Level of the anastomosis does not influence functional outcome after anterior rectal resection for rectal cancer

Anastomotic Height Is a Valuable Indicator of Long-term Bowel Function Following Surgery for Rectal Cancer

BACKGROUND

The exact relation between anastomotic height after rectal cancer surgery and postoperative bowel function problems has not been investigated in the long term, resulting in ineffective treatment.

OBJECTIVE

The goal of this study was to determine the effect of anastomotic height on long-term bowel function and generic quality of life.

DESIGN

This was a multicenter, cross-sectional study.

SETTINGS

Seven hospitals in the north of the Netherlands participated.

PATIENTS

All patients who underwent rectal cancer surgery between 2009 and 2015 in participating hospitals received the validated Defecation and Fecal Continence and Short-Form 36 questionnaires. Deceased patients, patients with a permanent stoma or an anastomosis >15 cm from the anal verge, patients with intellectual disability, and patients living abroad were excluded.

MAIN OUTCOME MEASURES

Primary outcomes were constipation (Rome IV), fecal incontinence (Rome IV), and major low anterior resection syndrome. Secondary outcomes were the generic quality of life scores.

RESULTS

The study population ( n = 630) had a median follow-up of 58.0 months. In multivariable analysis, constipation (OR = 1.08; 95% CI, 1.02-1.15; p = 0.011), fecal incontinence (OR = 0.91; 95% CI, 0.84-0.97; p = 0.006), and major low anterior resection syndrome (OR = 0.93; 95% CI, 0.87-0.99; p = 0.027), were significantly associated with anastomotic height. The curves illustrating the probability of constipation and fecal incontinence crossed at an anastomotic height of 7 cm, with 95% CIs overlapping between 4.5 and 9.5 cm. There was no relation between quality-of-life scores and anastomotic height.

LIMITATIONS

The study is limited by its cross-sectional design.

CONCLUSIONS

This study might serve as a guide for the clinician to effectively screen and treat fecal incontinence and constipation during patient follow-up after rectal cancer surgery. More attention should be paid to fecal incontinence in patients with an anastomosis below 4.5 cm and toward constipation in patients with an anastomosis above 9.5 cm. See Video Abstract at http://links.lww.com/DCR/B858 .

LA ALTURA ANASTOMTICA ES UN INDICADOR VALIOSO DE LA FUNCIN INTESTINAL A LARGO PLAZO DESPUS DE LA CIRUGA PARA EL CNCER DE RECTO

ANTECEDENTES:La relación exacta entre la altura anastomótica después de la cirugía de cáncer de recto y los problemas posoperatorios de la función intestinal no se ha investigado a largo plazo, lo que causa un tratamiento ineficaz.OBJETIVO:Determinar el efecto de la altura anastomótica sobre la función intestinal a largo plazo y la calidad de vida genérica.DISEÑO:Estudio multicéntrico transversal.DISEÑO DEL ESTUDIO:Participaron siete hospitales holandeses en el norte de los Países Bajos.PACIENTES:Todos los pacientes que se sometieron a cirugía de cáncer de recto entre 2009 y 2015 en los hospitales participantes recibieron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36. Se excluyeron pacientes fallecidos, pacientes con estoma permanente o anastomosis > 15 cm del borde anal, discapacidad intelectual o residentes en el extranjero.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron estreñimiento (Roma IV), incontinencia fecal (Roma IV) y síndrome de resección anterior baja mayor. Los resultados secundarios fueron las puntuaciones genéricas de calidad de vida.RESULTADOS:La población de estudio (N = 630) tuvo una mediana de seguimiento de 58.0 meses. En el análisis multivariable el estreñimiento (OR = 1,08, IC del 95%, 1,02-1,15, p = 0,011), incontinencia fecal (OR = 0,91, IC del 95%, 0,84-0,97, p = 0,006) y síndrome de resección anterior baja mayor (OR = 0,93, IC del 95%, 0,87-0,99, p = 0,027) se asociaron significativamente con la altura anastomótica. Las curvas que ilustran la probabilidad de estreñimiento e incontinencia fecal se cruzaron a una altura anastomótica de 7 cm, con IC del 95% superpuestos entre 4,5 y 9,5 cm. No hubo relación entre las puntuaciones de calidad de vida y la altura anastomótica.LIMITACIONES:El estudio está limitado por su diseño transversal.CONCLUSIONES:Este estudio podría servir como una guía para que el médico evalúe y trate eficazmente la incontinencia fecal y el estreñimiento durante el seguimiento de los pacientes después de la cirugía de cáncer de recto. Se debe prestar más atención a la incontinencia fecal en pacientes con anastomosis por debajo de 4,5 cm y al estreñimiento en pacientes con anastomosis por encima de 9,5 cm. Consulte Video Resumen en http://links.lww.com/DCR/B858 . (Traducción-Dr. Yazmin Berrones-Medina ).

The Impact of Postoperative Complications on Short- and Long-Term Health-Related Quality of Life After Total Mesorectal Excision for Rectal Cancer

BACKGROUND

Survival for rectal cancer patients has improved over the past decades. In parallel, long-term health-related quality of life (HRQoL) is gaining interest. This study focuses on the effect of complications following rectal cancer surgery on HRQoL and survival.

METHODS

The TME-trial (1996-1999) randomized patients with operable rectal cancer between surgery with preoperative short-course radiotherapy and surgery. Questionnaires including the Rotterdam Symptom Checklist were sent at 6 time points within the first 24 months and after 14 years the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Differences in HRQoL and survival between patients with and without complications were analyzed.

RESULTS

A total of 1207 patients were included, of which 482 (39.9%) patients experienced complications, surgical complications occurred in 177 (14.6%) patients, non-surgical complications in 197 (16.3%) and 108 patients (8.9%) had a combination of both types of complications. Three months after surgery, patients with a combination of surgical- and non-surgical complications, especially patients with anastomotic leakage, had the worst HRQoL. Twelve months postoperative HRQoL returned to a similar level as before surgery, regardless of complications. In patients who survived 14 years, no significant differences in HRQoL were seen between patients with and without complications. However, patients with complications did have lower overall survival.

CONCLUSION

This study shows that survival and short-term HRQoL are negatively affected by complications. Twelve months after surgery HRQoL had returned to the preoperative level regardless, of complications. Also, in patients that survived 14 years, there was no effect of complications on HRQoL detected.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality of life assessment in the late postoperative period of patients with rectal cancer submitted to total mesorectal excision

After the introduction of total mesorectal excision (TME) and radiochemotherapy, excellent results have been achieved in the treatment of patients with rectal cancer. With better oncologic control of the disease, the functional results of this type of therapeutic approach and their impact on the quality of life (QOL) of patients started to be increasingly valued. The aims of this study were to evaluate the QOL of patients with rectal cancer submitted to TME in the late postoperative period and the possible factors that directly influence their quality of life. A total of 72 patients submitted to TME due to extraperitoneal rectal tumor were assessed, after at least one postoperative year, by applying QOL questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38), in addition to a specific clinical questionnaire and rectal examination. Patients were evaluated regarding gender, age, indication of radiotherapy and chemotherapy preoperatively, length of postoperative period, distance from the anastomosis to the anal verge and general health status. The mean overall health status of patients was satisfactory (82.06). There was no difference in overall health status between patients with respect to gender, but the male patients had less insomnia (p = 0.002), better future prospects (p = 0.011), fewer effects of chemotherapy (p = 0.020) and better sexual function (p < 0.0001). Patients younger than 50 years had fewer urinary problems (p = 0.035), whereas those older than 65 years reported poorer sexual function (p = 0.012). Patients who underwent neoadjuvant therapy had more diarrhea (p = 0.012). Quality of life did not change significantly with time after surgery and the distance from the anastomosis to the anal verge. We conclude that patients undergoing TME have a good quality of life one year after the surgery and that the factors capable of affecting QOL should be identified and improved.

