Characteristic findings on defecography according to reconstruction method and defecatory disorder following sphincter-saving surgery for rectal cancer

Rectal Eversion as an Anus-sparing Technique in Laparoscopic Low Anterior Resection With Double Stapling Anastomosis: Long-term Functional Results

BACKGROUND

Rectal eversion (RE) is a natural orifice specimen extraction (NOSE) method that allows anus-sparing resection in very low rectal tumors. This study aims to share the long-term results of RE in laparoscopic rectal resection performed with double stapling anastomosis.

MATERIALS AND METHODS

A single-center retrospective cohort study was conducted for patients who underwent laparoscopic low anterior resection with RE. Age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, type of surgery, distance of the tumor to the dentate line, specimen extraction site, cancer stage, preoperative chemoradiotherapy, postoperative complications, and postoperative clinical follow-up findings were recorded. Incontinence was assessed using the Wexner score (WS). Low anterior resection syndrome (LARS) is determined by the LARS score. A 7-point Likert scale was used to evaluate the satisfaction of the patients.

RESULTS

A total of 17 patients underwent resection by RE for rectal tumors. Of the 11 patients included in the study, 4 were female and 7 were male. The mean age was 66.09±15.04 years. The mean follow-up was 64.18±16.83 months. The mean tumor diameter was 3.1 cm (range: 0.9 to 7.2 cm). The mean distance of the tumor from the dentate line was 2.7 cm (range: 1.2 to 5.6 cm). No anastomotic leak was observed in any patient. One patient had an anastomotic stenosis and was treated with balloon dilatation. The median LARS score was 16 (range 0 to 32) and 64% of the patients had no LARS. Two patients had minor LARS and 2 patients had major LARS. The median Wexner score was 3.5 (range 0 to 14). The median Likert scale was 7 (range 5 to 7). It was found that 55% of the patients were extremely satisfied, 18% were satisfied, and 27% were slightly satisfied with their surgery. There were no dissatisfied patients.

CONCLUSION

RE is a safe NOSE technique in laparoscopic double stapling anastomosis for rectal resection. There is a high level of long-term patient satisfaction with anus-sparing procedures via RE, even in the presence of various symptoms.

Development and validation of an MRI and clinicopathological factors prediction model for low anterior resection syndrome in anterior resection of middle and low rectal cancer

OBJECTIVE

To validate the predictive power of newly developed magnetic resonance (MR) morphological and clinicopathological risk models in predicting low anterior resection syndrome (LARS) 6 months after anterior resection of middle and low rectal cancer (MLRC).

METHODS

From May 2018 to January 2021, 236 patients with MLRC admitted to two hospitals (internal and external validation) were included. MR images, clinicopathological data, and LARS scores (LARSS) were collected. Tumor morphology data included longitudinal involvement length, maximum tumor diameter, proportion of tumor to circumference of the intestinal wall, tumor mesorectal infiltration depth, circumferential margin status, and distance between the tumor and anal margins. Pelvic measurements included anorectal angle, mesenterial volume (MRV), and pelvic volume. Univariate and multivariate logistic regression was used to obtain independent risk factors of LARS after anterior resection Then, the prediction model was constructed, expressed as a nomogram, and its internal and external validity was assessed using receiver operating characteristic curves.

RESULTS

The uni- and multivariate analysis revealed distance between the tumor and anal margins, MRV, pelvic volume, and body weight as significant independent risk factors for predicting LARS. From the nomogram, the area under the curve (AUC), sensitivity, and specificity were 0.835, 75.0 %, and 80.4 %, respectively. The AUC, sensitivity, and specificity in the external validation group were 0.874, 83.3 %, and 91.7 %, respectively.

CONCLUSION

This study shows that MR imaging and clinicopathology presented by a nomogram can strongly predict LARSS, which can then individually predict LARS 6 months after anterior resection in patients with MLRC and facilitate clinical decision-making.

CLINICAL RELEVANCE STATEMENT

We believe that our study makes a significant contribution to the literature. This method of predicting postoperative anorectal function by preoperative measurement of MRV provides a new tool for clinicians to study LARS.

Incidence and risk factors of bowel dysfunction after minimally invasive rectal cancer surgery and discrepancies between the Wexner score and the low anterior resection syndrome (LARS) score

PURPOSE

Bowel dysfunction after sphincter-preserving-surgery (SPS) impacts quality of life. The Wexner score (WS) and the low anterior resection syndrome (LARS) score (LS) are instruments for assessing postoperative bowel dysfunction. We analyzed the incidence of and risk factors for each symptom and examined the discrepancies between the two scores.

