A randomized trial comparing transanal irrigation and percutaneous tibial nerve stimulation in the management of low anterior resection syndrome

Treatment options for postoperative faecal incontinence after colorectal surgery

Postoperative faecal incontinence is a common and challenging complication following colorectal surgery, significantly impacting patients' quality of life. This article provides an overview of the types of colorectal surgical interventions that may contribute to faecal incontinence and explores various treatment options, ranging from conservative management to surgery. Conservative approaches include dietary modifications, bowel training and pharmacological treatments such as bulking agents, antidiarrhoeal medications and biofeedback therapy. For patients with persistent symptoms, advanced therapies such as sacral and tibial nerve stimulation are considered. Surgical options including sphincter repair, pouch formation, artificial anal sphincter implant or colostomy may be required for severe cases. The article reviews the most common treatment modalities, emphasising the importance of an individualised approach. Multidisciplinary care involving colorectal surgeons, physiotherapists and gastroenterologists is essential for optimising outcomes. Ultimately, the management of postoperative faecal incontinence requires careful assessment of the underlying cause, severity of symptoms and patient preferences to guide treatment selection.

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.

Systematic review of the management options available for low anterior resection syndrome (LARS)

BACKGROUND

Rectal cancer incidence is increasing. Low anterior resection is currently the gold standard surgical management. Postoperatively, patients may present with symptoms indicative of low anterior resection syndrome (LARS). LARS can be debilitating and is difficult to treat with low efficacy of treatment modalities. This systematic review aims to highlight the current evidence regarding LARS management.

METHODS

Systematic review of Medline, Cochrane and Embase used the following terms: "low anterior resection syndrome" AND "management", "low anterior resection syndrome" AND "treatment". Articles that focus solely of low anterior resection syndrome management in patients > 18 years were included. Bias risk was assessed via the Newcastle-Ottawa quality assessment scale for cohort studies and the JBI critical appraisal tool for randomized controlled trials. Due to heterogeneity of methodology, no statistical analysis was performed.

RESULTS

Thirty-eight articles with a total of 1914 patients were included in this review. Ninety-five per cent underwent surgery for malignancy. Treatment options included pharmacology, pelvic floor rehabilitation (PFR), transanal irrigation (TAI), sacral nerve modulation (SNM), percutaneous tibial nerve stimulation (PTNS) and "treatment programs" starting from the least invasive procedures escalating to more invasive treatments upon failure. The most common published medical therapies report Ramoestron use; however, studies are low impact. PFR showed significant improvement in LARS mostly in those with symptoms of faecal incontinence. However, long-term outcomes are inconsistent. TAI supplies pseudo-continence with its greatest benefit reported in those with incomplete evacuation. TAI has significant short-term effects on LARS but little long-term effect. TAI is also associated with a significant drop-out rate. SNM's hypothesised benefit is extrapolated from non-LARS associated FI. Results show improvements in FI but a high rate of explantation. PTNS evidence suggests little if any significant LARS improvement. A single "stepwise programme" study reported that 77 per cent did not progress further than diet and medication. Little evidence suggests benefit regarding diet or acupuncture.

DISCUSSION

There is no consensus as to the optimal treatment strategy for LARS. LARS is multifactorial and requires sensitive discussion between patient and surgeon to address the most prominent symptom. It requires physical and psychological input. No single treatment option provides superior results. Treatment is based on symptom control and patient acceptance.

Use of transanal irrigation (TAI) in the treatment of persistent bowel disorders in patients with endometriosis: A retrospective study

PURPOSE

Endometriosis has a strong impact on women's quality of life (QoL). Pain is the main symptom of the disease, but bowel dysfunctions such as fecal incontinence, constipation and voiding difficulties are also reported. Patients could suffer from a Low Anterior Resection Syndrome (LARS)-like syndrome. Transanal irrigation (TAI), known to alleviate LARS-related symptoms, has been suggested to aid bowel dysfunction in endometriosis patients, potentially facilitating pelvic floor rehabilitation.

METHODS

We retrospectively collected data from 60 patients with endometriosis and bowel dysfunction who had been prescribed with the Peristeen® Plus TAI system. Patient satisfaction, pain, QoL and LARS score were evaluated before (baseline) and after TAI treatment (follow-up of approximately 12 months).