The impact of surgical modality on self-reported body image, quality of life and survivorship after anterior resection for colorectal cancer – a mixed methods study

Background

There is growing enthusiasm for robotic and transanal surgery as an alternative to open or laparoscopic surgery for colorectal cancer (CRC). We examined the impact of surgical modality on body image and quality of life (QOL) in patients receiving anterior resection for CRC.

Methods

We used a mixed-methods approach, consisting of a chart review and semistructured interviews with CRC patients, at least 8 months after surgery. We assessed cosmetic outcomes and QOL using validated questionnaires.

Results

Thirty patients were stratified into open (n = 8), laparoscopic (n = 12) and robotic (n = 10) groups. Mean body image scores were significantly higher (i.e., poorer body image) in patients receiving open surgery (mean difference [MD] +5.7 with laparoscopy, p < 0.001). Open surgery was more detrimental to physical function, including strenuous activities, prolonged ambulation and self-care (MD –11.6 with laparoscopy, p = 0.039). Patients receiving laparoscopic surgery reported superior role (MD +27.6 with open surgery, p = 0.002) and social function (MD +13.7 with open surgery, p = 0.042), including the ability to enjoy hobbies, family life and social activities. Surgical modality did not impact emotional and cognitive function or symptoms including genitourinary function, pain and defecation.

Conclusion

The negative impact of open surgery on body image and physical function warrants further educational interventions for patients. The protective effect of laparoscopy on role and function may be associated with “tumour factors” that are unaccounted for in the European Organization for Research and Treatment of Cancer questionnaires. Open surgery is detrimental to body image and physical function in patients receiving anterior resection for CRC. Prospective randomized studies are required to validate these findings.

Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer

AIM

To assess factors independently associated with low anterior resection syndrome (LARS) following resection or rectal cancer.

METHOD

Cross-sectional study carried out in two acute-care teaching hospitals in Barcelona, Spain. Patients who had undergone sphincter preserving low anterior resection with curative intent, with total or partial mesorectal excision (with and without protective ileostomy) between January 2001 and December 2009 completed a self-administered questionnaire to assess bowel dysfunction after rectal cancer surgery. Predictors of LARS were assessed by univariate and multivariate analyses.

RESULTS

The questionnaire was sent to 329 patients (response rate 57.7%). Six cases of incomplete questionnaires were excluded. The study population included 184 patients (66.8% men) with a mean age of 63 years. There were 44 (23.9%) patients with no LARS, 36 (19.6%) with minor LARS and 104 (56.2%) with major LARS. In the univariate analysis, total mesorectal excision (P = 0.0008), protective ileostomy (P = 0.002), preoperative and postoperative radiotherapy (P = 0.0000), postoperative chemotherapy (P = 0.0046) and age (P = 0.035) were significantly associated with major LARS, whereas in the multivariate analysis, total mesorectal excision (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.02-4.65), preoperative radiotherapy (OR 4.33, 95% CI 2.03-9.27) and postoperative radiotherapy (OR 9.52, 95% CI 1.74-52.24) were independent risk factors for major LARS.

CONCLUSIONS

In this study, the risk of having major LARS increases with total mesorectal excision and both neoadjuvant and adjuvant radiotherapy. This article is protected by copyright. All rights reserved.

Functional outcome of low rectal resection evaluated by anorectal manometry

BACKGROUND

Low anterior resection syndrome (LARS) covers disordered bowel function after rectal resection, leading to deterioration in patients' quality of life. The aim of this study was to evaluate anorectal function after laparoscopic low anterior resection (LAR) by means of standardized instruments.

METHODS

This was a prospective clinical cohort study conducted in a single institution to assess functional outcome of patients 1 year after laparoscopic LAR by means of LARS score and high-resolution anorectal manometry.

RESULTS

In total, 65 patients were enrolled in the study. Mean tumour height was 9.4 ± 1.8 cm; total mesorectal excision during laparoscopic LAR with low end-to-end colorectal anastomosis was performed in all patients. One year after the surgery, minor LARS was detected in 33.9% of patients, major LARS in 36.9% of patients. Anorectal manometry revealed decreased resting pressure and normal squeeze pressure of the anal sphincters in the majority of our patients. Rectal compliance and rectal volume tolerability (first sensation, urge to defaecate and discomfort volume) were significantly reduced. The statistical testing of the correlation between LARS and manometry parameters showed that with increasing seriousness of LARS, values of some parameters (resting pressure, first sensation, urge to defaecate, discomfort volume and rectal compliance) were reduced.

CONCLUSION

This study indicates that the majority of patients after laparoscopic LAR experience symptoms of minor or major LARS. These patients have decreased resting anal sphincter pressures, decreased rectal volume tolerability and decreased rectal compliance.

Neoadjuvant therapy abolishes the functional benefits of a larger rectal remnant, as measured by magnetic resonance imaging after restorative rectal cancer surgery

BACKGROUND

The combination of advances in surgical technique and neoadjuvant therapy for rectal cancer has resulted in more patients undergoing sphincter-preserving surgery. Unfortunately, numerous patients subsequently experience bowel dysfunction, and may suffer from lifelong severe disability with major impact on their quality of life. The aim of the present study was to investigate whether the risk of severe LARS in patients was associated with the length of remnant rectum.

METHODS

A total of 125 patients who underwent sphincter-preserving surgery for rectal cancer were included. Postoperative bowel function was assessed using the low anterior resection syndrome (LARS) score a minimum of one year following surgery. The length of remnant rectum was measured on postoperative MRI of the pelvis and was correlated with the risk of having major LARS.

RESULTS

Overall, major LARS was observed in 38 per cent of patients. In the patients who underwent surgery alone, major LARS was reported by 27 per cent, and a larger remnant rectum was associated with a better functional outcome. In contrast, 80 per cent of patients who underwent combined preoperative chemoradiotherapy and surgery reported having major LARS. No association between the length of remnant rectum and the risk of major LARS was observed in patients treated with combined neoadjuvant therapy and surgery.

CONCLUSION

Both the length of remnant rectum and preoperative chemoradiotherapy had a major impact on the severity of bowel dysfunction after restorative rectal cancer surgery. No functional benefit from an irradiated rectal remnant was observed.

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

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

Complications after surgery for colorectal cancer affect quality of life and surgeon-patient relationship

AIM

This multicentric prospective study aimed to investigate how postoperative complications after surgery for colorectal cancer affect patients' quality of life and satisfaction with care.

METHOD

One hundred and sixteen patients operated on for colorectal cancer were enrolled in this study. Patients answered three questionnaires about generic (EORTC QLQ-C30) and disease-specific (EORTC QLQ-CR29) quality of life and treatment satisfaction (EORTC IN-PATSAT32) at the time of admission and at 1 and 6 months after surgery. Non-parametric tests and linear multiple regression models were used for statistical analysis.

