Evacuatory Dysfunction Research Articles

Low anterior resection syndrome phenotypes-Different symptom profiles for different patients.

Attention is increasingly being turned to functional outcomes as being central to colorectal cancer (CRC) survivorship. The current literature may underestimate the impact of evacuatory dysfunction on patient satisfaction with bowel function after anterior resection (AR) for CRC. The aim of this study was to investigate the impact of post-AR symptoms of storage and evacuatory dysfunction on patient satisfaction and health-related quality of life (HRQoL). A cross-sectional study was performed at an Australian hospital of patients post-AR for CRC (2012-2021). The postoperative bowel function scores used were: low anterior resection syndrome (LARS), St Mark's incontinence, Cleveland Clinic constipation and Altomare obstructive defaecation syndrome scores. Eight 'storage' and 'evacuatory' dysfunction symptoms were derived. A seven-point Likert scale measured patient satisfaction. The SF36v2® measured HRQoL. Linear regression assessed the association between symptoms, patient satisfaction and HRQoL. Overall, 248 patients participated (mean age 70.8 years, 57.3% male), comprising 103 with rectal cancer and 145 with sigmoid cancer. Of the symptoms that had a negative impact on patient satisfaction, six reflected evacuatory dysfunction, namely excessive straining (p < 0.001), one or more unsuccessful bowel movement attempt(s)/24 h (p < 0.001), anal/vaginal digitation (p = 0.005), regular enema use (p = 0.004), toilet revisiting (p = 0.004) and >10 min toileting (p = 0.004), and four reflected storage dysfunction, namely leaking flatus (p = 0.002), faecal urgency (p = 0.005), use of antidiarrhoeal medication (p = 0.001) and incontinence-related lifestyle alterations (p < 0.001). A total of 130 patients (53.5%) had 'no LARS', 56 (23.1%) had 'minor LARS' and 57 (23.4%) had 'major LARS'. Fifty-seven (44.5%) patients classified as having 'no LARS' had evacuatory dysfunction. Postoperative storage and evacuatory dysfunction symptoms have an adverse impact on patient satisfaction and HRQoL post-AR. The importance of comprehensively documenting symptoms of evacuatory dysfunction is highlighted. Further research is required to develop a patient satisfaction-weighted LARS-specific HRQoL instrument.

A prospective evaluation of the effect of transanal minimally invasive surgery (TAMIS) on low anterior resection syndrome

PurposeTransanal minimally invasive surgery (TAMIS) is a surgical alternative to transanal endoscopic microsurgery (TEM), transanal excision and proctectomy in the management of benign rectal polyps and early rectal cancers. Low anterior resection syndrome (LARS) describes the constellation of symptoms which result from and are common after distal colorectal resection. Symptoms include incontinence, frequency, urgency and evacuatory dysfunction. The aim of the current study was to prospectively evaluate pre- and post-operative LARS in patients who undergo TAMIS.MethodsWe conducted a prospective analysis of a consecutive series of patients who underwent TAMIS at our institution between January 2021 and February 2022. A LARS questionnaire was undertaken preoperatively, at 1 month and at 6 months post-operatively.ResultsTwenty patients were recruited to this pilot study. The mean age was 63 ± 12 years, 11 of the patients were male, mean pre-operative BMI was 29 ± 6 kg/m2, and 30% (n = 6) of patients underwent TAMIS for an invasive rectal cancer, with all patients receiving an R0 resection. Mean distance from the anal verge was 5.7 ± 3.2 cm, and mean lesion diameter was 46 ± 20.5 mm. A statistically significant interval reduction was observed between preoperative (20.3 ± 12.9) and 6-month post-operative (12.6 ± 9.7) LARS scores (p = 0.02) and also between 1-month (18.2 ± 10.6) and 6-month post-operative scores (p = 0.01).ConclusionsWe noted a high prevalence of LARS across our cohort preoperatively, and this had improved significantly at 6-month review post-TAMIS. This study reaffirms the safety and efficacy of TAMIS for the treatment of early rectal neoplasia.

