A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors. Int J Surg. 2018;56:234-241. [PMID: 29936195 DOI: 10.1016/j.ijsu.2018.06.031]

Score assessment and treatment in patients presenting with low anterior resection syndrome after sphincter-sparing rectal cancer surgery

BACKGROUND

Sphincter-sparing low anterior resection (SSLAR) with neoadjuvant radio-chemotherapy has been developed to avoid abdomino-perineal amputation and permanent colostomy in patients with low rectal cancer. However, many patients develop symptoms known as low anterior resection syndrome (LARS), including fecal urgency, incontinence, and a sensation of incomplete evacuation. The Low Anterior Resection Syndrome Score (LARS Score), a validated tool developed by Emmertsen and Laurberg, is used to assess symptom severity and guide treatment.

MATERIALS AND METHODS

We present a single-center cohort study including patients having undergone SSLAR for rectal cancer between 2014 and 2021 at Fribourg Cantonal Hospital. Initial LARS-scores were obtained by completion of the QoL questionnaire. Patients with minor LARS (scores 21-29) were treated with electrostimulation and bio-feedback physiotherapy. Those with major LARS (scores > 29) were first investigated by anal manometry followed by physiotherapy. All treatments took place in 2022/2023. After treatment, LARS-scores were calculated again.

RESULTS

Of 54 patients included in the study, 18.5% had minor LARS, 40.8% major LARS, and 40.8% had no LARS. Of all patients with LARS, 18 (56%) completed pelvic physiotherapy, whereas 14 (44%) refused the treatment. Before and after pelvic physiotherapy, the median LARS score was 32 [interquartile range 29.50-38.50] and 22.5 [18.5-28], respectively (p < 0.001 according to Wilcoxon signed-rank test). Analysis of risk factors did not reveal any significant difference in age, gender, diabetes, nicotine or alcohol use, previous abdominal surgery, tumor stage, chemo/radiotherapy, type of operation and anastomosis, or anastomotic leakage.

CONCLUSIONS

Approximately half of patients undergoing SSLAR experience LARS, and approximately one-third develop the major form. LARS scores may significantly improve with specific physiotherapeutic measures that have therefore been introduced as a standard procedure for all SSLAR patients at our institution.

Quality of life outcomes in colorectal cancer survivors: insights from an observational study at a tertiary cancer center

PURPOSE

Colorectal cancer (CRC) significantly impacts the quality of life (QoL) of survivors, yet detailed assessments of long-term QoL are sparse. This study evaluates QoL among CRC survivors, examining the influence of different treatments and patient characteristics on outcomes.

METHODS

We conducted a cross-sectional study at a tertiary cancer center in Portugal, enrolling CRC patients who underwent curative surgery from 2013 to 2022. QoL was assessed using the EORTC QLQ-C30 and QLQ-CR29 at 1-, 3-, 5-, and 10-year follow-up intervals. Subgroup analyses were performed based on tumor location, radiotherapy administration, chemotherapy administration, presence of a stoma, and time since treatment, with sociodemographic and clinical factors examined on univariate and multivariate analysis.

RESULTS

Of the 825 eligible patients, 324 were invited and 179 participated (response rate: 55.2%). Overall, patients reported high global QoL and functional scores with low symptom scores, comparable to those of the general population. However, rectal cancer survivors experienced poorer outcomes in role and social functioning, body image, and symptom management. Those receiving radiotherapy or chemotherapy reported more symptoms, with chemotherapy recipients showing lower functional scores. Patients with a stoma had significantly lower QoL across functional and symptom scales. Long-term survivors reported decreased physical functioning. Multivariate analysis identified female gender, open surgery, and chemotherapy as factors associated with reduced QoL.

CONCLUSION

This study highlights significant disparities in QoL outcomes between CRC survivors, with QoL influenced by gender, cancer location, radiotherapy or chemotherapy, stoma presence, and survivorship duration, underscoring the need for personalized support programs and tailored care plans.

Patterns of care and surgical outcomes for early-stage rectal cancer in the United States

BACKGROUND

Although limited trials have demonstrated the feasibility of rectal-preserving approaches in clinical T1-3N0 adenocarcinoma, local excision after neoadjuvant therapy has been associated with high rates of morbidity. We hypothesized that this strategy would be comparable to the standard, total mesorectal excision. The aim of this study was to describe trends of early-stage rectal cancer management.

METHODS

cT1-3N0 rectal cancers in the National Cancer Database (2006-2018) were grouped into 5 treatments: total mesorectal excision, total neoadjuvant therapy + local excision, neoadjuvant chemoradiotherapy + local excision, total neoadjuvant therapy + total mesorectal excision, and neoadjuvant chemoradiotherapy + total mesorectal excision. Morbidity was defined as a combination of readmissions and 30- and 90-day mortality.

RESULTS

We identified 22,793 patients. Neoadjuvant chemoradiotherapy + local excision had the highest proportion of patients ≥70 years (41%) and those with comorbidities (Charlson-Deyo score ≥2, 9%). Median stay was 1 day for local excision and 5 days for total mesorectal excision. Overall composite morbidity was 9%, which, after adjustment, was not statistically different between local excision and total mesorectal excision (odds ratio = 0.45, 95% confidence interval: 0.17-1.19). Among local excision patients, 56% had pathologic complete response, 33% were pStage I, and 12% pStage II-III. In multivariable analysis, all strategies had similar overall survival compared with total mesorectal excision, except for neoadjuvant chemoradiotherapy + local excision, which was associated with worse prognosis (hazard ratio = 1.57, 95% confidence interval: 1.21-2.03).

CONCLUSION

Although infrequent, neoadjuvant chemoradiotherapy/total neoadjuvant therapy + local excision were associated with high rates of tumor downstaging, suggesting that rectal-preserving strategies are feasible. However, 1 in 8 patients had more advanced disease, which may have compromised future total mesorectal excision planes. Together with the similar morbidity and relatively worse prognosis of neoadjuvant chemoradiotherapy + local excision, these observations should prompt careful patient selection for this approach, while cautioning against its widespread use.

A systematic review of preoperative radiological factors associated with the development of low anterior resection syndrome (LARS)

The aim of this systematic review is to summarise the available evidence for radiological changes associated with postoperative low anterior resection syndrome (LARS). A literature search was undertaken for all studies focusing on preoperative radiological predictors of postoperative LARS. Articles were selected from MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases up to October 2024. Eighty-four articles were screened: eighty-one were excluded and three were included in the analysis. All included studies focused on preoperative Magnetic Resonance Imaging (MRI) already performed as part of the oncological assessments, no study examined ultrasound or defecography. Authors retrospectively selected patients that underwent LAR, screened them with the LARS score, and reviewed preoperative MRI images with specific softwares in order to find radiological characteristics associated with LARS. Results showed that particular anatomical characteristics were present in patients that subsequently developed major LARS: the volume of the pubococcygeal + iliococcygeus muscles in 27 LARS patients out of 46 LAR (odds ratio-OR 14.7, 95% CI 1.7-128.3; p = 0.02), the thickness of the anorectal joint in 136 LARS out of 255 LAR preceded by neoadjuvant chemoradiotherapy (OR 0.653, 95% CI 0.565-0.756; p = 0.001) and the mesorectal/pelvic volumes in 135 LARS out of 236 LAR (Cox Regression analysis, p = 0.0017 and p = 0.0001 respectively). Pelvic floor musculature is a factor, among the others, that contributes to LARS. Future prospective studies need to validate these retrospective results, further delineate its influence, and investigate the potential contribution of other radiologic investigations (ultrasound and defecography) in this setting.

Deloyers Technique for Restoration of Bowel Continuity Following Extended Left Hemicolectomy: A Comprehensive Analysis of 97 Cases and Literature Review

BACKGROUND

Deloyers technique addresses challenges in restoring bowel continuity after extended left hemicolectomies. Despite being first described in 1958, the technique remains underused, with limited data on long-term outcomes.

OBJECTIVE

To evaluate the indications of surgical and functional outcomes of the Deloyers technique and review existing literature.

DESIGN

Using a prospectively maintained database, patient demographics and perioperative data were collected. A telephone interview was conducted to assess bowel function, and statistical analysis identified factors affecting bowel function.

SETTINGS

Single tertiary care center.

PATIENTS

Patients who underwent the Deloyers technique from January 1995 to February 2023.

RESULTS

A total of 97 patients were included. The most common indications were colorectal cancer (50.5%) and diverticular disease (21.6%). In 53.6% of cases, Deloyers technique was performed at reoperations, and in 70.1% of cases, a diverting loop ileostomy was created. Early surgical complications occurred in 7.2% of patients, including 5 anastomotic leaks, 1 colonic conduit ischemia, and 1 small-bowel obstruction. Late complications occurred in 8.2% of cases, including 6 anastomotic strictures and 2 chronic leaks. There was no perioperative mortality. A total of 40 patients were interviewed and reported an average of 3.5 bowel movements per day and 0.5 at night; 17.5% of patients used bowel stoppers and 52.5% of patients reported that their bowel function did not impact their quality of life. Previous radiotherapy and anastomosis <8 cm from the anal verge were associated with having 4 or more bowel movements per day ( p < 0.01).

MAIN OUTCOME MEASURES

Postoperative morbidity and bowel function.

LIMITATIONS

Retrospective analysis of a heterogeneous group of patients with different pathologies and indications for surgery.

CONCLUSIONS

Deloyers technique is a safe and effective alternative for restoring bowel continuity after extended left hemicolectomy. Postoperative functional results are generally satisfactory, with more favorable outcomes noted in patients with higher anastomoses and those who have not undergone prior pelvic radiotherapy. See Video Abstract .

