To what extent is the low anterior resection syndrome (LARS) associated with quality of life as measured using the EORTC C30 and CR38 quality of life questionnaires?

Effects of low anterior resection syndrome after colorectal cancer resections on health-related quality of life: a systematic review and meta-analysis

BACKGROUND

Low anterior resection syndrome (LARS) is a term that encompasses multidimensional bowel dysfunction that typically occurs following resections of rectum and distal parts of the colon. We aimed to systematically assess the available literature on the effects of bowel dysfunction after colorectal cancer (CRC) surgeries on health-related quality of life (HRQOL) and conduct a meta-analysis.

METHODS

Studies were included if they assessed patients who had undergone sphincter-preservation surgeries for CRC. Studies were eligible if they assessed bowel dysfunction using the LARS score and HRQOL using the European Organization for Research and Treatment Core Quality-of-Life Questionnaire (EORTC QLQ-C30).

RESULTS

Of 1410 reports, 28 studies were included. According to the analyses, patients with major LARS had lower global health status [weighted mean differences (WMD) = - 10.98; 95% confidence interval (CI) - 13.18, - 8.79], physical functioning (WMD = - 5.96; 95% CI - 7.40, - 4.52), role functioning (WMD = - 10.59; 95% CI - 12.54, - 8.63), emotional functioning (WMD = - 11.09; 95% CI - 14.34, 7.84), cognitive functioning (WMD = - 9.27; 95% CI - 12.22, - 6.32), and social functioning (WMD = - 15.73; 95% CI - 18.82, - 12.63) and higher scores of symptoms compared to patients with minor/no LARS.

CONCLUSIONS

The study findings suggest that patients with major LARS experience worse HRQOL compared to those with minor/no LARS.

REGISTRATION

PROSPERO, CRD42023479657.

Evaluation of surgical strategy for low anterior resection syndrome using preoperative low anterior resection syndrome score in China

BACKGROUND

Despite improved survival rates in rectal cancer treatment, many patients experience low anterior resection syndrome (LARS). The preoperative LARS score (POLARS) aims to address the limitations of LARS assessment by predicting outcomes preoperatively to enhance surgical planning.

AIM

To investigate the predictive accuracy of POLARS in assessing the occurrence of LARS.

METHODS

This study enrolled a total of 335 patients who underwent laparoscopic or robotic low anal sphincter-preserving surgery for rectal tumors. Patients were categorized into three groups according to their POLARS score: no LARS (score 0-20), minor LARS (score 21-29), and major LARS (score 30-42). The QLQ-C30/CR29 scores were compared among these groups, and the agreement between POLARS predictions and the actual LARS scores was analyzed.

RESULTS

The study population was divided into three groups: major LARS (n = 51, 27.42%), minor LARS (n = 109, 58.6%), and no LARS (n = 26, 13.98%). Significant differences in the QLQ-C30 scales of social function, diarrhea, and financial impact were detected between the no LARS and major LARS groups (P < 0.05) and between the minor LARS and major LARS groups (P < 0.05). Similarly, significant differences were detected in the QLQ-CR29 scales for blood and mucus in the stool, fecal incontinence, and stool frequency between the no LARS and minor LARS groups (P < 0.05), as well as between the minor LARS and major LARS groups (P < 0.05). The predictive precision for major LARS using the POLARS score was 82.35% (42/51), with a recall of 35.89% (42/117). The mean absolute error (MAE) between the POLARS score and the actual LARS score was 8.92 ± 5.47. In contrast, the XGBoost (extreme gradient boosting) model achieved a lower MAE of 6.29 ± 4.77, with a precision of 84.39% and a recall of 74.05% for predicting major LARS.

CONCLUSION

The POLARS score demonstrated effectiveness and precision in predicting major LARS, thereby providing valuable insights into postoperative symptoms and patient quality of life. However, the XGBoost model exhibited superior performance with a lower MAE and higher recall for predicting major LARS compared to the POLARS model.

Diagnosis and Treatment of Low Anterior Resection Syndrome

Defecation disorders following rectal resection have long been overlooked as an inevitable surgical complication due to the lack of established diagnostic criteria or definitions. However, these disorders have been recently termed low anterior resection syndrome (LARS), which is a defecation disorder that occurs following rectal resection and impairs the patient's quality of life (QOL). The LARS score developed by Emmertsen et al., which is a patient-reported outcome measure to evaluate the severity of bowel dysfunction following rectal surgery by scoring the major symptoms of LARS, facilitates the diagnosis and assessment of LARS and enables international comparison and validation through the use of validated scores generated according to the international standards. Based on comparisons with other evaluation instruments, the use of the LARS score is strongly recommended internationally for LARS screening in patients following rectal resection. Recent findings have indicated that multiple pathophysiological changes, including reservoir function and evacuation of the neorectum, anal sphincter function, negative impact of a diverting stoma, autonomic denervation, and radiotherapy, are involved in the etiology of LARS. Due to the lack of established treatments and prevention of LARS, a suggested treatment chart for patients with LARS was presented in the Management Guidelines for Low Anterior Resection Syndrome (MANUEL) project. Future surgical treatment should focus not only on the radical cure of cancer and safety of treatment but also on the maintenance and improvement of QOL, with particular attention to the preservation of function. Particularly for rectal cancer, surgeons must formulate treatment plans that consider the prevention and treatment of LARS.

Patient-reported outcomes after treatment for rectal cancer-A prospective nationwide study

AIM

While modern treatment has improved rectal cancer (RC) survival, it can cause late side effects that impact health-related quality of life (HRQoL). The aim of this study was to evaluate HRQoL and late effects 1 year after diagnosis in patients who underwent major resection for Stage I-III RC.

METHOD

All patients with RC registered in the Cancer Registry of Norway between 1 January 2019 and 31 December 2020, aged ≥ 18 years, and a control group without colorectal cancer were invited to participate in the study by answering a questionnaire on HRQoL and late effects. Functional domains and symptoms were compared in different patient groups and between patients and controls.

RESULTS

There were 558 patients and 1693 controls eligible for analysis. Response rates were 41% for patients and 23% for controls. Some differences in HRQoL were observed between treatment modalities. Major low anterior resection syndrome (LARS) was prevalent in 60.8% of patients, and was associated with lower functional and higher symptom scores compared with patients with no/minor LARS. Patients with major chronic pain [n = 86 (15.4%)] had significantly lower scores for most of the functional items and higher symptom scores than patients with no/minor chronic pain. Patients had some lower functional scores and several higher symptoms score compared with controls.

CONCLUSION

Patients who suffered from major LARS or major chronic pain had significantly impaired functions and more symptoms beyond change in bowel function and pain, respectively. Identification and treatment of these patient may hopefully be beneficial for their HRQoL.

Effect of neoadjuvant chemoradiation on anorectal function assessed with anorectal manometry: A systematic review and meta-analysis

AIM

Improvement in oncological survival for rectal cancer increases attention to anorectal dysfunction. Diagnostic questionnaires can evaluate quality of life but are subjective and dependent on patients' compliance. Anorectal manometry can objectively assess the continence mechanism and identify functional sphincter weakness and rectal compliance. Neoadjuvant chemoradiotherapy is presumed to affect anorectal function. We aim to assess anorectal function in rectal cancer patients who undergo total mesorectal excision, with or without neoadjuvant chemoradiation, using anorectal manometry measurements.

