International Journal of Colorectal Disease

, Volume 34, Issue 4, pp 747–762 | Cite as

To what extent is the low anterior resection syndrome (LARS) associated with quality of life as measured using the EORTC C30 and CR38 quality of life questionnaires?

  • Juliane Kupsch
  • Matthias Kuhn
  • Klaus E. Matzel
  • Joerg Zimmer
  • Olga Radulova-Mauersberger
  • Anja Sims
  • Helmut Witzigmann
  • Sigmar StelznerEmail author
Original Article



Treatment of rectal cancer often results in disturbed anorectal function, which can be quantified by the Low Anterior Resection Syndrome (LARS) score. This study investigates the association of impaired anorectal function as measured with the LARS score with quality of life (QoL) as measured with the EORTC-QLQ-C30 and CR38 questionnaires.


All stoma-free patients who had undergone sphincter-preserving surgery for rectal cancer from 2000 to 2014 in our institution were retrieved from a prospective database. They were contacted by mail and asked to return the questionnaires. QoL was evaluated in relation to LARS and further patient- and treatment factors using univariate and multivariate analysis.


Of the eligible patients (n = 331), 261 (78.8%) responded with a complete LARS score. Mean score for global QoL according to the EORTC-QLQ-C30 questionnaire was 63 ± 21 for all patients. If major LARS was present, mean score decreased to 56 ± 19 in contrast to 67 ± 20 in patients with no/minor LARS (p < 0.001). In regression analysis, major LARS was furthermore associated with reduced physical, role, emotional, cognitive and social functioning as well as impaired body image, more micturition problems and poorer future perspective. It was not related to sexual function. The variance explained by major LARS in the differences of QoL was approximately 10%.


The presence of major LARS after rectal resection for cancer is negatively associated with global health as well as many other aspects of QoL. Preserving anorectal function and treatment of LARS are potential measures to improve QoL in this patient group.


Rectal cancer Sphincter-preserving surgery Quality of life Low anterior resection syndrome score 



The authors are indebted to Lisa Domichowski, Medical Data Manager, for her support in data acquisition. The maintenance of the database at the Coloproctologic Unit of Dresden-Friedrichstadt General Hospital is supported by a grant from the Tumour Centre Dresden.

Compliance with ethical standards

Ethical approval was granted by the responsible institution (Saxon Physicians Chamber, No. EK-BR-92/15-1/134619).


