Low Anterior Resection Syndrome: Current Management and Future Directions

Abstract

Outcomes for rectal cancer surgery have improved significantly over the past 20 years with increasing rates of survival and recurrence, specifically local recurrence. These gains have been realized during a period of time in which there has been an increasing emphasis on sphincter preservation. As we have become increasingly aggressive in avoiding resection of the anus, we have begun accepting bowel dysfunction as a normal outcome. Low anterior resection syndrome, defined as a constellation of symptoms including incontinence, frequency, urgency, or feelings of incomplete emptying, has a significant impact on quality of life and results in many patients opting for a permanent colostomy to avoid these symptoms. In this article, we will highlight the most recent clinical and basic science research on this topic and discuss areas of future investigation.

Keywords

LAR syndrome - rectal cancer - low anterior resection

• References

• 1 Monson JR, Weiser MR, Buie WD , et al; Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum 2013; 56 (5) 535-550
• 2 Dennett ER, Parry BR. Misconceptions about the colonic J-pouch: what the accumulating data show. Dis Colon Rectum 1999; 42 (6) 804-811
• 3 Juul T, Ahlberg M, Biondo S , et al. Low anterior resection syndrome and quality of life: an international multicenter study. Dis Colon Rectum 2014; 57 (5) 585-591
• 4 Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL. Anterior resection syndrome. Lancet Oncol 2012; 13 (9) e403-e408
• 5 Ishiyama G, Hinata N, Kinugasa Y, Murakami G, Fujimiya M. Nerves supplying the internal anal sphincter: an immunohistochemical study using donated elderly cadavers. Surg Radiol Anat 2014; 36 (10) 1033-1042
• 6 Williamson ME, Lewis WG, Holdsworth PJ, Finan PJ, Johnston D. Decrease in the anorectal pressure gradient after low anterior resection of the rectum. A study using continuous ambulatory manometry. Dis Colon Rectum 1994; 37 (12) 1228-1231
• 7 Farouk R, Duthie GS, Lee PW, Monson JR. Endosonographic evidence of injury to the internal anal sphincter after low anterior resection: long-term follow-up. Dis Colon Rectum 1998; 41 (7) 888-891
• 8 Karanjia ND, Schache DJ, Heald RJ. Function of the distal rectum after low anterior resection for carcinoma. Br J Surg 1992; 79 (2) 114-116
• 9 Komatsu J, Oya M, Ishikawa H. Quantitative assessment of anal canal sensation in patients undergoing low anterior resection for rectal cancer. Surg Today 1995; 25 (10) 867-873
• 10 Tomita R, Igarashi S, Fujisaki S. Studies on anal canal sensitivity in patients with or without soiling after low anterior resection for lower rectal cancer. Hepatogastroenterology 2008; 55 (85) 1311-1314
• 11 Kaur G, Gardiner A, Duthie GS. Rectoanal reflex parameters in incontinence and constipation. Dis Colon Rectum 2002; 45 (7) 928-933
• 12 Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome. Colorectal Dis 2006; 8 (8) 650-656
• 13 Lee SJ, Park YS. Serial evaluation of anorectal function following low anterior resection of the rectum. Int J Colorectal Dis 1998; 13 (5–6) 241-246
• 14 Saigusa N, Belin BM, Choi HJ , et al. Recovery of the rectoanal inhibitory reflex after restorative proctocolectomy: does it correlate with nocturnal continence?. Dis Colon Rectum 2003; 46 (2) 168-172
• 15 Heppell J, Kelly KA, Phillips SF, Beart Jr RW, Telander RL, Perrault J. Physiologic aspects of continence after colectomy, mucosal proctectomy, and endorectal ileo-anal anastomosis. Ann Surg 1982; 195 (4) 435-443