RESULTS

Twelve patients had complications requiring further surgery (anastomotic leakage, abdominal bleeding, abdominal wall sepsis, wound infection). Patients with complications that required surgery reported a worse score of physical function, emotional function and anxiety than patients without such complications 1 month after surgery. These patients judged their general satisfaction with the quality of care and doctors' interpersonal skills, technical skills, information provision and availability to be worse than in patients without such complications. The presence of postoperative psychiatric complications and anastomotic leakage were independent predictors of quality of life (β = -0.30, P = 0.004, and β = -0.42, P < 0.001).

CONCLUSION

In patients undergoing surgery for colorectal cancer, complications requiring any kind of surgical management significantly affected patients' perception of all doctor-related items suggesting an impairment of the entire surgeon-patient relationship. Convincing patients that 'zero risk' cannot be achieved in surgical practice is therefore a priority.

Risk factors for abdominal bleeding after living-donor liver transplant

OBJECTIVES

The purpose of this study was to identify the incidence, outcomes, and risk factors of postoperative abdominal bleeding after living-donor liver transplant.

MATERIALS AND METHODS

Adult patients who had living-donor liver transplant between 2001 and 2013 were evaluated. Preoperative and intraoperative variables of transplant recipients were analyzed retrospectively with univariate analysis. Cox proportional hazards regression model was used to identify independent factors for postoperative bleeding.

RESULTS

There were 241 living-donor liver transplant recipients included in the study. Postoperative abdominal bleeding was observed in 12 recipients (5%). The 3-month cumulative survival was significantly lower in recipients who had postoperative bleeding (survival, 8 patients [67%]) than recipients who did not have postoperative bleeding (survival, 204 patients [89%]; P = .009). Univariate analysis showed that preoperative albumin level, Child-Pugh class, and intraoperative blood loss were risk factors for postoperative bleeding. In multivariate analysis, intraoperative blood loss and Child-Pugh status were significant risk factors for postoperative bleeding.

CONCLUSIONS

Living-donor liver transplant recipients who had postoperative bleeding had a poor outcome. Postoperative bleeding was associated with higher intraoperative blood loss and Child-Pugh class.

Review of bowel dysfunction of rectal cancer patients during the first five years after sphincter-preserving surgery: a population in need of nursing attention

PURPOSE

The aim of the review was to summarize the longitudinal changes in bowel dysfunction among patients with rectal cancer within the first five years following sphincter-preserving resection.

METHODS

A series of literature searches were conducted on six English-language electronic databases. Articles published after 1990 were searched. A total of 29 articles (reporting 27 studies) was found.

RESULTS

Bowel dysfunction, including an alteration in the frequency of bowel movements, incontinence, abnormal sensations, and difficulties with evacuation, is reported among patients with rectal cancer within the first five years after sphincter-preserving resection. These problems are most frequent and severe within the first year, especially within the first six months, and stabilize after one year. Some of the problems may last for years.

CONCLUSION

Supportive care for bowel dysfunction is needed, and should include the provision of information and psychological support delivered in multiple steps. Oncology nurses can play an important role in providing supportive care for rectal cancer patients with bowel dysfunction.

Post anterior rectal resection syndrome--a retrospective multicentre study

AIM

The long-term effects of surgical and non-surgical factors on increased stool frequency and incontinence following anterior resection have been variably reported. We investigated the effects of surgical characteristics on symptoms at 1 month and more than 1 year postoperatively following anterior resection of the rectum.

METHOD

In this retrospective study of patients who underwent anterior resection of the rectum during 2002-2006, patients were interviewed regarding symptoms at 1 month and more than 1 year postoperatively. Anterior resection of the rectum syndrome (ARRS) is more simply defined as incontinence and/or frequent bowel movements after surgery and graded as severe, moderate or mild.

RESULTS

Of the 165 patients who underwent anterior resection for rectal cancer during the study period, 106 were included in the analysis. The median follow-up period was 3.4 years (range 13-72 months). ARRS had a high prevalence 1 month postoperatively (55.6%) but abated in over half the cases at 1 year postoperatively. The likelihood of development of early but not late ARRS was associated with the anastomotic level suggesting adaptation. ARRS and continence were unaffected by total mesorectal excision, the use of adjuvant radiation or chemotherapy, patient age or disease stage.

CONCLUSION

The level of anastomosis in anterior resection of the rectum had a significant effect on the prevalence of ARRS using a new simpler definition 1 month after surgery but not 1 year or more postoperatively. Further data on neorectal reservoir reconstruction using the simpler ARRS definition are required.

A novel animal model of long-term sustainable anal sphincter dysfunction

BACKGROUND

Although intersphincteric resection can avoid the need for permanent colostomy in patients with lower rectal cancer, it sometimes causes anal sphincter dysfunction, thus resulting in a lifelong, debilitating disorder due to incontinence of solid and liquid stool. The development of regenerative medicine could improve this condition by regenerating impaired anal muscle. In order to prove this hypothesis, preliminary experiments in animals will be indispensable; however, an adequate animal model is currently lacking. The purpose of this study was to establish a novel animal model with long-term sustainable anal sphincter dysfunction.

MATERIALS AND METHODS

Twenty male Sprague-Dawley rats were allocated into sham operation (n = 10) and anal sphincter resection (ASR) (n = 10) groups. The ASR group underwent removal of the left half of both the internal and external anal sphincters. Both groups were evaluated for anal function by measuring their resting pressure before surgery and on postoperative day (POD) 1, 7, 14, and 28.

RESULTS

The rats in the sham operation group recovered their anal pressure up to baseline on POD 7. The rats in the ASR group showed a significant decrease in anal pressure on POD 1 (P < 0.0001) compared with the baseline, and kept this low pressure until POD 28 (P < 0.0001). The defect of the anal sphincter muscle was confirmed histologically in the ASR group on POD 28.

CONCLUSIONS

The present novel model exhibits continuous anal sphincter dysfunction for at least 1 mo and may contribute to further studies evaluating the efficacy of therapies such as regenerative medicine.

Minimally invasive surgery for colorectal cancer: quality of life and satisfaction with care in elderly patients

BACKGROUND

The purpose of this multicentric prospective study was to evaluate postoperative HRQL and satisfaction with care after laparoscopic colonic resection for colorectal cancer in elderly patients.

METHODS

A total of 116 patients were enrolled in this study: 33 patients older than age 70 years had laparoscopic colectomy, whereas 24 had open colectomy; 44 patients younger than age 70 years had laparoscopic colectomy and 15 of them had open colectomy. The patients answered to three questionnaires about generic (EORTC QLQ C30) and disease-specific quality of life (EORTC CR29) and about treatment satisfaction (EORTC IN-PATSAT32). Nonparametric tests and forward stepwise multiple regression analysis were used for statistical analysis.

RESULTS

One month after surgery, global quality of life (QL2 item) was significantly impaired in elderly patients who had laparoscopic colectomy compared with younger patients who had the same operation (p = 0.003). Similarly, role function (RF), physical function (PF), emotional function (EF), cognitive function (CF), and social function (SF) were impaired in elderly patients who had laparoscopic colectomy compared with younger patients (p < 0.001, p < 0.001, p = 0.013, p < 0.001, p = 0.01, respectively). Fatigue (FA), sleep disturbances (SL), appetite loss (AP), and dyspnea (DY) affected the quality of life of these patients more than younger patients (p < 0.001, p = 0.055, p = 0.051, and p = 0.003, respectively).

