastomosis; 12 received a colonic J-pouch. RESULTS Post-operatively, 25.8% of the patients were incontinent to solid stool and 54.8% were incontinent to liquid stool at least once a week. Mean and maximum resting tone (24+/-10 and 40+/-13 mmHg), maximum tolerable volume (77+/-28 ml) and rectal compliance (1.4+/-1.2 ml/mmHg) were reduced in anorectal manometry. Squeeze pressures remained unchanged. Only the maximum tolerable volume correlated significantly with the continence score (r=-0.45, p<0.05). The Wexner score and maximum tolerable volume were significantly better after colonic J-pouch reconstruction than after straight anastomosis (9.9+/-4.5 vs 13.4+/-4.0, p<0.05, 65+/-20 ml vs 100+/-27 ml, p<0.01). CONCLUSION Intersphincteric resection of the rectum leads to impaired post-operative continence. The functional outcome is improved with a colonic J-pouch.
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Affiliation(s)
- B Bittorf
- Department of Surgery, University of Erlangen-Nuremberg, Chirurgische Klinik, Krankenhausstr. 12, 91054 Erlangen, Germany.
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Abstract
BACKGROUND Abdominoperineal excision of the rectum with a permanent end-sigmoid colostomy was the classical operation for cancer of the distal third of the rectum. A number of factors have recently led to a more conservative approach, allowing sphincter preservation when excising tumours that are not invading the anal sphincter. METHODS The review is based on the published literature of the treatment of low rectal cancers accessed by searching Medline and other online databases. It includes a description of all the surgical options currently available for low rectal tumours, and a discussion of the advantages and disadvantages of the types of anastomosis and reconstruction. RESULTS AND CONCLUSION It is now technically possible to remove rectal cancer that is extending into the anal canal with preservation of the anal sphincter mechanism and with a satisfactory oncological outcome. Ultra-low colorectal and coloanal anastomosis, together with a colonic pouch or coloplasty, produces acceptable function in many patients. However, there is still controversy about the risk of tumour implantation, the place of downsizing neoadjuvant therapy, and true long-term functional outcome. Despite these concerns, surgeons should strive to perform rectal resection with sphincter preservation for low-lying rectal cancer whenever possible.
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Affiliation(s)
- M G Tytherleigh
- Department of Colorectal Surgery, John Radcliffe Hospital, Oxford OX3 9DZ, UK.
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Abstract
Rectal excision followed by low anastomosis is associated with high bowel frequency, urgency and faecal incontinence. These functional disorders results from the loss of the rectal pouch and may be also related to the damage of the anal sphincter or the loss of normal anorectal sensation. Formation of a colonic J pouch reduces the severity of the symptoms of the anterior resection syndrome mainly by decreasing bowel frequency. Creation of a J pouch may also improve the healing of coloanal anastomoses. However, there is no evidence of the role of the colonic J pouch in long term functional outcome of coloanal anastomoses. Moreover, the size of the J pouch increases with time and this may induce evacuation difficulties. Finally, the J pouch cannot be used in all patients, because of technical difficulties especially in obese men. Because the results after colonic J pouch are not perfect, new colonic pouches are developed. The caecal pouch is performed by using an ileocoecal interposition graft between the sigmoid and the anus. The transverse coloplasty is similar to that of stricturoplasty. The side-to-end coloanal anastomosis, giving a colonic blind end, is an other type of pouch. The first procedure seems technically complex with no demonstrated advantage. The second procedure is easy to construct and may be performed in all patients; however, there is a potential higher risk of leakage and functional results must be evaluated. The third procedure showed few advantages compared to a straight anastomosis.
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Affiliation(s)
- E Rullier
- Service de chirurgie digestive, hôpital Saint-André, 33075 Bordeaux, France
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19
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Zbar, Jayne, Mathur, Ambrose, Guillou. The importance of the internal anal sphincter (IAS) in maintaining continence: anatomical, physiological and pharmacological considerations. Colorectal Dis 2000; 2:193-202. [PMID: 23578077 DOI: 10.1046/j.1463-1318.2000.00159.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Zbar
- Professorial Surgical Unit, St James University Hospital, Leeds, UK
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Yamana T, Oya M, Komatsu J, Takase Y, Mikuni N, Ishikawa H. Preoperative anal sphincter high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity predict early postoperative defecatory function after low anterior resection for rectal cancer. Dis Colon Rectum 1999; 42:1145-51. [PMID: 10496554 DOI: 10.1007/bf02238566] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE The aims of this study were to correlate postoperative defecatory function after low anterior resection with clinical factors and physiologic parameters and to explore the possibility of predicting early postoperative defecatory function after low anterior resection. METHODS Thirty-two patients who underwent low anterior resection for rectal cancer were studied. Anorectal physiologic studies were performed preoperatively and six months postoperatively; maximum resting pressure, maximum squeeze pressure, length of the high pressure zone, neorectal sensory threshold, neorectal maximum tolerable volume, and anal mucosal electrosensitivity were recorded. Preoperative and postoperative defecatory function was scored between 0 (worst) and 6 (best) on the basis of bowel frequency, fecal incontinence, and urgency. RESULTS In univariate regression analyses, a longer preoperative high pressure zone and a more sensitive anal mucosa were associated with better postoperative defecatory function. Using multiple regression analysis, in which age, gender, the level of anastomosis, and preoperative physiologic parameters were examined as independent variables, a longer preoperative high pressure zone, a larger preoperative maximum tolerable volume, and lower sensory threshold of the anal canal were associated with better postoperative defecatory function. Postoperative function score was found to be predictable using the following formula: 1.47 + 0.496 x high pressure zone (cm) + 0.007 x maximum tolerable volume (ml) - 0.247 x sensory threshold (mA) of the anal canal. CONCLUSION Early postoperative defecatory function after low anterior resection is predictable from preoperative high pressure zone, maximum tolerable volume, and anal mucosal electrosensitivity.
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Affiliation(s)
- T Yamana
- Department of Surgery, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan
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21
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Abstract
BACKGROUND Low rectal cancer is usually managed by ultra-low anterior resection (ULAR) with total mesorectal excision and straight coloanal anastomosis. However, following this procedure patients often suffer from frequency, urgency of bowel action and, occasionally, faecal incontinence. To overcome such problems, a colon pouch may be fashioned and a subsequent colon pouch-anal anastomosis performed. The physiological and functional outcome following the use of a colon pouch are appraised. METHODS All relevant papers identified from a Medline search and papers from cross-referencing were reviewed. RESULTS AND CONCLUSION Creation of a colon pouch following ULAR results in reduced bowel frequency, and a lower incidence of urgency and faecal incontinence. Although there is a slightly increased incidence of evacuatory disorder and need for enemas or suppositories, this appears to be a minor problem which may possibly be overcome by using a smaller colon pouch. Compared with straight coloanal anastomosis following ULAR, the creation of a colon pouch produced a superior functional outcome.
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Affiliation(s)
- N Williams
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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