  1. 1.
    Heald RJ, Moran BJ, Ryall RDH, Sexton R, MacFarlane JK (1998) The Basingstoke Experience of total mesorectal excision. Arch Surg 133:894–899CrossRefGoogle Scholar
  2. 2.
    Merkel S, Klossek D, Göhl J, Papadopoulos T, Hohenberger W, Hermanek P (2009) Quality management in rectal carcinoma: what is feasible? Int J Color Dis 24:931–942CrossRefGoogle Scholar
  3. 3.
    Birgisson H, Talbäck M, Gunnarsson U, Påhlman L, Glimelius B (2005) Improved survival in cancer of the colon and rectum in Sweden. Eur J Surg Oncol 31:845–853CrossRefPubMedGoogle Scholar
  4. 4.
    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 30:797–806CrossRefGoogle Scholar
  5. 5.
    Battersby NJ, Juul T, Christensen P, Janjua AZ, Branagan G, Emmertsen KJ, Norton C, Hughes R, Laurberg S, Moran BJ, United Kingdom Low Anterior Resection Syndrome Study Group (2016) Predicting the risk of bowel-related quality-of-life impairment after restorative resection for rectal cancer: a multicenter cross-sectional study. Dis Colon Rectum 59:270–280CrossRefPubMedGoogle Scholar
  6. 6.
    Hupkens BJP, Martens MH, Stoot JH, Berbee M, Melenhorst J, Beets-Tan RG, Beets GL, Breukink SO (2017) Quality of life in rectal cancer patients after chemoradiation: watch-and-wait policy versus standard resection—a matched-controlled study. Dis Colon Rectum 60:1032–1040CrossRefGoogle Scholar
  7. 7.
    Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC et al (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85:365–376CrossRefGoogle Scholar
  8. 8.
    Sprangers MA, te Velde A, Aaronson NK (1999) The construction and testing of the EORTC colorectal cancer-specific quality of life questionnaire module (QLQ-CR38). Eur J Cancer 35:238–247CrossRefPubMedGoogle Scholar
  9. 9.
    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 255:922–928CrossRefGoogle Scholar
  10. 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 259:728–734CrossRefPubMedGoogle Scholar
  11. 11.
    Bittorf B, Matzel KE (2015) The LARS score for evaluation of low anterior resection syndrome. Coloproctology 37:262–265 [in German] CrossRefGoogle Scholar
  12. 12.
    Kupsch J, Jackisch T, Matzel KE, Zimmer J, Schreiber A, Sims A, Witzigmann H, Stelzner S (2018) Outcome of bowel function following anterior resection for rectal cancer—an analysis using the Low Anterior Resection Syndrome (LARS) score. Int J Color Dis 33:787–798CrossRefGoogle Scholar
  13. 13.
    Fayers PM, Aaronson NK, Bjordal K, Groenvold M, Curran D, Bottomly A, on behalf of the EORTC Quality of Life Group (2001) The EORTC QLQ-C30 Scoring Manual, 3rd edn. European Organisation for Research and Treatment of Cancer, BrusselsGoogle Scholar
  14. 14.
    Osoba D, Rodrigues G, Myles J, Zee B, Pater J (1998) Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol 16:139–144CrossRefGoogle Scholar
  15. 15.
    Young T, de Haes H, Curran D, Fayers P, Brandberg Y, Vanvoorden V, Bottomley A, on behalf of the EORTC Quality of Life Group (2002) Guidelines for assessing quality of life in EORTC clinical trials. EORTC Quality of Life Group Publication, BrusselsGoogle Scholar
  16. 16.
    Curran D, Aaronson N, Standaert B, Molenberghs G, Therasse P, Ramirez A, Koopmanschap M, Erder H, Piccart M (2000) Summary measures and statistics in the analysis of quality of life data: an example from an EORTC-NCIC-SAKK locally advanced breast cancer study. Eur J Cancer 36:834–844CrossRefPubMedGoogle Scholar
  17. 17.
    Scott NW, Fayers PM, Aaronson NK, Bottomley A, de Graeff A, Groenvold M, Gundy C, Koller M, Petersen MA, Sprangers MAG (2008) EORTC QLQ-C30 Reference Values. European Organisation for Research and Treatment of Cancer, BrusselsGoogle Scholar
  18. 18.
    Schwarz R, Hinz A (2001) Reference data for the quality of life questionnaire EORTC QLQ-C30 in the general German population. Eur J Cancer 37:1345–1351CrossRefPubMedGoogle Scholar
  19. 19.
    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) Low anterior resection syndrome and quality of life: an international multicenter study. Dis Colon rectum 94:1278–1284Google Scholar
  20. 20.
    Emmertsen KJ, Laurberg S, on behalf of the Rectal Cancer Function Study Group (2013) Impact of bowel dysfunction on quality of life after sphincter-preserving resection for rectal cancer. Br J Surg 100:1377–1387CrossRefPubMedGoogle Scholar
  21. 21.
    Nesbakken A, Nygaard K, Lunde OC (2001) Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 88:400–404CrossRefPubMedGoogle Scholar
  22. 22.
    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 181:335–346PubMedGoogle Scholar
  23. 23.
    Havenga K, DeRuiter MC, Enker WE, Welvaart K (1996) Anatomical basis of autonomic nerve-preserving total mesorectal excision for rectal cancer. Br J Surg 83:384–388CrossRefPubMedGoogle Scholar
  24. 24.
    Runkel N, Reiser H (2013) Nerve-oriented mesorectal excision (NOME): autonomic nerves as landmarks for laparoscopic rectal resection. Int J Color Dis 28:1367–1375CrossRefGoogle Scholar
  25. 25.
    Stelzner S, Böttner M, Kupsch J, Kneist W, Quirke P, West N, Witzigmann H, Wedel T (2018) Internal anal sphincter nerves—a macroanatomical and microscopical description of the extrinsic autonomic nerve supply of the internal anal sphincter. Color Dis 20:O7–O16CrossRefGoogle Scholar
  26. 26.