• 16 Nesbakken A, Nygaard K, Lunde OC. Mesorectal excision for rectal cancer: functional outcome after low anterior resection and colorectal anastomosis without a reservoir. Colorectal Dis 2002; 4 (3) 172-176
• 17 Lazorthes F, Fages P, Chiotasso P, Lemozy J, Bloom E. Resection of the rectum with construction of a colonic reservoir and colo-anal anastomosis for carcinoma of the rectum. Br J Surg 1986; 73 (2) 136-138
• 18 Seow-Choen F, Goh HS. Prospective randomized trial comparing J colonic pouch-anal anastomosis and straight coloanal reconstruction. Br J Surg 1995; 82 (5) 608-610
• 19 Ortiz H, De Miguel M, Armendáriz P, Rodriguez J, Chocarro C. Coloanal anastomosis: are functional results better with a pouch?. Dis Colon Rectum 1995; 38 (4) 375-377
• 20 Hallböök O, Påhlman L, Krog M, Wexner SD, Sjödahl R. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg 1996; 224 (1) 58-65
• 21 Lazorthes F, Chiotasso P, Gamagami RA, Istvan G, Chevreau P. Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis. Br J Surg 1997; 84 (10) 1449-1451
• 22 Ho YH, Seow-Choen F, Tan M. Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial. World J Surg 2001; 25 (7) 876-881
• 23 Dehni N, Tiret E, Singland JD , et al. Long-term functional outcome after low anterior resection: comparison of low colorectal anastomosis and colonic J-pouch-anal anastomosis. Dis Colon Rectum 1998; 41 (7) 817-822 , discussion 822–823
• 24 Baker JW. Low end to side rectosigmoidal anastomosis; description of technic. Arch Surg 1950; 61 (1) 143-157
• 25 Huber FT, Herter B, Siewert JR. Colonic pouch vs. side-to-end anastomosis in low anterior resection. Dis Colon Rectum 1999; 42 (7) 896-902
• 26 Machado M, Nygren J, Goldman S, Ljungqvist O. Similar outcome after colonic pouch and side-to-end anastomosis in low anterior resection for rectal cancer: a prospective randomized trial. Ann Surg 2003; 238 (2) 214-220
• 27 Machado M, Nygren J, Goldman S, Ljungqvist O. Functional and physiologic assessment of the colonic reservoir or side-to-end anastomosis after low anterior resection for rectal cancer: a two-year follow-up. Dis Colon Rectum 2005; 48 (1) 29-36
• 28 Jiang JK, Yang SH, Lin JK. Transabdominal anastomosis after low anterior resection: a prospective, randomized, controlled trial comparing long-term results between side-to-end anastomosis and colonic J-pouch. Dis Colon Rectum 2005; 48 (11) 2100-2108 , discussion 2108–2110
• 29 Z'graggen K, Maurer CA, Mettler D, Stoupis C, Wildi S, Büchler MW. A novel colon pouch and its comparison with a straight coloanal and colon J-pouch—anal anastomosis: preliminary results in pigs. Surgery 1999; 125 (1) 105-112
• 30 Z'graggen K, Maurer CA, Büchler MW. Transverse coloplasty pouch. A novel neorectal reservoir. Dig Surg 1999; 16 (5) 363-366
• 31 Z'graggen K, Maurer CA, Birrer S, Giachino D, Kern B, Büchler MW. A new surgical concept for rectal replacement after low anterior resection: the transverse coloplasty pouch. Ann Surg 2001; 234 (6) 780-785 , discussion 785–787
• 32 Ho YH, Brown S, Heah SM , et al. Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Ann Surg 2002; 236 (1) 49-55
• 33 Fürst A, Suttner S, Agha A, Beham A, Jauch KW. Colonic J-pouch vs. coloplasty following resection of distal rectal cancer: early results of a prospective, randomized, pilot study. Dis Colon Rectum 2003; 46 (9) 1161-1166
• 34 Pimentel JM, Duarte A, Gregório C, Souto P, Patrício J. Transverse coloplasty pouch and colonic J-pouch for rectal cancer—a comparative study. Colorectal Dis 2003; 5 (5) 465-470
• 35 Fazio VW, Zutshi M, Remzi FH , et al. A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers. Ann Surg 2007; 246 (3) 481-488 , discussion 488–490