CONCLUSIONS

Elderly patients undergoing laparoscopic colectomy for cancer experience less postoperative local complications than elderly patients undergoing open colectomy. Nevertheless, in the first postoperative month, these patients experience a worse global quality of life than younger patients undergoing the same operation with impairment of all the functions and the presence of fatigue, sleep disturbances, appetite loss, and dyspnea.

Perioperative outcomes after ultra low anterior resection in the era of neoadjuvant chemoradiotherapy

PURPOSE

Data on perioperative outcomes of sphincter preserving ultra low anterior resections (ULAR) following neoadjuvant chemoradiotherapy (NA-CTRT) is sparsely reported in literature.

METHODS

Prospective data of 68 patients was reviewed retrospectively. Patients who received preoperative chemoradiotherapy (CTRT, Group A, n = 45) were compared with those who were operated upfront (Group B, n = 23).

RESULTS

Overall, mean distance of the tumor from anal verge was 5.1 cm (range 3-8). In Groups A and B, it was 5.2 and 5.1 cm, respectively. In Group A, 3 patients had complete response, 40 had partial response and 2 had progressive disease. Overall, the mean distance of the anastomosis performed from the anal verge was 2.8 cm (range 1-4). In Groups A and B, it was 2.7 and 2.9 cm, respectively (NS). Mean blood loss in Groups A and B was 510.5 (range 200-2,200) and 345 mL (range 50-800), respectively (p = 0.037). Two patients in Group A required blood transfusion (range 1-2) compared to none in Group B. The overall complication rate was 26.5 % (18/68); in Groups A and B, it was 22.2 % and 34.8 %, respectively. There was no postoperative mortality. Postoperative stay for Groups A and B was 8 and 9.5 days (p = 0.009), respectively. In Group A, 23/45 patients, earlier planned for abdominoperineal resection, ultimately received sphincter-preserving ULAR.

CONCLUSION

ULAR can be performed safely without added morbidity or mortality after neoadjuvant chemoradiation. In some cases, earlier deemed to be suitable for APR, the neoadjuvant approach improved chances of sphincter conservation.

Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations

Between 25 and 80% of patients undergoing a low or very low anterior resection will suffer postoperatively, from a constellation of symptoms including fecal urgency, frequent bowel movements, bowel fragmentation and incontinence, collectively referred to as the low anterior resection syndrome (LARS). The etiology of LARS is multifactorial with the potential of sphincter injury during anastomosis construction, alterations in anorectal physiology, the development of a pudendal neuropathy, and a lumbar plexopathy with exacerbation of symptoms if there is associated anastomotic sepsis or the use of adjuvant and neoadjuavnt therapies. The symptoms of LARS may be obviated in part by the construction of a neorectal reservoir which may take the form of a colonic J-pouch, a transverse coloplasty, or a side-to-end anastomosis. This review outlines the factors contributing to LARS symptomatology along with the short- and medium-term functional results of comparative trials with the different types of neorectal reconstructions.

Long-term quality of life in pouch patients compared with stoma patients following rectal cancer surgery

AIM

Low and ultralow anterior resection for rectal cancer with colorectal or coloanal anastomosis does not compromise oncological results compared with abdominoperineal excision. Although avoidance of a permanent colostomy is regarded as beneficial for a patient's quality of life (QoL), patients undergoing sphincter-sparing surgery may develop a number of functional problems. A colonic pouch significantly improves functional outcome after rectal resection and low anastomosis and may positively influence QoL. The aim of this study was to compare QoL in long-term survivors who underwent ultralow anterior resection with total mesorectal excision and colonic J-pouch anastomosis (CPA) with patients treated with abdominoperineal excision (APE) and end colostomy for rectal cancer.

METHOD

The medical records from our institution's prospectively maintained rectal cancer database of 151 patients who underwent surgery for ultralow rectal cancer from 2001 to 2007 were analysed. QoL in 59 eligible patients was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 core and Colorectal Cancer 29. Results were compared for patients with CPA and APE.

RESULTS

The median follow-up in the 59 patients was 74 (37-119) months. QoL was good in all patients, but it was better in CPA than in APE patients. Global health status (P = 0.009), physical functioning (P = 0.0002), role functioning (P = 0.03), cognitive functioning (P = 0.046), social functioning (P = 0.002), body image (P = 0.053), embarrassment (P = 0.002) and urinary frequency (P = 0.003) were significantly improved for patients with CPA.

CONCLUSION

QoL after rectal resection and CPA was better than after APE in several respects. However, QoL should not be regarded as an isolated concept but rather as one of several possible clinical outcomes of interest.

Pathophysiological approach to bowel dysfunction after segmental colorectal resection for deep endometriosis infiltrating the rectum: a preliminary study

BACKGROUND

Colorectal segmental resection is performed worldwide in a majority of women presenting with symptomatic deep endometriosis infiltrating the rectum. The aim of the present study was to investigate the pathophysiological mechanisms involved in post-operative digestive dysfunction.

METHODS

We selected patients managed by colorectal resection for rectal endometriosis, who had developed post-operative severe constipation and whose follow up was superior to 24 months. To assess the mechanisms involved in the pathogenesis of this complaint, we performed a step-by-step work up including: low digestive tract endoscopy, colonic transit time measurement and when appropriate anorectal manometry, electromyography and defecographic evaluation.

RESULTS

Five out of 25 (20%) patients, whose age ranged from 27 to 41 years, were investigated for severe post-operative terminal constipation. Four different mechanisms responsible for terminal constipation were identified: tight stenosis of the colorectal anastomosis, post-operative neurological sequelae, colonic intussusception through the colorectal anastomosis and transit constipation that developed post surgery.

CONCLUSIONS

Post-operative constipation is a frequent complaint in women managed by colorectal resection for rectal endometriosis. A multidisciplinary approach is mandatory as pathophysiologic mechanisms may vary and prove difficult to understand. The risk of post-operative bowel dysfunction following colorectal endometriosis must be taken into account whenever this technique is proposed in young women presenting with a benign disease such as deep endometriosis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy

OBJECTIVE

Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA.

METHOD

Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary.

RESULTS

Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA.

CONCLUSION

A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

Pouch operation for rectal cancer

Many retrospective studies have found that the functional outcome after a low anterior resection for rectal cancer is better with colonic J-pouch reconstruction than with conventional straight anastomosis. This advantage was demonstrated in prospective, randomized trials and meta-analyses. However, despite its increasing popularity there are several areas of controversy about the use of the colonic J-pouch reconstruction. These issues include anastomotic leaks, the part of the colon used for the pouch, the pouch size, causes of difficulty in evacuation, indications (the optimum level of anastomosis), appropriateness for the elderly, and long-term (2 years or more after surgery) functional outcome. All relevant articles identified from MEDLINE databases were reviewed. The incidence of anastomotic leaks is apparently reduced by colonic J-pouch reconstruction. A 5-cm colonic J-pouch using the sigmoid colon increases the reservoir function without compromising evacuation, and provides better functional outcome than straight anastomosis, even 2 years or more after surgery, in patients whose anastomosis is less than 8 cm from the anal verge. Patients with ultralow anastomoses, less than 4 cm from the verge, appear to benefit the most. At a time when the indications for abdominoperineal excision appear to be reduced for low rectal cancer, the demand for colonic J-pouch reconstruction (the best technique in pouch operations) is therefore likely to increase.