TCNICA DE DELOYERS PARA LA RECONSTRUCCIN DE LA CONTINUIDAD INTESTINAL TRAS HEMICOLECTOMA IZQUIERDA AMPLIADA ANLISIS EXHAUSTIVO DE CASOS Y REVISIN BIBLIOGRFICA

ANTECEDENTES:La técnica de Deloyers aborda los retos que plantea la reconstrucción de la continuidad intestinal tras hemicolectomías izquierdas ampliadas. A pesar de haber sido descrita inicialmente en 1958, la técnica sigue siendo poco utilizada, con datos limitados sobre sus resultados a largo plazo.OBJETIVO:Evaluar las indicaciones y los resultados tanto quirúrgicos como funcionales de la técnica de Deloyers y revisar la bibliografía existente.DISEÑO:Gracias a una base de datos mantenida de forma prospectiva, se recopiló información demográfica y perioperatoria de los pacientes. Se realizó una entrevista telefónica para evaluar la función intestinal y el análisis estadístico identificó los factores que afectaban a la función intestinal.ENTORNO:Un único centro de atención terciaria.PACIENTES:Aquellos sometidos a técnica de Deloyers entre enero de 1995 y febrero de 2023.RESULTADOS:Se incluyó a un total de 97 pacientes. Las indicaciones más frecuentes fueron cáncer colorrectal (50,5%) y enfermedad diverticular (21,6%). En el 53,6% de los casos se realizó DT en las reoperaciones y en el 70,1% se creó una ileostomía de protección. Se encontraron complicaciones quirúrgicas tempranas en 7,2% de los pacientes, incluidas cinco fugas anastomóticas, una isquemia segmentaria de colon y una obstrucción del intestino delgado. Se describen complicaciones tardías en 8,2% de los pacientes, entre ellas 6 estenosis anastomóticas y 2 fugas crónicas. No hubo mortalidad perioperatoria. Se entrevistó a un total de 40 pacientes, que declararon una media de 3,5 deposiciones al día y 0,5 por la noche; el 17,5% utilizó tapones intestinales y el 52,5% de los pacientes declaró que su función intestinal no repercutía en su calidad de vida. La radioterapia previa y la anastomosis a menos de ocho cm del borde anal fueron asociadas con la evacuación de cuatro o más deposiciones al día ( p < 0,01).MEDIDAS DE RESULTADOS PRINCIPALES:Morbilidad postoperatoria y función intestinal.LIMITACIONES:Análisis retrospectivo de un grupo heterogéneo de pacientes con diferentes patologías e indicaciones quirúrgicas.CONCLUSIÓN:La técnica de Deloyers es una alternativa segura y eficaz para restaurar la continuidad intestinal tras una hemicolectomía izquierda ampliada. Los resultados funcionales postoperatorios son generalmente satisfactorios, observándose resultados más favorables en pacientes con anastomosis más altas y en aquellos que no han recibido radioterapia pélvica previa. (Traducción-Dr. Xavier Delgadillo ).

Truly Inevitable-Our Perspective on the Complications After Surgery for Rectal Cancer

Rectal cancer is one of the most common malignancies in the GI tract. Although recent technology and treatments are available today, complications are still there. The focus of this study is to draw attention towards the important complications and their management options in rectal cancer surgeries. Retrospective study of 57 patients diagnosed and operated with rectal cancer between 2012 and 2022 using questionnaire data. 21.05% developed complications following surgery for rectal cancer including SSI, LARS, anastomosis leak, and stomal stenosis. LARS was seen in 26.31% out of the 19 patients involved in the study (LAR + ULAR) of which 80% had minor LARS scores and 20% had major LARS scores. In LARS, 80% had received long-term chemoradiotherapy in a neoadjuvant setting. The study revealed a rising trend of rectal cancer in young individuals (35.08%). Complications are an inevitable part of rectal cancer surgery even with recent technology. Use of long-course radiotherapy in neoadjuvant settings and LAR and ULAR may improve sphincter preservation with the risk of increasing incidence of low anterior resection syndrome, and anastomosis leak should be used cautiously with proper patient selection.

Research on preventing low anterior resection syndrome following sphincter-preserving surgery for rectal cancer through high-risk screening and pelvic floor biofeedback therapy

PURPOSE

This study aims to evaluate the effectiveness of high-risk screening combined with pelvic floor biofeedback therapy in preventing low anterior resection syndrome (LARS) after sphincter-preserving surgery (SPS) for rectal cancer.

METHODS

Forty-three patients who underwent SPS for rectal cancer at Jiangxi Cancer Hospital from January to December 2022 were assigned to the standard care group and received standard care plus pelvic floor biofeedback therapy. Forty-nine patients treated from January to December 2023 were designated as the high-risk screening group and received high-risk screening for LARS in addition to the standard care group's treatment protocol. LARS scores and incidence rates at 1, 3, and 6 months postoperatively, anorectal pressure values, quality of life scores at 3 and 9 months, and treatment adherence were compared between the two groups.

RESULTS

The high-risk screening group showed significantly lower LARS scores and incidence rates at all postoperative intervals compared to the standard care group. Additionally, the high-risk screening group demonstrated better anorectal pressure and quality of life scores and achieved higher treatment adherence, with statistically significant differences between groups (p < 0.05).

CONCLUSIONS

High-risk screening combined with targeted pelvic floor biofeedback therapy following SPS for rectal cancer can effectively prevent LARS and improve postoperative recovery quality.

Neoadjuvant Treatment With Regorafenib and Capecitabine Combined With Radiotherapy in Locally Advanced Rectal Cancer: A Multicenter Phase Ib Trial (RECAP)-SAKK 41/16

BACKGROUND

The multi tyrosine kinase inhibitor regorafenib is active in metastatic colorectal cancer. Improvement in clinical outcome by adding regorafenib to long-course chemoradiotherapy (LcCRT) was investigated in molecularly undefined LARC.

METHODS

Patients with T3-4 and/or N+ but M0 rectal cancer were included. Neoadjuvant LcRCT consisted in capecitabine (C) 825mg/m2 d1-d38 and 28 fractions of 1.8Gy (50.4Gy). Regorafenib was added d1-14 and d22-35 in 3 dose escalation (DE) cohorts (40mg/80mg/120mg). The recommended dose (RD) was used for the expansion (EXP) cohort. Primary endpoints were dose-limiting toxicity (DLT) for DE and pathological response (near-complete regression [npCR] or complete regression [pCR]) for EXP.

RESULTS

Overall, 25 patients were included. Two DLTs occurred at the regorafenib dose level of 120 mg, thereby establishing the RD at 80mg daily. Among the 19 patients who were treated at the RD, 8 (42.1%; 1-sided 80% confidence interval [CI] (lower bound): 30.7%; 95% CI, 20.3%-66.5%) reached the primary endpoint (5 [26.3%] had npCR and 3 [15.8%] pCR). One additional patient received no surgery due to clinical complete response. All patients had R0 resections and clear circumferential margins. Postoperative complications occurred in 6 patients (35.3%). The most common grade ≥ 3 treatment-related adverse event in the EXP cohort was diarrhea (2 patients).

CONCLUSION

Adding regorafenib 80 mg to LcCRT in LARC resulted in both primary endpoints being met and yielded an expected pathological response rate. Toxicity was manageable, and postoperative complications were as expected.

Colorectal surgeon practice patterns of low anterior resection syndrome after rectal cancer treatment

BACKGROUND

Limited literature exists regarding surgeon perceptions and practice patterns for low anterior resection syndrome (LARS). In this study, we sought to understand how colon and rectal surgery faculty perceive and manage LARS.

METHODS

We invited colon and rectal surgery faculty (CRS faculty) members from all programs that offer an Accreditation Council for Graduate Medical Education (ACGME)-accredited colon and rectal surgery residency (n = 378) to participate in an electronic survey. Descriptive statistical analyses and ordered logistic regression were performed.

RESULTS

The survey achieved a response rate of 30.1% (116/378). The most common number of years in practice was 11-20 (33.6%). Many surgeons always counsel their patients on the risk of LARS preoperatively (76.7%), but 42.4% never routinely screen for LARS following rectal resection. One tenth of surgeons (10.3%) do not treat LARS. The treatment most often "always" used for LARS was lifestyle modifications with drug treatment (32.7%), followed by physical therapy (18.5%). Years in practice was significantly related to frequency of using biofeedback (OR = 0.74, 95% CI 0.54-1.00; p = 0.050), transanal irrigation (OR = 1.39, 95% CI 1.00-1.92; p = 0.047) and PFPT (OR = 0.73, 95% CI 0.54-0.98; p = 0.039).

DISCUSSION

Most CRS faculty counsel patients preoperatively about the risk of LARS and employ some treatment modality. The low rate of postoperative screening for LARS could be improved and there is a wide variation in LARS treatment practice. Updated guidelines for the management of LARS that incorporate recent literature, increased screening of postoperative patients, and efforts to provide patients access to effective treatments could help clinicians and patients to manage a difficult condition.

Optimal interventions for low anterior resection syndrome: Bayesian network meta-analysis of randomized controlled trials

BACKGROUND

The optimal intervention for managing low anterior resection syndrome (LARS) remains uncertain. This Bayesian network meta-analysis was conducted to compare and rank the effectiveness of various interventions on LARS.

METHODS

Randomized controlled trials (RCTs) addressing interventions for LARS were extracted from six electronic databases until September 2023. A network meta-analysis was performed using a Bayesian random-effects and consistency model. The results were presented as mean differences (MDs) with credible interval (CrI) or standardized mean differences (SMDs) with CrI.

