Low anterior resection syndrome

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Low anterior resection syndrome
Specialty Gastroenterology

Low anterior resection syndrome is a complication of lower anterior resection, a type of surgery performed to remove the rectum, typically for rectal cancer. It is characterized by changes to bowel function that affect quality of life, and includes symptoms such as fecal incontinence, incomplete defecation or the sensation of incomplete defecation (rectal tenesmus), changes in stool frequency or consistency, unpredictable bowel function, and painful defecation (dyschezia). [1] Treatment options include symptom management, such as use of enemas, or surgical management, such as creation of a colostomy. [2]

Contents

Signs and symptoms

Low anterior resection syndrome falls into two groups. Fecal urgency, incontinence, and increased frequency make up the first. Constipation, a sense of incomplete evacuation, and trouble emptying the bowels are included in the second category. Some patients describe characteristics from both groups, either switching back and forth between the two patterns or going through both at once. [3]

Causes

Low anterior resection syndrome emerges after rectal resection. [4]

Risk factors

The two factors that negatively affect patients' bowel function after lower anterior resection are low tumor height and radiation, either pre- or post-operative. Additionally linked to worse bowel function are stomas that are temporary in nature and those that have been in place for an extended length of time. This, however, is probably a reflection of the height of the tumor and potential surgical complications, which may also have a deleterious effect on bowel function. [5]

Mechanism

Multiple factors likely contribute to low anterior resection syndrome. During intersphincteric resection, the internal anal sphincter may sustain direct structural damage that leads to fecal incontinence, or secondary damage from the insertion of an anastomotic device through the anus during low anterior resection. [6] In particular, if the surgical approach reaches the posterolateral side of the prostate (in men), where both the sympathetic and parasympathetic nerve fibers enter the rectal wall, damage to the internal anal sphincter's nerve supply may also result in dysfunction. [7] [8]

When performing a low anterior resection, the conjoint longitudinal muscle may also sustain damage during the surgical dissection of the intersphincteric space. [3] Furthermore, in order to achieve a sufficient horizontal marginanally, the rectococcygeus muscle is frequently divided, which impairs the muscle's functionality. [7]

A decrease in the maximum allowable rectal volume following low anterior resection and an increase in the false urge to urinate can result from poor compliance brought on by rectal volume loss. [9]

The extrinsic spinal cord nerves that mediate the rectoanal inhibitory reflex may also be injured during a low anterior resection, resulting in intestinal dysfunction. [10] [11]

Diagnosis

Low anterior resection syndrome can be assessed using two patient questionnaires that have been validated. [3] After sphincter-preserving surgery, the 18-item validated Memorial Sloan Kettering Cancer Center Bowel Function Instrument (MSKCC-BFI) can be used to assess bowel function. It was developed in 2004. [12] A 5-item validated questionnaire called the LARS score was developed in 2012 by Emmertsen et al. in a Danish population as a second scoring system to evaluate bowel function following sphincter-preserving surgery for rectal cancer. [13]

Anorectal manometry objectively assesses anal sphincter function and rectal capacity by recording resting pressure, maximum squeezing pressure, rectoanal inhibitory reflex, rectal capacity, and compliance with a balloon catheter and pressure sensor. Although it can be used to direct and track the effectiveness of therapy, anorectal manometry is not necessary for the diagnosis of low anterior resection syndrome. [14]

Endoscopic rectal ultrasound is a useful tool for evaluating the pelvic floor and sphincter complex structure. [15]

Fecoflowmetry is a valuable technique for evaluating anorectal motor function following surgery. It works by tracking changes in flow against time and analyzing the fecal flow rate, which is the result of rectal detrusor action against anorectal outlet resistance. [16]

Treatment

The foundation of treatment for low anterior resection syndrome is conservative therapy, including pelvic floor rehabilitation, colonic irrigation, or minimally invasive procedures, such as spinal nerve stimulation. [17]

For the short-term treatment of a single symptom, certain patients should be treated with loperamide or antibiotics like neomicine or rifaximin (in the event of proximal expansion of native gut microbes or small-intestinal bacterial overgrowth shown with the lactulose breath test). [17]

Although bile acid sequestrants like colesevelam and 5-HT3 antagonists like ramosetron have shown intriguing early results, more research is still needed. [17]

Transanal irrigation is an inexpensive and successful treatment for the high frequency of defecations and incontinence linked to low anterior resection syndrome. [18] [19]

Sacral nerve stimulation (SNS) is associated with improved fecal incontinence and deferred defecation among individuals with normal as well as impaired sphincters, as well as in patients with low anterior resection syndrome. [20]

When fecal incontinence becomes unmanageable, surgery may be a viable treatment option. When all other forms of treatment have been exhausted, a stoma should be taken into consideration. Sphincteric substitution and other advanced surgical techniques ought to be reserved for a very select group of patients. [17]

See also

Related Research Articles

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<span class="mw-page-title-main">Anal fissure</span> Break or tear in anal canal skin

An anal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and undergarments, or sometimes in the toilet. If acute they are painful after defecation, but with chronic fissures, pain intensity often reduces and becomes cyclical.

