How Should the Low Anterior Resection Syndrome Score Be Interpreted?

Abstract

BACKGROUND: Bowel dysfunction after low anterior resection is often assessed by determining the low anterior resection syndrome score. What is unknown, however, is whether this syndrome is already present in the general population and which nonsurgical factors are associated. OBJECTIVE: The purpose of this study was to determine the prevalence of minor and major low anterior resection syndrome in the general Dutch population and which other factors are associated with this syndrome. DESIGN: This was a cross-sectional study. SETTINGS: The study was conducted within the general Dutch population. PATIENTS: The Groningen Defecation and Fecal Continence Questionnaire was distributed among a general Dutch population-based sample (N = 1259). MAIN OUTCOME MEASURES: Minor and major low anterior resection syndrome were classified according to the scores obtained. RESULTS: The median, overall score was 16 (range, 0–42). Minor low anterior resection syndrome was more prevalent than the major form (24.3% vs 12.2%; p < 0.001). Bowel disorders, including fecal incontinence, constipation, and irritable bowel syndrome were associated with the syndrome, whereas sex, age, BMI, and vaginal delivery were not. Remarkably, patients with diabetes mellitus were significantly more prone to experience minor or major low anterior resection syndrome. The ORs were 2.8 (95% CI, 1.8–4.4) and 3.7 (95% CI, 2.2–6.2). LIMITATIONS: We selected frequent comorbidities and other patient-related factors that possibly influence the syndrome. Additional important factors do exist and require future research. CONCLUSIONS: Minor and major low anterior resection syndrome occur in a large portion of the general Dutch population and even in a healthy subgroup. This implies that the low anterior resection syndrome score can only be used to interpret the functional result of the low anterior resection provided that a baseline measurement of each individual is available. Furthermore, because people with low anterior resection syndrome often experience constipation and/or fecal incontinence, direct examination and diagnosis of these conditions might be a more efficient approach to treating patient bowel dysfunctions. See Video Abstract at http://links.lww.com/DCR/B110. ¿CÓMO DEBE INTERPRETARSE LA PUNTUACIÓN DEL SÍNDROME DE RESECCIÓN ANTERIOR BAJA? ANTECEDENTES: La disfunción intestinal después de la resección anterior baja a menudo se evalúa determinando la puntuación del síndrome de resección anterior baja. Sin embargo, lo que se desconoce es si este síndrome ya está presente en la población general y qué factores no quirúrgicos están asociados. OBJETIVO: Determinar la prevalencia del síndrome de resección anterior baja menor y mayor en la población holandesa general y qué otros factores están asociados con este síndrome. DISEÑO: Estudio transversal. CONFIGURACIÓN: Población holandesa general. PACIENTES: El cuestionario de defecación y continencia fecal de Groningen se distribuyó entre una muestra general de población holandesa (N = 1259). PRINCIPALES MEDIDAS DE RESULTADO: El síndrome de resección anterior baja menor y mayor se clasificó de acuerdo con las puntuaciones obtenidas. RESULTADOS: La mediana de la puntuación general fue de 16.0 (rango 0-42). El síndrome de resección anterior baja menor fue más frecuente que la forma principal (24.3% versus 12.2%, (P <0.001). Los trastornos intestinales, incluyendo incontinencia fecal, estreñimiento y síndrome del intestino irritable se asociaron con el síndrome, mientras que el sexo, la edad y el cuerpo el índice de masa y el parto vaginal no lo hicieron. Notablemente, los pacientes con diabetes mellitus fueron significativamente más propensos a experimentar el síndrome de resección anterior baja menor o mayor. Las razones de probabilidad fueron 2.8 (IC 95%, 1.8-4.4) y 3.7 (IC 95%, 2.2 -6.2), respectivamente. LIMITACIONES: Se seleccionaron las comorbilidades frecuentes y otros factores relacionados con el paciente que posiblemente influyen en el síndrome. Existen otros factores importantes que requieren investigación en el futuro. CONCLUSIONES: El síndrome de resección anterior baja menor y mayor ocurre en una gran parte de la población holandesa general e incluso en un subgrupo sano. Esto implica que la puntuación del síndrome de resección anterior baja solo se puede utilizar para interpretar el resultado funcional de la resección anterior baja, siempre que esté disponible una medición inicial de cada individuo. Además, dado que las personas con síndrome de resección anterior baja a menudo experimentan estreñimiento y/o incontinencia fecal, el examen directo y el diagnóstico de estas afecciones pueden ser un enfoque más eficiente para tratar las disfunciones intestinales de los pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B110.

The impact of type 2 diabetes on long-term gastrointestinal sequelae after colorectal cancer surgery: national population-based study

“…A Danish study on a random sample of 3440 adult citizens from the general population demonstrated that 12–18 per cent of the adult female and 10–11 per cent of the adult male population suffered from symptoms corresponding to major LARS, and the symptoms were associated with unspecified physical disease 33 . A similar prevalence of 12 per cent was found in a general Dutch population, whereas the authors reported a prevalence of symptoms of major LARS at 24 per cent among individuals with diabetes 34 . Similar higher frequencies of small and large intestinal symptoms in individuals with T2D were reported in two reviews 35 , 36 .…”

Suboptimal Bowel Function after (Recto) Sigmoid Resection in Patients with Deep Infiltrating Endometriosis

“…It is known that after low anterior resection patients can develop LARS, and constipation or FI belong to the most typical symptoms of LARS [23][24][25]. As shown recently, LARS can also be present in the general population [26]. Nevertheless, patients from our study experience Major LARS significantly more often than controls.…”

“…With this study, researchers were unable to establish the direct causes of the suboptimal postoperative outcomes regarding patients' bowel functions. The defecatory disorders could already have existed before the patients developed DIE, because such disorders also occur in the 'healthy' population [26]. The causes could have developed or could have become progressively worse along with the growth of endometriosis.…”

Is evaluation by questionnaires sufficient to cover all aspects of bowel symptoms in rectal cancer patients after low anterior resection?

“…The LARS score has been proven to be highly sensitive for detecting LARS. However, recent studies showed that LARS is also common in the general population and therefore the score lacks specificity [ 17 , 33 , 34 ].…”

“…The items used in this questionnaire are as follows: incontinence for flatus, incontinence for liquid stools, frequency of bowel movements, clustering of stools and urgency. Adding item score values results in classification of LARS severity into three groups: 'no LARS' (0-20), 'minor LARS' (21)(22)(23)(24)(25)(26)(27)(28)(29) and 'major LARS' (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42). This questionnaire has been validated to evaluate LARS after RC surgery and translated into different languages and normative data have been published [17].…”