Cross-sectional study of low anterior resection syndrome in patients who have survived more than 5 years after sphincter-preserving surgery for rectal cancer / 中华胃肠外科杂志

Objective: In this study, we aimed to investigate the prevalence of low anterior resection syndrome (LARS) in patients who had survived for more than 5 years after sphincter-preserving surgery for rectal cancer and to analyze its relationship with postoperative time. Methods: This was a single-center, retrospective, cross-sectional study. The study cohort comprised patients who had survived for at least 5 years (60 months) after undergoing sphincter- preserving radical resection of pathologically diagnosed rectal adenocarcinoma within 15 cm of the anal verge in the Department of Gastrointestinal Surgery, Peking University People's Hospital from January 2005 to May 2016. Patients who had undergone local resection, had permanent stomas, recurrent intestinal infection, local recurrence, history of previous anorectal surgery, or long- term preoperative defecation disorders were excluded. A LARS questionnaire was administered by telephone interview, points being allocated for incontinence for flatus (0-7 points), incontinence for liquid stools (0-3 points), frequency of bowel movements (0-5 points), clustering of stools (0-11 points), and urgency (0-16 points). The patients were allocated to three groups based on these scores: no LARS (0-20 points), minor LARS (21-29 points), and major LARS (30-42 points). The prevalence of LARS and major LARS in patients who had survived more than 5 years after surgery, correlation between postoperative time and LARS score, and whether postoperative time was a risk factor for major LARS and LARS symptoms were analyzed. Results: The median follow-up time of the 160 patients who completed the telephone interview was 97 (60-193) months; 81 (50.6%) of them had LARS, comprising 34 (21.3%) with minor LARS and 47 (29.4%) with major LARS. Spearman correlation analysis showed no significant correlation between LARS score and postoperative time (correlation coefficient α=-0.016, P=0.832). Multivariate analysis identified anastomotic height (RR=0.850, P=0.022) and radiotherapy (RR=5.760, P<0.001) as independent risk factors for major LARS; whereas the postoperative time was not a significant risk factor (RR=1.003, P=0.598). The postoperative time was also not associated with LARS score rank and frequency of bowel movements, clustering, or urgency (P>0.05). However, the rates of incontinence for flatus (3/31, P=0.003) and incontinence for liquid stools (8/31, P=0.005) were lower in patients who had survived more than 10 years after surgery. Conclusions: Patients with rectal cancer who have survived more than 5 years after sphincter-preserving surgery still have a high prevalence of LARS. We found no evidence of major LARS symptoms resolving over time.

Clinical application and standardized implementation of intersphincteric resection / 中华胃肠外科杂志

Intersphincteric resection (ISR) is the ultimate sphincter-preserving surgical technique for low rectal cancer. To promote the standardized implementation of ISR, this review discusses the important issues regarding the clinical application of ISR with reference to the latest Chinese expert consensus on ISR. In terms of ISR-related pelvic anatomy of the rectum/anal canal, hiatal ligament is not identical with the anococcygeal ligament. At the level where the rectourethralis muscle continuously extends to the posteroinferior area of the membranous urethra from the rectum, the neurovascular bundle is identified between the posterior edge of rectourethralis muscle and the anterior edge of the longitudinal muscle of the rectum. This knowledge is crucial to detect the anterior dissection plane during ISR at the levator hiatus level. The indication criteria for ISR included: (1) stage I early low rectal cancer; (2) stage II-III low rectal cancer undergoing neoadjuvant treatment, and supra-anal tumors and juxta-anal tumors of stage ycT3NxM0, or intra-anal tumors of stage ycT2NxM0. However, signet ring cell carcinoma, mucinous adenocarcinoma and undifferentiated carcinoma should be contraindicated to ISR. For locally advanced low rectal cancer (especially anteriorly located tumor), neoadjuvant treatment should be carried out in a standardized manner. However, it should be recognized that neoadjuvant chemoradiotherapy was a risk factor for poor anal function after ISR. For surgical approaches for ISR, including transanal, transabdominal, and transanal transabdominal approaches, the choice should be based on oncological safety and functional consequences. While ensuring the negative margin, maximal preservation of rectal walls and anal canal contributs to better postoperative anorectal function. Careful attention must be paid to complications regarding ISR, with special focus on the anastomotic complications. The incidence of low anterior resection syndrome (LARS) was higher than 40%. However, this issue is often neglected by clinicians. Thus, management and rehabilitation strategies for LARS with longer follow-ups were required.