RESULTS

A total of 11 RCTs were included. In the short term (≤ 6 months), transanal irrigation (TAI) had significant positive impacts on overall LARS symptoms (MD (95% CrI) -14.13 (-20.11, -7.83)) and the severity of bowel incontinence (SMD (95% CrI) -1.34 (-1.97, -0.71)) compared with the control group. Pelvic floor rehabilitation (PFR) also exhibited significant improvements in bowel incontinence as compared with the control group (SMD (95% CrI) -0.56 (-0.88, -0.23)). TAI was ranked highest for reducing LARS symptoms, followed by PFR, and percutaneous tibial nerve stimulation (PTNS). In the long term (> 6 months), the results indicated that TAI was most likely to rank first, followed by PTNS, and PFR; however, no significant differences were observed.

CONCLUSIONS

In the short term, TAI was identified as the most effective treatment for managing LARS, followed by PFR. Both TAI and PTNS demonstrated promising potential in enhancing bowel function over the long term. Further trials are needed to confirm these findings.

The patient perspective on transanal irrigation treatment for low anterior resection syndrome after rectal cancer surgery - a qualitative and quantitative study

PURPOSE

The aim of the study was to explore long-term experiences of transanal irrigation (TAI) in patients with major low anterior resection syndrome (LARS).

METHODS

The study included a qualitative and quantitative analysis of patients who developed major LARS after rectal cancer surgery between 2016 and 2019 and have undergone treatment with TAI. The patients received questionnaires. Mean scores were calculated with time-to-deterioration. Individual semi-structured interviews were performed and analyzed, according to Graneheim and Lundman with patients who performed TAI regularly for more than one year.

RESULTS

In total 28 out of 39 patients responded to the questionnaires and 16 patients participated in the interviews. At mean 6-years follow-up, a 9.4 points difference in mean LARS score was obtained, (21.2 vs. 30.7) indicating less LARS symptoms in favor of the TAI treatment. Patients in the TAI group used less loperamide compared to the control group (36% vs. 79%). The use of bulky agents was similar. The interview text rendered into three main categories: regaining control in everyday life, need for structure and planning and becoming familiar with the procedure.

CONCLUSIONS

Treatment with TAI showed the potential to improve the quality of life of patients with major LARS. The improvements in their general well-being were valued over adjustments and time spent on TAI.

IMPLICATIONS FOR CANCER SURVIVORS

Bowel dysfunction remains after 6-years with lower LARS scores favoring the TAI treatment. In the absence of a definitive treatment, survivors of rectal cancer coping with LARS have shown appreciation of the TAI treatment.

Oncologic safety and technical feasibility of completion transanal total mesorectal excision after local excision; a cohort study from the International TaTME Registry

BACKGROUND

As part of an organ sparing strategy, a surgical local excision may be performed in patients with early-stage rectal cancer or following neoadjuvant (chemo)radiotherapy. In selected cases, a completion total mesorectal excision may be recommended which can be more complex because of the preceding local excision. A transanal approach to perform completion total mesorectal excision may offer an advantage through the better visualization of the surgical field in the distal rectum and less forceful retraction for exposure. However, the oncologic safety and technical feasibility of this approach have yet to be demonstrated in these patients. Therefore, the aim of this study was to evaluate the oncological and technical safety of completion transanal total mesorectal excision following a local excision in patients with rectal cancer.

METHODS

Patients from the prospective International Transanal Total Mesorectal Excision Registry who underwent a surgical local excision prior to completion transanal total mesorectal excision were retrospectively analyzed.

RESULTS

In total, 189 patients were included of which 22% received neoadjuvant radiotherapy. In 94% of the patients, a low anterior resection was performed. A primary anastomosis was constructed in 91% (n = 171/189) of the patients, with the majority also receiving a defunctioning stoma (84%, n = 144/171), of which 69% (n = 100/144) were reversed. Within 30 days, 7% developed an anastomotic leakage. The two-year local recurrence rate was 5% (n = 5/104) with an estimated rate of 3% (95% CI 0-7%). Two-year disease-free survival was 85% (n = 88/104) and overall survival was 95% (n = 99/104).

CONCLUSIONS

Transanal completion total mesorectal excision following local excision for rectal cancer is oncologically safe, with low complication rates and high restorative rates.

Preferences for treatment outcomes in rectal cancer: A discrete choice experiment among patients and healthy volunteers

AIM

Treatment for rectal cancer can leave patients with a permanent stoma or bowel dysfunction. In this work we aimed to examine preferences for treatment outcomes among people with and without rectal cancer.

METHOD

Our discrete choice experiment examined the effect of risk of cancer recurrence, presence of a stoma and bowel dysfunction on treatment preferences in 372 rectal cancer patients without a stoma, 269 with a stoma and 204 people without cancer.

RESULTS

Predictors of treatment preferences differed significantly between all groups (p < 0.0001). Avoiding a stoma was more important to stoma-naïve groups, while avoiding bowel dysfunction was more important to those with superior function. Reducing the risk of recurrence was valued highly, and equally, across the groups.

CONCLUSION

Experience of a stoma or bowel dysfunction resulted in higher tolerance of those treatment outcomes. Hearing from patients living with different treatment outcomes could help prepare newly diagnosed patients, and facilitate informed decision-making where patients have a choice.

"So, what are you saying?": A qualitative study of surgeon-patient communication in the rectal cancer consultations

INTRODUCTION

Patients with rectal cancer face a potentially life-limiting disease with multi-modal treatment options conferring substantial symptom burdens. Treatment decisions frequently require trade-offs and input from a multidisciplinary team: ideal cases for shared decision-making. Using qualitative analysis, we characterized the content of communication between surgeons and patients who have rectal cancer.

METHODS

We performed secondary analysis of audio-recorded clinic visits of patients with rectal cancer (n ​= ​18) with colorectal surgeons (n ​= ​8) at 5 academic centers. Four coders used inductive content analysis with an analytical emphasis on communication about decision-making.

RESULTS

Surgeons focused on communicating technical details of potential treatment pathways. Patients sought information around prognosis, functional changes, long-term recovery, and next steps. Surgeons laid groundwork for shared decision-making; patient goals were not routinely clarified. Decisions were typically deferred due to uncertainty and missing information needed to determine appropriate treatment options.

CONCLUSIONS

Our findings suggest avenues for surgeons to enhance communication around rectal cancer decision-making: acknowledging uncertainty and providing concrete information when able, focusing on topics such as prognosis, tradeoffs, and long-term recovery, and clarifying patient preferences.

High output stoma after surgery for rectal cancer - a risk factor for low anterior resection syndrome?

PURPOSE

The relationship between high-output stoma (HOS) and low anterior resection syndrome (LARS) was previously unclear. This study investigated the association between HOS and major LARS in rectal cancer patients with preventive stoma.

METHODS

We conducted a retrospective analysis of 653 rectal cancer patients who underwent prophylactic ileostomy reversal after low anterior resection at the Fourth Hospital of Hebei Medical University between 2018 and 2021. Patients were categorized into HOS and non-HOS groups based on stoma output within 3 months before surgery. Major LARS was assessed using the LARS score. The association between HOS and major LARS was analyzed using multifactor logistic regression models, subgroup analyses, and smoothing curve fitting methods.

RESULTS

Among the 653 patients, 53 (8.1%) experienced HOS, and 81 (12.4%) developed major LARS after stoma closure. The HOS group exhibited a significantly higher risk of major LARS compared to the non-HOS group (P < 0.001). Multivariate logistic regression indicated that HOS was associated with a 210% increased risk of major LARS (OR: 3.10; 95% CI: 1.56, 6.14; P = 0.001). Subgroup analysis revealed that this association was more pronounced in older patients (age > 60), those without hypertension, with N0-N1 staging, a history of chemotherapy, and longer stoma closure intervals (Q3, Q4).

CONCLUSION

HOS is significantly associated with major LARS in rectal cancer patients, particularly in certain clinical subgroups. These findings suggest the need for careful management of HOS to potentially reduce LARS occurrence after stoma closure.

The Diagnosis and Evolution of Patients with LARS Syndrome: A Five-Year Retrospective Study from a Single Surgery Unit

OBJECTIVES

The aim of the study was to assess the diagnosis and evolution of low anterior rectal resection syndrome (LARS) in patients admitted to a tertiary surgical center in Romania.

MATERIALS AND METHODS

From 120 patients initially included in the analysis, after applying the exclusion criteria, we selected 102 patients diagnosed and operated on for neoplasm of the upper, middle, and lower rectum for which resection and excision (partial or total) of mesorectum was associated. All the patients we treated in the general surgery department of the County Emergency Hospital of Craiova within a time frame of 5 years (1 October 2017-1 September 2022), and all experienced at least one symptom associated with LARS. The group included 68 men and 34 women aged between 35 and 88, who were followed-up for at least 2 years. Patients with progression of neoplastic disease, with advanced neurological disease, and those who died less than 2 years after surgery were excluded.

RESULTS

The overall incidence varied by gender, site of the tumor (requiring a certain type of surgery), and anastomotic complications, and it was directly proportional to the time interval between resection and restoration of continuity of digestion.

CONCLUSIONS

Obesity, size of the remaining rectum, total excision of the mesorectum, anastomotic complications, and prolonged ileostomy time are cofactors in the etiology of LARS. The LARS score decreased in most patients during the 2-year follow-up, although there were a small number of patients in whom the decrease was insignificant. The persistence of major LARS at 6 months after surgery may predict the need for a definitive colostomy.

