Analysis of Clinical Factors Associated with Anal Function after Intersphincteric Resection for Very Low Rectal Cancer

Department of Colorectal and Pelvic Surgery, National Cancer Center Hospital East, Chiba, Japan.
Diseases of the Colon & Rectum (Impact Factor: 3.75). 01/2009; 52(1):64-70. DOI: 10.1007/DCR.0b013e31819739a0
Source: PubMed


The purpose of this study was to identify factors that have a negative impact on anal function after intersphincteric resection.
We evaluated postoperative anal function in 96 patients with very lower rectal cancer who underwent intersphincteric resection by having patients fill out detailed questionnaires at 3, 6, 12, and 24 months after surgery. Univariate and multivariate analysis based on the Wexner incontinence score were used to identify factors associated with poor anal function after intersphincteric resection.
The mean Wexner score at 12 months after stoma closure was 10.0. Patients with frequent major soiling showed a Wexner score of >or=16, and this score was used as a cutoff value of poor anal function. In the univariate analysis, poor anal function was significantly associated with a greater extent of excision of the internal sphincter and with preoperative chemoradiotherapy. In the multivariate analysis, preoperative chemoradiotherapy was the only independent factor associated with poor anal function after intersphincteric resection (odds ratio=10.3; 95 percent confidence interval, 2.3-46.3, P < 0.01).
Preoperative chemoradiotherapy was identified as the risk factor with the greatest negative impact on anal function after intersphincteric resection, regardless of extent of excision of the internal sphincter.