<span class="mw-page-title-main">Rectal prolapse</span> Protrusion of the walls of the rectum outside the body

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

<span class="mw-page-title-main">Colorectal surgery</span> Field in medicine for disabilities in the rectum

Colorectal surgery is a field in medicine dealing with disorders of the rectum, anus, and colon. The field is also known as proctology, but this term is now used infrequently within medicine and is most often employed to identify practices relating to the anus and rectum in particular. The word proctology is derived from the Greek words πρωκτός proktos, meaning "anus" or "hindparts", and -λογία -logia, meaning "science" or "study".

An abdomino perineal resection, formally known as abdominoperineal resection of the rectum and abdominoperineal excision of the rectum is a surgery for rectal cancer or anal cancer. It is frequently abbreviated as AP resection, APR and APER.

Rectal bleeding refers to bleeding in the rectum, thus a form of lower gastrointestinal bleeding. There are many causes of rectal hemorrhage, including inflamed hemorrhoids, rectal varices, proctitis, stercoral ulcers, and infections. Diagnosis is usually made by proctoscopy, which is an endoscopic test.

<span class="mw-page-title-main">Anal fistula</span> Disease of the anus

Anal fistula is a chronic abnormal communication between the anal canal and the perianal skin. An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus. Anal fistulae commonly occur in people with a history of anal abscesses. They can form when anal abscesses do not heal properly.

<span class="mw-page-title-main">Proctocolectomy</span> Surgical removal of the colon and rectum

Proctocolectomy is the surgical removal of the entire colon and rectum from the human body, leaving the patients small intestine disconnected from their anus. It is a major surgery that is performed by colorectal surgeons, however some portions of the surgery, specifically the colectomy may be performed by general surgeons. It was first performed in 1978 and since that time, medical advancements have led to the surgery being less invasive with great improvements in patient outcomes. The procedure is most commonly indicated for severe forms of inflammatory bowel disease such as ulcerative colitis and Crohn's disease. It is also the treatment of choice for patients with familial adenomatous polyposis.

Total mesorectal excision (TME) is a standard surgical technique for treatment of rectal cancer, first described in 1982 by Professor Bill Heald at the UK's Basingstoke District Hospital. It is a precise dissection of the mesorectal envelope comprising rectum containing the tumour together with all the surrounding fatty tissue and the sheet of tissue that contains lymph nodes and blood vessels. Dissection is along the avascular alveolar plane between the presacral and mesorectal fascia, described as holy plane. Dissection along this plane facilitates a straightforward dissection and preserves the sacral vessels and hypogastric nerves and is a sphincter-sparing resection and decreases permanent stoma rates. It is possible to rejoin the two ends of the colon; however, most patients require a temporary ileostomy pouch to bypass the colon, allowing it to heal with less risk of infection, perforation or leakage.

A lower anterior resection, formally known as anterior resection of the rectum and colon and anterior excision of the rectum or simply anterior resection, is a common surgery for rectal cancer and occasionally is performed to remove a diseased or ruptured portion of the intestine in cases of diverticulitis. It is commonly abbreviated as LAR.

Rectal discharge is intermittent or continuous expression of liquid from the anus. Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of fecal incontinence but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge.

Solitary rectal ulcer syndrome or SRUS is a chronic disorder of the rectal mucosa. It commonly occurs with varying degrees of rectal prolapse. The condition is thought to be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation. Treatment is by normalization of bowel habits, biofeedback, and other conservative measures. In more severe cases various surgical procedures may be indicated. The condition is relatively rare, affecting approximately 1 in 100,000 people per year. It affects mainly adults aged 30–50. Females are affected slightly more often than males. The disorder can be confused clinically with rectal cancer or other conditions such as inflammatory bowel disease, even when a biopsy is done.

<span class="mw-page-title-main">Anismus</span> Failure to relax the pelvic floor muscles during defecation

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

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In fecal incontinence (FI), surgery may be carried out if conservative measures alone are not sufficient to control symptoms. There are many surgical options described for FI, and they can be considered in 4 general groups.

Transanal irrigation is medical procedure in which water is used to evacuate feces from the rectum and descending colon via the anus.