Should we preserve the inferior mesenteric artery during sigmoid colectomy?

Ligation of the inferior mesenteric artery (IMA) during sigmoid colectomy may cause sympathetic denervation of the rectal stump. The purpose of our study was to investigate the functional results after sigmoid resection following ligation or preservation of the IMA. We prospectively analysed 44 patients (21 female and 23 male, mean age 60.6 +/- 11.79 years) with sigmoid tumour. Sigmoid colectomy with preservation of the IMA was performed in 21 patients, and ligation of the IMA with sigmoidectomy was carried out in 23 patients. Bowel function follow-up was performed by use of questionnaires: standardized functional questionnaire, constipation-specific, and incontinence scales before, 6 and 12 months after surgery. The quality of life was measured by means of the Fecal Incontinence Quality of Life (FIQL) scale. After sigmoid colectomy with division of the IMA, patients presented with a higher rate of fecal incontinence and increased stool frequency compared with patients after sigmoid resection with preservation of the IMA. Deterioration of FIQL was also observed in patients with ligated IMA. Preservation of the IMA during sigmoid colectomy in selected patients lowers the frequency of postoperative impaired anorectal function.

Comparison of a colonic J-pouch and transverse coloplasty pouch in patients with rectal cancer after an ultralow anterior resection using fecoflowmetric profiles

PURPOSE

Because the standard straight coloanal anastomosis for low rectal cancer tends to result in unfavorable outcomes in terms of defecatory function, colonic pouch reconstruction has therefore recently been adopted in many institutions. The colonic J-pouch (CJP)- and transverse coloplasty pouch (TCP)-anal anastomoses have been adopted worldwide. However, the comparative benefits and drawbacks of the two procedures are uncertain. This study was designed to analyze the functional and clinical outcomes after an ultralow anterior resection (ULAR) using the fecoflowmetry (FFM).

METHODS

Between November 1996 and July 2005, 18 patients were studied retrospectively. They were evaluated by FFM, together with Kelly's clinical score (KCS), and anorectal manometric assessments were also performed.

RESULTS

The KCS directly correlated to the maximum fecal stream flow rate (Fmax). In this study, postoperative patients with good KCS as well as a high value of Fmax were seen more in the patients with CJP than in those with TCP.

CONCLUSION

From the viewpoint of FFM, the patients with CJP had a more favorable functional outcome than those with TCP. FFM provided quantitative and qualitative evaluations concerning the anorectal motor activity in patients who had undergone an ULAR for rectal cancer.

Functional outcome following restorative rectal cancer surgery

The trend towards preoperative adjuvant and neoadjuvant therapies in selected patients with rectal cancer has led to increases in sphincter preservation with a limited understanding of the factors governing unsatisfactory functional outcomes. Data would suggest the need for a more selective use of standard radiotherapeutic fields in low- to intermediate-risk cases where there appears to be limited survival or locoregional recurrence benefit and where there is under-reported toxicity. This article discusses the complex factors which impact on functional outcome following open rectal cancer surgery particularly when it is accompanied by adjuvant therapy.

Bowel problems, self-care practices, and information needs of colorectal cancer survivors at 6 to 24 months after sphincter-saving surgery

The aim of this study was to describe bowel problems, self-care practices, and information needs of patients who have recovered from the acute effects of sphincter-saving surgery for colorectal cancer. A retrospective, descriptive survey was conducted using a structured telephone interview and mailed questionnaires. The sample consisted of 101 patients who had undergone sphincter-saving surgery for colorectal cancer in the last 6 to 24 months. Most participants (71.3%) reported a change in bowel habits after surgery. The 6 most frequently reported gastrointestinal problems were incomplete evacuation (75.2%), excessive flatus (75.2%), urgency (73.3%), straining (61.4%), perianal soreness or itching (49.5%), and bloating (43.6%). Incontinence of feces (varying from smears to complete bowel action) was reported by 37.6% of participants. The most frequently reported information needs were related to diet (50.5%) and managing conditions such as diarrhea (31.7%), bloating/wind/gas (28.7%), pain (21.8%), and incomplete emptying of the bowel (18.8%). Patients who had recovered from the acute effects of sphincter-saving surgery for colorectal cancer reported a wide range of bowel problems and ongoing concerns about managing symptoms. Findings from this study provide valuable information to guide the development of educational resources to prevent or better manage bowel problems after surgery.

Minimally invasive surgery for colorectal cancer: quality of life, body image, cosmesis, and functional results

BACKGROUND

The aims of this cross-sectional study were to assess the long-term quality of life, the body image, and the cosmetic and functional results in patients who had laparoscopic-assisted for colorectal cancer.

METHODS

Forty-two patients were enrolled in this study: 21 consecutive patients who had undergone laparoscopic-assisted colonic resection and 21 patients who had open colonic resection, selected according to stage, gender, age, cancer site, and type of resection. The patients answered four questionnaires about their quality of life, body image, functional, and cosmetic results. Nonparametric tests were used for statistical analysis.

RESULTS

Postoperative hospital stay was shorter in patients who had laparoscopic-assisted resection. The cosmetic score was significantly better in the laparoscopic-assisted group than in the open group (p < 0.01). In spite of similar overall body image score, patients who had a laparoscopic-assisted resection reported a significantly better satisfaction with their own body (p = 0.05). Quality-of-life and functional results were similar in both groups.

CONCLUSIONS

The cosmetic results and the consequent satisfaction with the body were significantly better after laparoscopic assisted resection compared to equivalent open procedure. These effects seemed to be temporary but they could help patients to accept the burden of surgery.

Risk factors for faecal incontinence after rectal cancer treatment

BACKGROUND

Low anterior resection (LAR) may result in faecal incontinence. This study aimed to identify risk factors for long-term faecal incontinence after total mesorectal excision (TME) with or without preoperative radiotherapy (PRT).

METHODS

Between 1996 and 1999, patients with operable rectal cancer were randomized to TME with or without PRT. Eligible patients who underwent LAR were studied retrospectively at 2 years (399 patients) and 5 years (339) after TME.

RESULTS

At 5 years after surgery faecal incontinence was reported by 61.5 per cent of patients who had PRT and 38.8 per cent of those who did not (P < 0.001). Excessive blood loss and height of the tumour were associated with long-term faecal incontinence, but only in patients treated with PRT.

CONCLUSION

Faecal incontinence is likely to occur after PRT and TME, especially when the perineum is irradiated.

The efficacy and adverse effects of topical phenylephrine for anal incontinence after low anterior resection in patients with rectal cancer

BACKGROUND

Anal incontinence is experienced by some patients with rectal cancer who received low anterior resection. This study was to examine the efficacy and adverse effects of the alpha-1 adrenergic agonist phenylephrine, which causes contraction of the internal anal sphincter and raises the resting pressure in these patients.

PATIENTS AND METHODS

Thirty-five patients with anal incontinence were treated with 30% phenylephrine or a placebo randomly allocated in a double-blind study. The efficacy of the drug was assessed by changes in the following standardized questionnaire scores: the fecal incontinence severity index (FISI), fecal incontinence quality of life (FIQL) scales, and a global efficacy question. Anal sphincter function was evaluated using anorectal manometry.

