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„Low anterior resection syndrome“ (LARS) in Zahlen

Low anterior resection syndrome (LARS) in numbers

  • Leitthema
  • Published:
coloproctology Aims and scope

Zusammenfassung

Hintergrund

Das tiefe anteriore Resektionssyndrom („low anterior resection syndrome“, LARS) ist eine multifaktorielle Behandlungsfolge der Therapie von Rektumpathologien, wobei das Rektumkarzinom ganz im Fokus der Betrachtung steht. Neben der (Teil‑)Entfernung des Rektums wurden die Art der Rekonstruktion der Darmpassage, der operative Zugangsweg, die Anastomoseninsuffizienz, das Vorhandensein eines protektiven Stomas, die Strahlentherapie sowie Alter und Geschlecht als weitere Ursachen diskutiert.

Methode

Dieser Artikel fasst im Sinne eines narrativen Reviews die aktuelle Datenlage zu Häufigkeit eines LARS und das Ausmaß der Assoziation mit den genannten Risikofaktoren zusammen. Dabei wurde auf Angaben fokussiert, welche die Situation mit dem LARS-Score evaluierten.

Ergebnisse

In unselektionierten Serien und Metaanalysen tritt ein Major-LARS in etwa 45 % und ein Minor-LARS in 20 % der Fälle auf. Etwa 35 % der Patient*innen haben keine wesentlichen Symptome (no LARS). Das Risiko eines LARS nimmt mit zunehmendem Resektionsausmaß (entsprechend einer abnehmenden Anastomosenhöhe), nach durchgeführter Strahlentherapie, nach Anastomoseninsuffizienz und mit der Anlage eines protektiven Ileostomas zu. Bezüglich Zugangsweg, Rekonstruktionsverfahren sowie Alter und Geschlecht ist die Datenlage inkonsistent. Die Lebensqualität der Patient*innen wird durch Vorliegen eines Major-LARS beeinträchtigt.

Schlussfolgerung

LARS ist eine häufige Folge der Behandlung von Rektumkarzinomen, wobei verschiedene Faktoren eindeutig prädisponieren. Wegen der Tragweite dieser funktionellen Einschränkungen sollte die operative Behandlung des Rektumkarzinoms durch koloproktologisch spezialisierte Chirurgen erfolgen.

Abstract

Background

The low anterior resection syndrome (LARS) is a multifactorial treatment sequela of rectal pathologies, with rectal cancer being the leading condition. Apart from partial (PME) or total mesorectal excision (TME), reconstruction of coloanal continuity, surgical access, anastomotic leak, a protective enterostomy, radiotherapy as well as age and gender were discussed as further causes.

Methods

This review article summarizes the current literature with respect to the incidence of LARS and the association with the risk factors mentioned above. The focus was placed on the assessment using the LARS score.

Results

In non-selected patient series and metanalyses major and minor LARS occur in 45 % and 20 % respectively. Approximately 35% of patients do not suffer from anorectal dysfunction (no LARS). The risk of LARS increases with a greater extent of the operation (corresponding to a lower anastomosis), after radiotherapy, anastomotic leak, and protective ileostomy. Data regarding surgical access, mode of reconstruction, age and gender are inconsistent. Patients’ quality of life is significantly impaired by major LARS.

Conclusion

LARS is a common problem after treatment of rectal cancer with some clearly predisposing factors. Because of the impact of these functional sequelae, surgical treatment should be performed by specialized coloproctologic surgeons.