Rectal Reconstruction after Total Mesorectumectomy: Functional Outcomes and Quality of Life

Background. The study aims to compare the functional outcomes and quality of life in patients having variant rectal reconstruction procedures after low anterior resection for cancer.Materials and methods. A prospective randomised controlled trial enrolled 90 patients who underwent total mesorectumectomy with formation of J-pouch (J-P), side-to-end (STE) or end-to-end (ETE) anastomoses.Results and discussion. We analysed 22 J-P, 30 STE and 38 ETE patients. For technical reasons, 26.6 % J-Ps were remodelled to other anastomoses. The neorectal sensory threshold, first and permanent defecation urges and maximal tolerated volume were higher in J-P at months 3–6–12 postoperatively.Severe low anterior resection syndrome events at post-surgery month 6 were significantly more frequent in the ETE vs. J-P and STE cohorts (21, 0 and 3.3 %, respectively, p &lt; 0.05). Stool frequency was significantly lower in J-P vs. STE and ETE at months 3–6–12. Wexner score was 3, 5, 6 at month 6 (p &lt; 0.05) and 0, 1, 1 at month 12 for J-P, STE and ETE, respectively (p &gt; 0.05). Evacuatory dysfunction was present at month 6 in 59.1 J-P, 33.3 STE and 21.1 % ETE.Quality of life (FIQL) in J-P and STE was significantly higher vs. ETE anastomoses in the Lifestyle (3.21, 3.22 and 3.03, respectively, p &lt; 0.05) and Coping (3.29, 3.21 and 2.95, respectively, p &lt; 0.05) scales to month 12 postoperatively.Conclusion. The J-pouch formation after low anterior resection ameliorates anal continence at months 3–6 post-surgery, reduces low anterior resection syndrome and improves quality of life (FIQL). The ease of implementation and irrelevance of evacuatory dysfunction in side-to-end anastomosis make it a superior choice over end-to-end surgery.

Risk factors for developing anorectal dysfunction after anterior resection

BackgroundAnterior resection (AR) may result in defecatory dysfunction and the cause is multifactorial. The aim was to explore if dysfunction could be related to the part of the colon used for anastomosis (sigmoid or descending) and to identify other possible risk factors for bowel dysfunction after AR.MethodsThis is a retrospective study based on prospectively registered data from a regional registry at the surgical department in Västmanland 1996–2019. Bowel function was registered at 1 year after AR or after stoma reversal. In total, 470 stage I–III rectal cancer patients had AR whereof 412 were included in this study.ResultsClustering was seen in 57%, incontinence 29%, urgency 22%, and evacuatory dysfunction 16%. The part of the colon used for anastomosis, level of vascular tie, and gender were not significantly associated with defecatory dysfunction. The higher the anastomotic level, the lower the risk of incontinence (OR 0.75; CI 0.63–0.90; p < 0.001) and clustering (OR 0.78; CI 0.67–0.90; p < 0.001). Compared with patients without a loop-ileostomy, an increased risk of clustering (OR 1.89; 1.08–3.31; p = 0.03), incontinence (OR 2.48; 1.29–4.77; p < 0.01), and urgency (OR 4.61; CI 2.02–10.60; p < 0.001) was seen after loop-ileostomy closure. Preoperative radiotherapy had a negative impact on continence and clustering seen mainly in the unadjusted analysis.ConclusionThe part of the colon used for anastomosis was not a significantly associated functional outcome after anterior resection. Low anastomotic level and having had a diverting ileostomy were independent risk factors associated with negative functional outcomes.

