eISSN: 2299-0054
ISSN: 1895-4588
Videosurgery and Other Miniinvasive Techniques
Current issue Archive Videoforum Manuscripts accepted About the journal Supplements Abstracting and indexing Subscription Contact Instructions for authors
SCImago Journal & Country Rank

vol. 13
Original paper

Defunctioning ileostomy and mechanical bowel preparation may contribute to development of low anterior resection syndrome

Michał M. Nowakowski, Mateusz Rubinkiewicz, Natalia Gajewska, Grzegorz Torbicz, Michał Wysocki, Piotr Małczak, Piotr Major, Mateusz Wierdak, Andrzej Budzyński, Michał Pędziwiatr

Videosurgery Miniinv 2018; 13 (3): 306–314
Online publish date: 2018/07/03
View full text
Get citation
JabRef, Mendeley
Papers, Reference Manager, RefWorks, Zotero
Laparoscopic surgery is an approved technique in colorectal cancer treatment. Functional and quality-of-life studies have revealed significant changes in faecal continence.

To assess the incidence and risk factors of low anterior resection syndrome (LARS) in patients undergoing rectal resections for cancer.

Material and methods
We enrolled patients undergoing rectal resections in a general surgery department of a university hospital. The primary outcomes were the Jorge-Wexner scale and the LARS score 6 months after the end of treatment. The secondary outcomes were the risk factors for LARS development.

Fifty-six patients were included; 15 (26%) developed major LARS and 10 (18%) had minor LARS at 6 months. In univariate analysis the risk factors were: preoperative radiotherapy (p < 0.001, OR = 11.9, 95% CI: 2.98–47.48); shorter distance of the tumour from the anal verge (p = 0.001, OR = 0.69, 95% CI: 0.55–0.86); bowel preparation (p = 0.01, OR = 6.27, 95% CI: 1.51–26.07); low anterior rectal resection (p = 0.01, OR = 17.07, 95% CI: 1.86–156.83); and protective ileostomy (p = 0.001, OR = 15.97, 95% CI: 4.07–61.92). The risk factors for a higher Jorge-Wexner score in univariate analysis were greater diameter of tumour (p = 0.035), radiotherapy (p = 0.001), shorter distance from the anal verge (p = 0.002), bowel preparation (p = 0.042), low anterior rectal (LAR) (p = 0.01), ileostomy (p = 0.001), perioperative complications (p = 0.032), and readmission within 30 days (p = 0.034). In the multivariate analysis, readmissions and perioperative complications were significant.

In addition to typically described risk factors, two new ones have been identified. Mechanical bowel preparation and defunctioning ileostomy may also contribute to LARS development. However, due to the limitations of this study our observations require further confirmation in future trials.


risk factors, rectal cancer, low anterior resection, low anterior resection syndrome, mechanical bowel preparation, ileostomy