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Literatur

  1. 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 351:1731–1740

    Article  CAS  PubMed  Google Scholar 

  2. Hohenberger W, Merkel S, Matzel K, Bittdorf B, Papadopoulos T, Göhl J (2006) The influence of abdomino-peranal (intersphincteric) resection of lower third rectal carcinoma on the rates of sphincter preservation and locoregional recurrence. Colorectal Dis 8:23–33

    Article  CAS  PubMed  Google Scholar 

  3. Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL (2012) Anterior resection syndrome. Lancet Oncol 13:e403–408

    Article  PubMed  Google Scholar 

  4. Emmertsen KJ, Laurberg S (2012) Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg 255:922–928

    Article  PubMed  Google Scholar 

  5. Sun R, Dai Z, Zhang Y, Lu J, Zhang Y, Xiao Y (2021) The incidence and risk factors of low anterior resection syndrome (LARS) after sphincter-preserving surgery of rectal cancer: a systematic review and meta-analysis. Support Care Cancer 29:7249–7258

    Article  PubMed  Google Scholar 

  6. Croese AD, Lonie JM, Trollope AF, Vangaveti VN, Ho YH (2018) A meta-analysis of the prevalence of low anterior resection syndrome and systematic review of risk factors. Int J Surg 56:234–241

    Article  PubMed  Google Scholar 

  7. 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. Colorectal Dis 15:1130–1139

    CAS  PubMed  Google Scholar 

  8. Juul T, Ahlberg M, Biondo S, Espin E, Jimenez LM, Matzel KE, Palmer GJ, Sauermann A, Trenti L, Zhang W, Laurberg S, Christensen P (2014) International validation of the low anterior resection syndrome score. Ann Surg 259:728–734

    Article  PubMed  Google Scholar 

  9. Juul T, Battersby NJ, Christensen P, Janjua AZ, Branagan G, Laurberg S, Emmertsen KJ, Moran B, UK LARS Study Group (2015) Validation of the English translation of the low anterior resection syndrome score. Colorectal Dis 17:908–916

    Article  CAS  PubMed  Google Scholar 

  10. Kupsch J, Jackisch T, Matzel KE, Zimmer J, Schreiber A, Sims A, Witzigmann H, Stelzner S (2018) Outcome of bowel function following anterior resection for rectal cancer—an analysis using the low anterior resection syndrome (LARS) score. Int J Colorectal Dis 33:787–798

    Article  PubMed  Google Scholar 

  11. Pieniowski EHA, Nordenvall C, Johar A, Palmer G, Tumlin Ekelund S, Lagergren P, Abraham-Nordling M (2022) Defunctioning stoma in rectal cancer surgery—a risk factor for low anterior resection syndrome? Eur J Surg Oncol 23:S748–7983

    Google Scholar 

  12. De Simone V, Litta F, Persiani R, Rizzo G, Sofo L, Menghi R, Santullo F, Biondi A, Coco C, Sacchetti F, Longo F, Attalla El Halabieh M, Moroni R, Ratto C (2022) Effectiveness and validation of the Italian translation of the low anterior resection syndrome score in an Italian high-volume university hospital. Front Surg 9:917224

    Article  PubMed  PubMed Central  Google Scholar 

  13. Dilke SM, Hadjittofi C, Than M, Tozer PJ, Stearns AT, EQuLAR Study Group (2022) Anterior resection syndrome and quality of life with long-term follow-up after rectal cancer resection. Dis Colon Rectum 65:1251–1263

    Article  PubMed  Google Scholar 

  14. Hou XT, Pang D, Lu Q, Yang P, Jin SL, Zhou YJ, Tian SH (2015) Validation of the Chinese version of the low anterior resection syndrome score for measuring bowel dysfunction after sphincter-preserving surgery among rectal cancer patients. Eur J Oncol Nurs 19:495–501

    Article  PubMed  Google Scholar 

  15. Juul T, Elfeki H, Christensen P, Laurberg S, Emmertsen KJ, Bager P (2019) Normative data for the low anterior resection syndrome score (LARS score). Ann Surg 269:1124–1128

    Article  PubMed  Google Scholar 

  16. Dulskas A, Kavaliauskas P, Kulikauskas E, Smolskas E, Pumputiene K, Samalavicius NE, Nunoo-Mensah JW (2022) Low anterior resection syndrome: what have we learned assessing a large population? J Clin Med 11:4752

    Article  PubMed  PubMed Central  Google Scholar 

  17. Matzel KE, Stadelmaier U, Muehldorfer S, Hohenberger W (1997) Continence after colorectal reconstruction following resection: impact of level of anastomosis. Int J Colorectal Dis 12:82–87