• 36 Lee WY, Takahashi T, Pappas T, Mantyh CR, Ludwig KA. Surgical autonomic denervation results in altered colonic motility: an explanation for low anterior resection syndrome?. Surgery 2008; 143 (6) 778-783
• 37 Fürst A, Burghofer K, Hutzel L, Jauch KW. Neorectal reservoir is not the functional principle of the colonic J-pouch: the volume of a short colonic J-pouch does not differ from a straight coloanal anastomosis. Dis Colon Rectum 2002; 45 (5) 660-667
• 38 Ridolfi TJ, Tong WD, Takahashi T, Kosinski L, Ludwig KA. Sympathetic and parasympathetic regulation of rectal motility in rats. J Gastrointest Surg 2009; 13 (11) 2027-2033 , discussion 2033
• 39 Ridolfi TJ, Tong WD, Kosinski L, Takahashi T, Ludwig KA. Recovery of colonic transit following extrinsic nerve damage in rats. Scand J Gastroenterol 2011; 46 (6) 678-683
• 40 Gillis RA, Dias Souza J, Hicks KA , et al. Inhibitory control of proximal colonic motility by the sympathetic nervous system. Am J Physiol 1987; 253 (4 Pt 1) G531-G539
• 41 Tanabe Y, Hotokezaka M, Mibu R, Tanaka M. Effects of extrinsic autonomic denervation and myenteric plexus transection on colonic motility in conscious dogs. Surgery 2002; 132 (3) 471-479
• 42 Costedio MM, Hyman N, Mawe GM. Serotonin and its role in colonic function and in gastrointestinal disorders. Dis Colon Rectum 2007; 50 (3) 376-388
• 43 Gershon MD, Tack J. The serotonin signaling system: from basic understanding to drug development for functional GI disorders. Gastroenterology 2007; 132 (1) 397-414
• 44 Grider JR, Foxx-Orenstein AE, Jin JG. 5-Hydroxytryptamine4 receptor agonists initiate the peristaltic reflex in human, rat, and guinea pig intestine. Gastroenterology 1998; 115 (2) 370-380
• 45 Tong W, Kamiyama Y, Ridolfi TJ , et al. The role of 5-HT3 and 5-HT4 receptors in the adaptive mechanism of colonic transit following the parasympathetic denervation in rats. J Surg Res 2011; 171 (2) 510-516
• 46 Gribovskaja-Rupp I, Takahashi T, Ridolfi T, Kosinski L, Ludwig K. Upregulation of mucosal 5-HT3 receptors is involved in restoration of colonic transit after pelvic nerve transection. Neurogastroenterol Motil 2012; 24 (5) 472-478 , e218
• 47 Itagaki R, Koda K, Yamazaki M , et al. Serotonin (5-HT3) receptor antagonists for the reduction of symptoms of low anterior resection syndrome. Clin Exp Gastroenterol 2014; 7: 47-52
• 48 Wexner SD, Coller JA, Devroede G , et al. Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg 2010; 251 (3) 441-449
• 49 Mellgren A, Wexner SD, Coller JA , et al; SNS Study Group. Long-term efficacy and safety of sacral nerve stimulation for fecal incontinence. Dis Colon Rectum 2011; 54 (9) 1065-1075
• 50 Devroede G, Giese C, Wexner SD , et al; SNS Study Group. Quality of life is markedly improved in patients with fecal incontinence after sacral nerve stimulation. Female Pelvic Med Reconstr Surg 2012; 18 (2) 103-112
• 51 Chiarioni G, Salandini L, Whitehead WE. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology 2005; 129 (1) 86-97
• 52 Byrne CM, Solomon MJ, Young JM, Rex J, Merlino CL. Biofeedback for fecal incontinence: short-term outcomes of 513 consecutive patients and predictors of successful treatment. Dis Colon Rectum 2007; 50 (4) 417-427
• 53 Ho YH, Chiang JM, Tan M, Low JY. Biofeedback therapy for excessive stool frequency and incontinence following anterior resection or total colectomy. Dis Colon Rectum 1996; 39 (11) 1289-1292
• 54 Kim KH, Yu CS, Yoon YS, Yoon SN, Lim SB, Kim JC. Effectiveness of biofeedback therapy in the treatment of anterior resection syndrome after rectal cancer surgery. Dis Colon Rectum 2011; 54 (9) 1107-1113
• 55 Bartlett L, Sloots K, Nowak M, Ho YH. Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer. Tech Coloproctol 2011; 15 (3) 319-326