Low Anterior Resection Surgery Research Articles

Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer

BackgroundRectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up.AimsTo evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment.MethodsOne hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires.Results80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1–8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF.ConclusionsA significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.

Back to basics: informatienoden van zorgvragers na endeldarmchirurgie

Back to basics: information needs of patients after rectal surgery The past decades, there has been increased attention for the ‘educative attitude’ of caregivers. It appears to be quite a challenge to provide good education: many patients need support to understand, evaluate and apply relevant health information. Also, there is no ‘one size fits all’ method. In this qualitative research, the authors investigated what patients experienced as useful or obstructive in the education they were provided with during a complex care path. As a pilot study, they focused on oncological patients who had received rectal surgery. This subpopulation was chosen because of the many education moments and methods they had been confronted with. The authors conducted semi-structured interviews with oncological patients (n = 8) who had undergone (ultra)low anterior resection surgery in the general hospital AZ Delta in Roeselare (Belgium) from February 2020 to May 2022. The interviews focused on their patient information journeys. The information preferences and needs were very diverse. Some respondents wanted very detailed information, while others put faith in the doctor. Nonetheless, these interviews drew attention to the importance of personal relationships with the caregiver(s) and the use of basic education methods: verbal explanations and clarifications through images and the show-me method. Many forms of innovative formats are now available to make sure that patients receive all appropriate information in an accessible manner. While these efforts are crucial and appreciated, this research complements other studies that re-emphasize the importance of some ‘basics’ in communication, as well as the quality of the patient-provider relationship.

Close distal margin is associated with locoregional rectal cancer recurrence: A multicenter study.

The importance of the radial margin for rectal cancer resection is well understood. However, surgeons have deemphasized the distal margin, accepting very close distal margins to perform sphincter-preserving surgery. We hypothesized that distal margins < 1 cm would be an independent risk factor for locoregional recurrence. The objective was to determine whether close distal margins are associated with increased locoregional recurrence risk. This was a multi-institutional retrospective cohort study conducted at six academic medical centers including patients who received low anterior resection surgery for primary rectal cancer between 2007 and 2018. Of 556 low anterior resection patients, the rate of close distal margin was 12.8% (n = 71), and the locoregional recurrence rate was 5.0% (n = 28). The locoregional recurrence rate for close distal margin cases was 9.9% (n = 7) compared to 4.3% (n = 21) for distal margins ≥1.0 cm. In multivariable analysis, the only factor significantly associated with locoregional recurrence was close distal margin (adjusted odds ratio: 2.80, confidence interval: 1.08-7.25, p = 0.035). Rectal cancer patients with close distal margins (<1 cm) following low anterior resection had a significantly higher risk for locoregional recurrence. Therefore, the decision to perform low anterior resection with margins < 1 cm should be taken with caution.

Metastatic Breast Signet-Ring Cell Carcinoma from a Colonic Primary: Review of a Rare Case Report

Introduction: Colonic signet-ring cell carcinoma is a distinctive rare subtype of adenocarcinoma with a predilection for early metastasis. Among the rare extramammary metastatic adenocarcinomas to the breast, colonic signet-ring cell carcinomas constitute a small percentage. The distinction of a primary from a secondary breast signet-ring cell carcinoma is indispensable since it may result in different therapeutic approaches. Here we presented a rare case of metastatic breast signet-ring cell carcinoma from a rectal origin and review its distinctive histopathologic features. Case Presentation: A 37-year-old woman presented with a breast mass 3 months after undergoing low anterior resection surgery to remove a rectal mass, diagnosed as signet-ring cell carcinoma. Histopathologic examination of the core needle breast mass biopsy revealed tumor cells with signet-ring cell cytomorphology. The performed immunohistochemistry confirmed carcinoma of colonic origin. Conclusions: Colorectal signet-ring cell carcinoma is a rare and aggressive tumor. Its metastatic spread is most seen in the intra-abdominal area, with seldom reported cases of breast metastasis. Histologically, it can mimic a primary breast carcinoma, especially if no prior history of colonic origin exists. Accurate diagnosis is important since these two entities carry different therapeutic management. Proper immunophenotyping, obtaining a thorough clinical history and imaging studies facilitate a correct diagnosis.