RESULTS

Phenylephrine did not improve either the FISI score or any of the four FIQL scores. Five of 17 (29%) patients reported subjective improvement after phenylephrine compared with 4 of 12 (33%) using the placebo. The maximum resting anal pressure did not differ between baseline and after 4 weeks application of phenylephrine (30.0 to 27.3 mmHg). In the phenylephrine group, allergic dermatitis was developed in five patients and headache in two.

CONCLUSION

In the patients with anal incontinence after low anterior resection for rectal cancer, phenylephrine gel did not seem to be helpful in relieving symptoms with some adverse effects.

The United Kingdom National Bowel Cancer Project – Epidemiology and surgical risk in the elderly

OBJECTIVE

To evaluate the epidemiology and risk of surgery in the treatment of colorectal cancer in the elderly.

METHODS

Patients undergoing colorectal cancer surgery were identified from the Association of Coloproctology of Great Britain and Ireland (ACPGBI) bowel cancer database, comprising 47,455 patients treated over a 5-year period. Demographic characteristics and outcomes were compared between patients aged <75 and those 75 or above. The primary endpoint was 30-day mortality. Secondary endpoints were the length of hospital stay, abdominoperineal excision (APER) rates and lymph node harvest.

RESULTS

Elderly patients were likely to be female and have higher American Society of Anaesthesiology (ASA) grade, while Dukes' stage was lower. They underwent surgery less often (81% versus 88%, p<0.001), but more frequently needed urgent or emergency procedures (p<0.001) and non-excisional surgery (7.7% versus 6.6%, p<0.001). Operative mortality was significantly higher for the older age group (10.6% versus 3.8%, p<0.001), and their median length-of-stay was 2 days longer (p<0.001). Mortality has improved over time for elderly patients with ASA grade III, and Dukes' stage A and D disease, but not for other subgroups.

CONCLUSION

Significant differences in the demographic characteristics and operative risk-factors between under-75s, and those aged 75 or above exist. These variations are reflected in the inferior outcomes experienced by elderly patients.

Prospective Evaluation of the Defecatory Functional Results in Patients Following Aorto-Aortic Reconstruction Surgery for an Abdominal Aortic Aneurysm

PURPOSE

Anterior rectal resections have been associated with postoperative bowel function abnormalities, a condition defined as anterior resection syndrome. Autonomic denervation could be one of the possible mechanisms underlying this complication. Damage to the preaortic tissue containing autonomic nervous plexus during abdominal aortic reconstruction surgery may affect the anorectal defecation function.

METHODS

The anorectal function was prospectively studied in 22 patients undergoing abdominal aortic reconstruction surgery. The patients were examined preoperatively and 6 months postoperatively by symptom-specific questionnaires.

RESULTS

Postoperatively, the patients showed no significant impairment of the anorectal functions in both constipation- and fecal incontinence-specific questionnaires. Self-estimation of the defecatory function was slightly lower compared with preoperative scores.

CONCLUSION

An injury to the intermesenteric, inferior mesenteric, and superior hypogastric plexuses does not significantly influence the defecatory functions in patients following abdominal reconstruction surgery for an abdominal aortic aneurysm.

Outcome after rectum or sigmoid resection: a review for gynecologists

It remains unclear when to perform a discoid or segmental bowel resection for large endometriotic nodules with intestinal invasion. Moreover, endometriosis series are rather small to fully evaluate functional consequences of bowel resection. We therefore reviewed the incidence of leakage and functional problems after anterior and sigmoid resection as reported in the surgical literature albeit for other indications. Endoscopic resection clearly is feasible but requires an experienced surgeon. The incidence of leakage is not different after hand-sewn or stapled anastomosis, but is higher after a low rectum resection than after a sigmoid resection. Similarly, functional bowel problems are higher after a low rectum resection than after sigmoid resection. Low rectum resection in addition can be associated with functional bladder problems and sexual disturbances as anorgasmia. In conclusion, short- and long-term complications are much higher after a low rectum than after a sigmoid resection. This seems to be important in making the decision to perform a discoid or a segmental bowel resection for severe endometriosis.

Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome

OBJECTIVE

Many patients experience disordered defaecation after low anterior resection of the rectum (LARR). We analysed the anorectal function of these patients to determine which factors might contribute to this problem.

PATIENTS AND METHODS

Between November 2002 and January 2004, 18 consecutive patients (11 males and 7 females) who underwent LARR with total mesorectal excision (TME) for rectal cancer were assessed by anorectal manometry, balloon proctometry and the Wexner continence questionnaire before operation and at 6 months and 1 year following stoma closure. Sixteen volunteers (11 males and 5 females) were evaluated for comparison. Stepwise logistic regression was performed for variables that were highly significant at univariate analysis.

RESULTS

The mean daily preoperative stool frequency was 2, mean basal pressure (MBP) 43.12 cm H(2)O, maximum threshold volume (MTV) 181.8 ml, length of high-pressure zone (HPZ) 3.11 cm and the rectoanal inhibitory reflex (RAIR) was present in all the patients. Twelve months after stoma closure, the stool frequency was 3.3, MBP 37.7 cm H(2)O, MTV 146.3 ml, length of HPZ 2.88 cm and Wexner score 4.37. Comparing patients having a good anorectal function (Wexner score > or = 5) with those having an unsatisfactory function, we found that, on multivariate analysis, the factors that independently contributed to a poor outcome at 12 months after operation were the absence of RAIR as well as an MTV and HPZ below the fifth percentile of normal individuals.

CONCLUSIONS

Many patients undergoing LARR with TME for rectal cancer experience an anterior resection syndrome that persists for at least 1 year. Those with no RAIR and subnormal MTV and HPZ lengths can be predicted to have an unsatisfactory outcome.

Transabdominal anastomosis after low anterior resection: A prospective, randomized, controlled trial comparing long-term results between side-to-end anastomosis and colonic J-pouch

PURPOSE

Colonic J-pouch has been constructed to overcome reservoir dysfunction after restorative rectal surgery, whereas no effort has been made for sphincter dysfunction. We conducted a prospective, randomized study comparing surgical and functional outcomes between side-to-end anastomosis and colonic J-pouch after low anterior resection in which the anastomosis was constructed from the abdomen.

METHODS

Fifty-six consecutive patients with middle-to-low rectal cancer undergoing low anterior resection were randomly assigned to side-to-end or colonic J-pouch group preoperatively. Surgical outcomes of all the patients were recorded. Patients underwent functional evaluation, including anorectal manometry and functional assessment, preoperatively and then 3 months, 6 months, 1 year, and 2 years postoperatively.

RESULTS

Twenty-four patients in each group completed the study. The demographic data and preoperative functional assessment did not differ between the two groups. There was no significant difference in surgical outcomes with regard to anastomotic height (5 cm), blood loss, protective colostomy, operative time, complications, and adjuvant therapy. Anal pressures showed no significant change postoperatively and during the follow-up period; there were no differences between the two groups. Temporal minor fecal incontinence was noted in the early postoperative period in both groups. With regard to bowel function, a significant reduction of volume of urgency and maximal tolerable volume was found postoperatively in both groups; however, a faster recovery was noted in the colonic J-pouch group. Stool frequency increased significantly after surgery in both groups; however, in contrast to rectal volume, a faster recovery was noted in the side-to-end group.