RESULTS

Of the 60 patients meeting the inclusion criteria, 12 patients did not complete the questionnaires at follow-up and 16 patients discontinued treatment. Data analysis performed on 32 patients showed a mean increase of 3.6 points in patient satisfaction after TAI treatment and a mean pain reduction of 1.8 points (both, p-value < 0.001). LARS score decreased from a mean of 21.9 at baseline to a mean of 12.7 (p-value < 0.001). Accordingly, there was a notable improvement in patients' QoL.

CONCLUSION

TAI is a useful treatment for bowel dysfunctions in patients with endometriosis. When offered to these patients, TAI seems to represent a valuable strategy to reduce pelvic floor stress. This study confirms that TAI was associated to a significantly higher patients' satisfaction, as well as to a reduction of pain and LARS-like symptoms.

Consensus-driven protocol for transanal irrigation in patients with low anterior resection syndrome and functional constipation

BACKGROUND

This study aims to establish a consensus-based standard protocol for transanal irrigation (TAI) in patients with low anterior resection syndrome (LARS) and functional constipation.

METHODS

The Delphi method was utilized to reach a consensus among clinicians and nurses expert in the field of colorectal surgery and gastroenterology. To address various uncertainties concerning technical aspects, difficulties, and prescription of TAI, two questionnaires were developed and analyzed in two rounds. A binary approach was employed, setting a consensus threshold of 75% agreement.

RESULTS

In the first round, nurses achieved consensus on all statements, while clinicians required a second round to reach consensus, particularly regarding prescription and technical aspects. Clinicians reached consensus on prescribing TAI as a second-line treatment for LARS and functional constipation, following the failure of conservative measures such as dietary and lifestyle interventions. Timing considerations for patients with LARS encompass avoiding TAI within 1 month of stoma closure and waiting a minimum of 3 months. For functional constipation, TAI is recommended for slow transit constipation, emphasizing its preference over surgical options. Consensus was also reached on the choice of catheter for patients with LARS, training requirements for patients and caregivers, preparation of the patient's intestine before TAI, and recommended irrigations.

CONCLUSIONS

This consensus study successfully developed a standardized TAI protocol for LARS and functional constipation. It provides comprehensive guidelines for prescription and technical aspects, addressing the challenges encountered by healthcare professionals. The protocol aims to enhance patient care, improve treatment outcomes, and contribute to the advancement of TAI.

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.

Preventative strategies for low anterior resection syndrome

BACKGROUND

A common and debilitating complication of low anterior resection for rectal cancer is low anterior resection syndrome (LARS). As a multifactorial entity, LARS is poorly understood and challenging to treat. Despite this, prevention strategies are commonly overlooked. Our aim was to review the pathophysiology of LARS and explore current evidence on the efficacy and feasibility of prophylactic techniques.

METHODS

A literature review was performed between [1st January 2000 to 1st October 2023] for studies which investigated preventative interventions for LARS. Mechanisms by which LARS develop are described, followed by a review of prophylactic strategies to prevent LARS. Medline, Cochrane, and PubMed databases were searched, 189 articles screened, 8 duplicates removed and 18 studies reviewed.

RESULTS

Colonic dysmotility, anal sphincter dysfunction and neorectal dysfunction all contribute to the development of LARS, with the complex mechanism of defecation interrupted by surgery. Transanal irrigation (TAI) and pelvic floor rehabilitation (PFR) have shown benefits in preventing LARS, but may be limited by patient compliance. Intraoperative nerve monitoring (IONM) and robotic-assisted surgery have shown some promise in surgically preventing LARS. Nerve stimulation and other novel strategies currently used in treatment of LARS have yet to be investigated in their roles prophylactically.

CONCLUSIONS

To date, there is a limited evidence base for all preventative strategies including IONM, RAS, PFP and TAI. These strategies are limited by either access (IONM, RAS and PFP) or acceptability (PFP and TAI), which are both key to the success of any intervention. The results of ongoing trials will serve to assess acceptability, while technological advancement may improve access to some of the aforementioned strategies.

The Role of Percutaneous Tibial Nerve Stimulation (PTNS) in Low Anterior Resection Syndrome (LARS): A Systematic Review and Meta-analysis

PURPOSE

The aim of the present study was to evaluate the pooled efficacy of percutaneous tibial nerve stimulation (PTNS) in patients with low anterior resection syndrome (LARS).