Colonoscopy surveillance of colorectal cancer post-surgery in Sanglah General Hospital, Bali, Indonesia: a descriptive study

Background: The postoperative surveillance of patients treated for colorectal cancer is intended to prolong survival by diagnosing recurrent and metachronous cancers at a curable stage as well as preventing metachronous cancer by detection and removal of precancerous polyps. This study evaluates the surveillance colonoscopy and its association with sociodemographic and clinical findings in a descriptive study.Methods: This is a cross sectional study of colorectal cancer patients who underwent surveillance colonoscopy as follow up after tumor resection from January 2020 to September 2021 in Sanglah General Hospital. Clinical data were gathered from medical records and databases by a qualified reviewer. Data were analyzed descriptively using SPSS version 20 for Windows.Results: The majority of patients who underwent surveillance colonoscopy were male (82.40%), tumor location at rectum (58.8%), stage IV (29.40%), underwent low anterior resection surgery (35.30%) and received Folfox (35.30%) or Capeox (35.30%) adjuvant chemotherapy. There was 2 (11.80%) residual mass found in this study. There was no significant difference between subjects who underwent surveillance colonoscopy with residual mass and without residual mass in all variables assessed (p&gt;0.05).Conclusion: Colonoscopy surveillance plays an important role in early detection for any recurrence or pre-cancer lesion and metachronous cancer in a patient with colorectal malignancies in Sanglah General Hospital, Bali, Indonesia.

Introduction of a handmade vacuum-assisted sponge drain for the treatment of anastomotic leakage after low anterior rectal resection.

PurposeAnastomotic leakage, a known major postoperative complication, potentially leads to readmission, reoperation, and increased mortality rates in patients, such as rectal cancer patients following a low anterior resection (LAR). Currently, vacuum-assisted closure, as featured by B-Braun (B-Braun Medical B.V.), is already being used for the treatment of gastrointestinal leakages and fistulas. The main aim of this study was to introduce a novel method for creating a vacuum-assisted drain for the treatment of anastomotic leakage after LAR.MethodsAll 10 patients, who underwent LAR surgery from 2018 to 2019, were diagnosed with anastomotic leakage and had received neoadjuvant chemotherapy prior to surgery. Therefore, patients were treated with a handmade vacuum-assisted drain and were revisited every 5 to 7 days for further evaluations and drain replacement until leakage resolution. Physical features of cavity, time of diagnose, and duration of treatment were analyzed correspondingly. The handmade vacuum-assisted sponge drain was prepared for each patient in each session of follow-up.ResultsEight out of 10 patients experienced complete closure of the defect. The mean delay time from the day of operation to the diagnosis of anastomotic leakage was 61.0±80.4 days while the mean time for leakage closure was 117.6±68.3 days. Eventually, 7 cases underwent ileostomy reversal with no complications during a 3-month follow-up.ConclusionIn this study, we evaluated the healing process of anastomotic leakage after the usage of a handmade vacuum-assisted sponge drain in a case series method. In our trial, we provided an innovative cost-benefit method easily applicable in the operating room.

Risk Factors for Anastomotic Leakage after Low Anterior Resection.

Low anterior resection (LAR) is a standard surgical procedure for distal rectal carcinoma that allows creation of a colorectal anastomosis, with anal sphincter preservation and permanent colostomy avoidance. Anastomotic leakage (AL) is a potential complication of LAR present in 3% to 20% of cases leading to a significant increase in postoperative morbidity. AL represents a communication between the intra luminal and extra luminal compartments caused by a violation of the integrity of the intestinal wall. The risk factors of this procedure have been discussed and still remain a controversial issue. Prevention is the best management. Patients with predisposing factors should be paid special attention. Our objective was to identify and analyze the risk factors of anastomotic leakage after low anterior resection of rectal carcinoma. This study included all patients who underwent low anterior resection for rectal cancer at the Department of Surgery of University Hospital Kaspela between 2011 and 2016. Low anterior resections were performed in 141 patients during the study period. Due to a positive air leak test on 16 patients, a protective ileostomy was created and these patients were eliminated from the study. The sex distribution of the remaining 125 patients was 69 men (55.2%) and 56 women (44.8%). The height of the anastomosis from the dentate line was 3.0 cm on an average (range 2.5 to 4 cm). Anastomotic leakage remains the most feared and serious complication after low anterior resection surgery. The evidence suggests that the main risk factors for anastomotic leakage at low anterior resection are the height of the anastomosis and the high ASA score.