METHOD

MEDLINE, Embase, and Cochrane databases were searched for studies comparing perioperative anorectal manometry between neoadjuvant chemoradiation and upfront surgery for rectal cancers. Primary outcomes were resting pressure, squeeze pressure, sensory threshold volume and maximal tolerable volume.

RESULTS

Eight studies were included in the systematic review, of which seven were included for metanalysis. 155 patients (45.3%) had neoadjuvant chemoradiation before definitive surgery, and 187 (54.6%) underwent upfront surgery. Most patients were male (238 vs. 118). The standardized mean difference of mean resting pressure, mean and maximum squeeze pressure, maximum resting pressure, sensory threshold volume, and maximal tolerable volume favored the upfront surgery group but without statistical significance.

CONCLUSION

Currently available evidence on anorectal manometry protocols failed to show any statistically significant differences in functional outcomes between neoadjuvant chemoradiation and upfront surgery. Further large-scale prospective studies with standardized neoadjuvant chemoradiation and anorectal manometry protocols are needed to validate these findings.

Developing a multivariable prediction model of global health-related quality of life in patients treated for rectal cancer: a prospective study in five countries

PURPOSE

Rectal cancer and its treatment have a negative impact on health-related quality of life (HRQoL). If risk factors for sustained low HRQoL could be identified early, ideally before the start of treatment, individualised interventions could be identified and implemented to maintain or improve HRQoL. The study aimed to develop a multivariable prediction model for global HRQoL 12 months after rectal cancer treatment.

METHODS

Within COLOR II, a randomised, multicentre, international trial of laparoscopic and open surgery for rectal cancer, a sub-study on HRQoL included 385 patients in 12 hospitals and five countries. The HRQoL study was optional for hospitals in the COLOR II trial. EORTC QLQ-C30 and EORTC QLQ-CR38 were analysed preoperatively and at 1 and 12 months postoperatively. In exploratory analyses, correlations between age, sex, fatigue, pain, ASA classification, complications, and symptoms after surgery to HRQoL were studied. Bivariate initial analyses were followed by multivariate regression models.

RESULTS

Patient characteristics and clinical factors explained 4-10% of the variation in global HRQoL. The patient-reported outcomes from EORTC QLQ-C30 explained 55-65% of the variation in global HRQoL. The predominant predictors were fatigue and pain, which significantly impacted global HRQoL at all time points measured.

CONCLUSION

We found that fatigue and pain were two significant factors associated with posttreatment global HRQoL in patients treated for rectal cancer T1-T3 Nx. Interventions to reduce fatigue and pain could enhance global HRQoL after rectal cancer treatment.

TRIAL REGISTRATION

This trial is registered with ClinicalTrials.gov No. NCT00297791.

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.

Association between personality types and low anterior resection syndrome in rectal cancer patients following surgery

PURPOSE

Low anterior resection syndrome (LARS) has had many impacts on the lives of patients and substantial differences in emotional and social functions. The aim of this study was to investigate the correlation analysis of different personality traits in rectal cancer patients with LARS after undergoing curative surgery.

METHODS

This study was designed as a prospective cohort study. The inclusion criteria included (1) participants diagnosed with rectal cancer who underwent surgical resection of malignant tumors and (2) ECOG 0-1. The primary outcome was the correlation between different personality traits and low anterior resection syndrome in rectal cancer patients after radical surgery. Low anterior resection syndrome incidence rates were estimated by questionnaires and personality groups by the Type A and Type D Scale-14 Personality Inventory.

RESULTS

For all 161 participants in this study, the presence of a tumor at the lower anal verge and the receipt of neoadjuvant CCRT had a statistically significant positive correlation with the LARS score at 1 month, 6 months, and 1 year (Pearson correlation coefficient = -0.283, -0.374, and - 0.205, respectively), with a p value of less than 0.05. Personalities with Type A, Type D, and Type D-SI scores had a statistically significant positive correlation with LARS score at 1 month (Pearson correlation coefficient = 0.172, 0.162, and 0,164, p value = 0.03, 0.04, and 0.04).

CONCLUSION

Type A and Type D personalities are highly linked to LARS. Personalized support approaches can ultimately assist rectal cancer patients in overcoming difficulties after surgery and recovery and enhance their functional outcomes.

Low anterior resection syndrome and quality of life after intersphincteric resection for rectal cancer: a propensity score-matched study

PURPOSE

Our aim was to perform a propensity score-matched study to compare the long-term functional outcomes and quality of life following intersphincteric resection vs. low anterior resection (LAR) with very low anastomosis.

METHODS

Patients who underwent intersphincteric resection or low anterior resection with low anastomosis (≤ 4 cm from the anal verge) for rectal cancer between January 2017 and June 2020 were retrospectively included. A propensity score-matching process was performed. Functional outcomes and quality of life were assessed using the European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L), EORC-QLQ C30, EORC-QLQ CR29, Low Anterior Resection Syndrome (LARS), Wexner, and International Prostate Symptom Score (IPSS) questionnaires. The primary outcome was the presence of LARS at least 12 months after surgery. The second outcome was the postoperative quality of life of included patients.

RESULTS

After propensity matching, 128 patients were included, including 58 males and 70 females with a median age of 59.5. Patients in the intersphincteric resection group showed a higher incidence of incontinence to flatus (32.8% versus 14.0%, p = 0.043) and stools (42.2% versus 21.9%, p = 0.046), pain/discomfort (25.0% versus 7.8%, p = 0.001), and bowel dysfunction, while the LARS scores (15.0 versus 13.2, p = 0.461) and major LARS rates (26.6% versus 14.1%, p = 0.078) were comparable in both groups.

CONCLUSION

ISR leads to increased bowel incontinence rate and increased anal pain, without affecting the grade of low anterior resection syndrome, fecal urgency, and clustering. LAR might be the preferred sphincteric-preserving approach when negative resection margins and a safe anastomosis are guaranteed. Patients should be fully informed about potential functional impairment after sphincter-preservation procedures.

Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment

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.

The impact of restorative proctectomy versus permanent colostomy on health-related quality of life after rectal cancer surgery using the patient-generated index

BACKGROUND

The impact of bowel dysfunction versus colostomy on quality of life after rectal cancer surgery is poorly understood.

BACKGROUND

To evaluate the quality of life after rectal cancer surgery in patients with colostomy versus restorative proctectomy.

METHODS

A mixed-methods study measuring quality of life using the Patient-Generated Index, patients were asked to list up to 5 areas of their life affected by their surgery. Areas were then weighted according to patients' preferences for improvement to generate a score from 0-100. The areas reported by patients were linked to the International Classification of Functioning for content analysis. Bowel dysfunction was measured using the low anterior resection syndrome score, and patients were then grouped according to (1) colostomy, (2) no/minor, or (3) major low anterior resection syndrome. Quality of life was compared between groups.