    Article  CAS  PubMed  Google Scholar 

  18. 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 94:1278–1284

    Article  CAS  PubMed  Google Scholar 

  19. Marijnen CA, van de Velde CJ, Putter H, van den Brink M, Maas CP, Martijn H, Rutten HJ, Wiggers T, Kranenbarg EK, Leer JW, Stiggelbout AM (2005) Impact of short-term preoperative radiotherapy on health-related quality of life and sexual functioning in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 23:1847–1858

    Article  PubMed  Google Scholar 

  20. Chen TY, Wiltink LM, Nout RA, Meershoek-Klein Kranenbarg E, Laurberg S, Marijnen CA, van de Velde CJ (2015) Bowel function 14 years after preoperative short-course radiotherapy and total mesorectal excision for rectal cancer: report of a multicenter randomized trial. Clin Colorectal Cancer 14:106–114

    Article  PubMed  Google Scholar 

  21. Nicotera A, Falletto E, Arezzo A, Mistrangelo M, Passera R, Morino M (2022) Risk factors for low anterior resection syndrome (LARS) in patients undergoing laparoscopic surgery for rectal cancer. Surg Endosc 36:6059–6066

    Article  PubMed  PubMed Central  Google Scholar 

  22. Kiyozumi Y, Nagasaki T, Matsui S, Mukai T, Hiyoshi Y, Yamaguchi T, Akiyoshi T, Fukunaga Y (2022) The evaluation of postoperative bowel dysfunction in Japanese patients with rectal cancer. Surg Today. https://doi.org/10.1007/s00595-022-02598-1

    Article  PubMed  Google Scholar 

  23. Liang Z, Zhang Z, Wu D, Huang C, Chen X, Hu W, Wang J, Feng X, Yao X (2022) Effects of preoperative radiotherapy on long-term bowel function in patients with rectal cancer treated with anterior resection: a systematic review and meta-analysis. Technol Cancer Res Treat 21:15330338221105156

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hupkens BJP, Martens MH, Stoot JH, Berbee M, Melenhorst J, Beets-Tan RG, Beets GL, Breukink SO (2017) Quality of life in rectal cancer patients after chemoradiation: watch-and-wait policy versus standard resection—a matched-controlled study. Dis Colon Rectum 60:1032–1040

    Article  PubMed  Google Scholar 

  25. De B, Corrigan KL, Rooney MK, Ludmir EB, Das P, Smith GL, Taniguchi CM, Minsky BD, Koay EJ, Koong A, Morris VK, Messick CA, You YN, Chang GJ, Westney OL, Nogueras Gonzalez GM, Holliday EB (2022) Patient-reported bowel and urinary function in long-term survivors of squamous cell carcinoma of the anus treated with definitive intensity modulated radiation therapy and concurrent chemotherapy. Int J Radiat Oncol Biol Phys 114:78–88

    Article  PubMed  Google Scholar 

  26. 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 246:481–488

    Article  PubMed  PubMed Central  Google Scholar 

  27. Parc Y, Ruppert R, Fuerst A, Golcher H, Zutshi M, Hull T, Tiret E, Hemminger F, Galandiuk S, Fender S, Weber K, Zimmerman A, Aiello A, Fazio V (2019) Better function with a colonic J‑pouch or a side-to-end anastomosis?: a randomized controlled trial to compare the complications, functional outcome, and quality of life in patients with low rectal cancer after a J-pouch or a side-to-end anastomosis. Ann Surg 269:815–826

    Article  PubMed  Google Scholar 

  28. Hou S, Wang Q, Zhao S, Liu F, Guo P, Ye Y (2021) 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. World J Surg Oncol 19:130

    Article  PubMed  PubMed Central  Google Scholar 

  29. Hüttner FJ, Tenckhoff S, Jensen K, Uhlmann L, Kulu Y, Büchler MW, Ulrich A (2015) Meta-analysis of reconstruction techniques after low anterior resection for rectal cancer. Br J Surg 102:735–745