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    • "The study only included male patients who suffered from severe urgency or soiling postoperatively, since it has been reported that male patients often experience more severe defecatory malfunction than female patients when the anastomotic height is very low, as in ISR,16 and also because, in Japan, oral 5-HT3 antagonists are accepted treatment options for IBS-D only in male patients. "
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    ABSTRACT: Serotonin (5-hydroxytryptamine [5-HT])3 receptor antagonists are effective for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D), in which exaggerated intestinal/colonic hypermotility is often observed. Recent studies have suggested that the motility disorder, especially spastic hypermotility, seen in the neorectum following sphincter-preserving operations for rectal cancer may be the basis of the postoperative defecatory malfunction seen in these patients. We investigated the efficacy of 5-HT3 receptor antagonists in patients suffering from severe low anterior resection syndrome. A total of 25 male patients with complaints of uncontrollable urgency or fecal incontinence following sphincter-preserving operations were enrolled in this study. Defecatory status, assessed on the basis of incontinence score (0-20), urgency grade (0-3), and number of toilet visits per day, was evaluated using a questionnaire before and 1 month after the administration of the 5-HT3 antagonist ramosetron. All the parameters assessed improved significantly after taking ramosetron for 1 month. The effect was more prominent in cases whose anastomotic line was lower, ie, inside the anal canal. Defecatory function was better in patients who commenced ramosetron therapy within 6 months postoperatively, as compared to those who were not prescribed ramosetron for more than 7 months postoperatively. These results suggest that 5-HT3 antagonists are effective for the treatment of low anterior resection syndrome, as in diarrhea-predominant irritable bowel syndrome. The improvement in symptoms is not merely time dependent, but it is related to treatment with 5-HT3 antagonists.
    Clinical and Experimental Gastroenterology 03/2014; 7(1):47-52. DOI:10.2147/CEG.S55410
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    • "It is thought to effect 2% to 15% of community-dwelling adults [1,2]. Fecal incontinence is considered to be an aging disease because its prevalence increases to 13% among people older than 50 years [3], and is an iatrogenic disease that develops in 60% of rectal cancer patients after intersphincteric resection [4]. However, the treatment of fecal incontinence is an area of uncertainty because data from randomized trials are lacking to establish optimal approaches for its treatment [5]. "
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    ABSTRACT: Few studies have examined whether bioengineering can improve fecal incontinence. This study designed to determine whether injection of porous polycaprolactone beads containing autologous myoblasts improves sphincter function in a dog model of fecal incontinence. The anal sphincter of dogs was injured and the dogs were observed without and with (n = 5) the injection of porous polycaprolactone beads containing autologous myoblasts into the site of injury. Autologous myoblasts purified from the gastrocnemius muscles were transferred to the beads. Compound muscle action potentials (CMAP) of the pudendal nerve, anal sphincter pressure, and histopathology were determined 3 months after treatment. The amplitudes of the CMAP in the injured sphincter were significantly lower than those measured before injury (1.22 mV vs. 3.00 mV, P = 0.04). The amplitudes were not different between dogs with and without the injection of autologous myoblast beads (P = 0.49). Resting and squeezing pressures were higher in dogs treated with autologous myoblast beads (2.00 mmHg vs. 1.80 mmHg; 6.13 mmHg vs. 4.02 mmHg), although these differences were not significant in analyses of covariance adjusted for baseline values. The injection site was stained for smooth muscle actin, but showed evidence of foreign body inflammatory reactions. This was the first study to examine whether bioengineering could improve fecal incontinence. Although the results did not show definite evidence that injection of autologous myoblast beads improves sphincter function, we found that the dog model was suitable and reliable for studying the effects of a potential treatment modality for fecal incontinence.
    Journal of the Korean Surgical Society 04/2013; 84(4):216-24. DOI:10.4174/jkss.2013.84.4.216 · 0.73 Impact Factor
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    • "In this questionnaire, patients were asked about stool frequency (number of bowel movements per 24 h), fecal urgency (ability to defer stool evacuation for >15 minutes), stool fragmentation (>2 evacuations in 1 h), dyschesia (taking more than 15 minutes to defecate), nocturnal defecation, use of intestinal transit regulators, and need to wear a pad. Incontinence was assessed by the Wexner continence score [24], and we considered anal function to be poor if the Wexner score was 15 or more at 12 months [17,18]. Anastomotic stricture or occlusion was determined when the surgeon’s forefinger could not pass through the anastomotic site 3 months after surgery. "
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    ABSTRACT: Background Intersphincteric resection (ISR) has been used to avoid permanent colostomy in very low rectal cancer patients. This study aimed to assess the surgical safety and oncologic and functional outcomes of ISR. Methods The records of 30 consecutive very low rectal cancer patients who underwent ISR without neoadjuvant therapy were retrospectively analyzed; survival and locoregional recurrence rates were calculated by the Kaplan-Meier method. Incontinence was assessed by a functionality questionnaire and the Wexner score. Results The median distance between the distal margin of the dentate line was 10 mm. A total of 12, 4, and 14 patients underwent partial ISR, subtotal ISR, and total ISR, respectively. The mean distal resection margin was negative in all cases, and circumferential resection margin was positive in two cases. Morbidity was 33.3%: anastomotic stricture in seven patients, colonic J-pouch prolapse in two patients, and an anovaginal fistula in one patient. During the median, 56.2-month follow-up period, local, distant, and combined recurrences occurred in four, three, and two patients, respectively. The 5-year overall and disease-free survival rates were 76.5% and 68.4%, respectively. Local recurrence rates were 5.2% for the patients with Tis-T2 tumors as compared with 45.5% for those with T3 tumors (P = 0.008). The mean Wexner scores and stool frequencies, 12 months after stoma closure in 19 patients, were 11.5 and 6.6 per 24 h, respectively. Significant differences were not seen in the Wexner scores between partial ISR and subtotal/total ISR (11.8 ± 2.6 and 9.1 ± 5.6). Stool frequency (P = 0.02), urgency (P = 0.04), and fragmentation (P = 0.015) were worse in patients with anastomotic stricture than in those without; there was no symptom improvement in patients with anastomotic stricture. Conclusions The anastomotic strictures in patients undergoing ISR may have negatively affected anal function. For total ISR patients, at least, informed consent stating the possibility of a permanent colostomy is necessary.
    World Journal of Surgical Oncology 01/2013; 11(1):24. DOI:10.1186/1477-7819-11-24 · 1.41 Impact Factor
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