Síndrome de resección anterior baja y su relación con la calidad de vida: aplicación de cuestionario EuroQol-5 / Low anterior resection syndrome and quality of life: application of EuroQol-5 questionnaire

Resumen Introducción: Las cirugías con preservación de esfínter tienen como consecuencia el desarrollo de una disfunción defecatoria con diferentes grados, la cual es conocida como síndrome de resección anterior baja (LARS) y es medida con el cuestionario LARS Score. Objetivo: Determinar la asociación del cuestionario EuroQol-5 (calidad de vida) con los diferentes grados de LARS Score. Materiales y Método: Estudio de tipo transversal, aplicando el cuestionario LARS Score y EuroQol-5 a pacientes operados por cáncer de recto medio y bajo, durante el periodo 2004-2017. Se realiza análisis demográfico y del tipo de cirugía. Para determinar asociaciones entre variables se utilizan diferentes pruebas estadísticas, considerando significativo un valor de p < 0,05. Resultados: Se encuestó a 54 pacientes, 62,16% hombres, promedio de edad 58,44 años, el 37,03% presentó LARS Mayor. Los índices promedio de calidad de vida para pacientes No LARS es 0,75, para LARS Menor es 0,69 y para LARS Mayor es 0,61, la diferencia entre índices presenta un valor p = 0,246. 46,3% presenta problemas en actividades habituales. LARS Mayor presenta un Odd-Ratio de 3,8 y 4,7 para dolor/malestar y angustia/depresión respectivamente. 70% de los pacientes con LARS Mayor presentaron resección total del mesorrecto (TME) y el 45% corresponde a menores de 65 años. Discusión: No existe diferencia estadísticamente significativa entre los índices de calidad de vida según LARS Score. LARS Mayor tiene mayor posibilidad de desarrollar algún grado de dolor/malestar y angustia/depresión. El porcentaje de LARS Mayor es acorde a lo publicado y la TME es uno de los factores de mayor impacto en el desarrollo de LARS. Conclusiones: El LARS Score se relaciona de manera no significativa con el índice de calidad de vida entregado por el cuestionario EuroQol-5D, existiendo una tendencia a disminuir la calidad de vida a medida que empeora el LARS.

Introduction: Sphincter-sparing surgeries result in the development of a defecatory dysfunction with different degrees, which is known as low anterior resection syndrome (LARS) and is measured with the LARS Score questionnaire. Objective: To determine the association of the EuroQol-5 questionnaire with the different degrees of LARS Score. Materials and Method: Crosssectional study, applying the LARS Score and EuroQol-5 questionnaire to patients operated with low and middle rectal cancer, during the period 2004-2017. Demographic analysis and type of surgery are performed. Different statistical tests are used to determine associations between variables, considering a significant p value < 0.05. Results: 54 patients were surveyed, 62.16% men, mean age 58.44 years, 37.03% presented Mayor-LARS. The average quality of life indices for Non-LARS patients is 0.75, for Minor-LARS is 0.69 and for Mayor-LARS is 0.61, the difference between indices presents a p value = 0.246. 46.3% present problems in habitual activities. LARS Mayor presents an Odd-Ratio of 3.8 and 4.7 for pain/discomfort and anguish/depression respectively. 70% of patients with LARS Mayor presented SMT and 45% corresponded to those under 65 years of age. Discussion: There is no statistically significant difference between the quality of life indices according to the LARS Score. Mayor-LARS is more likely to develop some degree of Pain/Discomfort and anguish/depression. The percentage of Mayor-LARS is according to what has been published and the TME is one of the factors with the greatest impact on the development of LARS. Conclusion: The LARS Score is non-significantly related to the quality of life index provided by the EuroQol-5D questionnaire, and there is a tendency to decrease quality of life as the LARS worsens.

Síndrome de resección anterior baja en pacientes con cáncer de recto medio e inferior ¿Qué más podemos hacer? / Low anterior resection syndrome in patients with medium and low rectal cancer. What else can we do?

Resumen Durante las últimas décadas los avances en técnicas quirúrgicas, radioterapia y quimioterapia han logrado de forma significativa aumentar la sobrevida y disminuir la recidiva local en el cáncer de recto evitando una colostomía definitiva; sin embargo, este trascendental progreso médico no ha ido acompañado de una mejoría en los resultados funcionales de los pacientes sometidos a una cirugía conservadora de esfínter, siendo el conjunto de síntomas defecatorios posterior a la resección rectal, conocido como síndrome de resección anterior baja (LARS), una secuela prácticamente inevitable, que generalmente se asocia a disfunción sexual, urinaria, dolor crónico, altos costos en rehabilitación y control sintomático, además de una alteración importante en la calidad de vida. En este artículo presentamos una revisión completa y actualizada de las características clínicas y alternativas de tratamiento del LARS, finalizando con una propuesta de manejo integral multidisciplinario que destaca la importancia de la prehabilitación, evaluación objetiva de los síntomas, educación e información adecuada del paciente y su familia, además del trabajo en equipo en unidades especializadas de rehabilitación de piso pélvico, requisito fundamental a la hora de manejar adecuadamente esta patología.

During the last decades, advances in surgical techniques, radiotherapy and chemotherapy have significantly increased survival and reduced local recurrence in rectal cancer, avoiding a definitive colostomy. However, this transcendental medical progress has not been accompanied by an improvement in the functional results of patients after sphincter-preserving rectal resection, being the set of defecatory symptoms after rectal resection, known as low anterior resection syndrome (LARS), a practically inevitable sequel, which is usually associated with sexual or urinary dysfunction, chronic pain, high costs and an important alteration in the quality of life. In this article, we will present a complete and updated review of the clinical and alternative characteristics of LARS treatment, ending with a proposal for multidisciplinary and integral management that highlights the importance of prehabilitation, objective evaluation of symptoms, education and adequate information of the patient and his family, in addition to teamwork in units specialized in pelvic floor rehabilitation, a fundamental requirement when properly managing this pathology.