RESULTS

Overall, 121 patients were included (colostomy n = 39, restorative proctectomy n = 82). There were no differences in demographics, neoadjuvant radiotherapy, or time to follow-up between groups. In the restorative proctectomy group, 53% had no/minor, and 47% had major low anterior resection syndrome. Overall, patients with colostomy had significantly lower quality-of-life scores than those with restorative proctectomy. However, patients with major low anterior resection syndrome scored similarly to those with colostomy. On content analysis, patients with colostomies reported more problems with sexual function, body image, and sports. Patients with restorative proctectomy reported more problems with sleep, using transportation, and taking care of themselves.

CONCLUSION

Colostomy has a more detrimental impact on quality of life than restorative proctectomy. However, bowel dysfunction severity is important to consider. The patient experience between treatments differs.

Essential updates 2020/2021: Advancing precision medicine for comprehensive rectal cancer treatment

In the paradigm shift related to rectal cancer treatment, we have to understand a variety of new emerging topics to provide appropriate treatment for individual patients as precision medicine. However, information on surgery, genomic medicine, and pharmacotherapy is highly specialized and subdivided, creating a barrier to achieving thorough knowledge. In this review, we summarize the perspective for rectal cancer treatment and management from the current standard-of-care to the latest findings to help optimize treatment strategy.

Predictors of pre- and post-treatment bowel dysfunction severity in patients with rectal cancer

BACKGROUND

Treatment of rectal cancer is frequently associated with low anterior resection syndrome. However, data concerning the contribution rectal tumors have on pretreatment bowel-dysfunction is scarce. We sought to evaluate the impact of the untreated rectal cancer on bowel-dysfunction and the relationship of pretreatment and post-treatment function.

METHODS

A prospective database of adults with rectal cancer at a single university-affiliated colorectal referral center from August 2018 to March 2022 was queried. Bowel-dysfunction was measured using the low anterior resection syndrome score questionnaire (categorized as no, minor, or major low anterior resection syndrome) which was provided to patients at their primary visit, and after treatment. Patients were included if they underwent rectal cancer treatment and had pre- and post-treatment low anterior resection syndrome measurements. Observed low anterior resection syndrome scores were compared to normative low anterior resection syndrome data for age and sex-specific distributions from published data. Multiple multinomial regression compared pre- and post-treatment low anterior resection syndrome scores.

RESULTS

Overall, 121 patients were included with mean age 62.0 years (standard deviation 12.3), 74% male, and mean tumor height 8.7 cm (standard deviation 5.72). The proportion of pretreatment observed low anterior resection syndrome were 48% no low anterior resection syndrome, 28% minor, and 24% major. Male and older patients were more likely to have worse than predicted low anterior resection syndrome categories (P < .05). On average, low anterior resection syndrome category did not change after treatment (P = .618) and pretreatment low anterior resection syndrome category was a significant independent predictor of post-treatment category (P = .037).

CONCLUSION

Pretreatment bowel-dysfunction in rectal cancer patients is common and significantly worse than predicted for older and male patients. Importantly, pretreatment bowel-dysfunction predicted postoperative function. These results may better inform the shared decision-making process.

Quality of life and patient reported symptoms after colorectal cancer in a Swedish population

AIM

A proportion of patients treated for colorectal cancer have impaired quality of life (QoL) but it is uncertain if the level of QoL differs from the corresponding background population. This population-based cohort study aimed to evaluate health-related QoL in colorectal cancer patients and compare their QoL with that of a Swedish reference population.

METHODS

Patients who underwent surgery for colorectal cancer Stages I-III in the Stockholm-Gotland region in 2013-2015 received the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and the QLQ-CR29 questionnaires and the low anterior resection syndrome score, 1 year after surgery. Patient and tumour data were collected from the Swedish Colorectal Cancer Registry. The patient cohort was matched to a Swedish reference population regarding EORTC QLQ-C30. Global QoL was compared to the reference population and a patient group with impaired QoL was defined. Detailed patient-reported outcomes were analysed in relation to global QoL in the patient cohort.

RESULTS

A total of 925 patients returned the questionnaires and 358 patients (38.70%) reported a clinically relevant impaired global QoL compared to the reference population. Patients with impaired QoL reported clinically relevant and statistically significantly more complaints regarding bowel habits, pain and anxiety. After adjustment for sex, age and stoma, anxiety was the strongest predictor for impaired QoL, with OR 6.797 (95% CI 4.677-9.879).

CONCLUSION

A substantial proportion of patients treated for colorectal cancer have impaired global QoL. This impairment is strongly associated with several physical symptoms and anxiety.

A novel nomogram to predict low anterior resection syndrome (LARS) after ileostomy reversal for rectal cancer patients

BACKGROUND AND AIM

Low anterior resection syndrome (LARS) in patients undergoing low or ultra-low anterior resection (LAR) is a common problem and significantly impacts the quality of life. Patients with an ileostomy after LAR are more likely to develop LARS. However, there hasn't been a model predicting LARS occurrence in these patients. This study aims to construct a nomogram to predict the probability of LARS occurrence in patients with temporary ileostomy and guide preventive strategies before reversal.

METHODS

168 patients undergoing LAR with ileostomy from one center were enrolled as the training cohort, and 134 patients of the same inclusion criteria from another center were enrolled as the validation cohort. The training cohort was screened for risk factors for major LARS using univariate and multivariate logistic regression. The nomogram was constructed using the filtered variables, the ROC curve was used to describe the model's discrimination, and the calibration was used to describe the accuracy.

RESULTS

The optimal cut-off value for stoma closure time was 128 days. Three risk factors were identified using logistic regression analysis: preoperative radiotherapy (OR = 3.038, [95%CI 1.75-5.015], P = 0.005), stoma closure time (OR = 2.298, [95%CI 1.088-4.858], P = 0.029) and pN stage (OR = 1.739, [95%CI 1.235-3.980], P = 0.001). A nomogram was constructed based on these three variables and showed good performance predicting major LARS after stoma reversal. The area under the curve (AUC) was 0.827 in the training group and 0.821 in the validation group; The calibration curve suggested good precision in both groups.

CONCLUSIONS

This novel nomogram can accurately predict the probability of major LARS occurrence after ileostomy reversal for rectal cancer patients. This model can help screen ileostomy patients with high risks and guide individualized preventive strategies before stoma reversal.

Management of Low Anterior Resection Syndrome (LARS) Following Resection for Rectal Cancer

INTRODUCTION

A total of 60-80% of patients undergoing rectal resection (mostly as a treatment for rectal cancer) suffer from a variety of partly severe functional problems despite preservation of the anal sphincter. These patients are summarized under the term low anterior resection syndrome (LARS). Preoperative radiotherapy, vascular dissection and surgical excision of the low rectum and mesorectum lead, alone or all together, to a significant impairment of colonic and (neo-) rectal motility. This results in a variety of symptoms (multiple defecation episodes, recurrent episodes of urge, clustering, incontinence, etc.) which are associated with severe impairment of quality of life (QOL).

METHODS

This narrative review summarizes the present state of knowledge regarding the pathophysiology of LARS as well as the evidence for the available treatment options to control the symptoms resulting from this condition.

RESULTS

A review of the literature (Medline, Pubmed) reveals a variety of treatment options available to control symptoms of LARS. Medical therapy, with or without dietary modification, shows only a modest effect. Pelvic floor rehabilitation consisting of muscle exercise techniques as well as biofeedback training has been associated with improvement in LARS scores and incontinence, albeit with limited scientific evidence. Transanal irrigation (TAI) has gained interest as a treatment modality for patients with LARS due to an increasing number of promising data from recently published studies. Despite this promising observation, open questions about still-unclear issues of TAI remain under debate. Neuromodulation has been applied in LARS only in a few studies with small numbers of patients and partly conflicting results.

