Optimising functional outcomes in rectal cancer surgery

Fabio Nocera, Fiorenzo Angehrn, Markus von Flüe, Daniel C Steinemann, Fabio Nocera, Fiorenzo Angehrn, Markus von Flüe, Daniel C Steinemann

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.

Keywords: Functional outcome; Health related quality of life; Pelvic floor; Rectal cancer; Total mesorectal excision.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Figures

Fig. 1
Fig. 1
Injury levels, anorectal and bowel dysfunctions and subsequent symptoms after anterior resection (AR)
Fig. 2
Fig. 2
Diagnostic and therapeutic algorithm for low anterior resection syndrome (LARS) and urogenital dysfunctions after anterior resection (AR) for rectal cancer [SNM: sacral neuromodulation]

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