Anterior resection syndrome: What should we tell practitioners and patients in 2018?

Multidisciplinary management of infra-peritoneal rectal cancer has pushed back the frontiers of sphincter preservation, without impairment of carcinological outcome. However, functional intestinal sequelae, grouping together several symptoms known under the name of anterior resection syndrome (ARS), have emerged and become an increasingly frequent concern for both patients and physicians. The pathophysiology is complex: ARS is a combination in various degrees of stool frequency, incontinence for flatus and/or stools, urgency, and disorders in discrimination and evacuation. The "Low Anterior Resection Score" (LARS), validated in 2012, is currently used to evaluate the severity of ARS and its impact on quality of life. While ARS can show improvement over the first two years, symptoms persist for longer than two years in nearly 60% of patients and in half of these patients, ARS is considered severe. The most frequently reported independent risk factors of severe ARS include neo-adjuvant radiation therapy, the extent of resection (total mesorectal excision that includes inter-sphincteric resection), absence of colonic pouch and anastomotic leak. In the absence of surgical complications and/or local recurrence, physicians can draw from a wide therapeutic armamentarium in order to improve the functional outcome of patients, including diet and lifestyle modifications, gut motility regulators, multimodal rehabilitation (biofeedback, electro-stimulation) and sacral nerve modulation. Permanent colostomy is an alternative of last resort, proposed only when all other solutions fail. A better understanding of the natural history of ARS, its risk factors as well as the array of therapeutic alternatives should provide better patient information and optimize management.

Gastric pull-up reconstruction after treatment for advanced hypopharyngeal and cervical esophageal cancer.

OBJECTIVES: In advanced hypopharyngeal and cervical esophageal carcinoma, the choice of reconstruction technique after total circumferential pharyngolaryngectomy (TCPL) remains controversial. We studied results of digestive tract reconstruction using gastric pull-up, concomitant or secondary to TCPL or after failure of reconstruction. MATERIAL AND METHODS: Twenty-four patients treated by gastric pull-up after TCPL for advanced hypopharyngeal or cervical esophageal carcinoma between December 1998 and January 2011 were retrospectively reviewed. RESULTS: Two-year survival was 37.5% (n=9). Thirty-day mortality was 4.1% (n=1), but 3 more patients died before discharge. Perioperative morbidity was 54.1% (n=13), including 9 fistulas (37.5%). Seventeen patients (71%) recovered oral feeding. CONCLUSION: Gastric pull-up is an interesting reconstruction technique after TCPL with invasion of the esophageal mouth, allowing comfortable oral feeding, but with non-negligible morbidity and mortality. Long-term survival is not high, partly due to the unfavorable prognosis of advanced hypopharyngeal and cervical esophageal tumor. The present high rate of fistula raises doubts for this surgery as second-line reconstruction after primary failure.