MATERIAL AND METHODS

This study was based on the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. The primary endpoint was the pooled effect size of PTNS in LARS score (LARSS). Secondary endpoints included incontinence (Fecal Incontinence Score-FIC, Obstructive Defecation Syndrome-ODS), sexual functionality and quality of life (QoL) questionnaires, and manometric evaluations. Continuous outcomes were reported as weighted mean difference (WMD), with the corresponding 95% confidence interval (95% CI). Quality evaluation was performed via the National Institutes of Health (NIH) quality assessment tool.

RESULTS

Overall, 5 studies were included. PTNS resulted to reduced LARSS values (WMD: - 5.68, 95%CI: - 7.73, - 3.63, p < 0.001). A similar effect was noted in St Mark's FIC (p < 0.001) and ODS (p = 0.02) score. An improvement in several QoL scales was found. There was no effect in sexual functionality and manometric measurements. Compared to sham, PTNS significantly improved LARSS.

CONCLUSIONS

The application of PTNS in patients with LARS results in an improvement in multiple clinical parameters, including defecation functionality and quality of life. Due to several study limitations, further high quality RCTs are required to delineate the exact efficacy of PTNS.

Transanal irrigation as a therapeutic option for patients with incontinence and severe chronic constipation refractory to first-line treatment

INTRODUCTION

The aim is to evaluate the utility of transanal irrigation such as treatment of incontinence and severe chronic constipation which is refractory to first-line therapy, and to assess its impact into the symptomatology and quality of life.

METHODS

Observational retrospective study of patients with incontinence and chronic constipation that had initiated transanal irrigation in two hospitals of the region. We collect sociodemographic variables, comorbidity, previous treatments, tests, parameters and incidences during the irrigation, and punctuation in the Cleveland Clinic Incontinence and Constipation Scores and EuroQol-5D Quality Of Life Scale before and after the treatment.

RESULTS

40 patients, 20 with incontinence and 20 with chronic constipation. After an average period of 9 months of treatment, in 14 patients with incontinence we have observed a mean clinical improvement of 7,45 points before-after treatment measured with Cleveland Clinic Incontinence Score, and a mean improvement of 23 points in their quality of life before-after treatment measured with EQ5D Scale (P < .001); and in 16 patients with constipation a mean clinical improvement of 7,6 points before-after treatment measured with Cleveland Clinic Constipation Score, and a mean improvement of 31,5 points in their quality of life before-after treatment measured with EQ5D Scale (P < .001).

CONCLUSIONS

Transanal irrigation is an effective therapy for patients with incontinence and chronic constipation that are refractory to first-line therapies. It's an easy, self-administered and safe procedure. When the patient learns how to use it, the symptomatology and quality of life are improved.

Prospective cohort study of high-volume transanal irrigation in patients with constipation and/or faecal incontinence

AIM

The aim of this work was to determine the clinical efficacy of high-volume transanal irrigation (TAI) in patients with constipation and/or faecal incontinence using validated symptom and quality of life questionnaires.

METHOD

This was a prospective cohort study of 114 consecutive patients with constipation and/or faecal incontinence (Rome IV defined) who started TAI. A comprehensive questionnaire was completed at baseline and 4, 12, 26 and 52 weeks' follow-up. The primary objective was significant symptom reduction [≥30%; Cleveland Clinic Constipation Score (CCCS) and St Marks Incontinence Score (SMIS)] in those who continued TAI at 52 weeks. Secondary objectives were (1) continuation rates of TAI, (2) effect on quality of life (QoL) and (3) identification of predictors for continuation.

RESULTS

A total of 59 (51.8%) patients with constipation, 26 (22.8%) with faecal incontinence and 29 (25.4%) with coexistent symptoms were included. At 52 weeks, 41 (36.0%) patients continued TAI, 63 (55.2%) stopped and 10 (8.8%) patients were lost to follow-up. In those who continued TAI at 52 weeks (n = 41), no reduction of constipation symptoms was observed. Median Patient Assessment of Constipation Quality of Life scores decreased on most domains, indicating QoL improvement. Reduction of faecal incontinence occurred in 5/9 (55.6%) patients with faecal incontinence and in 3/10 (30.0%) patients with coexistent symptoms. The median SMIS per-individual decreased in patients with coexistent symptoms (2; interquartile range 0-4; p = 0.023). Median Fecal Incontinence Quality of Life scores increased in most domains, indicating improved QoL. No clinical characteristics predicted continuation.