<span class="mw-page-title-main">Steven D. Wexner</span> American physician

Steven D. Wexner is an American surgeon and physician. He is Director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center at Cleveland Clinic Florida. Wexner has received numerous regional, national, and international research awards. Through his multiple academic appointments, Wexner personally trains 15-20 surgeons each year, and he educates thousands more around the world through conferences and lectures. He is a resource for his colleagues from around the world for referral of patients with challenging or complex problems. In 2020, he was elected vice-chair of the Board of Regents of the American College of Surgeons for a one-year term. Since 1990. he has served as Symposium Director of the Cleveland Clinic Annual International Colorectal Disease Symposium. The Symposium was held in Fort Lauderdale or Boca Raton every year from 1990 to 2019. Since 2020, the Symposium has expanded to include host locations outside of the US with interruptions during the pandemic years of 2021–2022.

<span class="mw-page-title-main">Neurogenic bowel dysfunction</span> Human disease involving inability to control defecation

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References

  1. ↑ Keane, C; Fearnhead, NS; Bordeianou, LG; Christensen, P; Basany, EE; Laurberg, S; Mellgren, A; Messick, C; Orangio, GR; Verjee, A; Wing, K; Bissett, I; LARS International Collaborative, Group (March 2020). "International Consensus Definition of Low Anterior Resection Syndrome". Diseases of the Colon and Rectum. 63 (3): 274–284. doi:10.1097/DCR.0000000000001583. PMC   7034376 . PMID   32032141.{{cite journal}}: |first13= has generic name (help)
  2. ↑ Ridolfi, Timothy J.; Berger, Nicholas; Ludwig, Kirk A. (September 2016). "Low Anterior Resection Syndrome: Current Management and Future Directions". Clinics in Colon and Rectal Surgery. 29 (3): 239–245. doi:10.1055/s-0036-1584500. ISSN   1531-0043. PMC   4991969 . PMID   27582649.
  3. 1 2 3 Nguyen, Theresa H.; Chokshi, Reena V. (2020). "Low Anterior Resection Syndrome". Current Gastroenterology Reports. 22 (10): 48. doi:10.1007/s11894-020-00785-z. ISSN   1522-8037. PMC   8370104 . PMID   32749603.
  4. ↑ Garfinkle, Richard; Boutros, Marylise (2022). "Low Anterior Resection Syndrome: Predisposing Factors and Treatment". Surgical Oncology. 43. Elsevier BV: 101691. doi:10.1016/j.suronc.2021.101691. ISSN   0960-7404. PMID   34863592. S2CID   244673155.
  5. ↑ Croese, Alexander D.; Lonie, James M.; Trollope, Alexandra F.; Vangaveti, Venkat N.; Ho, Yik-Hong (2018). "A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors". International Journal of Surgery. 56. Ovid Technologies (Wolters Kluwer Health): 234–241. doi:10.1016/j.ijsu.2018.06.031. ISSN   1743-9191. PMID   29936195.
  6. ↑ Farouk, Ridzuan; Duthie, Graeme S.; Lee, Peter W. R.; Monson, John R. T. (1998). "Endosonographic evidence of injury to the internal anal sphincter after low anterior resection". Diseases of the Colon & Rectum. 41 (7). Ovid Technologies (Wolters Kluwer Health): 888–891. doi:10.1007/bf02235373. ISSN   0012-3706. PMID   9678375. S2CID   30437183.
  7. 1 2 Koda, Keiji; Yamazaki, Masato; Shuto, Kiyohiko; Kosugi, Chihiro; Mori, Mikito; Narushima, Kazuo; Hosokawa, Isamu; Shimizu, Hiroaki (April 1, 2019). "Etiology and management of low anterior resection syndrome based on the normal defecation mechanism". Surgery Today. 49 (10). Springer Science and Business Media LLC: 803–808. doi:10.1007/s00595-019-01795-9. ISSN   0941-1291. PMID   30937634. S2CID   91188842.
  8. ↑ Ishiyama, Gentaro; Hinata, Nobuyuki; Kinugasa, Yusuke; Murakami, Gen; Fujimiya, Mineko (April 2, 2014). "Nerves supplying the internal anal sphincter: an immunohistochemical study using donated elderly cadavers". Surgical and Radiologic Anatomy. 36 (10). Springer Science and Business Media LLC: 1033–1042. doi:10.1007/s00276-014-1289-3. ISSN   0930-1038. PMID   24691518. S2CID   38132969.