METHODS

A total of 142 patients with rectal cancer, who underwent minimally invasive SPS between May, 2018 and July, 2019, were included. A questionnaire survey using the two scores was given to the patients 2 years after SPS.

RESULTS

Tumor location and preoperative radiotherapy were independent risk factors for major LARS. Intersphincteric resection with a hand-sewn anastomosis (HSA) was an independent risk factor for high WS. Among the patients who underwent HSA, 82% experienced incontinence for liquid stools, needed to wear pads, and suffered lifestyle alterations. Of the 35 patients with minor LARS, only 1 had a high WS, and 80.0% reported no lifestyle alterations. Among the 75 patients with major LARS, 58.7% had a low WS and 21.3% reported no lifestyle alterations.

CONCLUSION

The results of this study provide practical data to help patients understand potential bowel dysfunction after SPS. The discrepancies between the WS and LS were clarified, and further efforts are required to utilize these scores in clinical practice.

Mesorectal reconstruction with pedicled greater omental transplantation to relieve low anterior resection syndrome following total intersphincteric resection in patients with ultra-low rectal cancer

BACKGROUND

Total intersphincteric resection (ISR) is the ultimate anus-preserving surgery for patients with ultra-low rectal cancer (ULRC), which can result in various degrees of anorectal dysfunction. Known as low anterior resection syndrome (LARS), it seriously affects the postoperative quality of life of patients. The aim of this study was to discuss the value of mesorectal reconstruction with pedicled greater omental transplantation (PGOT) to relieve LARS following total ISR in patients with ULRC, hoping to provide new ideas and strategies for the prevention and improvement of LARS.

METHODS

We retrospectively analyzed hospitalization data and postoperative anorectal function of 26 ULRC patients, who were met inclusion and exclusion criteria in our center from January 2015 to February 2022. And combined with the results of anorectal manometry and rectal magnetic resonance imaging (MRI) defecography of some patients, we assessed comprehensively anorectal physiological and morphological changes of the patients after surgery, and their correlation with LARS.

RESULTS

In this study, 26 patients with ULRC were enrolled and divided into observation group (n = 15) and control group (n = 11) according to whether PGOT was performed. There were no significant differences in surgical results such as operative time, intraoperative blood loss and postoperative complications between the two groups (P > 0.05). Postoperative follow-up showed that patients in both groups showed severe LARS within 3 months after surgery, but from the 3rd month after surgery, LARS in both groups gradually began to decrease, especially in the observation group, which showed faster recovery and better recovery, with statistically significant difference (P < 0.001). Through anorectal manometry, the mean rectal resting pressure in the observation group was significantly lower than that in the control group (P = 0.010). In addition, the postoperative thickness of the posterior rectal mesenterium in the observation group was significantly higher than that in the control group (P = 0.001), and also higher than the preoperative level (P = 0.018). Moreover, rectal MRI defecography showed that the neo-rectum had good compliance under the matting of greater omentum, and its intestinal peristalsis was coordinated.

CONCLUSIONS

ULRC patients, with the help of greater omentum, coordinated their neo-rectum peristalsis after total ISR and recovery of LARS was faster and better. PGOT is expected to be an effective strategy for LARS prevention and treatment of ULRC patients after surgery and is worthy of clinical promotion.

Effect of Anterograde Lavage via Temporary Loop Ileostoma on the Recovery of Bowel Function in Patients Receiving Stoma Closure: A Retrospective Cohort Study

BACKGROUND

The effect of anterograde lavage in patients with rectal cancer who underwent anterior resection and plan to receive stoma closure is unclear.

OBJECTIVE

This study aimed to investigate the effect of anterograde lavage on postoperative bowel function recovery in patients who underwent temporary loop ileostomy and stoma closure.

DESIGN

This was a hospital-based retrospective cohort study.

SETTINGS

This study was conducted at a tertiary referral center.

PATIENTS

All consecutive patients who underwent anterior resection for rectal cancer and were planning to receive stoma closure from March through December 2019 were included.

INTERVENTIONS

The enrolled patients were divided into 2 groups according to whether they received anterograde lavage before stoma closure.

MAIN OUTCOME MEASURES

Short-term functional outcomes, including time to first passing of flatus, first defecation time, and recovery time to first meal, were compared between the groups. Secondary outcomes included length of hospital stay, total cost of hospitalization, and postoperative complications.