CONCLUSION

One-third (n = 41) of patients continued TAI at 52 weeks. In those who continued TAI at 52 weeks, symptoms of faecal incontinence (SMIS) were reduced but not constipation (CCCS). QoL related to both constipation and faecal incontinence improved. No clinical characteristics predicted continuation.

Transanal irrigation in functional bowel disorders and LARS: short-term results from an Italian national study

PURPOSE

To evaluate the potential benefits associated with the short-term (6 months) treatment with transanal irrigation (TAI) in patients suffering from functional constipation (FC), functional fecal incontinence (FI), and low anterior resection syndrome (LARS).

METHODS

A multicenter observational study (12 centers; 369 patients) was conducted to assess the following primary and secondary objectives: to evaluate the level of satisfaction regarding bowel control and quality of life (QoL); to evaluate bowel symptoms severity and dropout frequency and reason. To this aim, validated questionnaires were provided to the patients at baseline (T0) and after 6 months of TAI treatment (T6) performed with the medical device Peristeen® Plus (Coloplast A/S, Denmark). Statistical analyses were conducted to compare the outcomes obtained at T0 and T6.

RESULTS

A 6-month treatment with TAI enabled a statistically significant (p < 0.05) improvement of QoL scores, satisfaction scores regarding bowel control, and severity indexes of disorder-related symptoms in patients suffering from FC, FI, and LARS. Globally, 8.0% of patients discontinued the treatment after 6 months as a result of occurrence of symptoms (2.4%) or other justifications (3.8%) such as personal reasons. None of the dropouts were due to treatment inefficacy.

CONCLUSION

Results of the present study suggest that short-term TAI treatment is beneficial for patients suffering from functional bowel disorders and LARS. Future analysis of prospective data will focus on the clinical outcomes associated with the long-term use (up to 24 months) of TAI when dealing with these types of medical conditions.

Systematic review and meta-analysis of randomized clinical trials on the treatment of low anterior resection syndrome

BACKGROUND

We conducted a systematic review of randomized clinical trials on treating low anterior resection syndrome to help inform current practice.

METHODS

This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of randomized clinical trials involved different treatments for low anterior resection syndrome. The risk of bias 2 tool was used to assess the risk of bias. The main outcomes were improvement in low anterior resection syndrome after treatment assessed by change in low anterior resection syndrome, fecal incontinence scores, and adverse treatment effects.

RESULTS

After an initial screening of 1,286 studies, 7 randomized clinical trials were included. Sample sizes ranged between 12 to 104 patients. Posterior tibial nerve stimulation was the most frequently assessed treatment in 3 randomized clinical trials. The weighted mean difference between posterior tibial nerve stimulation and medical treatment or sham therapy in follow-up low anterior resection syndrome score (-3.31, P = .157) was insignificant. Transanal irrigation reduced major low anterior resection syndrome symptoms by 61.5% compared with 28.6% after posterior tibial nerve stimulation with a significantly lower 6-month follow-up low anterior resection syndrome score. Pelvic floor training achieved better improvement in low anterior resection syndrome than standard care (47.8% vs 21.3%) at 6 months, but this was not maintained at 12 months (40.0% vs 34.9%). Ramosetron was associated with a greater short-term improvement in major low anterior resection syndrome (23% vs 8%) and a lower low anterior resection syndrome score (29.5 vs 34.6) at 4-weeks follow-up than Kegels or Sitz baths. No significant improvement in bowel function was noted after probiotics use as probiotics and placebo had similar follow-up low anterior resection syndrome scores (33.3 vs 36).

CONCLUSION

Transanal irrigation was associated with improvement in low anterior resection syndrome according to 2 trials, and ramosetron showed promising short-term results in one trial. Posterior tibial nerve stimulation had a marginal benefit compared with standard care. In contrast, pelvic floor training was associated with short-term symptomatic improvement, and probiotics showed no tangible improvement in low anterior resection syndrome symptoms. Firm conclusions cannot be drawn due to the small number of trials published.