    Article  PubMed  Google Scholar 

  30. Grass JK, Chen CC, Melling N, Lingala B, Kemper M, Scognamiglio P, Persiani R, Tirelli F, Caricato M, Capolupo GT, Izbicki JR, Perez DR (2021) Robotic rectal resection preserves anorectal function: systematic review and meta-analysis. Int J Med Robot 17:e2329

    Article  PubMed  Google Scholar 

  31. Jayne DG, Brown JM, Thorpe H, Walker J, Quirke P, Guillou PJ (2005) Bladder and sexual function following resection for rectal cancer in a randomized clinical trial of laparoscopic versus open technique. Br J Surg 92:1124–1132

    Article  CAS  PubMed  Google Scholar 

  32. Keane CR, O’Grady G, Bissett IP, Hayes JL, Hulme-Moir M, Eglinton TW, Solomon MJ, Lumley JW, Simes J, Stevenson ARL (2022) Functional outcome of laparoscopic-assisted resection versus open resection of rectal cancer: a secondary analysis of the australasian laparoscopic cancer of the rectum trial. Dis Colon Rectum 65:e698–e706

    Article  PubMed  Google Scholar 

  33. Bjoern MX, Nielsen S, Perdawood SK (2019) Quality of life after surgery for rectal cancer: a comparison of functional outcomes after transanal and laparoscopic approaches. J Gastrointest Surg 23:1623–1630

    Article  PubMed  Google Scholar 

  34. van der Heijden JAG, Qaderi SM, Verhoeven R, Custers JAE, Klarenbeek BR, Maaskant-Braat AJG, de Wilt JHW, PLCRC group (2021) Transanal total mesorectal excision and low anterior resection syndrome. Br J Surg 108:991–997

    Article  PubMed  Google Scholar 

  35. Kneist W, Wachter N, Paschold M, Kauff DW, Rink AD, Lang H (2016) Midterm functional results of taTME with neuromapping for low rectal cancer. Tech Coloproctol 20:41–49

    Article  CAS  PubMed  Google Scholar 

  36. Filips A, Haltmeier T, Kohler A, Candinas D, Brügger L, Studer P (2021) LARS is associated with lower anastomoses, but not with the transanal approach in patients undergoing rectal cancer resection. World J Surg 45:873–879

    Article  PubMed  Google Scholar 

  37. Alimova I, Chernyshov S, Nagudov M, Rybakov E (2021) Comparison of oncological and functional outcomes and quality of life after transanal or laparoscopic total mesorectal excision for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 25:901–913

    Article  CAS  PubMed  Google Scholar 

  38. Choy KT, Yang TWW, Prabhakaran S, Heriot A, Kong JC, Warrier SK (2021) Comparing functional outcomes between transanal total mesorectal excision (TaTME) and laparoscopic total mesorectal excision (LaTME) for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 36:1163–1174

    Article  PubMed  Google Scholar 

  39. Jutesten H, Buchwald PL, Angenete E, Rutegård M, Lydrup ML (2022) High risk of low anterior resection syndrome in long-term follow-up after anastomotic leakage in anterior resection for rectal cancer. Dis Colon Rectum 65:1264–1273

    Article  PubMed  Google Scholar 

  40. Parnasa SY, Chill H, Helou B, Cohen A, Alter R, Shveiky D, Mizrahi I, Abu-Gazala M, Pikarsky AJ, Shussman N (2022) Low anterior resection syndrome following rectal cancer surgery: are incidence and severity lower with long-term follow-up? Tech Coloproctol. https://doi.org/10.1007/s10151-022-02699-6

    Article  PubMed  Google Scholar 

  41. Al-Rashid F, Robitaille S, Liberman AS, Charlebois P, Stein B, Feldman LS, Fiore JF Jr, Lee L (2022) Trajectory of change of low anterior resection syndrome over time after restorative proctectomy for rectal adenocarcinoma. Tech Coloproctol 26:195–203