Erectile dysfunction after surgery for rectal cancer: a prospective study.

Erectile dysfunction may occur as a complication of surgical treatment of rectal cancer in male patients. We compared the rates of postoperative erectile dysfunction and response to medical treatment after low anterior resection (LAR) and Miles' procedures. Fifty patients who underwent the Miles' procedure or LAR were prospectively assessed. This study includes fifty patients with stages 1 and stage 2 rectal cancer based on clinical and radiologic assessments, who underwent Miles' (25 out of 50 patients underwent the Miles'procedure and ) or LAR (25 patients underwent LAR) procedures were prospectively assessed. The International Index of Erectile Function (IIEF) form was, used in the assessment to assess erectile dysfunction. This questionnaire, was administered preoperatively and 6 months postoperatively. For the patients with IIEF scores ≤ 25 at postoperative 6th months, tadalafil 5 mg is was given for 12 weeks and IIEF is was repeated after then. No significant differences were found in mean IIEF scores preoperatively (p= 0.695). In both groups, IIEF scores were significantly lower postoperatively compared with preoperatively (p= 0.00001, LAR; p= 0.00001, Miles'). Mean postoperative IIEF scores were significantly lower in patients who underwent Miles' compared with the LAR procedures (p= 0.0001). For patients with IIEF scores ≤ 25 at 6 months, tadalafil 5 mg was given for 12 weeks and IIEF scores were better in both groups (p= 0.00001). The erectile dysfunction rate after Miles' procedure was significantly higher than the rate of patients who developed erectile dysfunction after LAR surgery. We tried to emphasize that in after LAR surgery. We should not be concerned only with cancer treatment surgically in rectal tumour patients, but remember that situations affecting their social life, such as postoperative erectile dysfunction, have medical and psychologic importance.

Endovascular management of life threatening bleeding from a radiation induced internal iliac artery branch pseudoaneurysm

BackgroundAmong radiation induced arterial complications, stenoses and occlusions are commonly reported. Radiation induced pseudoaneurysms (PSA) and their management outcomes are rarely reported.Case presentationA 48 year old male underwent low anterior resection surgery for a clinically staged T2N0M0 rectal adenocarcinoma and adjuvant chemoradiation for the findings of lymphovascular invasion and focally positive distal margin 2 years prior to current admission. The patient now presented with syncope and anemia. The patient was hypotensive after an episode of hematochezia during the hospital stay. An urgent sigmoidoscopy revealed bleeding from friable necrotic rectal mucosa with focal pulsations along the left posterolateral aspect of the rectal wall. An emergent pelvic angiogram revealed active extravasation from a 3 mm PSA from the anterior division of left internal iliac artery. After coil embolization of the affected vascular branch on either side of the neck of PSA, there was no opacification of PSA or extravasation. The patient remained asymptomatic for 3 years.ConclusionsRadiation induced PSA must be considered in the absence of trauma. Endovascular coil-embolization of radiation induced PSAs from small caliber vessels can be an effective treatment.

