Functional Complications After Colon and Rectal Surgery
Although colorectal surgeons are adept at discussing potential complications of colorectal surgery, they may not be as thorough in the discussion of functional outcomes. Bowel dysfunction after low colorectal or coloanal anastomoses is extremely common an
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Key Concepts • Low anterior resection syndrome (LARS) is extremely common after proctectomy with a multifactorial etiology including damage to sphincters, variations in RAIR, intestinal motility changes, autonomic and somatic nerve injury, and pelvic floor dysfunction. • Radiation and pelvic sepsis may contribute to deterioration of bowel function. • Symptoms may include incontinence to stool or flatus, urgency, fragmentation of stool, difficult evacuation, and a sense of incomplete evacuation. • Alternative reconstructions utilizing colonic pouch or side-to-end anastomosis may be associated with better bowel function when compared to straight anastomoses. • Pelvic nerve damage during TME can impair urinary and sexual function as well as bowel function. • Sexual dysfunction occurs in both males and females and may manifest in women as dyspareunia and failure to lubricate with arousal. In men, erectile dysfunction and retrograde ejaculation may occur. • Colorectal surgeons may underappreciate the magnitude of bowel dysfunction after rectal cancer resection and its impact on quality of life. • There is no accepted treatment algorithm for bowel dysfunction after proctectomy; symptom control utilizing medications to slow and bulk stools, protection of the perianal skin, physical therapy, colonic irrigation, and in some cases sacral nerve stimulation are currently recognized therapies.
Introduction Colorectal cancer is the third most common cancer in men and women in the United States and approximately one-third of these cases are rectal cancers [1]. Total and partial
mesorectal excisions (TME) are commonly performed, and although colorectal surgeons are very adept at discussing potential complications of these operations, they may not be as thorough in the discussion of functional outcomes. Bowel dysfunction after low colorectal or coloanal anastomoses is extremely common and underappreciated. This dysfunction has been termed: low anterior resection syndrome (LARS). This chapter will discuss symptoms, etiology, and current treatment recommendations. Additionally, other potential functional problems that may be seen after a proctectomy will be covered.
Low Anterior Resection Syndrome Symptoms and Prevalence During rectal cancer resection, sphincter-preserving surgery has been considered desirable to permanent stoma if oncologic outcomes are equivalent. The introduction of highresolution imaging along with the tailored use of neoadjuvant radiation therapy has improved the ability of the surgeon to accomplish sphincter preservation [2]. However, the presumption that quality of life (QOL) would be improved without a permanent stoma has not borne out in the literature [3]. Both a Cochrane review and a meta-analysis indicated that QOL was equivalent between those who underwent abdominal perineal resection (APR) and those with sphincter preservation [4]. Although this finding has not been fully elucidated, many patients experience altered bowel function after low anterior resection (LAR), potentially offsetting the benefits of
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