Optimising functional outcomes in rectal cancer surgery

Abstract

Background By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention. Purpose This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted. Conclusion Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Functional outcomes after sphincter-preserving surgeries for low-lying rectal cancer: A review

“…The rectum is a storage reservoir of feces. Normal defecation processes are caused by a stimulation of rectal distention due to rectal filling and the recto-anal inhibitory reflex (RAIR) [15]. The coordination of both anal sphincter and pelvic floor muscles is important for fecal evacuation from the rectum.…”

“…For diarrhea-predominant symptoms, anti-diarrheal agents such as loperamide or codeine can be used to decrease stool frequency and increase the resting pressure of the anal sphincter [15,59]. In addition, serotonin (5-hydroxytryptamine [5-…”

“…mostly resulting from intraoperative pelvic autonomic nerve injury [53]. Sympathetic and parasympathetic nerves originate from L2-3 and S2-4 nerve roots, respectively, to form the pelvic plexus [15,77]. The superior hypogastric nerves from the preaortic plexus descend inferiorly and laterally, and join the splanchnic nerves of the S2-4 nerve roots to form the pelvic plexus [16].…”

Safety and efficacy of side-to-end anastomosis versus colonic J-pouch anastomosis in sphincter-preserving resections: an updated meta-analysis of randomized controlled trials

“…With the progress of surgical techniques and multimodal treatment, an increasing number of patients agree to undergo sphincter-preserving resections (SPRs) [1]. SPR maintains bowel continuity, and the procedure avoids permanent stoma [2].…”

Robotic Transanal Total Mesorectal Excision (RTaTME): State of the Art

“…In the last two decades this technique has revolutionized the results of rectal cancer surgery, demonstrating how surgical quality has a direct impact on local control and survival [ 2 , 3 ], the circumferential radial margin (CRM) and the integrity of mesorectal envelope being independent predictors of local recurrence [ 4 , 5 , 6 ]. Similarly, functional results can be considered a direct expression of the quality of surgery and are not always satisfying with conventional surgical techniques for rectal cancer treatment [ 7 , 8 ].…”