Outcome of bowel function following anterior resection for rectal cancer—an analysis using the low anterior resection syndrome (LARS) score
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.
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.
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.
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.
KeywordsLow anterior resection syndrome Low anterior resection syndrome score Sphincter-preserving surgery Rectal carcinoma Anorectal function
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 Tumor Center Dresden.
Compliance with ethical standards
Ethical approval was obtained from the responsible ethics committee (Saxon Physicians Chamber, No. EK-BR-92/15-1/134619).
- 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 48:1353–1365CrossRefPubMedGoogle Scholar
- 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 94:1278–1284Google Scholar
- 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):1130–1139Google Scholar
- 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 14:1727–1734CrossRefPubMedGoogle Scholar
- 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 95:1020–1028CrossRefPubMedGoogle Scholar
- 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]CrossRefPubMedGoogle Scholar
- 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 351:1731–1740CrossRefPubMedGoogle Scholar
- 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 147:339–351CrossRefPubMedGoogle Scholar
- 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
- 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
- 37.Association of Coloproctology of Great Britain and Ireland: Guidelines for the management of colorectal cancer. 3rd ed. 2007, www.acpgbi.org.uk/content/uploads/2007-CC-Management-Guidelines.pdf (accessed 2017-09-23)
- 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 6:166–175CrossRefPubMedGoogle Scholar
- 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 246:481–488CrossRefPubMedPubMedCentralGoogle Scholar