Prediction model construction for the occurrence of LARS after neoadjuvant therapy combined with laparoscopic total mesorectal excision in male patients with mid-low rectal cancer

BACKGROUND

Neoadjuvant chemoradiotherapy for rectal cancer improves surgical outcomes and reduces recurrence but can cause low anterior resection syndrome (LARS), affecting quality of life. This study aims to predict the risk of LARS in male patients with mid-low rectal cancer after laparoscopic total mesorectal excision (TME).

METHODS

Clinical data from 203 male patients with mid-low rectal cancer who underwent neoadjuvant therapy and laparoscopic resection were collected. Patients were divided into training (n=143) and validation (n=60) cohorts. LARS risk factors were identified using logistic regression, and a predictive model was constructed and validated using ROC curve, Hosmer-Lemeshow test, calibration curve, and decision curve analysis (DCA).

RESULTS

LARS occurred in 53.6% of the patients in this study. Multivariate logistic regression analysis revealed that BMI ≥ 25 kg/m², tumor distance from the anal margin < 5 cm, radiotherapy, and anastomotic leakage were independent risk factors for postoperative LARS in patients (P < 0.05). The areas under the ROC curves for the training cohort and validation cohort were 0.866 (95% CI: 0.807-0.925) and 0.724 (95% CI: 0.595-0.853), respectively, with both groups showing good goodness-of-fit test results (P > 0.05). The DCA curve indicated that the model had a high clinical utility.

CONCLUSIONS

BMI ≥ 25 kg/m², tumor distance from the anal margin < 5 cm, radiotherapy, and anastomotic leakage are independent risk factors for the occurrence of LARS after neoadjuvant therapy combined with laparoscopic TME in male patients with mid-low rectal cancer. These factors should be emphasized in clinical practice, and corresponding preventive measures should be promptly implemented.

Enhancing support for patients with low anterior resection syndrome: insights and educational resources from the LARSCAT project

PURPOSE

To address the educational gaps and support needs of patients with low anterior resection syndrome (LARS) following rectal cancer surgery. The LARSCAT project aimed to develop comprehensive resources to better inform patients and enhance their quality of life.

METHODS

A qualitative study was conducted between November 2022 and March 2023. Seven focus groups were formed, including six patients, two surgeons, and three nurses. Patients had undergone rectal cancer surgery with stoma reversal 2 to 12 years earlier, and all experienced major LARS. The focus groups, held in-person and online, explored the impact on daily life, social and sexual health, mood, rest, and relationships. Thematic analysis was performed to identify key issues and support strategies following the COREQ guidelines.

RESULTS

Participants reported insufficient information regarding potential dysfunctions after rectal cancer surgery, and difficulties finding reliable information online. The timing of receiving information varied according to individual coping mechanisms. LARS symptoms significantly impacted daily life, social activities, sexual health, and mood. Patients emphasised the need for more tailored information and supplementary written materials to read at their own pace. Consequently, three comprehensive documents were created and made available online.

CONCLUSION

This study highlights a significant gap in patient education on the long-term effects of rectal cancer surgery. The resources developed by the LARSCAT project aim to provide essential support to patients and healthcare professionals. Future research should focus on integrating these resources into routine care and evaluating their impact on patient outcomes and quality of life.

Risk factors of the low anterior resection syndrome (LARS) after ileostomy reversal in rectal cancer patient

This study is aimed at identifying risk factors of Low Anterior Resection Syndrome following ileostomy reversal in rectal cancer patients who had undergone preventive ileostomy. This retrospective analysis was conducted on a cohort of 605 patients treated at the Fourth Hospital of Hebei Medical University between January 2018 and December 2021. These patients were grouped based on LARS score, and Clinical and follow-up data were collected to conduct univariate analyses of potential factors influencing LARS occurrence based on variable type. Variables with statistical significance were included in a logistic regression model to analyze potential influences on the occurrence of LARS. Univariate and Multivariate logistic regression analysis showed that N2 stage (OR = 2.290 95%CI: 1.076-4.873, P = 0.031), chemoradiotherapy (OR = 2.271, 95%CI: 1.246-4.138, P = 0.007), and anastomosis height (OR = 0.836, 95%CI: 0.717-0.975, P = 0.022) were independent influences on the occurrence of LARS. In model 3 (adjusting for all covariates), the relationship between anastomotic height and patient LARS status showed a negative correlation. In subgroup analyses, there were significant differences in the effect of anastomotic height on LARS in subgroups with different hemoglobin concentrations. A high occurrence rate of LARS is observed in rectal cancer patients with preventive ileostomy reversal. N2 stage, history of chemoradiotherapy, and anastomotic height are independent influence factors for the occurrence of major LARS after ileostomy reversal.

Executive Summary of the American Radium Society on Appropriate Use Criteria for Nonoperative Management of Rectal Adenocarcinoma: Systematic Review and Guidelines

For patients with rectal cancer, the standard approach of chemotherapy, radiation therapy, and surgery (trimodality therapy) is associated with significant long-term toxicity and/or colostomy for most patients. Patient options focused on quality of life (QOL) have dramatically improved, but there remains limited guidance regarding comparative effectiveness. This systematic review and associated guidelines evaluate how various treatment strategies compare to each other in terms of oncologic outcomes and QOL. Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology were used to search for prospective and retrospective trials and meta-analyses of adequate quality within the Ovid Medline database between January 1, 2012, and June 15, 2023. These studies informed the expert panel, which rated the appropriateness of various treatments in 6 clinical scenarios through a well-established consensus methodology (modified Delphi). The search process yielded 197 articles that advised voting. Increasing data have shown that nonoperative management (NOM) and primary surgery result in QOL benefits noted over trimodality therapy without detriment to oncologic outcomes. For patients with rectal cancer for whom total mesorectal excision would result in permanent colostomy or inadequate bowel continence, NOM was strongly recommended as usually appropriate. Restaging with tumor response assessment approximately 8 to 12 weeks after completion of radiation therapy/chemoradiation therapy was deemed a necessary component of NOM. The panel recommended active surveillance in the setting of a near-complete or complete response. In the setting of NOM, 54 to 56 Gy in 27 to 31 fractions concurrent with chemotherapy and followed by consolidation chemotherapy was recommended. The panel strongly recommends primary surgery as usually appropriate for a T3N0 high rectal tumor for which low anterior resection and adequate bowel function is possible, with adjuvant chemotherapy considered if N+. Recent data support NOM and primary surgery as important options that should be offered to eligible patients. Considering the complexity of multidisciplinary management, patients should be discussed in a multidisciplinary setting, and therapy should be tailored to individual patient goals/values.

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.

By Any Other Name: Bowel Dysfunction After Proctectomy for Cancer and Its Predictive Factors in Administrative Databases

INTRODUCTION

Diagnosis, outcomes, and costs of care associated with bowel dysfunction after proctectomy for cancer remain underexplored in population-based studies. The lack of administrative coding for bowel dysfunction or low anterior resection syndrome has historically limited secondary data set outcomes analysis. The purpose of this study was to identify a bowel dysfunction phenotype in administrative claims data and characterize its prevalence, predictive factors, and costs.

MATERIALS AND METHODS

Patients were identified with employer-sponsored commercial insurance (MarketScan research databases) undergoing proctectomy for cancer for a retrospective cohort study. Bowel dysfunction was defined as any patient with diagnostic codes for diarrhea, constipation, incontinence, pelvic floor diagnostic testing, or rehabilitative procedures that occurred in the 18 mo to follow surgery. We performed Poisson regression to identify statistically significant covariates of bowel dysfunction occurrence following low anterior resection. A secondary comparative analysis was also performed of total costs of healthcare utilization following gastrointestinal continuity.

RESULTS

6426 proctectomy patients were identified, out of which 2131 had surgery for cancer. 847 patients undergoing proctectomy for cancer (39.7%) experienced bowel dysfunction during 18 mo of follow-up. The most common diagnoses were constipation (53.5%) and diarrhea (40.3%). Diagnostic procedures and rehabilitative procedures were performed in only 29.8% of those with symptoms. Neoadjuvant chemotherapy administration with radiation (incidence rate ratio = 1.23, 95% CI: 1.01-1.51) and without (incidence rate ratio = 1.20, 95% CI: 1.01-1.42) remained associated with postoperative bowel dysfunction when controlling for other factors. Chemoradiation therapy alone was not associated with bowel dysfunction. The median total follow-up costs with bowel dysfunction were $30,769 greater (P < 0.001).

CONCLUSIONS

More than one-third of patients have symptomatic bowel dysfunction within 18 mo after restored continuity, with multiagent chemotherapy being the strongest independent predictor. Bowel dysfunction is associated with more than twice healthcare costs postop.

Association Between Chemotherapy-Induced Peripheral Neuropathy and Low Anterior Resection Syndrome

INTRODUCTION

Low anterior resection syndrome (LARS) can be a debilitating condition that develops after undergoing sphincter-preserving surgery for rectal cancer. Chemotherapy-induced peripheral neuropathy is a common side effect of platinum-based chemotherapy agents used as systemic therapy for rectal cancer treatment. The purpose of this study was to determine the potential relationship between CIPN and LARS.

METHODS

This was a retrospective review of patients who underwent a low anterior resection for rectal cancer and received systemic therapy contacted at least six months from the most recent surgery. Eligible patients were called and completed the relevant surveys over the phone or email.

RESULTS

There was a total of 42 patients who completed the surveys with 33 (79%) having major LARS. Presence of a diverting ileostomy was the only significantly differentcharacteristic in those with major LARS versus those without. CIPN was independently associated with LARS (p = 0.046) on linear regression when controlling for neoadjuvant chemoradiation, diverting ileostomy and tumor distance from the anal verge.