Di B, Li Y, Wei K, et al. Laparoscopic versus open surgery for colon cancer: a  meta-analysis of 5-year follow-up outcomes. Surg Oncol 2013; 22: e39-43.
Małczak P, Mizera M, Witowski J, et al. Is the laparoscopic approach for rectal cancer superior to open surgery? A  systematic review and meta-analysis on short-term surgical outcomes. Videosurgery Miniinv 2018; 13: 129-40.
Yamamoto T, Kanazawa A, Matsubara H, et al. Safety and usefulness of needle-guided resection of levator muscles in laparoscopic abdominoperineal resection for low rectal cancer. Videosurgery Miniinv 2016; 11: 186-91.
Mohammed S, Anaya DA, Awad SS, et al. Sphincter preservation rates after radical resection for rectal cancer in the United States veteran population: opportunity for improvement in early disease. Ann Surg Oncol 2015; 22: 216-23.
Jorgensen ML, Young JM, Dobbins TA, et al. Assessment of abdominoperineal resection rate as a  surrogate marker of hospital quality in rectal cancer surgery. Br J Surg 2013; 100: 1655-63.
Bryant CLC, Lunniss PJ, Knowles CH, et al. Anterior resection syndrome. Lancet Oncol 2012; 13: e403-8.
Juul T, Ahlberg M, Biondo S, et al. Low anterior resection syndrome and quality of life. Dis Colon Rectum 2014; 57: 585-91.
Rockwood TH. Impact of fecal incontinence on quality of life. In: Fecal Incontinence: Diagnosis and Treatment. Springer-Verlag, Italy 2007; 73-7.
Reibetanz J, Kim M, Germer C, et al. Late complications and functional disorders after rectal resection: prevention, detection and therapy. Chirurg 2015; 86: 326-31.
Sałówka J, Nowakowski M, Wałęga P, et al. Influence of extent of rectal resection on superficial electromyography of the external anal sphincter in patients with rectal cancer. Proktologia 2008; 8: 237-53.
Nowakowski M, Tomaszewski K, Herman RM, et al. Developing a  new electromyography-based algorithm to diagnose the etiology of fecal incontinence. Int J Colorectal Dis 2014; 29: 747-54.
Rubin F, Douard R, Wind P. The functional outcomes of coloanal and low colorectal anastomoses with reservoirs after low rectal cancer resections. Am Surg 2014; 80: 1222-9.
Bregendahl S, Emmertsen KJ, Lous J, et al. Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a  population-based cross-sectional study. Color Dis 2013; 15: 1130-9.
Lundby L, Krogh K, Jensen VJ, et al. Long-term anorectal dysfunction after postoperative radiotherapy for rectal cancer. Dis Colon Rectum 2005; 48: 1343-9.
Yeoh E, Sun WM, Russo A, et al. A  retrospective study of the effects of pelvic irradiation for gynecological cancer on anorectal function. Int J Radiat Oncol Biol Phys 1996; 35: 1003-10.
Ziv Y, Zbar A, Bar-Shavit Y, et al. Low anterior resection syndrome (LARS): cause and effect and reconstructive considerations. Tech Coloproctol 2013; 17: 151-62.
Chew MH, Yeh YT, Lim E, et al. Pelvic autonomic nerve preservation in radical rectal cancer surgery: changes in the past 3 decades. Gastroenterol Rep 2016; 4: 173-85.
Pędziwiatr M, Pisarska M, Kisielewski M, et al. Is ERAS in laparoscopic surgery for colorectal cancer changing risk factors for delayed recovery? Med Oncol 2016; 33: 25.
Emmertsen KJ, Laurberg S, Emmertsen KJ, Laurberg S. Low anterior resection syndrome score. Ann Surg 2012; 255: 922-8.
Jorge JM, Wexner SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36: 77-97.
Luglio G, De Palma GD, Tarquini R, et al. Laparoscopic colorectal surgery in learning curve: role of implementation of a  standardized technique and recovery protocol. A  cohort study. Ann Med Surg 2015; 4: 89-94.
Clavien PA, Barkun J, De Oliveira ML, et al. The clavien-dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250: 187-96.
Pisarska M, Pędziwiatr M, Małczak P, et al. Do we really need the full compliance with ERAS protocol in laparoscopic colorectal surgery? A  prospective cohort study. Int J Surg 2016; 36: 377-82.
Pędziwiatr M, Pisarska M, Kisielewski M, et al. ERAS protocol in laparoscopic surgery for colonic versus rectal carcinoma: are there differences in short-term outcomes? Med Oncol 2016; 33: 56.
Gordon PH, Nivatvongs S. Principles and Practice of Surgery for the Colon, Rectum, and Anus. 3th ed. CRC Press; 2007; 1360.
Jimenez-Gomez LM, Espin-Basany E, Trenti L, et al. Factors associated with low anterior resection syndrome after surgical treatment of rectal cancer. Color Dis 2018; 20: 195-200.
Hughes DL, Cornish J, Morris C, et al. Functional outcome following rectal surgery-predisposing factors for low anterior resection syndrome. Int J Colorectal Dis 2017; 32: 691-7.
