Anterior Resection Research Articles

Enhancing support for patients with low anterior resection syndrome: insights and educational resources from the LARSCAT project

PurposeTo address the educational gaps and support needs of patients with low anterior resection syndrome (LARS) following rectal cancer surgery. The LARSCAT project aimed to develop comprehensive resources to better inform patients and enhance their quality of life.MethodsA qualitative study was conducted between November 2022 and March 2023. Seven focus groups were formed, including six patients, two surgeons, and three nurses. Patients had undergone rectal cancer surgery with stoma reversal 2 to 12 years earlier, and all experienced major LARS. The focus groups, held in-person and online, explored the impact on daily life, social and sexual health, mood, rest, and relationships. Thematic analysis was performed to identify key issues and support strategies following the COREQ guidelines.ResultsParticipants reported insufficient information regarding potential dysfunctions after rectal cancer surgery, and difficulties finding reliable information online. The timing of receiving information varied according to individual coping mechanisms. LARS symptoms significantly impacted daily life, social activities, sexual health, and mood. Patients emphasised the need for more tailored information and supplementary written materials to read at their own pace. Consequently, three comprehensive documents were created and made available online.ConclusionThis study highlights a significant gap in patient education on the long-term effects of rectal cancer surgery. The resources developed by the LARSCAT project aim to provide essential support to patients and healthcare professionals. Future research should focus on integrating these resources into routine care and evaluating their impact on patient outcomes and quality of life.

Anastomotic leakage after resection for rectal cancer and recurrence-free survival in relation to postoperative C-reactive protein levels

BackgroundAnastomotic leakage after rectal cancer surgery is linked to reduced survival and higher recurrence rates. While an aggravated inflammatory response may worsen outcomes, few studies have explored the combined effects of leakage and inflammation.MethodsThis is a retrospective multicenter cohort study including patients operated with anterior resection for rectal cancer in Sweden during 2014–2018. Anastomotic leakage within 12 months was exposure and primary outcome was recurrence-free survival. Mediation analysis was performed to evaluate the potential effect of systemic inflammatory response, as measured by the highest postoperative C-reactive protein (CRP) level within 14 days of surgery. Confounders were chosen using a causal diagram.ResultsSome 1036 patients were eligible for analysis, of whom 218 (21%) experienced an anastomotic leakage. At the end of follow-up at a median of 61 months after surgery, recurrence-free survival amounted to 82.6% and 77.8% in the group with and without leakage, respectively. The median highest postoperative CRP value after surgery was higher in the leakage group (219 mg/l), compared with the group without leakage (108 mg/l). Leakage did not lead to worse recurrence-free survival (HR 0.66; 95% CI 0.43–0.94), and there was no apparent effect through postoperative highest CRP (HR 1.12; 95% CI 0.93–1.29).ConclusionsIn conclusion, anastomotic leakage, with its accompanying CRP increase, was not found to be associated with recurrence-free survival after anterior resection for rectal cancer in this patient cohort. Larger, even more detailed studies are needed to further investigate this topic.

Our experience at Bangabandhu Sheikh Mujib Medical University on laparoscopic assisted surgery for rectal cancer

Background: Rectal cancer is a leading cause of mortality worldwide, with laparoscopic surgery emerging as a viable alternative to open surgery due to its benefits in postoperative recovery, pain management and survival rates. Despite its advantages, laparoscopic colorectal resection faces scrutiny over oncologic safety and technical demands, limiting its widespread adoption. Methods: This retrospective descriptive study analyzed 60 patients with colorectal adenocarcinoma treated at the Department of Colorectal Surgery, BSMMU, from January 2018 to December 2018. Inclusion criteria encompassed clinically diagnosed colorectal cancer with histological confirmation. Data on demographics, tumor characteristics, surgical details and postoperative outcomes were collected and analyzed with SPSS software. Results: Among the 60 patients, 32 were male, with a mean age of 52 years. Tumors within 5 cm of the anal verge necessitated abdominoperineal resections (n=44), while anterior resections were performed for the remaining (n=16). All patients achieved adequate proximal margins (>5 cm) and most (90%) had distal margins >2 cm. The average operative time ranged from 190 to 270 minutes, with no intraoperative complications and a postoperative stay of 3-5 days. Patients reported less postoperative pain and faster recovery. Conclusions: Laparoscopic colorectal surgery demonstrated similar oncologic outcomes to open surgery but involved a longer operative time and required advanced surgical skills. The benefits included reduced blood loss, lower postoperative pain and a shorter hospital stay, although costs were higher. A need for expert surgeons in selected patients is emphasized for optimal outcomes. Laparoscopic resection for rectal cancer aligns with oncologic principles and offers a safe, effective approach, yielding improved recovery metrics compared to traditional surgery. Further analysis on cost-effectiveness, especially for lower socioeconomic populations, is warranted to enhance accessibility.