Advances in diagnosis and treatment of low anterior resection syndrome

Rectal cancer is one of the most common cancers. As much as 90% of patients with low rectal cancer complain of increased frequency of defecation, fecal incontinence, and evacuation problems after surgery, which is termed as low anterior resection syndrome (LARS). LARS detrimentally affects the quality of life for patients with rectal cancer. In this paper, we review the pathogenesis, risk factors, assessment tools, and treatment strategies for LARS.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Randomized Controlled Clinical Trial of Transanal Irrigation Versus Conservative Treatment in Patients With Low Anterior Resection Syndrome After Rectal Cancer Surgery

OBJECTIVE

The aim of the study was to evaluate transanal irrigation (TAI) as a treatment for low anterior resection syndrome (LARS).

BACKGROUND

LARS is a bowel disorder that is common after sphincter preserving rectal cancer surgery. Despite symptomatic medical treatment of LARS many patients still experience bowel symptoms that may have a negative impact on quality of life (QoL). TAI is a treatment strategy, of which the clinical experience is promising but scientific evidence is limited.

MATERIALS AND METHODS

A multicenter randomized trial comparing TAI (intervention) with conservative treatment (control) was performed. Inclusion criteria were major LARS, age above 18 years, low anterior resection with anastomosis and a defunctioning stoma as primary surgery, >6 months since stoma reversal, anastomosis without signs of leakage or stricture, and no signs of recurrence at 1-year follow-up. The primary endpoint was differences in bowel function at 12-month follow-up measured by LARS score, Cleveland Clinic Florida Fecal Incontinence Score, and 4 study-specific questions. The secondary outcome was QoL.

RESULTS

A total of 45 patients were included, 22 in the TAI group and 23 in the control group. Follow-up was available for 16 and 22 patients, respectively. At 12 months, patients in the TAI group reported significantly lower LARS scores (22.9 vs 32.4; P =0.002) and Cleveland Clinic Florida Fecal Incontinence Score (6.4 vs 9.2; P =0.050). In addition, patients in the TAI group also scored significantly higher QoL [8 of 16 European Organisation for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) QoL aspects] compared with the control group.

CONCLUSIONS

The results confirm our clinical experience that TAI reduces symptoms included in LARS and improves QoL.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of Tibial Nerve Stimulation on Fecal Incontinence in Patients With Low Anterior Resection Syndrome Following Surgery for Colorectal Cancer

OBJECTIVE

To systematically review the available literature on the efficacy of tibial nerve stimulation on faecal incontinence and quality of life in adult patients with low anterior resection syndrome following surgery for colorectal cancer.

METHODS

A primary search of electronic databases was conducted adopting a combination of search terms related to the following areas of interest: "efficacy", "tibial nerve stimulation" and "low anterior resection syndrome". A secondary search of the grey literature was performed in addition to checking the reference list of included studies and review papers. The review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A descriptive analysis was used to integrate the review findings.

RESULTS

Five distinct studies involving 116 patients met the inclusion criteria for the review. The included studies suggest that tibial nerve stimulation may have a positive effect on faecal incontinence and quality of life in some patients with low anterior resection syndrome and might be considered as an additional treatment option.

CONCLUSION

There were a limited number of studies and a great degree of heterogeneity of evidence due to differences in participants' baseline characteristics, dropout rates, and follow-up periods. Further research adopting validated, consistent, and complex outcome assessment methods is recommended to determine the efficacy of tibial nerve stimulation for treatment of patients with low anterior resection syndrome.

The Role of Traditional Acupuncture in Low Anterior Resection Syndrome Treatment: A Pilot Study

BACKGROUND

There is limited evidence on the efficacy of acupuncture in bowel dysfunction treatment.

OBJECTIVE

The aim of this pilot study was to investigate the potential value of acupuncture in the treatment of low anterior resection syndrome.

DESIGN

This was an open-design pilot study.

SETTINGS

This was a single-center study.

PATIENTS

Nine (5 female) patients with major low anterior resection syndrome were included.

INTERVENTIONS

All patients underwent acupuncture by a trained specialist once a week for 10 weeks.

MAIN OUTCOME MEASURES

Bowel function was assessed by using the low anterior resection syndrome score and the Memorial Sloan-Kettering Cancer Center bowel function instrument before the procedure, just after finishing the course of acupuncture, and 6 months after the treatment.

