Using transanal irrigation in the management of low anterior resection syndrome: a service audit

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Is transanal irrigation the best treatment possibility for low anterior resection syndrome? A multicenter, randomized clinical trial: study protocol

Background

Up to 50% of patients who undergo rectal resection suffer from various and partly severe functional problems, despite the preservation of the anal sphincter. These complaints are defined as low anterior resection syndrome (LARS). So far, there are no randomized clinical trials regarding the most effective treatment for LARS. Our aim is to evaluate whether transanal irrigation improves bowel function and quality of life in patients following low anterior resection compared to best supportive care.

Methods

Patients who have undergone low anterior resection will be approached for this study. On patient's visit, complaints regarding the defecation as well as any deterioration in their overall quality of life will be assessed using questionnaires such as the Low Anterior Resection Syndromes score, Wexner score, European Organization for Research and Treatment of Cancer (EORTC) Quality of Life (QOL) CR-29, and Measure Yourself Medical Outcome Profile tool. Few additional target questions will be also asked, such as "Would you recommend the treatment to anybody; did you expect the improvement following the treatment; etc." Questionnaires and scales will be filled on follow-up visits every 3 months for 1 year.

Discussion

This multicenter, randomized controlled trial will lead to a better understanding of LARS treatment. Moreover, it will be a hypothesis-generating study and will inform areas needing future prospective studies.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT05920681).

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

BACKGROUND

Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed.

OBJECTIVE AND METHODS

To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer.

RESULTS

The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy.

CONCLUSIONS

In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.

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.

Machine learning model for prediction of low anterior resection syndrome following laparoscopic anterior resection of rectal cancer: A multicenter study

BACKGROUND

Low anterior resection syndrome (LARS) severely impairs patient postoperative quality of life, especially major LARS. However, there are few tools that can accurately predict major LARS in clinical practice.

AIM

To develop a machine learning model using preoperative and intraoperative factors for predicting major LARS following laparoscopic surgery of rectal cancer in Chinese populations.

METHODS

Clinical data and follow-up information of patients who received laparoscopic anterior resection for rectal cancer from two medical centers (one discovery cohort and one external validation cohort) were included in this retrospective study. For the discovery cohort, the machine learning prediction algorithms were developed and internally validated. In the external validation cohort, we evaluated the trained model using various performance metrics. Further, the clinical utility of the model was tested by decision curve analysis.

RESULTS

Overall, 1651 patients were included in the present study. Anastomotic height, neoadjuvant therapy, diverting stoma, body mass index, clinical stage, specimen length, tumor size, and age were the risk factors associated with major LARS. They were used to construct the machine learning model to predict major LARS. The trained random forest (RF) model performed with an area under the curve of 0.852 and a sensitivity of 0.795 (95%CI: 0.681-0.877), a specificity of 0.758 (95%CI: 0.671-0.828), and Brier score of 0.166 in the external validation set. Compared to the previous preoperative LARS score model, the current model exhibited superior predictive performance in predicting major LARS in our cohort (accuracy of 0.772 for the RF model vs 0.355 for the preoperative LARS score model).

CONCLUSION

We developed and validated a robust tool for predicting major LARS. This model could potentially be used in the clinic to identify patients with a high risk of developing major LARS and then improve the quality of life.

An overview of transanal irrigation devices: an update

Transanal irrigation (TAI) is safe and effective treatment for constipation and faecal incontinence, but it should not be carried out before less invasive options have been tried. A thorough patient assessment and consideration of their preferences and tolerance should determine suitability and system choice. The range of available TAI equipment can be overwhelming. Therefore, to aid health professionals, this article presents a summary of the latest available devices on the market, as well as guidance on how to select a suitable device. TAI devices can be categorised into low-or high-volume; cones, catheters or balloon inflating devices; manual, electric pump or gravity-fed systems; and bed systems. Determining whether a low or high volume of water is required is a good starting point for device selection. Nurses should be aware of available devices and select one most suitable for a patient, as well as adequately train them in its usage and provide follow-up support. Nurses should communicate the potential improvement to quality of life TAI can offer and encourage adherence to avoid premature discontinuation.