Usefulness of participation of endoscopic surgical skill qualification system-qualified surgeons in laparoscopic high anterior resection.

A technical qualification system was established by the Japanese Society of Endoscopic Surgery in 2004, and its effectiveness in low anterior resection (LAR) has been reported. We herein performed a subgroup analysis of the effectiveness of the participation of technically qualified surgeons in laparoscopy-assisted high anterior resection (HAR), a procedure used for the technical qualification of surgeons. The EnSSURE study enrolled 3188 patients who underwent laparoscopic rectal resection for rectal cancer between January 2014 and December 2016 at 56 Japanese hospitals. The outcomes of HAR were compared between groups with and without the participation of technically qualified surgeons. The background of the two groups were equalized by propensity score matching. In the group with the participation of qualified surgeons, the operative time was significantly shorter (p = .0427), more lymph nodes were dissected (p = .0207), and the conversion rate to open surgery was lower (p = .0016); however, no significant difference was observed in blood loss (p = .0616), the R0 resection rate (p = 1.00), intraoperative complication rate (p = .160), postoperative complication rate (p = 1.00), or reoperation rate (p = .6999) between the two groups. Furthermore, no significant difference was noted in long-term outcomes (recurrence-free survival (p = .275) or overall survival (p = .941)). In HAR, the technical benefits of the participation of qualified surgeons was limited to a shorter operative time and lower conversion rate. Nevertheless, the qualification is unique in that it predicts the usefulness of reducing complications in more technically challenging procedures when its effectiveness in LAR is considered.

Oncological and Clinical Impacts of Routine Splenic Flexure Mobilization in Anterior Resection

Oncological and Clinical Impacts of Routine Splenic Flexure Mobilization in Anterior Resection

Comparative Outcomes of End-to-End versus Side-to-End Colorectal Anastomosis Following Low Anterior Resection for Rectal Cancer

Comparative Outcomes of End-to-End versus Side-to-End Colorectal Anastomosis Following Low Anterior Resection for Rectal Cancer

Erectile dysfunction is an underdiagnosed consequence of low anterior resection and abdominoperineal resection for colorectal cancer.

To explore the frequency and predictive factors of erectile dysfunction diagnosis after colorectal cancer surgery. The Surveillance, Epidemiology, and End Results-Medicare database was used to identify a national sample of men undergoing surgery for colorectal cancer from 2004 to 2015. Men aged > 65years with any index surgery within 1year of diagnosis of colorectal cancer were included. Men with a history of prior erectile dysfunction, metastatic cancer, or genitourinary cancer prior to their index procedure were excluded. The primary outcome was a new diagnosis of erectile dysfunction within 2years of the index procedure. A total of 28,248 men aged > 65 years who underwent colorectal cancer surgery were identified. The rates of erectile dysfunction diagnosis 2years after surgery were 3.6% for hemicolectomy, 5.3% for low anterior resection, and 6.4% for abdominoperineal resection. On multivariable analysis, low anterior resection (HR: 1.27, 95%CI 1.08 to 1.51, p < 0.01) and abdominoperineal resection (HR: 1.49, 95%CI 1.14 -1.93, p < 0.01) were independently associated with increased risk of erectile dysfunction compared to hemicolectomy. Minimally invasive surgery was independently associated with an increased risk of erectile dysfunction compared to open surgery (HR: 1.44, 95% CI 1.25-1.65, p < 0.001). Compared to hemicolectomy, men treated with low anterior resection and abdominoperineal resection have a higher risk of being diagnosed with erectile dysfunction within 2years of treatment. The absolute rate of erectile dysfunction diagnosis was low compared to rates reported in prior controlled trials, suggesting that patients are underdiagnosed in real-world settings.

Safety and Feasibility of Umbilical Stoma After Low Anterior Resection Using Propensity Score Matching

Safety and Feasibility of Umbilical Stoma After Low Anterior Resection Using Propensity Score Matching

Coding the issue: low anterior resection syndrome following rectal cancer treatment.

Coding the issue: low anterior resection syndrome following rectal cancer treatment.

