Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
International Journal of Colorectal Disease
Published in: International Journal of Colorectal Disease 6/2018

01-06-2018 | Original Article

Outcome of bowel function following anterior resection for rectal cancer—an analysis using the low anterior resection syndrome (LARS) score

Authors: Juliane Kupsch, Thomas Jackisch, Klaus E. Matzel, Joerg Zimmer, Andreas Schreiber, Anja Sims, Helmut Witzigmann, Sigmar Stelzner

Published in: International Journal of Colorectal Disease | Issue 6/2018

Login to get access

Abstract

Purpose

Severity of anorectal dysfunction after low anterior resection is associated with various patient- and treatment-related factors. We aimed to quantify anorectal dysfunction after treatment for rectal cancer using the low anterior resection syndrome (LARS) score.

Methods

We retrieved from a prospective database 331 eligible patients on whom anterior resection for rectal cancer had been performed from 2000 to 2014. All patients were sent a LARS score accompanied by a supplementary questionnaire. Response rate was 78.8% (261 patients). The main outcome measure was the relation of the LARS score to potentially associated patient and treatment factors. Secondary endpoints were further measures that reflect anorectal dysfunction, e.g., Vaizey score.

Results

Overall, 144 (55.2%) patients exhibited scores > 20 reflecting minor (n = 51 (19.5%)) or major (n = 93 (35.6%)) LARS. A significant difference for scores > 20 was found for intersphincteric resection (IR, 73.2% affected patients) compared to total mesorectal excision (TME, 58.4%) and partial mesorectal excision (PME, 38.0%, p = 0.001). Radio(chemo)therapy resulted in LARS scores > 20 in 64.6% of patients compared to 43.1% in patients without irradiation (p = 0.001). Type of procedure (TME and IR as compared to PME), radio(chemo)therapy, and younger age were independently associated with LARS in logistic regression analysis. However, younger age remained the only independent factor for higher scores after exclusion of PME.