CONCLUSIONS

Developing severe CIPN is associated with developing LARS. Further studies evaluating the etiology behind this relationship should be conducted.

Analysis of the correlation between defunctioning stoma and postoperative low anterior resection syndrome in rectal cancer: a prospective cohort study

BACKGROUND

To evaluate the effect of stoma-related factors (stoma or no stoma, stoma type, and stoma reversal time) on the occurrence of low anterior resection syndrome (LARS), a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life, which includes fecal incontinence, fecal urgency and frequent defecation.

METHODS

Patients who underwent radical rectal cancer surgery from July 2018 to July 2022 in a tertiary hospital were included. Baseline data, tumor condition, operation condition and postoperative recovery were obtained by clinical observation. Follow-up data were collected by telephone follow-up. The chi-square and Fisher exact tests were used to analyse differences, coefficient of contingency was used to determine correlations, and independent risk factors for the occurrence of LARS (Patients with a score of 21 or more points were defined as having LARS using the LARS score) were further determined by binary logistic regression.

RESULTS

A total of 480 patients met the inclusion criteria, of which 267 used a defunctioning stoma and 213 did not use a defunctioning stoma. There was a positive correlation between defunctioning stoma (P < 0.001, P < 0.001, P < 0.05) and the occurrence of LARS at 3, 6, and 12 months postoperatively, and there was no significant correlation between the stoma type or stoma reversal time and the occurrence of LARS at 3, 6 and 12 months postoperatively (P > 0.05). In binary logistic regression analysis, high BMI (Exp(B) = 1.072, P = 0.039), tumor closer to dentate line (Exp(B) = 0.910, P = 0.016), and ultra-low anterior resection (Exp(B) = 2.264, P = 0.011) increased the possibility of LARS at 3 months postoperatively; high BMI, proximity of the tumor to the dentate line, and ultra-low anterior resection were not independent risk factors for LARS at 6 months postoperatively (P > 0.05). However, proximity of the tumor to the dentate line (Exp(B) = 0.880, P = 0.035) increased the likelihood of LARS at 12 months postoperatively, while high BMI and ultra-low anterior resection remained non-significant as independent risk factors for LARS at 12 months postoperatively (P > 0.05).

CONCLUSIONS

Defunctioning stoma was not an independent risk factor for the occurrence of LARS, whereas high BMI, tumor closer to dentate line, and ultra-low anterior resection were independent risk factors for the occurrence of LARS.

TRIAL REGISTRATION

Not applicable.

Application of pelvic floor rehabilitation in patients with colorectal cancer: a scoping review

BACKGROUND

Pelvic floor rehabilitation is common in patients with colorectal cancer, the purpose of this study is to analyze the role of pelvic floor rehabilitation in patients with colorectal cancer and to understand the specific details of pelvic floor rehabilitation intervention in patients with colorectal cancer.

METHODS

Six databases were searched for this scoping review and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews.

RESULTS

A total of 1014 studies were searched, and 12 studies were finally included for analysis. The study found that pelvic floor rehabilitation for colorectal cancer patients can help improve bowel symptoms, quality of life, and psychological status of colorectal cancer patients after surgery, but details of the interventions for pelvic floor rehabilitation for colorectal cancer patients are not standardized.

CONCLUSIONS

Pelvic floor rehabilitation has shown positive significance in patients with colorectal cancer, but there is a lack of uniform standards in the process of pelvic floor rehabilitation intervention in patients with colorectal cancer.

A Systematic Review of Comparative Effectiveness of Interventions for Low Anterior Resection Syndrome: Impacts on Bowel Function and Quality of Life

Low anterior resection syndrome (LARS) is a common complication following sphincter-preserving surgical resection for rectal cancer, characterized by symptoms such as fecal incontinence, urgency, and altered bowel habits, which significantly affect patients' quality of life. This cluster of symptoms not only limits their day-to-day physical activity but also has a debilitating effect on their emotional and mental well-being, undermining their integration and overall psychological health. This systematic review aimed to evaluate the effectiveness of invasive and non-invasive interventions for LARS, including pelvic floor rehabilitation, transanal irrigation, and various surgical options such as sacral neuromodulation and stoma formation, either as part of primary surgery or as a definitive treatment option for refractory cases. We systematically searched relevant databases for studies published in the last decade, focusing on adult patients diagnosed with LARS post-low anterior resection (LAR), with outcomes assessed through bowel function and quality of life metrics. The review identified six studies that met our eligibility criteria; a pooled cohort of 794 patients was identified, with sample sizes ranging from 37 to 430 participants. Our analysis revealed that pelvic floor rehabilitation significantly improves bowel function and quality of life in patients with LARS; yet, the optimal management approach remains unclear due to variability in patient responses. These findings highlight the inherent complexity and heterogeneity of LARS management, underscoring the necessity for multifaceted and individualized treatment strategies. Although pelvic floor rehabilitation shows promise, especially among motivated patients, its long-term sustainability remains uncertain. Surgical options are typically reserved for severe cases and carry significant risks and psychological impacts. For patients identified as being at high risk for LARS, treatment options must be considered and discussed at an earlier phase of their care. Our review concludes with the need for a tailored, patient-centered approach to managing LARS, highlighting the importance of ongoing research to fill existing evidence gaps. There is a need for translational research across various treatment modalities, comparing their effects, cost-effectiveness, implementation strategies, and the consequent effects on patients' quality of life and mental health.

Decision-making preferences and regret in rectal cancer patients undergoing restorative proctectomy: A prospective cohort study

BACKGROUND

How patients make treatment choices in rectal cancer is poorly understood and may affect long-term regret and satisfaction. The objective of this study is to characterize decision-making preferences and their effect on decisional regret in patients undergoing restorative proctectomy for rectal cancer.

METHODS

A prospective cohort study was conducted in a single academic specialist rectal cancer center from October 2018 to June 2022. Adult patients who underwent restorative proctectomy at least one year prior were recruited. Health literacy was assessed using the BRIEF instrument. Decision-making preferences regarding cancer treatment were assessed using the Control Preferences Scale. Decisional regret regarding their choice of restorative proctectomy was assessed using the Decision Regret Score. Bowel dysfunction was measured using the low anterior resection syndrome score.

RESULTS

Overall, 123 patients were included. Health literacy was categorized as adequate in 63%, marginal in 25%, and limited in 12%. Patients with adequate health literacy were more likely to prefer a collaborative decision-making role compared with those with low health literacy (86% vs 65%, P = .016). Patients with incongruence between preferred and actual decision-making roles were more likely to report high regret (56% vs 25%, P = .003). Patients with major low anterior resection syndrome were also more likely to experience high regret compared with patients with no/minor low anterior resection syndrome (44% vs 25%, P = .036).

CONCLUSION

A significant proportion of patients with rectal cancer undergoing restorative proctectomy do not have a decision-making role that is congruent with their preferences, and these patients experience a high degree of regret.

Neoadjuvant Treatment in Rectal Cancer

A major advance in rectal cancer was the evidence supporting short-course radiotherapy and long-course chemoradiotherapy. Both have been shown to improve local outcomes. Total neoadjuvant therapy (TNT) is the new kid on the block that provides further benefit of improving local responses as well as reducing systemic relapses, thus increasing overall survival. Details of the four key TNT trials are discussed. They pave the way for nonoperative management for patients who achieve clinical complete responses.

TAilored SToma policY after TME for rectal cancer: The TASTY approach

AIM

Diverting stomas are routinely used in restorative surgery following total mesorectal exicision (TME) for rectal cancer to mitigate the clinical risks of anastomotic leakage (AL). However, routine diverting stomas are associated with their own complication profile and may not be required in all patients. A tailored approach based on personalized risk of AL and selective use of diverting stoma may be more appropriate. The aim of the TAilored SToma policY (TASTY) project was to design and pilot a standardized, tailored approach to diverting stoma in low rectal cancer.

METHOD

A mixed-methods approach was employed. Phase I externally validated the anastomotic failure observed risk score (AFORS). We compared the observed rate of AL in our cohort to the theoretical, predicted risk of the AFORS score. To identify the subset of patients who would benefit from early closure of the diverting stoma using C-reactive protein (CRP) we calculated the Youden index. Phase II designed the TASTY approach based on the results of Phase I. This was evaluated within a second prospective cohort study in patients undergoing TME for rectal cancer between April 2018 and April 2020.

RESULTS

A total of 80 patients undergoing TME surgery for rectal cancer between 2016 and 2018 participated in the external validation of the AFORS score. The overall observed AL rate in this cohort of patients was 17.5% (n = 14). There was a positive correlation between the predicted and observed rates of AL using the AFORS score. Using ROC curves, we calculated a CRP cutoff value of 115 mg/L on postoperative day 2 for AL with a sensitivity of 86% and a negative predictive value of 96%. The TASTY approach was designed to allocate patients with a low risk AFORS score to primary anastomosis with no diverting stoma and high risk AFORS score patients to a diverting stoma, with early closure at 8-14 days, if CRP values and postoperative CT were satisfactory. The TASTY approach was piloted in 122 patients, 48 (39%) were identified as low risk (AFORS score 0-1) and 74 (61%) were considered as high risk (AFORS score 2-6). The AL rate was 10% in the low-risk cohort of patient compared to 23% in the high-risk cohort of patients, p = 0.078 The grade of Clavien-Dindo morbidity was equivalent. The incidence of major LARS was lowest in the no stoma cohort at 3 months (p = 0.014).