Temporal Changes of Low Anterior Resection Syndrome Score after Sphincter Preservation: A Prospective Cohort Study on Repetitive Assessment of Rectal Cancer Patients

Background: There is a relative shortage of studies directly addressing the postoperative rectal cancer patients’ evacuatory dysfunction, as estimated by the low anterior resection syndrome (LARS) score at repeated assessment time-points. The aim of the present study was to prospectively evaluate the incidence of LARS at predefined time intervals during the first 3 years after sphincter preserving rectal cancer surgery and to enlighten the effect of identified risk factors. Materials and methods: Seventy-eight patients, who remained alive and recurrence-free 2 years after (ultra-) low anterior resection were prospectively assessed at 6, 12, 18, 24, 30 and 36 months postoperatively, using the LARS score as bowel dysfunction outcome measure. All patients have completed the 2-year follow-up functional assessment, while 56 and 37 of them have been evaluated up to the 30th and the 36th postoperative month, respectively. Results: The proportion of patients with “major and minor” LARS significantly decreased during the first 3 evaluations (up to 18 months) (74% vs 62% vs 35%, p = 0.0001). The tumor distance from the anal verge and the neoadjuvant radiotherapy were identified as risk factors for high LARS score at 6 months (p < 0.03). The tumor distance remained as risk factor throughout the entire follow-up. All patients with high tumors were alleviated from symptoms reflecting “major” or “minor” LARS at 18 months. Most patients (90%) after radiotherapy showed a high LARS score in the first semester, but improved afterwards. Conclusion: Overall, the LARS score improves in the majority of patients after 18 months, with low tumor height and radiation adversely affecting them. Our results may be useful in more accurately define the postoperative “functional course” of rectal cancer patients and in aiding their consultation on expected functional outcome.

3117 “A Gut Feeling”: Autonomic Instability and Dysbiosis in Connective Tissue Disease

INTRODUCTION: Ehlers-Danlos Syndrome (EDS) is a connective tissue disease in which mutations in certain genes result in a disruption of normal collagen. There are several subtypes of the disease. Among the various subtypes which exist, hypermobility is the most common. Many of these patients can have co-existing gastrointestinal symptoms, which are often times overlooked by practitioners. CASE DESCRIPTION/METHODS: A 23 year old female presented with chest tightness, daily palpitations, and diarrhea which had been persistent for three days. Her past medical history was notable for spinal stenosis and lactose intolerance. She denied any associated abdominal pain, fever, or chills. Her family history was non contributory. One month later, she continued to have diarrhea and heartburn. She endorsed symptoms of mucorrhea with associated bright red blood per rectum, lower abdominal pain, and fecal urgency. A thorough physical examination revealed hyper flexible joints and greater than normal mobility of her fingers. After genetic testing, she was later diagnosed with Ehlers-Danlos Type 3. DISCUSSION: Up to 57% of patients with EDS have coexisting functional bowel disorders.1 Chronic gastrointestinal discomfort was reported in 86% of patients with Ehlers-Danlos – hyper mobile subtype.2 Gastrointestinal complications can include gastro esophageal reflux disease, hiatal hernia, gastritis, gastric emptying, irritable bowel syndrome (found in 62% of patients), rectal evacuatory dysfunction, and delayed colonic transit.1,2,4 Symptoms are thought to occur as a result of bidirectional signaling between gut bacteria and the brain. Enterochromaffin cells are not only accessible by enteric microbiota but also have contact with afferent and efferent nerve terminals acting as “transducers” between the gut and brain,8 able to secrete various compounds, including serotonin. One study showed that pretreatment of animals with probiotic formulation consisting of Lactobacillus helveticus R0052 and Bifidobacterium longum R0175 attenuated hypothalamic pituitary axis and autonomic nervous system activities, which were assessed through the measurement of plasma cortisol and catecholamines.10 In our patient, she was treated with a course of Rifaximin for IBS-D and was placed on a bowel regimen including a probiotic. At a four-week follow up, her symptoms had improved.

The value of anterior resection survivorship programmes

Up to 80% of people with rectal cancer undergo sphincter-preserving surgery and, of these, around 90% subsequently have a change in bowel habit, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. The wide spectrum of symptoms after resection and reconstruction of the rectum is termed anterior resection syndrome. Many patients feel isolated by their symptoms, which can have a devastating effect on their quality of life. This article describes the development of a patient-led support group, supported by clinical nurse specialists, for people with bowel dysfunction following surgery and treatment for rectal cancer.