RESULTS

The average age was 56.44 (50-65; SD ±5.4). Median age was 56 years. At the end of the procedure, all patients reported significant improvement in low anterior resection syndrome symptoms: the average low anterior resection syndrome score before acupuncture was 39 (±2.7), after acupuncture it was 30.3 (±10.6), and 6 months after acupuncture it was 7.22 (±10.244; p < 0.000). The average Memorial Sloan-Kettering Cancer Center bowel function instrument score before acupuncture was 55.33 (±11.55), after the procedure it was 60 (±14.97), and 6 months later it was 70.22 (±12.2; p < 0.000).

LIMITATIONS

The small sample size and the fact that this is a single-center nonblinded study are limitations of this work.

CONCLUSIONS

Acupuncture may be effective in low anterior resection syndrome treatment and needs further evaluation. The procedure is safe and feasible. See Video Abstract at http://links.lww.com/DCR/B700.

REGISTRATION

ClinicalTrials.gov: NCT03916549.

EL PAPEL DE LA ACUPUNTURA TRADICIONAL EN EL TRATAMIENTO DEL SNDROME DE RESECCIN ANTERIOR BAJA UN ESTUDIO PILOTO

ANTECEDENTES:Existe evidencia limitada sobre la eficacia de la acupuntura para el tratamiento de la disfunción intestinal.OBJETIVO:El objetivo de este estudio piloto fue investigar el valor potencial de la acupuntura en el tratamiento del síndrome de resección anterior baja.DISEÑO:Este fue un estudio piloto de diseño abiertoAJUSTES:Este fue un estudio en un solo centroPACIENTES:Fueron incluidos nueve pacientes con síndrome de resección anterior baja (muy sintomáticos), cinco de ellos eran mujeresINTERVENCIONES:Todos los pacientes fueron tratados con acupuntura, una vez a la semana durante diez semanas por un especialista capacitado.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal fue evaluada, antes del procedimiento, justo al finalizar el ciclo de acupuntura y a los seis meses, utilizando la puntuación (score) para el síndrome de resección anterior baja y el instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center.RESULTADOS:La edad media fue 56,44 (50 - 65) (DE ± 5,4). Edad mediana 56 años. Al final del procedimiento, todos los pacientes manifestaron una mejoría significativa de los síntomas del síndrome de resección anterior baja: La puntuación promedio del síndrome de resección anterior baja antes de la acupuntura fue 39 (± 2,7), después de - 30,3 (± 10,6) y 6 meses después de 7,22 (± 10,244) (p <0,000). El puntaje promedio del instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center antes de la acupuntura fue 55.33 (± 11.55), después del procedimiento 60 (± 14.97) y 6 meses después 70.22 (± 12.2) (p <0,000).LIMITACIONES:Tamaño de muestra pequeño, estudio no cegado en un solo centro.CONCLUSIONES:La acupuntura puede ser eficaz en el tratamiento del síndrome de resección anterior baja, pero es necesario continuar evaluando su utilidad. El procedimiento es seguro y factible. Consulte Video Resumen en http://links.lww.com/DCR/B700.

Managing Bowel Symptoms After Sphincter-Saving Rectal Cancer Surgery: A Scoping Review

CONTEXT

Rectal cancer is common and it is often treated by surgery with or without chemoradiation. Cancer treatment frequently results in bowel symptoms.

OBJECTIVES

The review aim was to chart the management options for bowel symptoms following rectal cancer surgery.

METHODS

A scoping review was undertaken searching nine healthcare databases, using relevant search terms and Boolean operators following PRISMA-ScR guidance. Data were extracted into an Excel spreadsheet using headings from the United Kingdom Department of Health guidance and are reported narratively.

RESULTS

30 heterogeneous studies met the inclusion criteria, including 853 patients. The most commonly reported bowel symptom was fecal incontinence; the most frequent management strategy was sacral nerve stimulation. Most studies reported on a single management option, often used to manage more than one bowel symptom. Often failure to satisfactorily improve symptoms using options such as medication was needed prior to progressing to other management options. In some studies more than one management option was used, such as rehabilitation programmes.

CONCLUSION

It is likely that to effectively manage the bowel symptoms experienced after rectal cancer treatment, more than one management option may be used-. Additionally, different management options may need to be tried concurrently.

