Factors determining low anterior resection syndrome after rectal cancer resection: A study in Thai patients.
OBJECTIVE
Defective defecation function, also known as low anterior resection syndrome (LARS), is a common problem after surgical treatment of rectal cancer that has a detrimental effect on quality of life. This study aimed to look for the incidence of LARS in patients whose native rectum could not be kept and determine factors influencing major LARS.


METHODS
Rectal cancer patients who underwent tumor removal with mesorectal excision and colorectal anastomosis by a colorectal surgeon during the years 2004-2013 were asked to participate a structured interview using the verified version of the Low Anterior Resection Score questionnaire. Clinical parameters were analyzed against the incidence of major LARS. The cut-off anastomotic level that corresponded to the risk of major LARS was calculated by using a receiver operating characteristic curve. Anorectal physiology was compared between those with major LARS and those without LARS by anorectal manometry.


RESULTS
This study included 129 patients (67 men and 62 women). Incidences of minor LARS (LAR score 21-29) and major LARS (LARS score ≥ 30) score 21een those with major LARS and those univariate analysis, factors associated with major LARS were extent of operation, presence of temporary ostomy, and chemoradiation therapy. Major LARS was found at 28.2% in those who underwent low anterior resection, which was significantly higher than the incidence of 5.2% in the anterior resection group (p < 0.01). Radiation therapy was the only factor independently associated with major LARS at an odds ratio of 6.55 (95% confidence interval: 2.37-18.15). The receiver operating characteristic curve plot between sensitivity and specificity of the anastomotic level in determining major LARS showed an area under the curve of 0.73. The cut-off anastomotic level that best predicted major LARS was at 5 cm, which gave a negative predictive value of 89%. Individual defecation symptoms that were significantly associated with major LARS included pain on defecation, difficulty holding stool, and needing to use a pad. Anorectal manometry showed a significant difference in the resting anal pressure and squeeze pressure, which suggests that derangement in sphincteric function caused by surgery and postoperative adjuvant treatment may contribute to the LARS.


CONCLUSIONS
LARS is a significant problem found in about one third of rectal cancer patients after colorectal anastomosis. Symptoms of concern include pain on defecation and decreased ability to hold. Risk of having major LARS increases with adjuvant treatment and lower anastomotic level.
Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
Patomphon
P
Ekkarat
Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; Tumor Biology Research Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand.
Teeranut
T
Boonpipattanapong
Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
Kasaya
K
Tantiphlachiva
Department of Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand; Tumor Biology Research Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand. Electronic address: surasak.sa@psu.ac.th.
Surasak
S
Sangkhathat
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical; D003106:Colon / Q000601:surgery; D005242:Fecal Incontinence / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D012004:Rectal Neoplasms / Q000601:surgery*; D012007:Rectum / Q000601:surgery*; D012307:Risk Factors; D011795:Surveys and Questionnaires; D013577:Syndrome; D013785:Thailand; D016896:Treatment Outcome
continence; low anterior resection syndrome; rectal cancer