RESULTS

A total of 222 eligible participants were included in the analysis, including 114 in the lavage group and 108 in the nonlavage group. No statistically significant differences were found in age, sex ratio, or distance between the anastomotic line and dentate line. In the lavage group, patients' time to first passing of flatus (38 vs 42 h; p = 0.006), first defecation time (42 vs 48 h; p < 0.001), recovery time to first meal (48 vs 55.5 h; p < 0.001), and length of hospital stay (5 vs 7 d; p < 0.001) were significantly shorter than those in the nonlavage group, and the total cost of hospitalization was significantly lower than that of the nonlavage group (25,000 vs 28,000 RMB; p < 0.001). No significant difference was found in the incidence of postoperative complications between the 2 groups (p = 0.067).

LIMITATIONS

This study is limited by its relatively small sample size and retrospective design with single-center participants.

CONCLUSIONS

Anterograde lavage before stoma closure is safe and noninvasive. For patients receiving anterior resection and planning to have stoma closure, this procedure can potentially help recover bowel function more rapidly. See Video Abstract at http://links.lww.com/DCR/C51.

EFECTO DEL LAVADO ANTERGRADO MEDIANTE ILEOSTOMA TEMPORAL EN ASA SOBRE LA RECUPERACIN DE LA FUNCIN INTESTINAL EN PACIENTES QUE RECIBEN CIERRE DE ESTOMA UN ESTUDIO DE COHORTE RETROSPECTIVO

ANTECEDENTES:No está claro el efecto del lavado anterógrado en pacientes con cáncer de recto con resección anterior que planean recibir el cierre del estoma.OBJETIVO:Investigar el efecto del lavado anterógrado en la recuperación de la función intestinal posoperatoria en pacientes que se sometieron a ileostomía en asa temporal y cierre de estoma.DISEÑO:Estudio de cohorte retrospectivo basado en el hospital.AJUSTES:Centro de referencia terciario.PACIENTES:Todos los pacientes que se sometieron a una resección anterior por cáncer de recto y que planeaban recibir el cierre del estoma desde marzo hasta diciembre de 2019.INTERVENCIONES:Los pacientes inscritos se dividieron en dos grupos según si recibieron lavado anterógrado antes del cierre del estoma.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados funcionales a corto plazo, incluido el tiempo de la primera evacuación de flatos, tiempo de la primera defecación y tiempo de recuperación hasta la primera comida, se compararon entre los grupos. Resultados secundarios incluyeron duración de la estancia hospitalaria, costo total de la hospitalización y complicaciones posoperatorias.RESULTADOS:Se incluyeron en el análisis un total de 222 participantes elegibles, incluidos 114 en el grupo de lavado y 108 en el grupo de no lavado. No hubo diferencias estadísticamente significativas en la edad, la proporción de sexos o la distancia entre la línea de anastomosis y la línea dentada. En el grupo de lavado, el tiempo de la primera evacuación de flatos de los pacientes (38 vs 42 h; p = 0,006), el tiempo de la primera defecación (42 vs 48 h; p < 0,001), el tiempo de recuperación hasta la primera comida (48 vs 55,5 h; p < 0,001) y la duración de la estancia hospitalaria (5 vs 7 días; p < 0,001) fueron significativamente más cortos que los del grupo de no lavado, y el costo total de la hospitalización fue significativamente menor que el del grupo de no lavado (25000 vs 28000 RMB; p < 0,001). No hubo diferencia significativa en la incidencia de complicaciones postoperatorias entre los dos grupos (p = 0,067).LIMITACIONES:Este estudio está limitado por su tamaño de muestra relativamente pequeño y su diseño retrospectivo con participantes de un solo centro.CONCLUSIONES:El lavado anterógrado antes del cierre del estoma es seguro y no invasivo. Para los pacientes que se someten a una resección anterior y planean cerrar el estoma, este procedimiento puede ayudar potencialmente a recuperar la función intestinal más rápidamente. Consulte Video Resumen en http://links.lww.com/DCR/C51. (Traducción-Dr. Francisco M. Abarca-Rendon).

Analysis of presacral tissue structure in LARS and the prevention of LARS by reconstruction of presacral mesorectum with pedicled greater omentum flap graft

BACKGROUND

The greater omentum has played a unique biological role in regenerative surgery. The aim of our study was to alter the anterior sacral structure by filling the anterior sacral space with the greater omentum and evaluate its effect on the low anterior resection syndrome (LARS) after total mesorectal excision (TME) surgery for low rectal cancer.

METHODS

We retrospectively collected clinical data of patients with primary low rectal cancer who underwent TME and ileostomy closure in our hospital from March 2018 to March 2020. Spearman correlation analysis was conducted to analyze the correlation between postoperative mesorectal fascia (MRF) thickness and LARS score. Subsequently, we prospectively used a tipped greater omental flap graft to reconstruct the anterior rectal sacral structures (MRF reconstruction) in 17 patients and compared LARS scores and rectal compliance (RC) at week 12 after closure of the ileostomy in both groups.