CONCLUSION

This study demonstrates the feasibility and safety of employing a selective approach to diverting stoma in patients with a low anastomosis following TME surgery for rectal cancer.

Functional outcomes following anterior resection for colorectal cancer: a needs assessment and proposal of a nurse-led remote management algorithm

AIM

With the rise of structured, remote follow-up of colorectal cancers, there is the potential risk of underdiagnosing and undermanaging low anterior resection syndrome (LARS). This cohort study aims to determine the rate of LARS and its patterns of care, with the aim of generating a risk-stratified management algorithm that can be employed for nurse-led follow-up.

METHOD

Patients who underwent elective anterior resection for the management of colorectal cancer between 1 January 2017 and 31 December 2021 were sent quality-of-life questionnaires (EORTC-QLQ-CR29 and LARS score) and surveyed for LARS symptoms and management utilized.

RESULTS

Out of 70 patients who completed questionnaires, 71.4% had LARS and 42.9% had major LARS. The international Delphi consensus definition identified more patients (n = 50) with LARS than the LARS score (n = 41). Tumours located <8 cm from the anal verge, ULAR, and temporary stoma were predictive of major LARS on univariate analysis. However, only temporary stoma was predictive for LARS (OR 7.89 (1.15-53.95), P = 0.035) and majors LARS (8.14 (1.79-37.01), P = 0.007) on multivariate analysis. Forty-four percent of patients with LARS did not have input from any health professional for this condition. Consultation with specialist allied health and/or colorectal surgeons ranged from 4% to 22%.

CONCLUSIONS

Our study highlights that with the current remote follow-up system focused on cancer outcomes a significant proportion of patients with LARS are overlooked, resulting in the underutilization of relevant health professionals and management options. We propose a nurse-led management algorithm to address this issue while still minimizing surgical outpatient load.

Long-Term Functional Outcome After Early vs. Late Stoma Closure in Rectal Cancer Surgery: Sub-analysis of the Multicenter FORCE Trial

PURPOSE

The aim of this study was to assess the effect of early stoma closure on bowel function after low anterior resection (LAR) for rectal cancer.

METHODS

Patients participating in the FORCE trial who underwent LAR with protective stoma were included in this study. Patients were subdivided into an early closure group (< 3 months) and late closure group (> 3 months). Endpoints of this study were the Wexner Incontinence, low anterior resection syndrome (LARS), EORTC QLQ-CR29, and fecal incontinence quality of life (FIQL) scores at 1 year.

RESULTS

Between 2017 and 2020, 38 patients had received a diverting stoma after LAR for rectal cancer and could be included. There was no significant difference in LARS (31 vs. 30, p = 0.63) and Wexner score (6.2 vs. 5.8, p = 0.77) between the early and late closure groups. Time to stoma closure in days was not a predictor for LARS (R2 = 0.001, F (1,36) = 0.049, p = 0.83) or Wexner score (R2 = 0.008, F (1,36) = 0.287, p = 0.60) after restored continuity. There was no significant difference between any of the FIQL domains of lifestyle, coping, depression, and embarrassment. In the EORTC QLQ-29, body image scored higher in the late closure group (21.3 vs. 1.6, p = 0.004).

CONCLUSION

Timing of stoma closure does not appear to affect long-term bowel function and quality of life, except for body image. To improve functional outcome, attention should be focused on other contributing factors.

Does one-stitch method of temporary ileostomy affect the stoma-related complications after laparoscopic low anterior resection in rectal cancer patients?

PURPOSE

This current study attempted to investigate whether one-stitch method (OM) of temporary ileostomy influenced the stoma-related complications after laparoscopic low anterior resection (LLAR).

METHODS

We searched for eligible studies in four databases including PubMed, Embase, Cochrane Library, and CNKI from inception to July 20, 2023. Both surgical outcomes and stoma-related complications were compared between the OM group and the traditional method (TM) group. The Newcastle-Ottawa Scale (NOS) was adopted for quality assessment. RevMan 5.4 was conducted for data analyzing.

RESULTS

Totally 590 patients from six studies were enrolled in this study (272 patients in the OM group and 318 patients in the TM group). No significant difference was found in baseline information (P > 0.05). Patients in the OM group had shorter operative time in both the primary LLAR surgery (MD = - 17.73, 95%CI = - 25.65 to - 9.80, P < 0.01) and the stoma reversal surgery (MD = - 18.70, 95%CI = - 22.48 to -14.92, P < 0.01) than patients in the TM group. There was no significant difference in intraoperative blood loss of the primary LLAR surgery (MD = - 2.92, 95%CI = - 7.15 to 1.32, P = 0.18). Moreover, patients in the OM group had fewer stoma-related complications than patients in the TM group (OR = 0.55, 95%CI = 0.38 to 0.79, P < 0.01).

CONCLUSION

The OM group had shorter operation time in both the primary LLAR surgery and the stoma reversal surgery than the TM group. Moreover, the OM group had less stoma-related complications.

Incidence of low anterior resection syndrome and its association with the quality of life in patients with lower rectal tumors

PURPOSE

Low anterior resection syndrome (LARS) causes devastating symptoms and impairs the quality of life (QOL). This study investigated the incidence and risk factors of LARS and their association with the QOL in patients with lower rectal tumors.

METHODS

Patients who underwent anus-preserving surgery for lower rectal tumors between 2014 and 2019 and who had anal defecation between 2020 and 2021 were surveyed. The LARS score measured severity, and the QOL was evaluated using the Japanese version of the Fecal Incontinence Quality-of-Life Scale (JFIQL). The primary endpoint was the incidence of Major LARS, and the secondary endpoints were risk factors and association with the JFIQL.

RESULTS

Of 107 eligible patients, 82 (76.6%) completed the LARS survey. The incidence of Major LARS was 48%. Independent risk factors included neoadjuvant chemoradiotherapy (CRT) and a short interval (< 24 months after surgery; odds ratio, 4.6; 95% confidence interval: 1.1-19, both). The LARS score was moderately correlated with the JFIQL generic score (correlation coefficient: - 0.54). The JFIQL scores were significantly worse in the Minor and Major LARS groups than in the No LARS group.

CONCLUSIONS

Major LARS was found in 48% of lower rectal tumors, and independent risk factors include neoadjuvant CRT and a short interval. The QOL was significantly impaired in patients with both Minor and Major LARS.

Nonoperative management and local excision after neoadjuvant chemoradiation therapy for rectal cancer

Locally advanced extraperitoneal rectal cancer represents a significant clinical challenge, and currently, the standard treatment is based on neoadjuvant chemoradiation therapy (CRT) followed by radical surgical resection with total mesorectal excision (TME). In the last 30 years, its management has undergone significant changes due to the improvement of complementary radio- and chemotherapy treatments, the improvement of minimally invasive surgical approaches and the diffusion of organ-sparing approaches, such as nonoperative management, commonly called "watch and wait" (NOM) and local excision (LE), in highly selected patients who achieve a major or complete response to neoadjuvant CRT. This review aimed to critically examine the efficacy and oncological safety of NOM and LE compared to those of standard TME in rectal cancer patients after neoadjuvant CRT. Both the pros and cons of these approaches were strictly analyzed, providing a comprehensive and critical overview of these novel management strategies for rectal cancer.

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.

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.

Comparison of a robotic surgery program for rectal cancer: short- and long-term results from a comparative, retrospective study between two laparoscopic and robotic reference centers

BACKGROUND

It is assumed that robotic-assisted surgery (RAS) may facilitate complex pelvic dissection for rectal cancer compared to the laparoscopic-assisted resection (LAR). The aim of this study was to compare perioperative morbidity, short- and long-term oncologic, and functional outcomes between the RAS and LAR approaches.

METHODS

Between 2015 and 2021, all rectal cancers operated on by (LAR) or (RAS) were retrospectively reviewed in two colorectal surgery centers.

RESULTS

A total of 197 patients were included in the study, with 70% in the LAR group and 30% in the RAS group. The tumor location and stage were identical in both groups (not significant = NS). The overall postoperative mortality rate was not significantly different between the two groups. (0% LAR; 0.5% RAS; NS). The postoperative morbidity was similar between the two groups (60% LAR vs 57% RAS; NS). The number of early surgical re-interventions within the first 30 days was similar (10% for the LAR group and 3% for the RAS group; NS). The rate of complete TME was similar (88% for the LAR group and 94% for the RAS group; NS). However, the rate of circumferential R1 was significantly higher in the LAR group (13%) compared to the RAS group (2%) (p = 0.009). The 3-year recurrence rate did not differ between the two groups (77% for both groups; NS). After a mean follow-up of three years, the incidence of anterior resection syndrome was significantly lower in the LAR group compared to the RAS group (54 vs 76%; p = 0.030).

CONCLUSIONS

The use of a RAS was found to be reliable for oncologic outcomes and morbidity. However, the expected benefits for functional outcomes were not observed. Therefore, the added value of RAS for rectal cancer needs to be reassessed in light of new laparoscopic technologies and patient management options.

Point/Counterpoint #2: Current Clinical Considerations With Nonoperative Management of Rectal Cancer

ABSTRACT

Locally advanced rectal cancer has historically been treated with multimodal therapy consisting of radiation therapy, chemotherapy, and total mesorectal excision. However, recent prospective trials and registry studies have demonstrated similar disease outcomes with nonoperative management for patients who experience an excellent clinical response to radiation and chemotherapy. This article reviews data regarding nonoperative management for rectal cancer, and highlights current challenges and limitations in a point-counterpoint format, in the context of two clinical cases.

Low Anterior Resection Syndrome following Restorative Proctectomy for Rectal Cancer: Can the Surgeon Have Any Meaningful Impact?