CONCLUSION

LARS is a frequent problem after sphincter-preserving rectal surgery and leads to a marked impairment of QOL. Due to the large number of patients suffering from this condition, mandatory identification, as well as treatment of affected patients, must be considered during surgical as well as oncological follow-up. The use of a standardized treatment algorithm will lead to sufficient control of symptoms and a high probability of a marked improvement in QOL.

Pathway Of Low Anterior Resection syndrome relief after Surgery (POLARiS) feasibility trial protocol: a multicentre, feasibility cohort study with embedded randomised control trial to compare sacral neuromodulation and transanal irrigation to optimised conservative management in the management of major low anterior resection syndrome following rectal cancer treatment

INTRODUCTION

Rectal cancer is common with a 60% 5-year survival rate. Treatment usually involves surgery with or without neoadjuvant chemoradiotherapy or adjuvant chemotherapy. Sphincter saving curative treatment can result in debilitating changes to bowel function known as low anterior resection syndrome (LARS). There are currently no clear guidelines on the management of LARS with only limited evidence for different treatment modalities.

METHODS AND ANALYSIS

Patients who have undergone an anterior resection for rectal cancer in the last 10 years will be approached for the study. The feasibility trial will take place in four centres with a 9-month recruitment window and 12 months follow-up period. The primary objective is to assess the feasibility of recruitment to the POLARiS trial which will be achieved through assessment of recruitment, retainment and follow-up rates as well as the prevalence of major LARS.Feasibility outcomes will be analysed descriptively through the estimation of proportions with confidence intervals. Longitudinal patient reported outcome measures will be analysed according to scoring manuals and presented descriptively with reporting graphically over time.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Wales REC1; Reference 22/WA/0025. The feasibility study is in the process of set up. The results of the feasibility trial will feed into the design of an expanded, international trial.

TRIAL REGISTRATION NUMBER

CT05319054.

Association between adherence to the American Cancer Society Nutrition and Physical Activity Guidelines and stool frequency among colon cancer survivors: a cohort study

Purpose

We sought to determine whether adherence to the American Cancer Society (ACS) Nutrition and Physical Activity Guidelines was associated with better bowel function among colon cancer survivors.

Methods

This prospective cohort study included patients surgically treated for stage I–IV colon cancer enrolled in the Lifestyle and Outcomes after Gastrointestinal Cancer (LOGIC) study between February 2017 and May 2021. Participants were assigned an ACS score (0–6 points) at enrollment. Stool frequency (SF) was assessed every 6 months using the EORTC QLQ-CR29. Higher SF is an indication of bowel function impairment. ACS score at enrollment was examined in relation to SF at enrollment and over a 3-year period. Secondarily, we examined associations between the ACS score components (body mass index, dietary factors, and physical activity) and SF. Multivariable models were adjusted for demographic and surgical characteristics.

Results

A total of 112 people with colon cancer (59% women, mean age 59.5 years) were included. Cross-sectionally, for every point increase in ACS score at enrollment, the odds of having frequent stools at enrollment decreased by 43% (CI 0.42–0.79; p < 0.01). Findings were similar when we examined SF as an ordinal variable and change in SF over a 3-year period. Lower consumption of red/processed meats and consuming a higher number of unique fruits and vegetables were associated with lower SF (better bowel function) at enrollment.

Conclusions

Colon cancer survivors who more closely followed the ACS nutrition and physical activity guidelines had lower SF, an indication of better bowel function.

Implications for Cancer Survivors

Our findings highlight the value of interventions that support health behavior modification as part of survivorship care for long-term colon cancer survivors.

Anterior Resection Syndrome and Quality of Life With Long-term Follow-up After Rectal Cancer Resection

BACKGROUND

Surgical and systemic therapies continue to advance, enabling restorative resections for distal rectal cancer. These operations are associated with low anterior resection syndrome. Recent studies with methodological and size limitations have investigated the incidence of low anterior resection syndrome after anterior resection. However, the long-term trajectory of low anterior resection syndrome and its effect on health-related quality of life remain unclear.

OBJECTIVE

The purpose of this study was to assess the impact of anterior resection and reversal of ileostomy on long-term health-related quality of life and low anterior resection syndrome.

DESIGN

Patient demographics were analyzed alongside low anterior resection syndrome and health-related quality-of-life qualitative scores (EORTC-QLQ-C30) obtained through cross-sectional postal questionnaires.

SETTING

Patients who underwent anterior resection of the rectum for cancer with defunctioning ileostomy between 2003 and 2016 at 2 high-volume centers in the United Kingdom were identified, excluding those experiencing anastomotic leakage.

PATIENTS

Among 478 eligible patients, 311 (65.1%) participated at a mean of 6.5 ± 0.2 years after anterior resection. Demographics and neoadjuvant chemoradiotherapy rates were similar ( p > 0.05) between participants and nonparticipants.

RESULTS

The percentage of patients who experienced major low anterior resection syndrome was 53.4% (166/311). Health-related quality-of-life functional domain scores improved in the years after reversal of ileostomy, with significant changes in constipation ( p = 0.01), social function ( p = 0.03), and emotional scores ( p = 0.02), as well as a reduction in the prevalence of major low anterior resection syndrome ( p = 0.003).

LIMITATIONS

The main limitation of this study was that the data collected were cross-sectional rather than longitudinal, and that nonresponders may have had worse cancer symptoms.

CONCLUSIONS

In this first large-scale study assessing long-term function after anterior resection and reversal of ileostomy, there is a linear improvement in major low anterior resection syndrome beyond 6 years, alongside improvements in key quality-of-life measures. See Video Abstract at http://links.lww.com/DCR/B825 .