Right pelvic kidney during intersphincteric resection for locally advanced rectal cancer: a case report

BackgroundSimultaneous occurrence of colorectal malignancy with pelvic kidney has been considered a rare phenomenon. A review of the related literature revealed three previous reports of rectal cancer and pelvice kidney.Case presentationThis case report describe the case of 40-year-old Asian man with complaints of bleeding and a feeling of discomfort in his anus. A colonoscopy revealed a raised large multilobulated mass in his rectum. Multiple biopsies of the lesion were done after detecting a tumor in his rectum 4 cm above the dentate line; a diagnosis of rectal adenocarcinoma was made by pathological examinations. Subsequent investigations, carried out by computed tomography (CT) scans, incidentally showed an ectopic pelvic kidney. Because of the progress of the rectal cancer, our patient was a candidate for neoadjuvant radiotherapy. Six weeks after radiotherapy, he underwent total mesorectal excision (TME) surgery maintaining the ectopic kidney after using a coloanal anastomosis for additional curative surgery. A very low anterior resection surgery was performed to maintain the ectopic kidney. Thereafter, adjuvant chemotherapy was performed.ConclusionsDue to the proximity of the tumor to the pelvic viscera, especially the ectopic kidney, the probability of inadequate abscission of the lesion in surgery and radiotherapy, as well as complications and localized relapse were increased so that the kidney could be maintained. Carrying out careful pre-treatment examinations can result in maintaining an ectopic kidney and its daily conditioned function dependent on the status of the patient, including the proximity of the ectopic kidney to the tumor, anatomical position, and prior damage. The lesson learned from the present case is that radiotherapy and surgery are possible treatments in the presence of pelvic kidney and rectal cancer without incurring renal damage.

Anesthetic Management of 70 Year Old Woman with Cor triatriatum Sinister

A 70 year old woman with no specific underlying disease was referred to the department of surgery of our hospital to have low anterior resection surgery for rectal cancer. Preoperative transthoracic echocardiography (TTE) revealed perforated fibromuscular septum which divides the left atrium into two chambers. Patients with Cor Triatriatum (CT) can show a clinical feature of mitral stenosis (MS) or tricuspid stenosis (TS) according to the degree of intra atrial membrane fenestration. Therefore careful anesthetic management is needed when we deal with this patients who undergo general anesthesia. Our patient was tolerable throughout the general anesthesia with propofol, volatile agent and opioid. The surgery was done without any hemodynamic event. And there was no postoperative complications.

Bowel symptoms and self-care strategies of survivors in the process of restoration after low anterior resection of rectal cancer

BackgroundThe purpose of this research is to identify the bowel symptoms and self-care strategies for rectal cancer survivors during the recovery process following low anterior resection surgery.MethodsA total of 100 participants were investigated under the structured interview guide based on the dimensions of “symptom management theory”.Results92% of participants reported changes in bowel habits, the most common being the frequent bowel movements and narrower stools, which we named it finger-shaped consistency stools. The 6 most frequently reported bowel symptoms were excessive flatus (93%), clustering (86%), urgency (77%), straining (62%), bowel frequency (57%) and anal pendant expansion (53%). Periodic bowel movements occurred in 19% participants. For a group of 79 participants at 6 to 24 months post-operation, 86.1% reported a significant improvement of bowel symptoms. Among 68 participants of this subgroup with significant improvements, 70.5% participants reported the length of time it took was at least 6 months. Self-care strategies adopted by participants included diet, bowel medications, practice management and exercise.ConclusionsIt is necessary to educate patients on the symptoms experienced following low anterior resection surgery. Through the process of trial and error, participants have acquired self-care strategies. Healthcare professionals should learn knowledge of such strategies and help them build effective interventions.

Long-term effects of neoadjuvant chemoradiotherapy followed by sphincter-preserving resection on anal sphincter function in relation to quality of life among locally advanced rectal cancer patients: a cross-sectional analysis.