Postoperative bowel dysfunction following restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long term sequela of rectal cancer treatment. While many of the established risk factors for LARS are non-modifiable, others may be well within the surgeon's control. Several pre-, intra-, and postoperative decisions may have a significant impact on postoperative bowel function. Some of these factors include the extent of surgical resection, surgical approach, choice of anastomotic reconstruction, and use of fecal diversion. This review article summarizes the available evidence regarding how surgical decision-making can affect postoperative bowel function.

Low anterior resection syndrome phenotypes-Different symptom profiles for different patients

AIM

Attention is increasingly being turned to functional outcomes as being central to colorectal cancer (CRC) survivorship. The current literature may underestimate the impact of evacuatory dysfunction on patient satisfaction with bowel function after anterior resection (AR) for CRC. The aim of this study was to investigate the impact of post-AR symptoms of storage and evacuatory dysfunction on patient satisfaction and health-related quality of life (HRQoL).

METHOD

A cross-sectional study was performed at an Australian hospital of patients post-AR for CRC (2012-2021). The postoperative bowel function scores used were: low anterior resection syndrome (LARS), St Mark's incontinence, Cleveland Clinic constipation and Altomare obstructive defaecation syndrome scores. Eight 'storage' and 'evacuatory' dysfunction symptoms were derived. A seven-point Likert scale measured patient satisfaction. The SF36v2® measured HRQoL. Linear regression assessed the association between symptoms, patient satisfaction and HRQoL.

RESULTS

Overall, 248 patients participated (mean age 70.8 years, 57.3% male), comprising 103 with rectal cancer and 145 with sigmoid cancer. Of the symptoms that had a negative impact on patient satisfaction, six reflected evacuatory dysfunction, namely excessive straining (p < 0.001), one or more unsuccessful bowel movement attempt(s)/24 h (p < 0.001), anal/vaginal digitation (p = 0.005), regular enema use (p = 0.004), toilet revisiting (p = 0.004) and >10 min toileting (p = 0.004), and four reflected storage dysfunction, namely leaking flatus (p = 0.002), faecal urgency (p = 0.005), use of antidiarrhoeal medication (p = 0.001) and incontinence-related lifestyle alterations (p < 0.001). A total of 130 patients (53.5%) had 'no LARS', 56 (23.1%) had 'minor LARS' and 57 (23.4%) had 'major LARS'. Fifty-seven (44.5%) patients classified as having 'no LARS' had evacuatory dysfunction.

CONCLUSION

Postoperative storage and evacuatory dysfunction symptoms have an adverse impact on patient satisfaction and HRQoL post-AR. The importance of comprehensively documenting symptoms of evacuatory dysfunction is highlighted. Further research is required to develop a patient satisfaction-weighted LARS-specific HRQoL instrument.

Long-term Changes in Low Anterior Resection Syndrome in Survivors of Rectal Cancer: Longitudinal Follow-up of a Randomized Controlled Trial

BACKGROUND

Postoperative bowel dysfunction, also known as low anterior resection syndrome, is common in rectal cancer survivors and significantly impacts quality of life. Although long-term longitudinal follow-up is lacking, improvement of the syndrome is commonly believed to happen only within the first 2 years.

OBJECTIVE

This study aimed to depict the longitudinal evolvement of low anterior resection syndrome beyond 3 years and explore factors associated with changes.

DESIGN

Longitudinal long-term follow-ups were performed for the single center with the largest cohort within the multicenter FOWARC randomized controlled trial.

SETTING

A quaternary referral center.

PATIENTS

Individuals diagnosed with rectal cancer who received long-course neoadjuvant chemotherapy or chemoradiotherapy, followed by sphincter-preserving radical proctectomy.

MAIN OUTCOME MEASUREMENTS

Change of low anterior resection syndrome score and stoma status.

RESULTS

Of the 220 patients responding to the first follow-up at a median of 39 months, 178 (80.9%) responded to the second follow-up after a median of 83 months. During this interval, the mean low anterior resection syndrome score improved from 29.5 (95% CI, 28.3-30.7) to 18.6 (95% CI, 16.6-20.6). Fifty-six (31.5%) patients reported improvement from major to no/minor severity, and 6 (3.4%) patients had new stomas because of severe bowel dysfunction. Neoadjuvant radiotherapy ( p = 0.016) was independently and negatively associated with improvement of the score.

LIMITATIONS

Loss of follow-up during the long-term follow-ups.

CONCLUSIONS

Most rectal cancer survivors with low anterior resection syndrome continued to improve beyond 3 years after proctectomy. Neoadjuvant radiotherapy was negatively associated with long-term improvement of low anterior resection syndrome. See Video Abstract .

CAMBIO A LARGO PLAZO DEL SNDROME DE RESECCIN ANTERIOR BAJA EN SUPERVIVIENTES DE CNCER DE RECTO SEGUIMIENTO LONGITUDINAL DE UN ENSAYO CONTROLADO ALEATORIO

ANTECEDENTES:La disfunción intestinal posoperatoria, también conocida como síndrome de resección anterior baja, es común en los sobrevivientes de cáncer de recto y afecta significativamente la calidad de vida. Aunque falta un seguimiento longitudinal a largo plazo, comúnmente se cree que la mejoría del síndrome ocurre sólo dentro de los primeros dos años.OBJETIVO:Este estudio tiene como objetivo representar la evolución longitudinal del síndrome de resección anterior baja más allá de los 3 años y explora los factores asociados con el cambio.DISEÑO:Se realizaron seguimientos longitudinales a largo plazo para el único centro con la cohorte más grande dentro del ensayo controlado aleatorio multicéntrico FOWARC.AJUSTE:Un centro de referencia cuaternario.PACIENTES:Individuos diagnosticados con cáncer de recto que recibieron quimioterapia neoadyuvante de larga duración o quimiorradioterapia, seguida de proctectomía radical con preservación del esfínter.PRINCIPALES MEDICIONES DE RESULTADO:Cambio en la puntuación del síndrome de resección anterior baja y el estado del estoma.RESULTADOS:De los 220 pacientes que respondieron al primer seguimiento con una mediana de 39 meses, 178 (80,9%) respondieron al segundo seguimiento después de una mediana de 83 meses. Durante el intervalo, la puntuación media del síndrome de resección anterior baja mejoró de 29,5 (intervalo de confianza [IC] del 95%: 28,3-30,7) a 18,6 (IC del 95%: 16,6-20,6). 56 (31,5%) pacientes informaron una mejoría de mayor a ninguna gravedad, y 6 (3,4%) pacientes tuvieron un nuevo estoma debido a una disfunción intestinal grave. La radiación neoadyuvante (p = 0,016) se asoció de forma independiente y negativa con la mejora de la puntuación.LIMITACIONES:Pérdida de seguimiento durante los seguimientos a largo plazo.CONCLUSIÓN:La mayoría de los sobrevivientes de cáncer de recto con síndrome de resección anterior baja continuaron mejorando más allá de los 3 años después de la proctectomía. La radiación neoadyuvante se asoció negativamente con la mejora a largo plazo del síndrome de resección anterior baja. (Traducción-Dr Yolanda Colorado ).

Treatment of anterior resection syndrome: A systematic review and network meta-analysis

INTRODUCTION

There has been a lack of research comparing the efficacy of various treatments for low anterior resection syndrome (LARS).

METHODS

We conducted a comprehensive search across six electronic databases and a paired meta-analysis was undertaken to assess the effectiveness of the interventions. Furthermore, a network meta-analysis was utilized to compare the efficacy of different treatments for LARS.

RESULTS

This study encompassed nine randomized controlled trials, involving a total of 450 patients. Compared to routine care, 5-HT3 receptor antagonists (follow-up<3 months) and percutaneous tibial nerve stimulation (3 months ≤ follow-up <6 months) were effective in reducing the LARS score. Pelvic floor rehabilitation (follow-up≤3 months) was effective in decreasing daily number of bowel movements when compared to routine care. The network meta-analysis indicated that 5-HT3 receptor antagonists (follow-up<3 months) were the most effective in reducing both the LARS score and the daily number of bowel movements. Transanal irrigation (3 months ≤ follow-up ≤ 12 months) was most effective in reducing the LARS score. Additionally, 5-HT3 receptor antagonists demonstrated relative efficacy in improving patients' quality of life (follow-up ≤ 1 month).

CONCLUSIONS

This review indicates that 5-HT3 receptor antagonists and anal irrigation show significant promise in the treatment of LARS. Nevertheless, the contributions of percutaneous tibial nerve stimulation and pelvic floor rehabilitation to LARS treatment should not be overlooked. Given the clinical heterogeneity observed among the studies, the results should be interpreted with caution.

The Impact of Dietary Factors on the Relief of Bowel Dysfunction Among Patients with Rectal Cancer After the Sphincter-Saving Surgery-A Prospective Cohort Study

PURPOSE

The study aims at exploring the impact of dietary intake on the relief of bowel dysfunction among patients with rectal cancer after the sphincter-saving surgery.

METHODS

A prospective cohort design was used. A total of 299 patients were followed up at a tertiary hospital in East China between April 2020 and July 2021. Postoperative food intake was assessed with a food frequency questionnaire, and bowel dysfunction was assessed with Memorial Sloan Kettering Cancer Center's bowel function scale. The generalized estimating equation and the generalized additive mixed model were used to analyze the collected data.