Rectal evacuatory dysfunction in patients with genital prolapse

Rectal evacuatory dysfunction in patients with genital prolapse

Severe Gastrointestinal Dysmotility in Patients With Ehlers-Danlos Syndrome: Case Series - 1 Center Experience

Gastrointestinal complications are relatively frequent in Ehlers-Danlos syndrome (EDS). Intestinal dysmotility is significantly more frequent in EDS patients than in general population and it has a very difficult investigational approach, requiring a high clinical suspicion for diagnosis. Therapeutic approach may be challenging in the context of limited options and disabling nature of the disease. EDS is considered a multisystem disease, as connective tissue is present throughout the body, the digestive tract can be affected as well. Previous studies have associated EDS with a spectrum of gastrointestinal complications such as chronic constipation, hiatus hernia, Crohn's disease, fecal incontinence, rectal evacuatory dysfunction, functional gastrointestinal disorder, gastroesophageal reflux, recurrent gastritis, delayed gastric emptying and recurrent abdominal pain. In this case series, the authors report six cases of global gut dysmotility in Ehlers-Danlos syndrome. We try to highlight that EDS can lead to significant gut failure that is not only difficult to diagnose but is challenging to treat. All the patient's required at least one form of nutritional support either by tube feeding or intravenous nutrition. Some of the patient's required surgical intervention to treat the significant dysmotility. The table below shows our patients characteristics, diagnostic and feeding methods and the surgical intervention if needed. All the reported patients were females diagnosed clinically with EDS hypermobility type (type 3), mean age was 24 years, mean BMI was 23 kg /m2. Five of them diagnosed with POTS (cases 1, 2, 3, 4, 5), only one patient had Mast cell activation syndrome (case 1).Three patients were diagnosed with SIBO (cases 3, 4, 6), five patients required parenteral nutrition (cases 1, 2, 4, 5, 6). Five patients needed tube feeds at some point (cases 1, 2, 4, 5, 6). (See table1). Sever gut dysmotility among patients with Ehlers-Danlos syndrome is not uncommon and possibly underdiagnosed. It must always be taken into account when treating EDS patients with persistent gastro-intestinal symptoms, especially in the presence of autonomic dysfunction features (including POTS) and failure to maintain weight.Table: Table. POTS, postural orthostatic tachycardia syndrome; SIBO, small intestinal bacterial overgrowth; MCAS, mast cell activation syndrome; SBFT, small bowel follow through

Defining low anterior resection syndrome: a systematic review of the literature.

There is increasing awareness of the poor functional outcome suffered by many patients after sphincter-preserving rectal resection, termed 'low anterior resection syndrome' (LARS). There is no consensus definition of LARS and varying instruments have been employed to measure functional outcome, complicating research into prevalence, contributing factors and potential therapies. We therefore aimed to describe the instruments and outcome measures used in studies of bowel dysfunction after low anterior resection and identify major themes used in the assessment of LARS. A systematic review of the literature was performed for studies published between 1986 and 2016. The instruments and outcome measures used to report bowel function after low anterior resection were extracted and their frequency of use calculated. The search revealed 128 eligible studies. These employed 18 instruments, over 30 symptoms, and follow-up time periods from 4weeks to 14.6years. The most frequent follow-up period was 12months (48%). The most frequently reported outcomes were incontinence (97%), stool frequency (80%), urgency (67%), evacuatory dysfunction (47%), gas-stool discrimination (34%) and a measure of quality of life (80%). Faecal incontinence scoring systems were used frequently. The LARS score and the Bowel Function Instrument (BFI) were used in only nine studies. LARS is common, but there is substantial variation in the reporting of functional outcomes after low anterior resection. Most studies have focused on incontinence, omitting other symptoms that correlate with patients' quality of life. To improve and standardize research into LARS, a consensus definition should be developed, and these findings should inform this goal.