Jiménez-Rodríguez RM, Segura-Sampedro JJ, Rivero-Belenchón I, et al. Is the interval from surgery to ileostomy closure a  risk factor for low anterior resection syndrome? Colorectal Dis 2017; 19: 485-90.
Pisarska M, Gajewska N, Małczak P, et al. Defunctioning ileostomy reduces leakage rate in rectal cancer surgery – systematic review and meta-analysis. Oncotarget 2018; 9: 20816-25.
Zhou MW, Wang ZH, Chen ZY, et al. Advantages of early preventive ileostomy closure after total mesorectal excision surgery for rectal cancer: an institutional retrospective study of 123 consecutive patients. Dig Surg 2017; 34: 305-11.
Menahem B, Lubrano J, Vallois A, et al. Early closure of defunctioning loop ileostomy: is it beneficial for the patient? A  meta-analysis. World J Surg 2018; 27: doi: 10.1007/s00268-018-4603-0.
Farag S, Rehman S, Sains P. Early vs delayed closure of loop defunctioning ileostomy in patients undergoing distal colorectal resections: an integrated systematic review and meta-analysis of published randomized controlled trials. Color Dis 2017; 19: 1050-7.
Güenaga KF, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2011; 7: CD001544.
Courtney DE, Kelly ME, Burke JP, et al. Postoperative outcomes following mechanical bowel preparation before proctectomy: a  meta-analysis. Colorectal Dis 2015; 17: 862-9.
Moghadamyeghaneh Z, Hanna MH, Carmichael JC, et al. Nationwide analysis of outcomes of bowel preparation in colon surgery. J Am Coll Surg 2015; 220: 912-20.
Scarborough JE, Mantyh CR, Sun Z, et al. Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection. Ann Surg 2015; 262: 331-7.
Kiran RP, Murray ACA, Chiuzan C, et al. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg 2015; 262: 416-25.
Morris MS, Graham LA, Chu DI, et al. Oral antibiotic bowel preparation significantly reduces surgical site infection rates and readmission rates in elective colorectal surgery. Ann Surg 2015; 261: 1034-40.
Klinger AL, Green H, Monlezun DJ, et al. The role of bowel preparation in colorectal surgery: results of the 2012-2015 ACS-NSQIP Data. Ann Surg 2017; doi: 10.1097/SLA.0000000000002568.
van’t Sant HP, Weidema WF, Hop WCJ, et al. The influence of mechanical bowel preparation in elective lower colorectal surgery. Ann Surg 2010; 251: 59-63.
Pittet O, Nocito A, Balke H, et al. Rectal enema is an alternative to full mechanical bowel preparation for primary rectal cancer surgery. Color Dis 2015; 17: 1007-10.
Nuytens F, Develtere D, Sergeant G, et al. Perioperative radiotherapy is an independent risk factor for major LARS: a  cross-sectional observational study. Int J Color Dis 2018; doi: 10.1007/s00384-018-3043-5.
Trenti L, Galvez A, Biondo S, et al. Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: a  cross-sectional study. Eur J Surg Oncol 2018; 44: 1031-9.
Romaniszyn M, Richter P, Walega P, et al. Low-anterior-resection syndrome. How does neoadjuvant radiotherapy and low resection of the rectum influence the function of anal sphincters in patients with rectal cancer? Preliminary results of a  functional assessment study. PolJ Surg 2012; 84: 177-83.
Haas S, Faaborg P, Liao D, et al. Anal sphincter dysfunction in patients treated with primary radiotherapy for anal cancer: a  study with the functional lumen imaging probe. Acta Oncol (Madr) 2018; 57: 465-72.
Ihnát P, Slívová I, Tulinsky L, et al. Anorectal dysfunction after laparoscopic low anterior rectal resection for rectal cancer with and without radiotherapy (manometry study). J Surg Oncol 2018; 117: 710-6.
Colorectal Cancer Collaborative G. Adjuvant radiotherapy for rectal cancer: a  systematic overview of 8,507 patients from 22 randomised trials. Lancet 2001; 358: 1291-304.
Kapiteijn E, Marijnen CA, Nagtegaal ID, et al. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 2001; 345: 638-46.
Kupsch J, Jackisch T, Matzel KE, et al. Outcome of bowel function following anterior resection for rectal cancer – an analysis using the low anterior resection syndrome (LARS) score. Int J Colorectal Dis 2018; 33: 787-98.
Lim RS, Yang TX, Chua TC. Postoperative bladder and sexual function in patients undergoing surgery for rectal cancer: a  systematic review and meta-analysis of laparoscopic versus open resection of rectal cancer. Techn Coloproctol 2014; 18: 993-1002.
Quick links
© 2018 Termedia Sp. z o.o. All rights reserved.
Developed by Bentus.
PayU - płatności internetowe