Low Anterior Resection Syndrome: Predisposing Factors and Treatment

Bowel dysfunction after restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long-term sequela of rectal cancer treatment that has a significant impact on quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause is likely multifactorial, and there are numerous patient, tumor, and treatment-level factors associated with its development. In accordance with these risk factors, several strategies have been proposed to mitigate LARS postoperatively, including modifications in the technical approach to restorative proctectomy and advancements in the multidisciplinary care of rectal cancer. Furthermore, a clinically applicable pre-operative nomogram has been developed to estimate the risk of LARS postoperatively, which may help in counseling patients before surgery. The management of LARS begins with identifying those who manifest symptoms, as postoperative bowel dysfunction often goes unrecognized. This goal is best achieved with the systematic screening of patients using validated Patient-Reported Outcome Measures. Once a patient with LARS is identified, conservative management strategies should be implemented. When available, a dedicated LARS nurse and/or multidisciplinary team can be an invaluable resource in engaging patients and educating them regarding LARS self-care. If symptoms of LARS persist or worsen over time despite conservative measures, second-line interventions, such as transanal irrigation or pelvic floor rehabilitation, can be initiated. A small proportion of patients will ultimately require an intervention such as sacral neuromodulation or permanent colostomy for refractory, major LARS symptoms.

Transanal Irrigation for Neurogenic Bowel Disease, Low Anterior Resection Syndrome, Faecal Incontinence and Chronic Constipation: A Systematic Review

Transanal irrigation (TAI) has received increasing attention as a treatment option in patients with bowel dysfunction. This systematic review was conducted according to the PRISMA guidelines and evaluates the effect of TAI in neurogenic bowel dysfunction (NBD), low anterior resection syndrome (LARS), faecal incontinence (FI) and chronic constipation (CC). The primary outcome was the effect of TAI on bowel function. Secondary outcomes included details on TAI, quality of life (QoL), the discontinuation rate, adverse events, predictive factors for a successful outcome, and health economics. A systematic search for articles reporting original data on the effect of TAI on bowel function was performed, and 27 eligible studies including 1435 individuals were included. Three randomised controlled trials, one non-randomised trial, and 23 observational studies were included; 70% of the studies were assessed to be of excellent or good methodological quality. Results showed an improvement in bowel function among patients with NBD, LARS, FI, and CC with some studies showing improvement in QoL. However, discontinuation rates were high. Side effects were common, but equally prevalent among comparative treatments. No consistent predictive factors for a successful outcome were identified. Results from this review show that TAI improves bowel function and potentially QoL; however, evidence remains limited.

Management guidelines for low anterior resection syndrome - the MANUEL project

AIM

Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS.

METHOD

The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project.

RESULTS

The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts.

CONCLUSIONS

The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.

Knowledge, attitudes, practices, and related factors of low anterior resection syndrome management among colorectal surgery nurses: a multicenter cross-sectional study

PURPOSE

With the widespread development of low and ultra-low rectal sphincter-preservation surgery, low anterior resection syndrome, a new clinical challenge, has received increased attention. As the principal practitioners of this syndrome management, colorectal surgery nurses require sufficient relevant knowledge and skills, but few studies have been conducted of their actual ability and practice of managing the syndrome. The study adopted a knowledge, attitude, and practice model to evaluate low anterior resection syndrome management among colorectal surgery nurses.

METHOD

A multicenter cross-sectional study was conducted, in which 361 registered nurses in colorectal surgery from 6 hospitals in 4 cities were enrolled. A structured paper questionnaire was used to collect demographics, scale scores for knowledge, attitudes and management practice, and training needs.

RESULTS

Participants scored poorly in knowledge, attitude, and practice. Whether training had been received or not was an important factor affecting the knowledge, attitude, and practice of nurses, and the majority of participants had not received training. Nurses with lower levels of education had worse knowledge and practice, and contract nurses scored lower than staff nurses in terms of knowledge and attitude.

CONCLUSIONS

The critical role of nurses in patient management places high demands on their knowledge, attitude, and practice. However, the present study demonstrated that the current knowledge, attitude, and practice of colorectal surgery nurses regarding the syndrome gave cause for concern, and whether training had been received was a key factor affecting these three aspects. Therefore, training is a key strategy to eliminate the gaps identified.