CONCLUSIONS

Anastomosis after low anterior resection for middle to low rectal cancer could be performed safely from the abdomen. It minimized sphincter injury and showed good continence preservation. On the other hand, the surgical outcomes and long-term functional results of side-to-end anastomosis were comparable with colonic J-pouch. Side-to-end anastomosis provides an easier, alternative way for reconstruction after restorative rectal surgery.

Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer

AIMS

The aims of the study were (1) to evaluate quality of life (QoL) and functional outcome in patients following anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer, and (2) whether these outcomes were dependent on the level of anastomosis.

METHODS

Patients who were without recurrent or metastatic disease were identified from the Norwegian Rectal Cancer Registry. QoL was assessed by the EORTC questionnaires QLQ-C30 and QLQ-CR38, and rectal function by a short questionnaire. Of 319 patients studied, 229 had undergone AR and 90 APR. The median age was 73 years, and the median time since surgery was 64 months.

RESULTS

Mean QoL scores for body image and male sexual problems were better following AR than APR (P<0.01), also in patients with a low (< or = 3 cm) anastomosis. Patients who had undergone AR had higher mean scores for constipation (P<0.001) and more often used anti-diarrhoeal medication (P=0.005), than patients who had undergone APR. Patients with a low anastomosis (< or = 3 cm) had more incontinence for gas and solid stools (P<0.05), and had more incontinence (P=0.006) compared with patients with higher anastomosis, but there was no difference in QoL. Subgroup analysis showed that irradiated patients (n=34) had worse rectal function in terms of frequency, urgency, and incontinence (P<0.01).

CONCLUSIONS

Although rectal function was impaired in patients with low anastomosis, patients who had undergone AR had better QoL than patients who had undergone APR.

Sacral nerve stimulation for faecal incontinence following a rectosigmoid resection for colorectal cancer

INTRODUCTION

Following recto-sigmoid resection some patients may become faecally incontinent and remain so despite conservative treatment. This multicentre prospective study assessed the use of sacral nerve stimulation (SNS) in this group.

METHODS

All patients had more than or equal to 4 days of faecal incontinence for solid or liquid stools over a 21-day period following recto-sigmoid resection for colorectal carcinoma. The operation had to have been deemed curative. They had to have failed pharmacological and biofeedback treatment.

RESULTS

Three male patients met these criteria. One had had a colo-anal and two a colo-rectal anastomosis for rectal carcinoma. All patients had intact internal and external anal sphincters. Two patients had a successful temporary stimulation period and proceeded to permanent implantation. Pre-operative symptom duration was 1 year in the permanently implanted patients. They were followed up for 12 months. SNS improved the number of faecally incontinent episodes in both patients. Ability to defer was improved in both patients from 0--5 min to 5--15 min. The faecal incontinence-specific ASCRS quality of life assessment improved in all four subcategories.

CONCLUSION

This study demonstrates that SNS may be effective in the treatment of patients with faecal incontinence following recto-sigmoid resection if conservative treatment has failed.

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The management of rectal cancer in the elderly

INTRODUCTION

The majority of patients with rectal cancer are elderly. Due to the increasingly aging population the number of people with colorectal cancer is increasing. As medical advances in the areas of local therapy, radiation therapy, and surgical technique, such as, laparoscopy are made more elderly patients are offered various types of treatment for rectal cancer. As the number of treatment options increase, the debate on how to treat elderly patients' with rectal cancer intensifies.

METHODS

A Medline search using "rectal cancer," "elderly," "local therapy," "radical surgery," and "radiation therapy" as key words was performed for English-language articles. Further references were obtained through cross-referencing the bibliography cited in each work.

DISCUSSION

Numerous treatment options exists for elderly patients with rectal cancer. These range from transanal local excision to radical surgery. The best treatment option for a certain elderly patient is multifactorial and includes tumor stage, operative curability, preoperative functioning of the patient, patient comorbidities, quality of life goals, and patient preference.

CONCLUSION

Age, taken as an independent variable, is not a contraindication to any specific type of therapy, including radical surgery with primary anastomsis. Patients' who meet the criteria for local resection should undergo this procedure. However, for tumors which are not amenable to local resection, these patients should be considered for radical surgery if this provides the best chance for cure. Elderly patients who can tolerate a major operation, and have good preoperative sphincter function should undergo a resection with primary anastomosis.

Denervation of the neorectum as a potential cause of defecatory disorder following low anterior resection for rectal cancer

PURPOSE

The aim of this study was to determine whether denervation of the sigmoid colon during low anterior resection contributes to the postoperative motility characteristics of the neorectum and to the defecatory function of patients.

METHODS

Sixty-seven patients who underwent either low or ultralow anterior resection for rectal cancer were evaluated. In accordance with the length of denervated neorectum, each patient was assigned to either the short-denervation or long-denervation group, determined by whether the inferior mesenteric artery was divided. Colonic propagated contraction was then measured by means of intraluminal pressure monitoring. Transit time was calculated with orally administered radiopaque markers.

RESULTS

Propagated contraction down to the neorectum was significantly less common in the long-denervation group (14/36) than in the short group (12/15, P < 0.05), whereas spastic minor contraction at the neorectum was significantly more common in the long-denervation group (21/36) than the in short group (3/15, P < 0.05). Colonic transit time below the sigmoid colon was significantly longer in long group (6.4 hours) than in the short group (3.4 hours, P < 0.01). Although motility disorder of the neorectum was correlated with clinical defecatory malfunctions, including multiple evacuations, urgency, and soiling, no significant correlation was noted between the length of the denervated neorectum and the defecatory disorders.

CONCLUSIONS

Motility of the neorectum following low anterior resection appears degraded by intraoperative maneuvers that cause denervation of the remnant sigmoid colon. Motility disorder of the neorectum, but not the length of the denervated neorectum causing the disorder, correlates well with several defecatory malfunctions. This finding suggests that postoperative defecatory disorder as a result of low anterior resection is caused by many factors in addition to denervation of the neorectum.

Defecatory malfunction caused by motility disorder of the neorectum after anterior resection for rectal cancer

BACKGROUND

The correlation between postoperative defecatory status after anterior resection for rectal cancer and physiologic neorectal motility has not been well delineated.

METHODS

Sixty patients who underwent anterior resection were examined. Motility of the neorectum was examined with 4-sensor intraluminal pressure monitoring, and segmental colonic transit time was determined with radiopaque Sitzmarks (Konsyl, Fort Worth, Texas) capsules.

RESULTS

Twenty-eight patients experienced loss of propagated contraction waves down to the neorectum, which was closely correlated with a prolonged transit time through the neosigmoid colon and neorectum. In 26 patients, minor spastic waves were observed at the neorectum, which did not correlate well with the loss of propagated waves. The loss of propagation and the existence of spastic waves were significantly correlated with urgency of defecation and multiple evacuations. The latter was also associated with major soiling and with patients' assessments of impaired defecatory function.

CONCLUSIONS

The physiologic motility of the neorectum is one of the factors responsible for postoperative defecatory function after anterior resection for rectal cancer.

Quality of life in rectal cancer patients: a four-year prospective study

OBJECTIVE

To assess long-term quality of life in a population-based sample of rectal cancer patients.