Rectal Evacuatory Dysfunction:An Overview of Causes, Consequences and Cures

Evacuatory Dysfunction is difficulty in emptying the rectum which may occur even with frequent visits to the toilet and/ or passing soft motions “. An alternative definition for evacuatory dysfunction is a constellation of symptoms such as prolonged repeated straining at bowel movements, sensation of incomplete evacuation, and the need for digital manipulation.

Clinical application of the LARS score: results from a pilot study.

The impact of the low anterior resection syndrome (LARS) on quality of life has underscored the importance of measuring functional outcomes after treatment for rectal cancer. The aim of this study was to evaluate whether the LARS score as a single questionnaire was useful enough in the clinical setting. Patients treated by curative anterior resection for rectal cancer were sent the LARS score and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 questionnaires by post. Patients classified as "minor" and "major" LARS according to the LARS score were visited. Assessment included several scores (Vaizey score, Altomare Obstructed Defecation Syndrome score, Bristol scale). Patients with urgency/faecal incontinence also filled in a bowel diary and the FIQL score. Seventy patients returned the questionnaires, 49 of whom ("major LARS" and "minor LARS") were visited and 19 ("no LARS") were assessed by phone. Four different clinical patterns were identified. The group with urgency/faecal incontinence was the largest (33.8%), whereas 17.7% referred evacuatory dysfunction. The LARS score did not correctly evaluate 18 patients: 5 who were classified as no LARS but had severe evacuatory dysfunction and 13 patients categorized as LARS but without significant bowel dysfunction, 9 of whom were classified as major LARS. The LARS score may overestimate the impact on quality of life in some patients and may underestimate the impact of severe evacuatory dysfunction. Due to the complexity of the LARS, the LARS score as a single questionnaire might not be enough to assess bowel function. A complete clinical evaluation and additional questionnaires might be required.

Diagnostic disagreement between tests of evacuatory function: a prospective study of 100 constipated patients.

Evacuatory dysfunction (ED) is a common cause of constipation and may be sub-classified on the basis of specialist tests. Such tests may guide treatment e.g., biofeedback therapy for 'functional' defecatory disorders (FDD). However, there is no gold standard, and prior studies have not prospectively and systematically compared all tests that are used to diagnose forms of ED. One hundred consecutive patients fulfilling Rome III criteria for functional constipation underwent four tests: expulsion of a rectal balloon distended to 50 mL (BE50 ) or until patients experienced the desire to defecate (BEDDV ), evacuation proctography (EP) and anorectal manometry. Yields and agreements between tests for the diagnosis of ED and FDD were assessed. Positive diagnostic yields for ED were: BEDDV 18%, BE50 31%, EP 38% and anorectal manometry (ARM) 68%. Agreement was substantial between the two balloon tests (k = 0.66), only fair between proctography and BE50 (k = 0.27), poor between manometry and proctography (k = 0.01), and there was no agreement between the balloon tests and manometry (k = -0.07 for both BE50 and BEDDV ). For the diagnosis of FDD, there was only fair agreement between ARM and EP (k = 0.23), ARM ± BE50 and EP (k = 0.18), ARM and EP ± BE50 (k = 0.30) and ARM ± BE50 and EP ± BE50 (k = 0.23). There is considerable disagreement between the results of various tests used to diagnose ED and FDD. This highlights the need for a reappraisal of both diagnostic criteria, and what represents the 'gold standard' investigation.

Prevention and management of anterior resection syndrome

Because of the improvement of surgical technique and the widely use of multimodality therapy, more patients with rectal cancer undergo sphincter-preserving surgery. However, it has been reported that up to 90% of such patients will suffer from bowel dysfunction, ranging from increased bowel frequency to faecal incontinence or evacuatory dysfunction. This wide spectrum of symptoms after resection of the rectum has been termed anterior resection syndrome (ARS). This disordered bowel function has a substantial negative effect on quality of life, however, the causal mechanisms have not been clarified. The present review discusses the clinical manifestation, underlying mechanisms, as well as prevention and treatment strategies.