SEGUIMIENTO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA Y LA CALIDAD DE VIDA POR CNCER DE RECTO

ANTECEDENTES:Los tratamientos tanto quirúrgicos como sistémicos continúan evolucionando día a día, así éstos permiten resecciones restaurativas por cáncer de recto distal. Estas operaciones están asociadas con el síndrome de resección anterior baja. Estudios recientes con limitaciones tanto metodológicas como de talla han estudiado la incidencia del síndrome de resección anterior bajo post-quirúrgico. Sin embargo, la evolución a largo plazo del síndrome de resección anterior baja y su acción sobre la calidad de vida relacionadas con la salud siguen sin estar claros.OBJETIVO:Evaluar el impacto de la resección anterior baja y el cierre de la ileostomía en la calidad de vida relacionadas con la salud a largo plazo y el síndrome post-resección anterior.AJUSTE:Se incluyeron todos los pacientes sometidos a una reseccción anterior baja de recto por cáncer asociada a una ileostomía de protección entre 2003 y 2016 en dos centros de gran volumen en el Reino Unido, se excluyeron los pacientes que presentaron fuga anastomótica.DISEÑO:Se revisaron los datos demográficos de todos los pacientes que presentaban el síndrome de resección anterior baja, se revisaron las puntuaciones de la calidad de vida relacionadas con el estado general de salud (EORTC-QLQ-C30) obtenidas a través de cuestionarios transversales enviados por correo.PACIENTES:478 pacientes fueron escogidos, 311 (65,1%) participaron del estudio en una media de 6,5 ± 0,2 años después de la resección anterior. Las tasas demográficas y de radio-quimioterapia neoadyuvante fueron similares (p > 0,05) entre los participantes y los no participantes.RESULTADOS:El porcentaje de pacientes que experimentaron síndrome de resección anterior baja mayor fue del 53,4% (166/311).PRINCIPALES MEDIDAS DE RESULTADO:Las puntuaciones funcionales en la calidad de vida relacionadas con estado general de salud mejoraron en los años posteriores al cierre de la ileostomía de protección, los cambios fueron significativos con relación al estreñimiento (p = 0,01), con relación a la actividad social (p = 0,03) y con las puntuaciones emocionales (p = 0,02), así como con la reducción de la prevalencia del síndrome de resección anterior baja mayor (p = 0,003).LIMITACIONES:La principal limitación del presente estudio mostró que los datos recopilados fueron transversales y no longitudinales, y que los pacientes no respondedores pueden haber tenido peores síntomas relacionados con el cáncer.CONCLUSIONES:Este primer estudio a gran escala, evalúa la función a largo plazo después de la resección anterior baja y el cierre de la ileostomía, demuestra una mejoría lineal en el síndrome de resección anterior baja de grado importante, más allá de los 6 años, asociado con la mejoría en las medidas clave de calidad de vida. Consulte Video Resumen en http://links.lww.com/DCR/B825 . (Traducción-Dr. Xavier Delgadillo ).

The role of colonic motility in low anterior resection syndrome

Low anterior resection syndrome (LARS) describes the symptoms and experiences of bowel dysfunction experienced by patients after rectal cancer surgery. LARS is a complex and multifactorial syndrome exacerbated by factors such as low anastomotic height, defunctioning of the colon and neorectum, and radiotherapy. There has recently been growing awareness and understanding regarding the role of colonic motility as a contributing mechanism for LARS. It is well established that rectosigmoid motility serves an important role in coordinating rectal filling and maintaining continence. Resection of the rectosigmoid may therefore contribute to LARS through altered distal colonic and neorectal motility. This review evaluates the role of colonic motility within the broader pathophysiology of LARS and outlines future directions of research needed to enable targeted therapy for specific LARS phenotypes.

Patient-Reported Bowel and Urinary Function in Long-Term Survivors of Squamous Cell Carcinoma of the Anus Treated With Definitive Intensity Modulated Radiation Therapy And Concurrent Chemotherapy

PURPOSE

Definitive radiation therapy with concurrent chemotherapy is curative for nonmetastatic squamous cell carcinoma of the anus (SCCA). However, the true effect of chemoradiation on long-term functional outcomes is poorly understood owing to limited follow-up and patient-reported outcomes (PROs).

METHODS AND MATERIALS

We conducted a cross-sectional survey of 248 patients with SCCA treated with definitive intensity modulated radiation and concurrent chemotherapy from 2010 to 2018 who were alive and without recurrence. PRO measures were collected, including Functional Assessment of Cancer Therapy-General (FACT-G7), Fecal Incontinence Quality of Life (FIQoL), Low Anterior Resection Syndrome (LARS), and International Consultation on Incontinence Questionnaires (ICIQ). Models were used to determine the association between demographic, tumor, treatment, and dosimetric data with PROs.

RESULTS

One hundred twelve (45%) patients completed PROs. Median [interquartile range (IQR)] time from radiation completion to survey was 51 [37-85] months. The median scores [IQR] for FACT-G7, FIQoL, and LARS were 21 [15-24], 14 [11-16], and 32 [25-37], respectively. For men, median subscores [IQR] for ICIQ voiding and incontinence subscores were 5 [2-6] and 1 [1-3], respectively. For women, median subscores [IQR] for ICIQ voiding, incontinence, and filling were 1 [1-3], 5 [3-8], and 4 [2-5], respectively. Higher (better) FIQoL scores were associated with higher (better) FACT-G7 scores (β = 0.83; 95% confidence interval, 0.58-1.09; P < .001), and higher (worse) LARS scores were associated with lower (worse) FACT-G7 scores (β = -0.22; 95% confidence interval, -0.31 to -0.13; P < .001). A separate multivariable analysis revealed higher bowel bag D1% was associated with lower (worse) FIQoL (P = .001) and higher (worse) LARS (P = .003) scores. Higher bladder V40 Gy was associated with increased (worse) ICIQ voiding subscore (P = .001).

CONCLUSIONS

Patients treated with modern chemoradiation for SCCA experience significant long-term bowel toxic effects with considerable effect on quality of life. Minimizing bowel hotspots and bladder V40 Gy may improve bowel and urinary function. Other interventions to reduce long-term toxic effects and improve quality of life are needed.

The Longitudinal Course of Low-anterior Resection Syndrome: An individual Patient Meta-analysis

OBJECTIVE

We aimed to better understand the longitudinal course of low anterior resection syndrome (LARS) to guide patient expectations and identify those at risk of persisting dysfunction.

SUMMARY BACKGROUND DATA

LARS describes disordered bowel function after rectal resection that significantly impacts quality of life.

METHODS

MEDLINE, EMBASE, CENTRAL, and CINAHL databases were systematically searched for studies that enrolled adults undergoing anterior resection for rectal cancer and used the LARS score to assess bowel function at ≥2 postoperative time points. Regression analyses were performed on deidentified patient-level data to identify predictors of change in LARS score from baseline (3-6months) to 12-months and 18-24 months.

RESULTS

Eight studies with a total of 701 eligible patients were included. The mean LARS score improved over time, from 29.4 (95% confidence interval 28.6-30.1) at baseline to 16.6 at 36 months (95% confidence interval 14.2%-18.9%). On multivariable analysis, a greater improvement in mean LARS score between baseline and 12 months was associated with no ileostomy formation [mean difference (MD) -1.7 vs 1.7, P < 0.001], and presence of LARS (major vs minor vs no LARS) at baseline (MD -3.8 vs -1.7 vs 5.4, P < 0.001). Greater improvement in mean LARS score between baseline and 18-24 months was associated with partial mesorectal excision vs total mesorectal excision (MD-8.6 vs 1.5, P < 0.001) and presence of LARS (major vs minor vs no LARS) at baseline (MD -8.8 vs -5.3 vs 3.4, P < 0.001).

CONCLUSIONS

LARS improves by 18 months postoperatively then remains stable for up to 3 years. Total mesorectal excision, neoadjuvant radiotherapy, and ileostomy formation negatively impact upon bowel function recovery.

Functional Outcome of Laparoscopic-Assisted Resection Versus Open Resection of Rectal Cancer: A Secondary Analysis of the Australasian Laparoscopic Cancer of the Rectum Trial

BACKGROUND

Low anterior resection syndrome has a significant impact on the quality of life in rectal cancer survivors. Previous studies comparing laparoscopic to open rectal resection have neglected bowel function outcomes.

OBJECTIVE

This study aimed to assess whether there is a difference in the functional outcome between patients undergoing laparoscopic versus open resection for rectal adenocarcinoma.