SUMMARY BACKGROUND DATA

Quality of life in rectal cancer patients who suffer reduced bowel and sexual function is very important. Few studies, however, have long term follow-up data or sufficient sample sizes for reliable comparisons between operation groups.

PATIENTS AND METHODS

A 4-year prospective study of rectal cancer patients' quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-30 and CR38 questionnaires.

RESULTS

A total of 329 patients returned questionnaires. Overall, anterior resection patients had better quality of life scores than abdominoperineal extirpation patients. High-anterior resection patients had significantly better scores than both low-anterior resection and abdominoperineal extirpation patients. Low-anterior resection patients, however, overall had a better quality of life than abdominoperineal extirpation patients, especially after 4 years. Abdominoperineal extirpation patients' quality of life scores did not improve over time. Stoma patients had significantly worse quality of life scores than nonstoma patients. Quality of life improved greatly for patients whose stoma was reversed.

CONCLUSIONS

Anterior resection and nonstoma patients, despite suffering micturition and defecation problems, had better quality of life scores than abdominoperineal extirpation and stoma patients. Comparisons between abdominoperineal extirpation and anterior resection patients should consider the effect of temporary stomas. Improvements in quality of life scores over time may be explained by reversal of temporary stomas or physiologic adaptation.

A prospective evaluation of anorectal function after total mesorectal excision in patients with a rectal carcinoma

BACKGROUND

Rectum resection with total mesorectal excision (TME) and neorectal anastomosis often compromises anorectal function. Insight into the underlying mechanisms is lacking. Therefore, a prospective study was designed to investigate the relationship between clinical and functional outcomes preoperatively and postoperatively.

METHODS

Eleven patients with rectal cancer were examined before and 4 and 12 months after surgery and compared with 11 healthy volunteers (HVs). Anorectal (neorectal) function was examined by clinical outcome questionnaire, anal manometry, rectal compliance, and sensation. Six HVs also underwent barostat measurements in the sigmoid colon.

RESULTS

Clinical parameters of soiling and passive incontinence (loss of stool without sensation) increased significantly until 12 months postoperatively, whereas urgency and tenesmus increased temporarily, returning to preoperative values at 12 months. In anorectal measurements, anal sphincter function was grossly preserved; however, rectal-anal inhibitory reflex (RAIR) was decreased at 4 months but recovered after 1 year. Neorectal compliance was similar to that of HV sigmoid, increasing slightly after 12 months but still significantly lower than that of normal rectum. Neorectal sensation to pressure distention was similar to that of normal rectum, however accompanied by smaller volumes. Neorectal distention induced contractions of large amplitude at 4 months, returning to normal after 12 months.

CONCLUSIONS

Our results suggest that the transient increase in urgency and tenesmus after surgery results from a temporary increase in neorectal "irritability" accompanied by some adaptation of compliance in time. In contrast, episodes of incontinence and soiling are increased after 1 year most likely because of reduced neorectal capacity and RAIR recovery in the presence of a low basal anal sphincter pressure.

Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy

OBJECTIVE

Anorectal function is greatly disturbed after rectal surgery with or without radiotherapy (RT). To clarify the underlying mechanisms, we designed a prospective study to evaluate the effect of RT and surgery on anorectal function and clinical outcome of patients with a rectal carcinoma.

METHODS

Thirty-four patients with a rectal carcinoma participated in this study. They filled out a symptom questionnaire and underwent anal manometry, anal and rectal mucosal electrosensitivity testing, and a rectal barostat, before surgery, 4 and 12 months postoperatively. Thirteen patients were lost to follow-up, 14 underwent surgery alone (total mesorectal excision [TME]), and seven also received RT (RT + TME).

RESULTS

Functional outcome was disappointing in both groups, with at 4 months a significantly higher defecation frequency after RT + TME as compared with TME. Anal sphincter function and rectal sensitivity to pressure-controlled distention were not affected by either treatment. Rectal compliance, however, was significantly reduced after RT + TME at 4 and 1 2 months, resulting in lower rectal volumes at the thresholds for first sensation and desire to defecate. Rectal but not anal mucosal electrosensitivity was higher after TME + RT.

CONCLUSIONS

Anorectal function after rectal surgery with or without RT is greatly hampered because of a decreased rectal compliance. After 12 months, partial improvement is shown, especially in the absence of RT.

Anorectal functional disorders in the absence of anorectal inflammation in patients with Crohn's disease

BACKGROUND

Histological alterations in the enteric nervous system (ENS) have been described in patients suffering from Crohn's disease (CD). The aim of this study was to investigate whether patients with CD without rectal inflammation have abnormal anorectal function compared with healthy volunteers.

METHODS

Fifty-four patients with CD and 26 healthy volunteers were examined by anorectal manometry and answered a standardized questionnaire. No patient had active CD in the rectum as determined by endoscopy.

RESULTS

Maximum anal resting and squeeze pressures did not differ between patients and healthy volunteers. The rectoanal inhibitory reflex was absent in 24 of 54 patients and two of 26 healthy volunteers (P < 0.05). The first sensation to distension of the rectal balloon was reported at mean(s.e.m.) 57.9(4.4) ml by patients and 37.5(2.2) ml by healthy volunteers (P < 0.01). The standardized interview revealed additional disorders of anorectal function in patients with CD.

CONCLUSION

Anorectal function appears to be altered in many patients with CD even in the absence of macroscopic anorectal disease. This may be due to a disorder of the ENS.

Mesorectal excision for rectal cancer: functional outcome after low anterior resection and colorectal anastomosis without a reservoir

OBJECTIVE: The anal sphincters, neorectal capacity and motility may be affected by injury to the autonomic nerves during rectal resection. Anorectal function also depends on the method used for restoration of intestinal continuity, and colonic reservoir reconstruction has been recommended in ultralow anastomosis. This study was undertaken to evaluate the results after nerve preserving mesorectal excision and colorectal anastomosis without a reservoir. PATIENTS AND METHODS: Thirty-five consecutive patients who underwent low anterior resection with primary healing of the anastomosis, were included. Anal manometry with stationary pull through technique, rectal volumetry and symptom scoring (written questionnaires with visual analogue scales) were performed prior to and 12 months after surgery. Anal sphincter function was evaluated in all patients, but five patients with a colonic reservoir were excluded from the other evaluations. Thirty patients entered the main study; 14 patients having a total mesorectal excision (TME) and a low anastomosis (LA) (4-6 cm) and 16 patients a partial mesorectal excision (PME) and a high anastomosis (HA) (7-11 cm from the anal verge). RESULTS: Anal resting and squeeze pressure and rectal sensibility (threshold volume) were unchanged after the operation. The rectal volume eliciting urge to defecate was reduced from median 95 ml to 70 ml (P < 0.01), and the maximum tolerable rectal volume was reduced from 200 to 135 ml (P < 0.01) after the operation. The maximum tolerable volume was significantly lower in patients with LA than in patients with HA (P < 0.01). Overall functional results were good. The patients reported problems with complete bowel emptying (median VAS-score reduction from 90 to 60, P < 0.01), and minor incontinence problems (median VAS-score reduction from 100 to 90, P= 0.03). The reduction of VAS-scores was more pronounced in LA than HA patients (without reaching statistical significance). CONCLUSIONS: Anal sphincter function was preserved after mesorectal excision. Neorectal capacity was reduced, most pronounced in patients with LA. The overall functional results were satisfactory and slightly better in patients with HA than in those with LA.