Correction to ‘Oncological outcome following Hartmann's procedure compared with anterior resection and abdominoperineal resection for rectal cancer—The type of procedure does not influence local recurrence or distant metastasis: A population‐based study’

Correction to ‘Oncological outcome following Hartmann's procedure compared with anterior resection and abdominoperineal resection for rectal cancer—The type of procedure does not influence local recurrence or distant metastasis: A population‐based study’

Risk factors of the low anterior resection syndrome (LARS) after ileostomy reversal in rectal cancer patient

This study is aimed at identifying risk factors of Low Anterior Resection Syndrome following ileostomy reversal in rectal cancer patients who had undergone preventive ileostomy. This retrospective analysis was conducted on a cohort of 605 patients treated at the Fourth Hospital of Hebei Medical University between January 2018 and December 2021. These patients were grouped based on LARS score, and Clinical and follow-up data were collected to conduct univariate analyses of potential factors influencing LARS occurrence based on variable type. Variables with statistical significance were included in a logistic regression model to analyze potential influences on the occurrence of LARS. Univariate and Multivariate logistic regression analysis showed that N2 stage (OR = 2.290 95%CI: 1.076–4.873, P = 0.031), chemoradiotherapy (OR = 2.271, 95%CI: 1.246–4.138, P = 0.007), and anastomosis height (OR = 0.836, 95%CI: 0.717–0.975, P = 0.022) were independent influences on the occurrence of LARS. In model 3 (adjusting for all covariates), the relationship between anastomotic height and patient LARS status showed a negative correlation. In subgroup analyses, there were significant differences in the effect of anastomotic height on LARS in subgroups with different hemoglobin concentrations. A high occurrence rate of LARS is observed in rectal cancer patients with preventive ileostomy reversal. N2 stage, history of chemoradiotherapy, and anastomotic height are independent influence factors for the occurrence of major LARS after ileostomy reversal.

Defunctioning Ileostomy After Low Anterior Resection of Rectum: Morbidity Related to Fashioning and Closure.

Background and Objectives: The aim of this study was to assess any predisposing factors to the morbidity of fashioning and reversal of diverting ileostomy in a prospective cohort of patients who have undergone TME and low colo-rectal or colo-anal anastomosis for rectal cancer. Materials and Methods: Consecutive patients with rectal cancer undergoing low anterior resection and a defunctioning loop ileostomy in three surgical units from 2016 to 2020 were included in the study and retrospectively analyzed. Results: One hundred eighty-two patients from three centres were included. Ileostomy-related mortality was 0.5%, attributed to renal failure.. Ileostomy-related morbidity was 46%. Postoperative ileus was seen in 37.4%, and dehydration in 18.8% of the patients. The readmission rate for ileostomy-related reasons was 15.4%. Stoma care was problematic in 15.7% or poor in 7% of the cases. Advanced age, male gender and obesity were independent risk factors for ileostomy-related morbidity. Ileostomy was reversed in 165 patients. The morbidity in 165 patients was 16%. Ileus was seen in 10.3%, anastomotic leak in 4.8% and wound infection in 12.7% of the cases. One patient died because of an anastomotic leak. No predisposing factors that affect the outcomes of ileostomy closure were identified. Conclusions: Diverting ileostomy-related morbidity is high. Life threatening dehydration and renal failure from ileus is more commonly seen in elderly, male and obese patients and should be anticipated. Ileostomy closure-related morbidity is low.

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

PurposeEndometriosis 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.MethodsWe 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).ResultsOf 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.ConclusionTAI 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.

Preventive Strategies in Anesthetizing a High-Risk Patient for Robotic Surgery: A Case Report

The physiologic consequences of intraabdominal insufflation and extreme positioning in robotic surgery predispose a patient with heart failure to complications. Reports on anesthetic strategies to prevent adverse events in patients with heart failure undergoing these types of surgeries are sparse. A 65-year-old male, who was a known case of heart failure with reduced ejection fraction (EF), was scheduled for robot-assisted low anterior resection for rectal adenocarcinoma. Preoperative diagnostic tools such as echocardiography, 12-lead electrocardiography, and blood tests guided preoperative risk assessment, and anesthesia-related planning and interventions. A balanced anesthetic technique using sevoflurane, atracurium, and fentanyl, with postoperative bilateral rectus sheath and subcostal block was used. In addition to standard monitors, arterial pulse pressure variation (PPV) was utilized for goal-directed fluid therapy to prevent complications. Patient tolerated surgery and anesthesia well with no report of any complication during the perioperative course. Patient was eventually discharged and scheduled for follow-up. The physiologic consequences of robotic surgery compound the already elevated risk for complications of a patient with heart failure. Anesthetic strategies to actively prevent adverse events are of paramount importance.