    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 39:994–999CrossRefPubMedGoogle Scholar
  27. 27.
    Aigner F, Hörmann R, Fritsch H, Pratschke J, D’Hoore A, Brenner E, Williams N, Biebl M, TAMIS TME Collaboration Group (2015) Anatomical considerations for transanal minimal-invasive surgery: the caudal to cephalic approach. Color Dis 17:O47–O53CrossRefGoogle Scholar
  28. 28.
    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 30:71–78CrossRefGoogle Scholar
  29. 29.
    Koedam TWA, van Ramshorst GH, Deijen CL, Elfrink AKE, Meijerink WJHJ, Bonjer HJ, Sietses C, Tuynman JB (2017) Transanal total mesorectal excision (TaTME) for rectal cancer: effects on patient-reported quality of life and functional outcome. Tech Coloproctol 21:25–33CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    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 42:841–847CrossRefPubMedGoogle Scholar
  31. 31.
    Andersson J, Angenete E, Gellerstedt M, Angerås U, Jess P, Rosenberg J, Fürst A, Bonjer J, Haglind E (2013) Health-related quality of life after laparoscopic and open surgery for rectal cancer in a randomized trial. Br J Surg 100:941–949CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Hjermstad MJ, Fayers PM, Bjordal K, Kaasa S (1998) Using reference data on quality of life--the importance of adjusting for age and gender, exemplified by the EORTC QLQ-C30 (+3). Eur J Cancer 34:1381–1389CrossRefPubMedGoogle Scholar
  33. 33.
    van de Poll-Franse LV, Mols F, Gundy CM, Creutzberg CL, Nout RA, Verdonck-de Leeuw IM, Taphoorn MJ, Aaronson NK (2011) Normative data for the EORTC QLQ-C30 and EORTC-sexuality items in the general Dutch population. Eur J Cancer 47:667–675CrossRefPubMedGoogle Scholar
  34. 34.
    Parc Y, Zutshi M, Zalinski S, Ruppert R, Fürst A, Fazio VW (2009) Preoperative radiotherapy is associated with worse functional results after coloanal anastomosis for rectal cancer. Dis Colon Rectum 52:2004–2015CrossRefPubMedGoogle Scholar
  35. 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 20:1816–1828CrossRefPubMedGoogle Scholar
  36. 36.
    Trenti L, Galvez A, Biondo S, Solis A, Vallribera-Valls F, Espin-Basany E, Garcia-Granero A, Kreisler E (2018) Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: a cross-sectional study. Eur J Surg Oncol 44:1031–1039CrossRefPubMedGoogle Scholar
  37. 37.
    Contin P, Kulu Y, Bruckner T, Sturm M, Welsch T, Müller-Stich BP, Huber J, Büchler MW, Ulrich A (2014) Comparative analysis of late functional outcome following preoperative radiation therapy or chemoradiotherapy and surgery or surgery alone in rectal cancer. Int J Color Dis 29:165–175CrossRefGoogle Scholar
  38. 38.
    Samuelian JM, Callister MD, Ashman JB, Young-Fadok TM, Borad MJ, Gunderson LL (2012) Reduced acute bowel toxicity in patients treated with intensity-modulated radiotherapy for rectal cancer. Int J Radiat Oncol Biol Phys 82:1981–1987CrossRefPubMedGoogle Scholar
  39. 39.
    Wiltink LM, Chen TYT, Nout RA, Meershoek-Klein Kranenbarg E, Fiocco M, Laurberg S, van de Velde CJH, Marijnen CAM (2014) Health-related quality of life 14 years after preoperative short-term radiotherapy and total mesorectal excision for rectal cancer: report of a multicenter randomised trial. Eur J Cancer 50:2390–2398CrossRefPubMedGoogle Scholar
  40. 40.
    Stephens RJ, Thompson LC, Quirke P, Steele R, Grieve R, Couture J, Griffiths GO, Sebag-Montefiore D (2010) Impact of short-course preoperative radiotherapy for rectal cancer on patients’ quality of life: data from the Medical Research Council CR07/National Cancer Institute of Canada Clinical Trials Group C016 randomized clinical trial. J Clin Oncol 28:4233–4239CrossRefPubMedGoogle Scholar
  41. 41.
    Adam JP, Denost Q, Capdepont M, van Geluwe B, Rullier E (2016) Prospective and longitudinal study of urogenital dysfunction after proctectomy for rectal cancer. Dis Colon rectum 59:822–830CrossRefPubMedGoogle Scholar
  42. 42.
    Kobayashi K, Morita S, Shimonagayoshi M, Kobayashi M, Fujiki Y, Uchida Y, Yamaguchi K (2008) Effects of socioeconomic factors and cancer survivors’ worries on their quality of life (QOL) in Japan. Psychooncology 17:606–611CrossRefPubMedGoogle Scholar
  43. 43.
    Movsas B, Scott C, Watkins-Bruner D (2006) Pretreatment factors significantly influence quality of life in cancer patients: a Radiation Therapy Oncology Group (RTOG) analysis. Int J Radiat Oncol Biol Phys 65:830–835CrossRefPubMedGoogle Scholar
  44. 44.
    Siassi M, Weiss M, Hohenberger W, Lösel F, Matzel K (2009) Personality rather than clinical variables determines quality of life after major colorectal surgery. Dis Colon rectum 52:662–668CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of General, Visceral and Thoracic Surgery, Dresden-Friedrichstadt General HospitalTeaching Hospital of the Technical University of DresdenDresdenGermany
  2. 2.Institute for Medical Informatics and Biometry, (Carl Gustav Carus) Faculty of MedicineTechnische Universität DresdenDresdenGermany
  3. 3.Department of Surgery, Section Coloproctology, University Hospital ErlangenFriedrich-Alexander University Erlangen-NürnbergErlangenGermany
  4. 4.Department of Radiation Therapy, Dresden-Friedrichstadt General HospitalTeaching Hospital of the Technical University of DresdenDresdenGermany

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