BackgroundThere is growing recognition for the consequences of rectal cancer treatment to maintain an adequate functional sphincter in the long-term rather than preserving the anal sphincter itself. This study aims to evaluate long-term effects of neoadjuvant chemoradiotherapy (nCRT) followed by sphincter-preserving resection on anal sphincter function in relation to quality of life (QoL) among locally advanced rectal cancer patients.MethodsTwenty-nine patients treated with nCRT followed by low anterior resection surgery were included in this study. Data on patient demographics, tumor location and symptoms of urgency and fecal soiling were recorded and evaluated with respect to Wexner Fecal Incontinence Scoring Scale, European Organization for Research and Cancer (EORTC) cancer-specific (EORTC QLQ-C30) and colorectal cancer-specific (EORTC QLQ-CR38) questionnaires and anorectal manometrical findings. Correlation of manometrical findings with Wexner Scale, EORTC QLQ-CR38 scores and EORTC QLQ-C30 scores was also evaluated.ResultsMedian follow-up was 45.6 months (ranged 7.5–98 months. Higher scores for incontinence for gas (p = 0.001), liquid (p = 0.048) and solid (p = 0.019) stool, need to wear pad (p = 0.001) and alteration in life style (p = 0.004) in Wexner scale, while lower scores for future perspective (p = 0.010) and higher scores for defecation problems (p = 0.001) in EORTC QLQ-CR38 were noted in patients with than without urgency. Manometrical findings of resting pressure (mmHg) was positively correlated with body image (r = 0.435, p = 0.030) and sexual functioning (r = 0.479, p = 0.011) items of functional scale, while rectal sensory threshold (RST) volume (mL) was positively correlated with defecation problems (r = 0.424, p = 0.031) items of symptom scale in EORTC QLQ-CR38 and negatively correlated with social function domain (r = −0.479, p = 0.024) in EORTC QLQ-C30. RST volume was also positively correlated with Wexner scores including incontinence for liquid stool (r = 0.459, p = 0.024), need to wear pad (r = 0.466, p = 0.022) and alteration in lifestyle (r = 0.425, p = 0.038).ConclusionThe high risk of developing functional anal impairment as well as the systematic registration of not only oncological but also functional and QoL related outcomes seem important in rectal cancer patients in the long-term disease follow-up.

Fecal Incontinence and Quality of Life in Adults With Rectal Cancer After Lower Anterior Resection.

The purpose of this study was to explore the prevalence of fecal incontinence (FI) and its impact on health-related quality of life in rectal cancer patients following low anterior resection surgery for colorectal cancer. Descriptive, cross-sectional study. Patients who were diagnosed with rectal cancer and underwent low anterior resection were recruited from a 1264-bed hospital in southern Taiwan. Potential participants were mailed a questionnaire survey. They were followed up 8 to 16 months postoperatively. Some clinical data were collected via retrospective review of their medical records. Questionnaires were mailed to 172 patients, and 71 with colorectal cancer underwent low anterior resection and agreed to participate and completed questionnaires in the research, reflecting a return rate of 41%. Data were collected on demographic characteristics and disease-related variables. Participants were asked if they had experienced FI during the past week. Fecal incontinence health-related quality of life was measured using the Cleveland Clinic Incontinence Score (CCIS) and the Fecal Incontinence Quality of Life Index. Completion of the questionnaire required approximately 15 minutes. More than half of the 71 participants (n = 45; 63.4%) experienced incontinence of flatus, 42.3% (n = 30) reported incontinence of liquid stool, and 14.1% (n = 10) stated that they experienced incontinence of solid stool. Based on mean CCIS scores, 35.2% (n = 25) experienced moderate to severe FI. One-third wore pads to contain FI and 21.1% changed daily activities because of FI. Nearly two-thirds reported FI during the week prior to completing the research questionnaire. The average Fecal Incontinence Quality of Life Index cumulative score was significantly lower in the FI group (2.62 ± 0.61) than in the without-FI group (3.32 ± 0.77; P < .001), as were all subscale mean scores (all P < .01-.001). Fecal incontinence is prevalent among persons undergoing low anterior resection for colorectal cancer. Persons with FI report poor health-related quality of life compared to persons who retained fecal continence. Health care providers should assess these patients for FI and treat or refer those who experience this common problem.

Double Decompression of Presacral Collection by Heald Anal Stent and Foley Catheter Combination

The authors demonstrate the effective drainage of presacral sepsis following low anterior resection surgery using the novel approach of both the Heald anal stent and a Foley catheter combined. The Heald stent was placed trans-anally without the need for anaesthetic and an 18Fr Foley was placed through this. A presacral collection was drained through the stent, allowing the patient to be discharged after a week without the need to return to the operating theatre. The Heald stent may be used to successfully drain a presacral collection by double decompression of the rectum and the presacral space.