Rectal Eversion as an Anus-sparing Technique in Laparoscopic Low Anterior Resection With Double Stapling Anastomosis: Long-term Functional Results.

Rectal eversion (RE) is a natural orifice specimen extraction (NOSE) method that allows anus-sparing resection in very low rectal tumors. This study aims to share the long-term results of RE in laparoscopic rectal resection performed with double stapling anastomosis. A single-center retrospective cohort study was conducted for patients who underwent laparoscopic low anterior resection with RE. Age, sex, body mass index, American Society of Anesthesiologists (ASA) classification, type of surgery, distance of the tumor to the dentate line, specimen extraction site, cancer stage, preoperative chemoradiotherapy, postoperative complications, and postoperative clinical follow-up findings were recorded. Incontinence was assessed using the Wexner score (WS). Low anterior resection syndrome (LARS) is determined by the LARS score. A 7-point Likert scale was used to evaluate the satisfaction of the patients. A total of 17 patients underwent resection by RE for rectal tumors. Of the 11 patients included in the study, 4 were female and 7 were male. The mean age was 66.09±15.04 years. The mean follow-up was 64.18±16.83 months. The mean tumor diameter was 3.1cm (range: 0.9 to 7.2cm). The mean distance of the tumor from the dentate line was 2.7cm (range: 1.2 to 5.6cm). No anastomotic leak was observed in any patient. One patient had an anastomotic stenosis and was treated with balloon dilatation. The median LARS score was 16 (range 0 to 32) and 64% of the patients had no LARS. Two patients had minor LARS and 2 patients had major LARS. The median Wexner score was 3.5 (range 0 to 14). The median Likert scale was 7 (range 5 to 7). It was found that 55% of the patients were extremely satisfied, 18% were satisfied, and 27% were slightly satisfied with their surgery. There were no dissatisfied patients. RE is a safe NOSE technique in laparoscopic double stapling anastomosis for rectal resection. There is a high level of long-term patient satisfaction with anus-sparing procedures via RE, even in the presence of various symptoms.

Summary of Professor HUANG Jinchang's experience of electroacupuncture at Baliao acupoints for low anterior resection syndrome of rectal cancer

This paper introduces Professor HUANG Jinchang's experience in treating low anterior resection syndrome (LARS) of rectal cancer. Based on the clinical experience in treating fecal incontinence after rectal cancer surgery, Professor HUANG Jinchang proposes that the primary pathogenesis of LARS is spleen-kidney yang deficiency with internal obstruction of damp turbidity. The treatment approach should focus on strengthening the spleen, warming the kidney, and eliminating turbidity. The Baliao acupoints are specifically selected to eliminate turbidity, promote yang , facilitate the qi flow of the viscera, and regulate the opening and closing of the anus. Emphasis is placed on deep needling at the Baliao acupoints, with flexible acupoint selection based on accompanying symptoms. Additionally, moxibustion and bloodletting cupping are used to restore regular bowel movements and improve the quality of life for patients who have undergone anus-preserving surgery for rectal cancer.

Effect of left colonic artery preservation on perfusion at the anastomosis in rectal cancer surgery evaluated with intraoperative ultrasound

PurposeIntraoperative ultrasound was used to assess the flow velocity in the marginal vessel arch adjacent to the anastomosis, critical for evaluating the anastomotic blood supply. This technique also enabled us to investigate the potential effects of preserving the left colonic artery on the perfusion of the anastomosis.MethodsThis prospective study included 40 rectal cancer patients who underwent laparoscopic anterior resection between January 2021 and January 2023. The length of the inferior mesenteric artery (IMA) was measured from its origin to the first branch, and the diameters of the mesenteric vessel IMA, left colonic artery (LCA), and marginal mesenteric artery (MMA) were recorded. Blood flow velocity and Doppler ultrasound waveforms of the MMA near the anastomosis were collected. Measurements were taken both before and after clamping the IMA using atraumatic forceps. The tardus parvus pattern of the MMA ultrasound waveforms was recorded to evaluate the hypoperfusion status of the anastomosis.ResultsThe mean velocities of MMA were 47.9 cm/s before clamping and 34.9 cm/s after atraumatic clamping, indicating significant differences (p < 0.05). Thirteen patients (32.5%) exhibited a Tardus parvus pattern after IMA atraumatic clamping. Multivariate analysis revealed older age and LCA diameter as independent clinical predictors of the hypoperfusion status after IMA clamping.ConclusionsPreservation of the LCA may improve perfusion near the anastomosis during rectal cancer surgery. Older age and LCA diameter can be considered useful predictors of the mesenteric hypoperfusion status after IMA ligation. Intraoperative ultrasound can evaluate the perfusion of the MMA near the anastomosis.Chinese Clinical Trial Registry—Registration number: ChiCTR2000041475