Changes to gastrointestinal function after surgery for colorectal cancer

Bowel function is increasingly considered as an important outcome for patients undergoing surgery for colorectal cancer. Increasing technical skills and technological advances have meant fewer patients require a long-term stoma but this comes at the cost, often, of poor function. With a larger range of treatment options available for a given cancer, both function and oncology should be considered in parallel when counselling patients before surgery. In the perioperative phase, bowel function can be improved with minimally invasive surgery and enhanced recovery after surgery protocols, with limited evidence for targeted medical therapies. Early detection and sound management of surgical complications such as anastomotic leak and stricture can mitigate their adverse effects on bowel function. Long-term gastrointestinal dysfunction manifests as diarrhoea and low anterior resection syndrome for colon and rectal cancer respectively. Multi-modal strategies for low anterior resection syndrome are emerging to improve significantly quality of life after restorative rectal cancer surgery.

Low Anterior Resection Syndrome

PURPOSE OF REVIEW

Low anterior resection syndrome is a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life. In this review, we summarize the major features and pathophysiology of this syndrome and discuss treatment approaches.

RECENT FINDINGS

Quality of life correlates significantly with severity of low anterior resection syndrome. Prompt assessment and initiation of therapy are essential to rehabilitating damaged mechanical and neural structures. Anorectal manometry demonstrates a global decrease in sphincteric function postoperatively, though in many patients, function does recover. Transanal irrigation, pelvic floor rehabilitation, and biofeedback are the mainstays of the treatment of major LARS. Definitive stoma can be considered in therapy refractory LARS > 2 years. The development of low anterior resection syndrome likely involves an interplay between mechanical and neural pathways. Clinically, patients present at varying levels of severity, and scoring systems are available to help assess patient symptoms and guide therapy. Treatment approaches range from conservative therapies to biofeedback and sacral nerve stimulation. Future randomized controlled trials aimed at risk stratification of patients and development of severity-based treatment algorithms are warranted.

"Prophylactic" transanal irrigation (TAI) to prevent symptoms of low anterior resection syndrome (LARS) after rectal resection: results at 12-month follow-up of a controlled randomized multicenter trial

BACKGROUND

Low anterior resection syndrome (LARS) is associated with a severe negative impact on patients' quality of life (QOL). In a recent prospective randomized controlled trial (RCT) by our group, early ("prophylactic") use of transanal irrigation (TAI) following rectal resection for rectal cancer was shown to improve symptoms associated with LARS significantly compared with a group under supportive therapy (ST) within 1 and 3 months following closure of the protective ileostomy. The aim of the present study was to evaluate the outcome after 12 months when patients had the option to choose between the two therapeutic options and/or modify the regimen of TAI (volume and time).

METHODS

In the RCT, 18 patients had been allocated to start with TAI following ileostomy closure, while 19 patients remained on ST only. Once the 3-month follow-up had been completed patients could choose between TAI or ST, respectively, and were invited for follow-up after 12 months. The maximum number of bowel movements during the day and the Wexner and LARS score as well as physical (PC) and mental (MC) component of the SF-36 questionnaire were evaluated. Furthermore, in patients who had changed their treatment arm, reasons for this decision were reported.

RESULTS

Six patients were lost to follow-up (all in the ST group). One patient from the ST group started with TAI due to problems associated with LARS, bringing the total number of TAI patients to 19. Nine patients from the previous TAI arm changed to ST due to the long duration of the emptying process (n: 8) or pain during TAI (n: 1), respectively. After 12 months, the median volume of water used for irrigation was 600 ml (range 200-1000 ml). The ten patients who continued with TAI patients showed a lower number of defecation episodes per daytime (TAI median 3; 1-6, ST median 5; 2-10, p: 0.018) and per night (TAI median 0; 0-1, ST median 1; 0-5, p: 0.004) compared to the ST group. Although the LARS score was lower in patients who used TAI after 12 months (TAI median 18; 9-32, ST median 30; 3-39), this failed to reach the level of significance (p: 0.063). Evaluation of the Wexner score and the 36-item Short Form Health Survey as well as comparison of patients who remained on TAI (n: 9) versus those who had stopped TAI after 3 months (n: 9) failed to find any statistically significant difference between TAI and ST.

CONCLUSIONS

This follow-up study revealed that a considerable number of patients decided to stop TAI within 12 months. However, the number of bowel movements during the day were still lower when TAI was used than when patients had ST only.

CATEGORY

Randomized trial.

REGISTRATION NUMBER

DRKS00011752, https://apps.who.int/trialsearch/ .