Impact of Rising Grades of Internal Rectal Intussusception on Fecal Continence and Symptoms of Constipation

A theory of rectal intussusception has been advanced that intrarectal intussusception, intra-anal intussusception, and external rectal prolapse are points on a continuum and are a cause of fecal incontinence and constipation. This study evaluates the association among rectal intussusception, constipation, fecal incontinence, and anorectal manometry. Patients undergoing defecography were studied from a prospectively maintained database and classified according to the Oxford Rectal Prolapse Grade as normal or having intra-rectal, intra-anal, or external intussusception. Patient symptoms were assessed using the Constipation Severity Index and the Fecal Incontinence Severity Index. Quality-of-life surveys were also used. Patients also underwent anorectal manometry. The study was conducted at a tertiary care university medical center (Massachusetts General Hospital). The study included 147 consecutive patients undergoing evaluation for evacuatory dysfunction and involved defecography, symptoms questionnaires, and anorectal physiology testing from January 2011 to December 2013. Symptom severity and quality-of-life scores were measured, as well as anal manometry results. Increasing Oxford grade was associated with an increase in severity of fecal incontinence (median score: normal = 23.9, intrarectal = 21.0, intra-anal = 30.0, external prolapse = 35.3; β = 4.71; p = 0.009), which persisted in a multivariable model including age (β = 2.13; p = 0.03), and decreased sphincter pressures (median mean resting pressure: normal = 75.4, intra-rectal = 69.7, intra-anal = 64.3, external prolapse = 48.3; β = -8.57; p = 0.003), which did not persist in a multivariable model. Constipation severity did not increase with rising intussusception (mean score: normal = 37.4, intrarectal = 35.0, intra-anal = 41.4, external prolapse = 32.9; p = 0.79), and balloon expulsion improved rather than worsened (normal = 47.1%, intrarectal = 60.5%, intra-anal = 82.9%, external prolapse = 93.1%; p < 0.001). The study was limited because it was an observational study from a single center. Increasing grades of rectal intussusception are associated with increasing fecal incontinence but not constipation.

PTH-032 Functional Outcomes after Endoscopic Submucosal Dissection of Large Rectal Polyps

IntroductionLarge rectal polyps can cause a variety of symptoms. Removal of these lesions results in symptom resolution but may also lead to symptoms of evacuatory dysfunction. In this study, we...

PTU-051 Post-Partum Defecatory Dysfunction: A Complex Problem Involving Co-Existing Faecal Incontinence and Rectal Evacuatory Disorder

IntroductionFaecal incontinence and urgency are well-recognised sequelae of obstetric injury, however there is a paucity of literature describing the co-existence of symptoms of rectal evacuatory dysfunction (RED) and faecal incontinence...

PWE-010 Biofeedback-A simple and Effective way of Managing Rectal Evacuatory Dysfunction Secondary to Pelvic Floor Dyssynergia and Rectal Hyposensitivity

IntroductionBiofeedback is safe and effective in the management of rectal evacuatory dysfunction (RED), but there is limited data on medium to long-term follow-up. This study evaluated the effectiveness of biofeedback...

Sa1513 Functional Outcomes After Endoscopic Submucosal Dissection of Large Rectal Polyps

Large rectal polyps can cause a variety of symptoms. Removal of these lesions results in symptom resolution but may also lead to symptoms of evacuatory dysfunction. In this study, we present the functional outcomes and patient satisfaction after endoscopic submucosal dissection (ESD) of rectal polyps greater than 40mm in size.

Sa2028 Epidemiology of Fecal Incontinence in US Adults From 2005 to 2010: Prevalence, Trends and Risk Factors

the anal verge (P,0.01), whilst gender and anastomotic height were not associated with constipation. Neither age nor radiotherapy were associated with constipation or FI. Conclusions: Bowel dysfunction, consisting of FI and constipation (characterised by evacuatory dysfunction), appears to be prevalent after anterior resection surgery and persists up to a decade after surgery. Low anastomotic height, reflecting loss of more rectum, is associated with FI, but not constipation.