Identification of risk factors for postoperative complications after right colectomy and low anterior resection in patients ≥85 years old with colorectal cancer using the National Clinical Database

AbstractAimThe purpose of this study was to evaluate factors associated with surgical outcomes and postoperative complications (Grade ≥3 by Clavien–Dindo classification) of right hemicolectomy (RH) and low anterior resection (LAR) for colorectal cancer in patients ≥85 years old.MethodsWe retrospectively analyzed National Clinical Database (NCD) data on patients aged ≥85 years who underwent RH and LAR for colorectal cancer between 2017 and 2020. All possible preoperative factors were used to explore the risk factors for serious postoperative complication in these very elderly patients with colorectal cancer.ResultsFor RH, the operative mortality rate was 1.1% (98 cases), and the rate of serious postoperative complications was 5.2% (480 cases). Similarly, the mortality rate was 1.1% (27 cases), and the rate of serious complications (Clavien–Dindo Grade ≥3) was 8.7% (206 cases) for LAR. Based on multivariate analysis, independent risk factors for serious postoperative complications were male sex, ADL (partially dependent), hypertension, platelets (&lt;150 000/μL), serum Na (&lt;138 mEq/L), and PT‐INR (&gt;1.1) for RH, and ASA‐PS (Grade ≥3), history of pneumonia, creatinine (&gt;1.2 mg/day), and serum Na (&lt;138 mEq/L) for LAR.ConclusionsThe present results for RH and LAR suggest that surgical treatment for patients aged ≥85 years old is safe and feasible. Surgeons need to pay special attention more to physical status and past medical history than to tumor factors to prevent serious postoperative complications in these older patients with colorectal cancer.

SURG-14. PATTERNS OF PROGRESSION OF TEMPORAL LOBE GLIOBLASTOMAS: EVIDENCE FOR THE ROLE OF TEMPORAL LOBECTOMY

Abstract Glioblastomas extend beyond the contrast-enhancing tumor, and supramaximal resections into non-enhancing (NE) tumor improves survival. Yet, supramaximal resection is difficult to achieve in most cases. For temporal lobe tumors, supramaximal anterior temporal lobe resection is feasible and safe. Case series have shown a survival advantage by resecting the anterior temporal lobe. This study aims to explore patterns of tumor progression in temporal lobe glioblastomas and whether the presence of NE tumor in the temporal tip could be used as a biomarker to predict the site of progression. We searched a single institution tumor database looking for patients who had glioblastomas in the temporal lobe, who underwent complete resection of enhancing tumor, and went on to have chemoradiotherapy. Patients needed to have imaging demonstrating first progression. We determined pre-operatively if NE tumor had extended into the temporal tip. At progression, the direction of tumor progression was recorded and assessed if it would have been resected should a lobectomy have been performed. We identified 55 patients that fulfilled our entry criteria (mean age 57.7 years, range 19.6-72.9; 37 male). In 16 cases, the anterior temporal lobe was resected; these patients were not used in further assessments. In 25 cases (64.1%), the tumor progressed into the residual anterior temporal lobe. In 16 cases (41.0%), a lobectomy would have encompassed the area of progression. NE tumor was seen in the tip in 28 cases (71.8%). This could predict progression into the anterior temporal lobe with a sensitivity of 76.2% (95%CI: 54.9-90.6%) and specificity of 33.1% (95%CI: 11.8-61.6%). The likelihood ratio of tumor progression was 1.14 (95%CI: 0.75-1.74). We conclude that temporal lobe glioblastomas most commonly progress into the anterior temporal lobe, but NE tumor is not a suitable predictive biomarker. Developing suitable biomarkers and biomarker-driven trials of temporal lobectomy for glioblastomas are needed.

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

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. 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. 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 1month of stoma closure and waiting a minimum of 3months. 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. 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.