RESULTS

The average daily intake of livestock and poultry meats and dairy products during the first 6 months after sphincter-saving surgery was significantly associated with the relief of bowel dysfunction. Bowel dysfunction was relieved most quickly among patients who consumed 40.81 to 59.1 g/d of livestock and poultry meat during the first 3 months after surgery. Bowel dysfunction improved more slowly during the first 6 months after surgery among patients who consumed greater than 107.11 g/d dairy products than among patients who consumed 0 g/d dairy products.

CONCLUSION

The impact of dietary factors on bowel dysfunction observed in this study added to the limited evidence about the specific effects of consuming foods and nutrients on defecation dysfunction, and these results provided a theoretical basis for the use of dietary modification programs aimed at relieving bowel dysfunction as soon as possible.

Neoadjuvant treatment of colorectal cancer: comprehensive review

BACKGROUND

Neoadjuvant therapy has an established role in the treatment of patients with colorectal cancer. However, its role continues to evolve due to both advances in the available treatment modalities, and refinements in the indications for neoadjuvant treatment and subsequent surgery.

METHODS

A narrative review of the most recent relevant literature was conducted.

RESULTS

Short-course radiotherapy and long-course chemoradiotherapy have an established role in improving local but not systemic disease control in patients with rectal cancer. Total neoadjuvant therapy offers advantages over short-course radiotherapy and long-course chemoradiotherapy, not only in terms of increased local response but also in reducing the risk of systemic relapses. Non-operative management is increasingly preferred to surgery in patients with rectal cancer and clinical complete responses but is still associated with some negative impacts on functional outcomes. Neoadjuvant chemotherapy may be of some benefit in patients with locally advanced colon cancer with proficient mismatch repair, although patient selection is a major challenge. Neoadjuvant immunotherapy in patients with deficient mismatch repair cancers in the colon or rectum is altering the treatment paradigm for these patients.

CONCLUSION

Neoadjuvant treatments for patients with colon or rectal cancers continue to evolve, increasing the complexity of decision-making for patients and clinicians alike. This review describes the current guidance and most recent developments.

The effect of robotic surgery on low anterior resection syndrome in patients with lower rectal cancer: a propensity score-matched analysis

BACKGROUND

Many patients experience anorectal dysfunction after rectal surgery, which is known as low anterior resection syndrome (LARS). Robotic systems have many technical advantages that may be suitable for functional preservation after low rectal resection. Thus, the study aimed to explore whether robotic surgery can reduce the incidence and severity of LARS.

METHODS

Patients undergoing minimally invasive sphincter-sparing surgery for low rectal cancer were enrolled between January 2015 and December 2020. The patients were divided into robotic or laparoscopic groups. The LARS survey was conducted at 6, 12 and 18 months postoperatively. Major LARS scores were analysed as the primary endpoint. In order to reduce confounding factors, one-to-two propensity score matches were used.

RESULTS

In total, 342 patients were enrolled in the study. At 18 months postoperatively, the incidence of LARS was 68.7% (235/342); minor LARS was identified in 112/342 patients (32.7%), and major LARS in 123/342 (36.0%). After matching, the robotic group included 74 patients, and the laparoscopic group included 148 patients. The incidence of major LARS in the robotic group was significantly lower than that in the laparoscopic group at 6, 12, and 18 months after surgery. In multivariate logistic regression analysis, tumour location, laparoscopic surgery, intersphincteric resection, neoadjuvant therapy, and anastomotic leakage were independent risk factors for major LARS after minimally invasive sphincter-sparing surgery for low rectal cancer. Furthermore, a major LARS prediction model was constructed. Results of model evaluation showed that the nomogram had good prediction accuracy and efficiency.

CONCLUSIONS

Patients with low rectal cancer may benefit from robotic surgery to reduce the incidence and severity of LARS. Our nomogram could aid surgeons in setting an individualized treatment program for low rectal cancer patients.

Ondansetron for Low Anterior Resection Syndrome (LARS): A Double-Blind, Placebo-Controlled, Cross-Over, Randomized Study

OBJECTIVE

The aim of the study was to examine the efficacity and safety of ondansetron, a serotonin receptor antagonist, to treat patients with low anterior resection syndrome (LARS).

BACKGROUND

LARS after rectal resection is common and debilitating. Current management strategies include behavioral and dietary modifications, physiotherapy, antidiarrheal drugs, enemas, and neuromodulation, but the results are not always satisfactory.

METHODS

This is a randomized, multicentric, double-blinded, placebo-controlled, and cross-over study. Patients with LARS (LARS score >20) no longer than 2 years after rectal resection were randomized to receive either 4 weeks of ondansetron followed by 4 weeks of placebo (O-P group) or 4 weeks of placebo followed by 4 weeks of ondansetron (P-O group). The primary endpoint was LARS severity measured using the LARS score; secondary endpoints were incontinence (Vaizey score) and irritable bowel syndrome quality of life (IBS-QoL questionnaire). Patients' scores and questionnaires were completed at baseline and after each 4-week treatment period.

RESULTS

Of 46 randomized patients, 38 were included in the analysis. From baseline to the end of the first period, in the O-P group, the mean (SD) LARS score decreased by 25% [from 36.6 (5.6) to 27.3 (11.5)] and the proportion of patients with major LARS (score >30) went from 15/17 (88%) to 7/17 (41%), ( P =0.001). In the P-O group, the mean (SD) LARS score decreased by 12% [from 37 (4.8) to 32.6 (9.1)], and the proportion of major LARS went from 19/21 (90%) to 16/21 (76%). After crossover, LARS scores deteriorated again in the O-P group receiving placebo, but further improved in the P-O group receiving ondansetron. Mean Vaizey scores and IBS QoL scores followed a similar pattern.

CONCLUSIONS

Ondansetron is a safe and simple treatment that appears to improve both symptoms and QoL in LARS patients.

Management of rectal cancer in the era of total neoadjuvant therapy and watch and wait: A multidisciplinary team discussion at the Australasian Gastro-Intestinal Trials Group (AGITG) Annual Scientific Meeting 2022

Rectal cancer is a common malignancy. The management of rectal cancer has recently evolved and has undergone a paradigm shift with the advent of treatment approaches such as total neoadjuvant therapy and the watch-and-wait approach. However, despite the recently available evidence, there is no consensus on the optimal management approach in the setting of locally advanced rectal cancer. To address some of the controversies, a joint multidisciplinary panel discussion was conducted at the Australasian Gastro-Intestinal Trials Group (AGITG) Annual Scientific Meeting in November 2022. Members from different subspecialties formed two panels and discussed three clinical cases in a debate format. Each case represented some of the complex issues faced by clinicians in this setting. The discussion is now presented in this manuscript, which depicts the different available management approaches and reiterates the importance of a multidisciplinary approach.

Challenges in evaluating pelvic floor physiotherapy based strategies in low anterior resection syndrome: a systematic review and qualitative analysis

AIM

Physiotherapy is an established treatment strategy for low anterior resection syndrome (LARS). However, data on its efficacy are limited. This is in part due to the inherent challenges in study design in this context. This systematic review aims to analyse the methodology of studies using pelvic floor physiotherapy for treatment of LARS to elucidate the challenges and limitations faced, which may inform the design of future prospective trials.

METHODOLOGY

A systematic review of the literature was undertaken through MEDLINE, Embase and Cochrane Library, yielding 345 unique records for screening. Five studies were identified for review. Content thematic analysis of study limitations was carried out using the Braun and Clarke method. Line-by-line coding was used to organize implicit and explicit challenges and limitations under broad organizing categories.

RESULTS

Key challenges fell into five overarching categories: patient-related issues, cancer-related issues, adequate symptomatic control, intervention-related issues and measurement of outcomes. Adherence, attrition and randomization contributed to potential bias within these studies, with imbalance in the baseline patient characteristics, particularly gender and baseline pelvic floor function scores. Outcome measurements consisted of patient-reported measures and quality of life measures, where significant improvements in bowel function according to patient-reported outcome measures were not reflected in the quality of life scores.

CONCLUSION

Upcoming trial design in the area of pelvic floor physiotherapy for faecal incontinence related to rectal cancer surgery can be cognisant of and design around the challenges identified in this systematic review, including the reduction of bias, exclusion of the placebo effect and the potential cultural differences in attitude towards a sensitive intervention.

Long-term bowel functional outcomes following anal sphincter-preserving surgery for upper and middle rectal cancer: a single-center longitudinal study

PURPOSE

Despite advances in neoadjuvant chemoradiotherapy and anal sphincter-preserving surgery for rectal cancer, bowel dysfunction is still unavoidable and negatively affects patients' quality of life. In this longitudinal study, we aimed to investigate the changes in bowel function with follow-up time and the effect of neoadjuvant chemoradiotherapy on bowel function following low anterior resection for rectal cancer.

METHODS

In this study, 171 patients with upper or middle rectal cancer who underwent low anterior resection between 2012 and 2018 were included. Bowel function was assessed longitudinally with Memorial Sloan Kettering Cancer Center Bowel Function Instrument and Wexner scores every 6 months after restoration of bowel continuity. Patients with at least 2 follow-up visits were included.

RESULTS

Overall, 100 patients received neoadjuvant chemoradiotherapy. Urgency, soilage, and fecal incontinence were noted within 24 months in the patients treated with neoadjuvant chemoradiotherapy. After 2 years of follow-up, significant bowel dysfunction and fecal incontinence were observed in the neoadjuvant chemoradiotherapy group. Low tumor level and neoadjuvant chemoradiotherapy were associated with delayed bowel dysfunction.

CONCLUSION

Neoadjuvant chemoradiotherapy in combination with low tumor level was significantly associated with delayed bowel dysfunction even after 2 years of follow-up. Therefore, careful selection and discussion with patients are paramount.