Conclusions

The LARS score identified a substantial proportion of patients after surgery for rectal cancer with anorectal dysfunction. The extent of surgical procedure is independently associated with the severity of symptoms whereas the role of radiotherapy needs further assessment.
Literature
1.
Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL (2012) Anterior resection syndrome. Lancet Oncol 13:e403–e408CrossRefPubMed
2.
Temple LK, Bacik J, Savatta SG, Gottesman L, Paty PB, Weiser MR, Guillem JG, Minsky BD, Kalman M, Thaler HT, Schrag D, Wong WD (2005) The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer. Dis Colon Rectum 48:1353–1365CrossRefPubMed
3.
Matzel KE, Stadelmaier U, Muehldorfer S, Hohenberger W (1997) Continence after colorectal reconstruction following resection: impact of level of anastomosis. Int J Color Dis 12:82–87CrossRef
4.
Lange MM, den Dulk M, Bossema ER, Maas CP, Peeters KCMJ, Rutten HJ, Klein Kranenbarg E, Marijnen CAM, van de Velde CJH, Cooperative clinical investigators of the Dutch total mesorectal excision trial (2007) Risk factors for faecal incontinence after rectal cancer treatment. Br J Surg 94:1278–1284
5.
Nesbakken A, Nygaard K, Lunde OC (2001) Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 88:400–404CrossRefPubMed
6.
Bregendahl S, Emmertsen KJ, Lous J, Laurberg S (2013) Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a population-based cross-sectional study. Color Dis 15(9):1130–1139
7.
Neuman HB, Schrag D, Cabral C, Weiser MR, Paty PB, Guillem JG, Minsky BD, Wong WD, Temple LK (2007) Can differences in bowel function after surgery for rectal cancer be identified by the European Organization for Research and Treatment of Cancer quality of life instrument? Ann Surg Oncol 14:1727–1734CrossRefPubMed
8.
Emmertsen KJ, Laurberg S (2012) Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg 255:922–928CrossRefPubMed
9.
Juul T, Battersby NJ, Christensen P, Janjua AZ, Branagan G, Laurberg S, Emmertsen KJ, Moran B, UK LARS Study Group (2015) Validation of the English translation of the low anterior resection syndrome score. Color Dis 17:908–916CrossRef
10.
Juul T, Ahlberg M, Biondo S, Espin E, Jimenez LM, Matzel KE, Palmer GJ, Sauermann A, Trenti L, Zhang W, Laurberg S, Christensen P (2014) International validation of the low anterior resection syndrome score. Ann Surg 259:728–734CrossRefPubMed
11.
Bittorf B, Matzel KE (2015) The LARS score for evaluation of low anterior resection syndrome. Coloproctology 37:262–265 [in German]CrossRef
12.
13.
14.
Enker WE, Thaler HT, Cranor ML, Polyak T (1995) Total mesorectal excision in the operative treatment of carcinoma of the rectum. J Am Coll Surg 181:335–346PubMed
15.
Runkel N, Reiser H (2013) Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection. Int J Color Dis 28:1367–1375CrossRef
16.
Havenga K, Enker WE, McDermott K, Cohen AM, Minsky BD, Guillem J (1996) Male and female sexual and urinary function after total mesorectal excision with autonomic nerve preservation for carcinoma of the rectum. J Am Coll Surg 182:495–502PubMed
17.
Maurer CA, Z’Graggen K, Renzulli P, Schilling MK, Netzer P, Büchler MW (2001) Total mesorectal excision preserves male genital function compared with conventional rectal cancer surgery. Br J Surg 88:1501–1505CrossRefPubMed
18.
Lange MM, Maas CP, Marijnen CA, Wiggers T, Rutten HJ, Kranenbarg EK, van de Velde CJ, Cooperative Clinical Investigators of the Dutch Total Mesorectal Excision Trial (2008) Urinary dysfunction after rectal cancer treatment is mainly caused by surgery. Br J Surg 95:1020–1028CrossRefPubMed
19.
Kinugasa Y, Arakawa T, Murakami G, Fujimiya M, Sugihara K (2014) Nerve supply to the internal anal sphincter differs from that to the distal rectum: an immunohistochemical study of cadavers. Int J Color Dis 29:429–436CrossRef
20.
Stelzner S, Wedel T (2015) Anatomic principles of nerve-sparing rectal surgery. Coloproctology 37:240–247 [in German]CrossRef
21.
Stelzner S, Böttner M, Kupsch J, Kneist W, Quirke P, West N, Witzigmann H, Wedel T (2018) Internal anal sphincter nerves—a macroanatomical and microscopic description of the extrinsic autonomic nerve supply of the internal anal sphincter. Color Dis 20:O7–O16CrossRef
22.
Fischer J, Hellmich G, Jackisch T, Puffer E, Zimmer J, Bleyl D, Kittner T, Witzigmann H, Stelzner S (2015) Outcome for stage II and III rectal and colon cancer equally good after treatment improvement over three decades. Int J Color Dis 30:797–806CrossRef
23.
Schmiegel W, Pox C, Adler G, Fleig W, Fölsch UR, Frühmorgen P, Graeven U, Hohenberger W, Holstege A, Junginger T, Kühlbacher T, Porschen R, Propping P, Riemann JF, Sauer R, Sauerbruch T, Schmoll HJ, Zeitz M, Selbmann HK (2004) S3-guideline conference “Colorectal Carcinoma 2004”. Z Gastroenterol 42:1129–1177 [in German]CrossRefPubMed
24.
Sauer R, Becker H, Hohenberger W, Rödel C, Wittekind C, Fietkau R, Martus P, Tschmelitsch J, Hager E, Hess CF, Karstens JH, Liersch T, Schmidberger H, Raab R, German Rectal Cancer Study Group (2004) Preoperative versus postoperative chemoradiotherapy for rectal cancer. N Engl J Med 351:1731–1740CrossRefPubMed