  9. ↑ Williamson, Michael E.R.; Lewis, Wyn G.; Holdsworth, Peter J.; Finan, Paul J.; Johnston, David (1994). "Decrease in the anorectal pressure gradient after low anterior resection of the rectum". Diseases of the Colon & Rectum. 37 (12). Ovid Technologies (Wolters Kluwer Health): 1228–1231. doi:10.1007/bf02257786. ISSN   0012-3706. PMID   7995148. S2CID   21101741.
  10. ↑ Remes-Troche, Jose M.; De-Ocampo, Sherrie; Valestin, Jessica; Rao, Satish S. C. (2010). "Rectoanal Reflexes and Sensorimotor Response in Rectal Hyposensitivity". Diseases of the Colon & Rectum. 53 (7). Ovid Technologies (Wolters Kluwer Health): 1047–1054. doi:10.1007/dcr.0b013e3181dcb2d6. ISSN   0012-3706. PMC   3929945 . PMID   20551758.
  11. ↑ Meunier, Patrick; Mollard, Pierre (1977). "Control of the internal anal sphincter (manometric study with human subjects)". Pflügers Archiv: European Journal of Physiology. 370 (3). Springer Science and Business Media LLC: 233–239. doi:10.1007/bf00585532. ISSN   0031-6768. PMID   563054. S2CID   31668284.
  12. ↑ Temple, Larissa K.; Bacik, Jennifer; Savatta, Salvatore G.; Gottesman, Lester; Paty, Philip B.; Weiser, Martin R.; Guillem, José G.; Minsky, Bruce D.; Kalman, Michelle; Thaler, Howard T.; Schrag, Deborah; Wong, Douglas W. (2005). "The Development of a Validated Instrument to Evaluate Bowel Function After Sphincter-Preserving Surgery for Rectal Cancer". Diseases of the Colon & Rectum. 48 (7). Ovid Technologies (Wolters Kluwer Health): 1353–1365. doi:10.1007/s10350-004-0942-z. ISSN   0012-3706. PMID   15868235. S2CID   1647820.
  13. ↑ Juul, T.; Battersby, N. J.; Christensen, P.; Janjua, A. Z.; Branagan, G.; Laurberg, S.; Emmertsen, K. J.; Moran, B. (September 11, 2015). "Validation of the English translation of the low anterior resection syndrome score". Colorectal Disease. 17 (10). Wiley: 908–916. doi:10.1111/codi.12952. ISSN   1462-8910. PMID   25807963. S2CID   25000841.
  14. ↑ Cura Pales, Chris George; An, Sanghyun; Cruz, Jan Paolo; Kim, Kwangmin; Kim, Youngwan (August 31, 2019). "Postoperative Bowel Function After Anal Sphincter-Preserving Rectal Cancer Surgery: Risks Factors, Diagnostic Modalities, and Management". Annals of Coloproctology. 35 (4). Korean Society of Coloproctology: 160–166. doi:10.3393/ac.2019.08.10. ISSN   2287-9714. PMC   6732333 . PMID   31487762.
  15. ↑ Leão, Pedro; Santos, Catarina; Goulart, André; Caetano, Ana Célia; Sousa, Maria; Hogemann, Gerrit; Parvaiz, Amjad; Figueiredo, Nuno (March 19, 2019). "TaTME: analysis of the evacuatory outcomes and EUS anal sphincter". Minimally Invasive Therapy & Allied Technologies. 28 (6). Informa UK Limited: 332–337. doi:10.1080/13645706.2019.1567555. ISSN   1364-5706. PMID   30888248. S2CID   83463271.
  16. ↑ Shafik, Ahmed; Abdel-Moneim, Khalid (1993). "Fecoflowmetry". Diseases of the Colon & Rectum. 36 (1). Ovid Technologies (Wolters Kluwer Health): 35–42. doi:10.1007/bf02050299. ISSN   0012-3706. PMID   8416777. S2CID   8557578.
  17. 1 2 3 4 Martellucci, Jacopo (2016). "Low Anterior Resection Syndrome: A Treatment Algorithm". Diseases of the Colon & Rectum. 59 (1): 79–82. doi:10.1097/DCR.0000000000000495. ISSN   0012-3706. PMID   26651116 . Retrieved January 12, 2024.
  18. ↑ Rosen, H.; Robert-Yap, J.; Tentschert, G.; Lechner, M.; Roche, B. (September 20, 2011). "Transanal irrigation improves quality of life in patients with low anterior resection syndrome". Colorectal Disease. 13 (10). Wiley: e335–e338. doi:10.1111/j.1463-1318.2011.02692.x. ISSN   1462-8910. PMID   21689359. S2CID   27684102.
  19. ↑ Koch, S. M. P.; Rietveld, M. P.; Govaert, B.; van Gemert, W. G.; Baeten, C. G. M. I. (May 19, 2009). "Retrograde colonic irrigation for faecal incontinence after low anterior resection". International Journal of Colorectal Disease. 24 (9). Springer Science and Business Media LLC: 1019–1022. doi:10.1007/s00384-009-0719-x. ISSN   0179-1958. PMID   19452159. S2CID   25813307.
  20. ↑ Ramage, L.; Qiu, S.; Kontovounisios, C.; Tekkis, P.; Rasheed, S.; Tan, E. (August 8, 2015). "A systematic review of sacral nerve stimulation for low anterior resection syndrome". Colorectal Disease. 17 (9). Wiley: 762–771. doi:10.1111/codi.12968. ISSN   1462-8910. PMID   25846836. S2CID   13501469.

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