DESIGN

Cross-sectional prevalence of low anterior resection syndrome was assessed in a secondary analysis of the multicenter phase 3 randomized clinical trial, Australasian Laparoscopic Cancer of the Rectum Trial (ACTRN12609000663257).

SETTING

There were 7 study subsites across New Zealand and Australia.

PATIENTS

Participants were adults with rectal cancer who underwent anterior resection and had bowel continuity.

MAIN OUTCOME MEASURES

Postoperative bowel function was evaluated using the validated low anterior resection syndrome score and Bowel Function Instrument.

RESULTS

The Australasian Laparoscopic Cancer of the Rectum Trial randomized 475 patients with T1-T3 rectal adenocarcinoma less than 15 cm from the anal verge. A total of 257 participants were eligible for, and invited to, participate in additional follow-up; 163 (63%) completed functional follow-up. Overall cross-sectional prevalence of major low anterior resection syndrome was 49% (minor low anterior resection syndrome 27%). There were no differences in median overall Bowel Function Instrument score nor low anterior resection syndrome score between participants undergoing laparoscopic versus open surgery (66 vs 67, p = 0.52; 31 vs 27, p = 0.24) at a median follow-up of 69 months.

LIMITATIONS

The major limitations are a result of conducting a secondary analysis; the likelihood of an insufficient sample size to detect a difference in prevalence between the groups and the possibility of selection bias as a subset of the randomized population was analyzed.

CONCLUSIONS

Bowel dysfunction affects a majority of rectal cancer patients for a significant time after the operation. In this secondary analysis of a randomized trial, surgical approach does not appear to influence the likelihood or severity of low anterior resection syndrome. See Video Abstract at http://links.lww.com/DCR/B794.

RESULTADO FUNCIONAL DE LA RESECCIN ASISTIDA POR LAPAROSCOPIA VERSUS RESECCIN ABIERTA EN CNCER DE RECTO ANLISIS SECUNDARIO DEL ESTUDIO DE CNCER DE RECTO LAPAROSCPICO DE AUSTRALASIA

ANTECEDENTES:El síndrome de resección anterior baja tiene un impacto significativo en la calidad de vida de los supervivientes de cáncer de recto. Los estudios anteriores que compararon la resección rectal laparoscópica con la abierta no han presentado resultados de la función intestinal.OBJETIVO:Evaluar si existe una diferencia en el resultado funcional entre los pacientes sometidos a resección laparoscópica versus resección abierta por adenocarcinoma de recto.DISEÑO:La prevalencia transversal del síndrome de resección anterior baja se evaluó en un análisis secundario del ensayo clínico aleatorizado multicéntrico de fase 3, Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia (Australasian Laparoscopic Cancer of the Rectum Trial, ACTRN12609000663257).AJUSTE:Siete subsitios de estudio en Nueva Zelanda y Australia.PACIENTES:Los participantes eran adultos con cáncer de recto que se sometieron a resección anterior con anastomosis.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal posoperatoria se evaluó utilizando el previamente validado puntaje LARS y el Instrumento de Función Intestinal.RESULTADOS:El Estudio Sobre el Cáncer de Recto Laparoscópico de Australasia asignó al azar a 475 pacientes con adenocarcinoma rectal T1-T3 a menos de 15 cm del borde anal. 257 participantes fueron elegibles e invitados a participar en un seguimiento adicional. 163 (63%) completaron el seguimiento funcional. La prevalencia transversal general de LARS mayor fue del 49% (LARS menor 27%). No hubo diferencias en la puntuación media general del Instrumento de Función Intestinal ni en la puntuación LARS entre los participantes sometidos a cirugía laparoscópica versus cirugía abierta (66 frente a 67, p = 0,52; 31 frente a 27, p = 0,24) en una mediana de seguimiento de 69 meses.LIMITACIONES:Las principales limitaciones son el resultado de realizar un análisis secundario; se analizó la probabilidad de un tamaño de muestra insuficiente para detectar una diferencia en la prevalencia entre los grupos y la posibilidad de sesgo de selección como un subconjunto de la población aleatorizada.CONCLUSIONES:La disfunción intestinal afecta a la mayoría de los pacientes con cáncer de recto durante un tiempo significativo después de la operación. En este análisis secundario de un ensayo aleatorizado, el abordaje quirúrgico no parece influir en la probabilidad o gravedad del síndrome de resección anterior baja. Consulte Video Resumen en http://links.lww.com/DCR/B794. (Traducción-Dr. Felipe Bellolio).

The impact of bowel dysfunction on health-related quality of life after rectal cancer surgery: a systematic review

BACKGROUND

Symptoms of bowel dysfunction after sphincter-preserving rectal cancer surgery have an important impact on health-related quality of life (HRQOL), but that relationship is complex. A better understanding of this relationship allows for better informed shared decision-making about surgery. Our objective was to perform a systematic review to determine which HRQOL domains are most affected by postoperative bowel dysfunction.

METHODS

A systematic review of the CINAHL, Cochrane Library, Embase, Medline, PsycInfo, PubMed, Web of Science, and Scopus databases was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included studies that evaluated bowel function after sphincter-preserving rectal cancer surgery and assessed HRQOL using a validated instrument. The quality of HRQOL analysis was assessed using an 11-item checklist. The main outcome was the impact bowel dysfunction had on global and domain specific quality-of-life indices. The impact was evaluated for clinical relevance using the Minimum Clinical Important Difference (MCID) for each specific HRQOL instrument.

RESULTS

Out of 952 unique citations, 103 studies were full-text reviews. Eighteen studies met the inclusion criteria (4 prospective cohorts and 9 cross-sectional studies). Of the 15 studies with long-term follow-up, the time to assessment after surgery ranged from 1.2 to 14.6 years. The low anterior resection syndrome score and European Organization for Research and Treatment core quality-of-life questionnaire (EORTC QLQ-C30) were the most commonly used instruments. Medium and large magnitudes in MCID were seen for global health, social functioning, emotional functioning, fatigue, diarrhea, and financial difficulties. Among included studies, the most consistently reported functional domains affected by bowel function were social functioning and emotional functioning.

CONCLUSIONS

Following sphincter-preserving rectal cancer surgery, poor bowel function mainly affects the social and emotional functional domains of HRQOL, which in turn impact global scores. This finding can help inform patients about expected changes in HRQOL after rectal cancer surgery and facilitate individualized treatment decisions.

Clinical Utility and Characteristics of the LARS Score Compared to the CCIS

PURPOSE

The low anterior resection syndrome (LARS) score (LS) has been widely validated and has become an international tool for evaluating postoperative bowel dysfunction. However, many physicians still use the conventional incontinence scores in LARS treatment. Moreover, interpretation of LS and its relationship with conventional incontinence scores are not yet well understood. Here we compared the LS with the Cleveland Clinic Incontinence Score (CCIS) to clarify the clinical utility and characteristics of the LARS score.

METHODS

We performed a multicentre observational study, recruiting 246 rectal cancer patients following sphincter-preserving surgery. Patients completed the LS, CCIS, and SF36 questionnaires.