RESULTS

There were 47 patients with No-MRF reconstruction (31 males, mean age 60.68 ± 9.21 years) and 17 with MRF reconstruction (10 males, mean age 49.82 ± 14.74 years). Correlation analysis indicated that MRF thickness and RC were negatively correlated with LARS severity (p < 0.05). The LARS score of patients with MRF reconstruction at 12 weeks was significantly better than that of those with No-MRF reconstruction (32.97 ± 2.65 vs. 26.94 ± 1.52, p = 0.001), and the RC of MRF reconstruction were lower (2.80 ± 0.55 vs. 3.67 ± 0.38, p = 0.001). In addition, MRF reconstruction and No-MRF reconstruction have the similar incidence of postoperative complications (p = 0.156). No hemorrhage or necrosis of the greater omentum flap was observed in any of the patients.

CONCLUSIONS

Greater omentum flap transplantation can significantly improve the symptoms of LARS at 12 weeks after ileostomy closure and we expect it to become a new surgical procedure for the treatment of low rectal cancer.

A study on the clinical application of greater omental pedicle flap transplantation to correct anterior resection syndrome in patients with low rectal cancer

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.

Fecoflowmetric analysis of anorectal motor function in postoperative anal-preserving surgery patients with low rectal cancer comparison with the wexner score and anorectal manometry

The aim of this study was to elucidate whether fecoflowmetry (FFM) could evaluate more detailed evacuative function than anorectal manometry by comparing between FFM or anorectal manometric findings and the clinical questionnaires and the types of surgical procedure in the patients who received anal-preserving surgery. Fifty-three patients who underwent anal-preserving surgery for low rectal cancer were enrolled. The relationships between FFM or the manometric findings and the clinical questionnaires and the types of procedure of anal-preserving surgery were evaluated. There were significant differences between FFM markers and the clinical questionnaire and the types of the surgical procedure, whereas no significant relationship was observed between the manometric findings and the clinical questionnaire and the types of the surgical procedure. FFM might be feasible and useful for the objective assessment of evacuative function and may be superior to manometry for patients undergoing anal-preserving surgery.

A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome

The aim of this review is to characterize the functional results and "anterior resection syndrome" (ARS) after sphincter-saving surgery for rectal cancer. The purpose of sphincter-saving operations is to save the anal sphincters by avoiding the need for rectal abdomino-perineal resection with a permanent stoma. A variety of alternative techniques have been proposed and, today, ultra-low anterior resections of the rectum are commonplace. Inevitably rectal resections modify anorectal physiology. The backdrop of the functional asset for ultralow anterior resections is related to a small neorectal capacity with high endo-neorectal pressures that act together on a weakened sphincteric mechanism. Sometimes a defecation disorder called ARS may be induced and the patient experiences an extremely low quality of life. Impaired bowel function is usually provoked either by colonic dysmotility, neorectal reservoir dysfunction, anal sphincter damage or by a combination of these factors. Surgical technique defects can contribute to these possible causes: anastomotic ischemia, short length of the descending colon and stretching of neorectal mesentery may play a role. Unfortunately, there is no therapeutic algorithm or gold standard treatment that may be used for ARS. Nevertheless, it is rational to use conservative therapy first and then resort to surgery. Drugs, rehabilitative treatment and sacral neuromodulation may be used; after failure of conservative methods, surgical treatment can be considered.

Damage to anal sphincter/levator ani muscles caused by operative procedure in anal sphincter-preserving operation for rectal cancer

BACKGROUND

Details of postoperative damage to anal sphincter tonus following sphincter-preserving operation for rectal cancer remain unclear.

METHODS

Postoperative anal tonus was measured using 3-dimensional (3D) vector manometry in 56 patients. Anal length with pressure from any direction was defined as total length (TL). Length with circular pressure (LCP), which is only measurable using 3D manometry, was also evaluated.

RESULTS

In operations associated with low anastomosis, both TL and LCP at rest were significantly shortened when compared with control (high interior resection [HAR]). In particular, degraded LCP at rest was obvious. Anal lengths in squeezing state were preserved except in cases with intersphincteric resection (ISR). Postoperative incontinence score inversely correlated with functional anal length at rest.

CONCLUSIONS

Although the sphincter muscles are mechanically preserved, function of the internal sphincter and subsequent defecatory function can be degraded in cases with operative procedures including surgical maneuvers at the pelvic floor.