25.
Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Büchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the international study Group of Rectal Cancer. Surgery 147:339–351CrossRefPubMed
26.
27.
Battersby NJ, Bouliotis G, Emmertsen KJ, Juul T, Glynne-Jones R, Branagan G, Christensen P, Laurberg S, Moran BJ, UK and Danish LARS Study Groups (2017) Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score. Gut. https://​doi.​org/​10.​1136/​gutjnl-2016-312695
28.
Matzel KE, Stadelmaier U, Bittorf B, Hohenfellner M, Hohenberger W (2002) Bilateral sacral spinal nerve stimulation for fecal incontinence after low anterior rectum resection. Int J Color Dis 17:430–434CrossRef
29.
Ramage L, Qiu S, Kontovounisios C, Tekkis P, Rasheed S, Tan E (2015) A systematic review of sacral nerve stimulation for low anterior resection syndrome. Color Dis 17:762–771CrossRef
30.
Martellucci J (2016) Low anterior resection syndrome: a treatment algorithm. Dis Colon Rectum 59:79–82CrossRefPubMed
31.
Kneist W, Kauff DW, Juhre V, Hoffmann KP, Lang H (2013) Is intraoperative neuromonitoring associated with better functional outcome in patients undergoing open TME? Results of a case-control study. Eur J Surg Oncol 39:994–999CrossRefPubMed
32.
Kneist W, Rink AD, Kauff DW, Konerding MA, Lang H (2015) Topography of the extrinsic internal anal sphincter nerve supply during laparoscopic-assisted TAMIS TME: five key zones of risk from the surgeon’s view. Int J Color Dis 30:71–78CrossRef
33.
Luca F, Valvo M, Guerra-Cogorno M, Simo D, Blesa-Sierra E, Biffi R, Garberoglio C (2016) Functional results of robotic total intersphincteric resection with hand-sewn coloanal anastomosis. Eur J Surg Oncol 42:841–847CrossRefPubMed
34.
Pollack J, Holm T, Cedermark B, Altman D, Holmström B, Glimelius B, Mellgren A (2006) Late adverse effects of short-course preoperative radiotherapy in rectal cancer. Br J Surg 93:1519–1525CrossRefPubMed
35.
Loos M, Quentmeier P, Schuster T, Nitsche U, Gertler R, Keerl A, Kocher T, Friess H, Rosenberg R (2013) Effect of preoperative radio(chemo)therapy on long-term functional outcome in rectal cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 20:1816–1828CrossRefPubMed
36.
Samuelian JM, Callister MD, Ashman JB, Young-Fadok TM, Borad MJ, Gunderson LL (2012 Apr) Reduced acute bowel toxicity in patients treated with intensity-modulated radiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 82:1981–1987CrossRefPubMed
37.
38.
Glimelius B, Tiret E, Cervantes A, Arnold D, ESMO Guidelines Working Group (2013) Rectal cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol 24(suppl.6):vi81–vi88PubMed
39.
Goodman KA, Patton CE, Fisher GA, Hoffe SE, Haddock MG, Parikh PJ, Kim J, Baxter NN, Czito BG, Hong TS, Herman JM, Crane CH, Hoffman KE (2016) Appropriate customization of radiation therapy for stage II and III rectal cancer: executive summary of an ASTRO Clinical Practice Statement using the RAND/UCLA Appropriateness Method. Pract Radiat Oncol 6:166–175CrossRefPubMed
40.
Fazio VW, Zutshi M, Remzi FH, Parc Y, Ruppert R, Fürst A, Celebrezze J Jr, Galanduik S, Orangio G, Hyman N, Bokey L, Tiret E, Kirchdorfer B, Medich D, Tietze M, Hull T, Hammel J (2007) A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers. Ann Surg 246:481–488CrossRefPubMedPubMedCentral
41.
Hüttner FJ, Tenckhoff S, Jensen K, Uhlmann L, Kulu Y, Büchler MW, Ulrich A (2015) Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg 102:735–745CrossRefPubMed
42.
Metadata
Title
Outcome of bowel function following anterior resection for rectal cancer—an analysis using the low anterior resection syndrome (LARS) score
Authors
Juliane Kupsch
Thomas Jackisch
Klaus E. Matzel
Joerg Zimmer
Andreas Schreiber
Anja Sims
Helmut Witzigmann
Sigmar Stelzner
Publication date
01-06-2018
Publisher
Springer Berlin Heidelberg
Published in
International Journal of Colorectal Disease / Issue 6/2018
Print ISSN: 0179-1958
Electronic ISSN: 1432-1262
DOI
https://doi.org/10.1007/s00384-018-3006-x

Other articles of this Issue 6/2018

International Journal of Colorectal Disease 6/2018 Go to the issue

Original Article

Safety of mFOLFOX6/XELOX as adjuvant chemotherapy after curative resection of stage III colon cancer: phase II clinical study (The FACOS study)

Original Article

Retromesenteric course of the middle colic artery—challenges and pitfalls in D3 right colectomy for cancer

Original Article

Reappraisal of the lateral rectal ligament: an anatomical study of total mesorectal excision with autonomic nerve preservation

Short Communication

A pooled analysis of en bloc right hemicolectomy with pancreaticoduodenectomy for locally advanced right-sided colon cancer

Review

What have we learned in minimally invasive colorectal surgery from NSQIP and NIS large databases? A systematic review

Original Article

Colorectal cancer surveillance in Portuguese families with lynch syndrome: a cohort study