RESULTS

The response rate was 76.4%, and a total of 180 patients were analysed. The LS was strongly correlated with the CCIS (P < 0.001, rs = 0.727). However, among 116 patients determined to not have incontinence (CCIS 0-5), 51 (44%) were diagnosed with LARS (29 with minor LARS and 22 with major LARS). Among 68 patients without LARS, only 3 were diagnosed as having incontinence (CCIS > 6). In comparison with background factors, aging and elapsed time were associated with only LS. High LS and CCIS both showed significant quality-of-life impairment as assessed by the SF-36.

CONCLUSION

This is the first study to determine the difference in the numeric values between the CCIS and LS. The LS can be a convenient tool for LARS screening, identifying a wide range of patients with LARS, including those with incontinence evaluated by CCIS. Assessment using the CCIS may often underestimate LARS.

Quality of Life in Patients With Rectal Resections and End-to-End Primary Anastomosis Using a Standardized Perioperative Pathway

Objectives: Lower rectal resection is associated with a high rate of postoperative complications and, therefore, adversely impacts the postoperative health-related quality of life (QoL). Though sporadically practiced in different centers, there is no standard perioperative protocol for the management of patients with rectal growths. The aim of this analysis is to evaluate the patient-reported outcomes after low rectal resections followed by an end-to-end-reconstruction and temporary covering ileostomy using a multidisciplinary fail-safe-concept.

Methods: Between 2015 and 2020, we evaluated patient reported outcomes after open and laparoscopic rectal resections with end-to-end reconstruction with a primary straight anastomosis using a standardized perioperative pathway All patients with stoma were excluded from the study. The data for the QoL of patients was collected using the established Low Anterior Resection Syndrome (LARS)-score and the EORTC-C30 and CR-29 questionnaires at a single postoperative timepoint.

Results: We recruited 78 stoma-free patients for this analysis. Of 78 patients included in the study, 87.2% were operated laparoscopically and the mean global health status was 67.95 points, while a major LARS was detected in 48 (61.5%) patients. No anastomotic leakage (AL) occurred within the study cohort. There was no significant change in the LARS-score or the global health status depending on the follow-up-period.

Conclusion: This study shows that good QoL and functional outcomes with no AL are achievable following end-to-end straight anastomosis using a standardized perioperative surgical fail-safe protocol procedure.

Defecation disorder and anal function after surgery for lower rectal cancer in elderly patients

AIM

This study aims to investigate the association of patient age with defecation disorders and anal function after lower rectal cancer surgery.

METHODS

We retrospectively reviewed the data of 141 consecutive patients with lower rectal cancer who underwent sphincter-preserving operation. The patients were classified into five categories by age thresholds at 65, 70, 75, 80, and 85 years, for disaggregate analysis. Anal manometry was used for measuring the maximum resting pressure, high-pressure zone, and maximum squeeze pressure. Anal manometry was performed preoperatively and at 3, 6, 9, and 12 months postoperatively. The Wexner and low anterior resection syndrome scores were assessed at 1, 3, 6, 9, and 12 months after rectal surgery or stoma closure for patients with ileostomy.

RESULTS

The data of 117 patients were reviewed. No significant differences were found between the younger and elderly groups in any characteristics across the six age groups. The preoperative intra-anal pressures of the elderly patients were slightly lower than those of the younger patients; however, there was no significant difference in the course of postoperative intra-anal pressures. Defecation disorder, as measured by the Wexner and low anterior resection syndrome scores, improved significantly in elderly patients compared to younger patients.

CONCLUSION

There was no significant difference in the course of postoperative intra-anal pressures between the elderly and younger patients. However, defecation disorders in elderly patients significantly improved compared with younger patients. Sphincter-preserving operation can be a viable treatment option for active elderly patients.

Improvement of low anterior resection syndrome beyond 2 years after total mesorectal excision

AIM

Bowel dysfunction after sphincter-preserving proctectomy, also known as low anterior resection syndrome (LARS), has significant impact on survivors of rectal cancer. This study aimed to assess the temporal change of LARS beyond 2 years after proctectomy, which has not been fully studied.

METHODS

We longitudinally enrolled consecutive patients who had received total mesorectal excision in a tertiary academic medical center, with preoperative neoadjuvant therapy if indicated. LARS score was longitudinally assessed by two serial follow-ups, with a fixed interval of 18 months.

RESULTS

Overall, 107 patients responded for the first follow-up after a median of q20 months, 96 of whom responded for the second follow-up after a median of 38 months. At the first follow-up, 48 patients (44.9%) reported major LARS, compared with 23 (24.0%) at the second follow-up (p < 0.001). Mean LARS score improved from 27.3 to 18.6, mostly from "urgency" (12.2 vs. 6.2, p < 0.001) and "clustering of stools" (9.7 vs. 7.7, p = 0.001). Anastomosis less than 3 cm from the anal verge was independently associated with LARS improvement.

CONCLUSION

Bowel dysfunction continues to improve 2 years after total mesorectal excision, with most symptom relief in urgency and stool clustering, especially in patients with lower anastomosis.

A novel bowel rehabilitation programme after total mesorectal excision for rectal cancer: the BOREAL pilot study

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.

[Low anterior resection syndrome-Causes and treatment approaches]

BACKGROUND

With improvement of the oncological prognosis and more sphincter-preserving procedures for rectal cancer of the lower third, the functional sequelae of anterior rectal resection become more and more predominant and are summarized under the term low anterior resection syndrome (LARS).

MATERIAL AND METHODS

In this narrative review the causes, associated factors, prevalence, diagnostics and treatment strategies are presented based on an evaluation of the international literature.

RESULTS

The central role of the rectum in the physiology of defecation and continence explains the frequency of symptoms following anterior rectal resection. In an unselected patient population a major LARS is to be expected in approximately 40% and a minor LARS in approximately 20%. The most important factor is the length of the remaining rectal stump. The diagnosis of LARS is made clinically and can be quantified by scores, especially by the LARS score. Treatment options range from patient counselling to stoma construction and a symptom-related, stepwise approach is generally accepted.

CONCLUSION

While the evidence for the causes, the quantification and determination of associated factors of LARS is good, the treatment options are based either on experience or on only few studies.

Transanal total mesorectal excision and low anterior resection syndrome

BACKGROUND

Bowel dysfunction after rectal cancer surgery is common, with some experiencing low anterior resection syndrome (LARS) is common after rectal cancer surgery. This study examined if transanal total mesorectal excision (TaTME) has a similar risk of LARS and altered quality of life (QoL) as patients who undergo low anterior resection (LAR).

METHODS

Patients who underwent TaTME or traditionally approached total mesorectal excision in a prospective colorectal cancer cohort study (2014-2019) were propensity score matched in a 1 : 1 ratio. LARS and QoL scores were assessed before and after surgery with a primary endpoint of major LARS at 12 months analysed for possible association between factors by logistic regression.

RESULTS

Of 61 TaTME and 317 LAR patients eligible, 55 from each group were propensity score matched. Higher LARS scores (30.6 versus 25.4, P = 0.010) and more major LARS (65 versus 42 per cent, P = 0.013; OR 2.64, 95 per cent c.i. 1.22 to 5.71) were reported after TaTME. Additionally, QoL score differences (body image, bowel frequency, and embarrassment) were worse in the TaTME group.

CONCLUSIONS

TaTME may be associated with more severe bowel dysfunction than traditional approaches to rectal cancer.