    Article  CAS  PubMed  Google Scholar 

  42. Keane C, Sharma P, Yuan L, Bissett I, O’Grady G (2019) Impact of temporary ileostomy on long-term quality of life and bowel function: a systematic review and meta-analysis. ANZ J Surg 90:687–692

    Article  PubMed  Google Scholar 

  43. Wells CI, Vather R, Chu MJ, Robertson JP, Bissett IP (2015) Anterior resection syndrome—a risk factor analysis. J Gastrointest Surg 19:350–359

    Article  PubMed  Google Scholar 

  44. Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl R (2007) Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer. Ann Surg 246:207–214

    Article  PubMed  PubMed Central  Google Scholar 

  45. Vogel I, Reeves N, Tanis PJ, Bemelman WA, Torkington J, Hompes R, Cornish JA (2021) Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis. Tech Coloproctol 25:751–760

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Keane C, Park J, Öberg S, Wedin A, Bock D, O’Grady G, Bissett I, Rosenberg J, Angenete E (2019) Functional outcomes from a randomized trial of early closure of temporary ileostomy after rectal excision for cancer. Br J Surg 106:645–652

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Kneist W, Kauff DW, Rahimi Nedjat RK, Rink AD, Heimann A, Somerlik K, Koch KP, Doerge T, Lang H (2010) Intraoperative pelvic nerve stimulation performed under continuous electromyography of the internal anal sphincter. Int J Colorectal Dis 25:1325–1331

    Article  PubMed  Google Scholar 

  48. Kneist W (2022) Pelvines intraoperatives neuromonitoring. coloproctology 44:251–257

    Article  Google Scholar 

  49. Kneist W, Ghadimi M, Runkel N, Moesta T, Coerper S, Benecke C, Kauff DW, Gretschel S, Gockel I, Jansen-Winkeln B, Lang H, Gorbulev S, Ruckes C, Kronfeld K, NEUROS study group (2022) Pelvic intraoperative neuromonitoring prevents dysfunction in patients with rectal cancer: results from a multicenter, randomized, controlled clinical trial of a NEUROmonitoring system (NEUROS). Ann Surg. https://doi.org/10.1097/SLA.0000000000005676

    Article  PubMed  Google Scholar 

  50. Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC et al (1993) The European organization for research and treatment of cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85:365–376

    Article  CAS  PubMed  Google Scholar 

  51. Kupsch J, Kuhn M, Matzel KE, Zimmer J, Radulova-Mauersberger O, Sims A, Witzigmann H, Stelzner S (2019) To what extent is the low anterior resection syndrome (LARS) associated with quality of life as measured using the EORTC C30 and CR38 quality of life questionnaires? Int J Colorectal Dis 34:747–762

    Article  PubMed  Google Scholar 

  52. Osoba D, Rodrigues G, Myles J, Zee B, Pater J (1998) Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol 16:139–144

    Article  CAS  PubMed  Google Scholar 

  53. Juul T, Ahlberg M, Biondo S, Espin E, Jimenez LM, Matzel KE, Palmer GJ, Sauermann A, Trenti L, Zhang W, Laurberg S, Christensen P (2014) Low anterior resection syndrome and quality of life: an international multicenter study. Dis Colon Rectum 94:1278–1284

    Google Scholar 

  54. Garfinkle R, Ky A, Singh A, Morin N, Ghitulescu G, Faria J, Vasilevsky CA, Boutros M (2021) Financial and occupational impact of low anterior resection syndrome in rectal cancer survivors. Colorectal Dis 23:1777–1784

    Article  PubMed  Google Scholar 

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  1. Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig AöR, Liebigstr. 20, 04103, Leipzig, Deutschland

    Sigmar Stelzner, Matthias Mehdorn & Ines Gockel

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S. Stelzner, M. Mehdorn und I. Gockel geben an, dass kein Interessenkonflikt besteht.

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Stelzner, S., Mehdorn, M. & Gockel, I. „Low anterior resection syndrome“ (LARS) in Zahlen. coloproctology 45, 9–15 (2023). https://doi.org/10.1007/s00053-022-00674-1

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