Management guidelines for low anterior resection syndrome - the MANUEL project

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.

Optimizing sacral neuromodulation for low anterior resection syndrome: learning from our experience

AIM

The aim of this work was to review our institutional series of patients treated with sacral neuromodulation (SNM) for low anterior resection syndrome (LARS) and evaluate possible factors associated with therapeutic success.

METHOD

Twenty-five patients were treated with SNM for LARS between 2008 and 2019. SNM was performed as per our institutional protocol. Patients were evaluated with Wexner and LARS scores before and after SNM treatment. A visual analogue scale (1-10) was used to evaluate overall patient satisfaction with SNM.

RESULTS

There were significant differences between the mean LARS score values before (37.82) and after (29) SNM therapy (P < 0.004). The mean Wexner score was higher (16.24) before SNM treatment than afterwards (11.13) (P < 0.004). There was a direct relationship between the height of anastomosis and LARS score (P = 0.035): there were big changes in LARS scoring (pre-/post-SNM therapy) in patients with higher anastomoses, and vice versa. Patients who received radiotherapy scored lower in mean satisfaction (6.38) than patients without previous radiotherapy (8.22) (P = 0.008). There was an important positive association between Wexner score and patient satisfaction (P = 0.001): relevant changes in Wexner scoring after SNM therapy were associated with high patient satisfaction, and vice versa.

CONCLUSION

Our study showed a relationship between changes in Wexner and LARS scores before and after SNM and overall patient satisfaction with SNM therapy. These findings also suggest patients with previous radiotherapy may have worse results with SNM (based on lower overall satisfaction), and that higher anastomoses have a greater impact on the post-SNM LARS score.

Patients' preferences for sphincter preservation versus abdominoperineal resection for low rectal cancer

BACKGROUND

Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients' preferences for treatment for low rectal cancer.

METHODS

Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection.

RESULTS

A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5-25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients.

CONCLUSION

An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients' value functional outcomes with a low anastomosis.

Unintended consequences of treating early rectal cancers for complete clinical response with chemoradiotherapy

The aim was to examine the current trend in rectal cancer, which is to extend ’watch-and-wait’ to earlier-stage tumors, not normally treated with chemoradiotherapy, to define the up-side and down-side regarding quality of life (QOL) and anorectal/sexual/urinary function from this approach. We reviewed the literature regarding a ‘watch-and-wait’ strategy after neoadjuvant chemoradiotherapy. The primary outcome measure was complete clinical response. Secondary measures included colostomy rate, functional outcomes and QOL. There is a trend to use chemoradiotherapy in earlier tumors using dose-escalation of radiation and/or additional chemotherapy, resulting in high rates of complete clinical response, which may impact adversely on QOL if radical surgery is subsequently required. Focusing on organ-preservation as the primary goal of treatment rather than overall functional outcomes and QOL for the whole population, may not provide patients with sufficient information for optimal decision-making.

Organ-saving surgery for rectal cancer after neoadjuvant chemoradiation: Analysis of failures and long-term results

BACKGROUND

To analyze long-term results and risk of relapse in the clinical TNM stages II and III, mid-low rectal cancer patients (RC pts), treated with transanal local excision (LE) after major response to neoadjuvant chemoradiation (n-CRT).

METHODS

Thirty-two out of 345 extraperitoneal cT3-4 or N+ RC pts (9.3%) underwent LE.

INCLUSION CRITERIA

extraperitoneal RC, adenocarcinoma, ECOG Performance Status ≤2. Pts with distant metastases were excluded.

RESULTS

All pts showed histologically clear margins of resection and 81.2% were restaged ypT0/mic/1. Nine out of 32 (28.1%) pts relapsed: 7 (21.8%) showed a local recurrence, of which 5 (15.6%) at the endorectal suture, 1 (3.1%) pelvic and 1 (3.1%) mesorectal. Two pts (6.2%) relapsed distantly. Among the pT0/1, 11.5% relapsed vs 100% of the pT2 and pT4 ones. The six pts relapsing locally or in the mesorectal fat underwent a salvage total mesorectal excision surgery. The old patient with pelvic recurrence relapsed after 108 months and underwent a re-irradiation; the two pts with distant metastases were treated with chemotherapy followed by radical surgery.

CONCLUSIONS

Presently combined approach seems a valid option in major responders, confirming its potential curative impact in the ypT0/mic/1 pts. A strict selection of pts is basic to obtain favourable results.

Quality of Life After Radiotherapy for Rectal and Anal Cancer

Purpose of Review

With advances in radiation therapy (RT) techniques for rectal and anal cancers allowing for the modulation of critical normal tissues, there has been an increased emphasis on improving the quality of life (QOL) of cancer survivors. Herein, we review the literature to examine the impact of RT on QOL and patient reported outcomes (PROs) to better inform providers about the challenges of survivorship.

Recent Findings

Large systematic reviews, recent studies and long-term follow-up of pivotal clinical trials have shown that RT impacts QOL, particularly fecal continence and sexual function. Modern preoperative RT techniques allow for decreased dose to organs-at-risk will likely improve QOL.

Summary

RT, though critical in the treatment of rectal and anal cancer, has a profound impact on QOL for some patients. Recent studies have included PROs and validated QOL metrics to better inform providers and patients.

Patient-Reported Outcomes in Surgical Oncology: An Overview of Instruments and Scores

Traditional measures of quality and effectiveness in surgical oncology have focused on morbidity, mortality, and when available, recurrence rates. Measuring patient-reported outcomes (PROs) has become more widely accepted during the last decade. This article reviews instruments commonly used in the surgical treatment of cancer patients to evaluate PROs. In addition, it discusses the linkage of PROs and health-related quality of life measures with traditional surgical complications and highlights future directions related to the expanding use of PROs in the surgical care of cancer patients.

Neoadjuvant radiotherapy for rectal cancer management

Thirty per cent of all colorectal tumours develop in the rectum. The location of the rectum within the bony pelvis and its proximity to vital structures presents significant therapeutic challenges when considering neoadjuvant options and surgical interventions. Most patients with early rectal cancer can be adequately managed by surgery alone. However, a significant proportion of patients with rectal cancer present with locally advanced disease and will potentially benefit from down staging prior to surgery. Neoadjuvant therapy involves a variety of options including radiotherapy, chemotherapy used alone or in combination. Neoadjuvant radiotherapy in rectal cancer has been shown to be effective in reducing tumour burden in advance of curative surgery. The gold standard surgical rectal cancer management aims to achieve surgical removal of the tumour and all draining lymph nodes, within an intact mesorectal package, in order to minimise local recurrence. It is critically important that all rectal cancer cases are discussed at a multidisciplinary meeting represented by all relevant specialties. Pre-operative staging including CT thorax, abdomen, pelvis to assess for distal disease and magnetic resonance imaging to assess local involvement is essential. Staging radiology and MDT discussion are integral in identifying patients who require neoadjuvant radiotherapy. While Neoadjuvant radiotherapy is potentially beneficial it may also result in morbidity and thus should be reserved for those patients who are at a high risk of local failure, which includes patients with nodal involvement, extramural venous invasion and threatened circumferential margin. The aim of this review is to discuss the role of neoadjuvant radiotherapy in the management of rectal cancer.