Long term persistence and risk factors for anorectal symptoms following sphincter preserving surgery for rectal cancer
Authors: Koifman Eduard , Armoni Mor , Gorelik Yuri , Harbi Assaf , Streltsin Yulia , Duek Daniel , Brun Rita , Mazor Yoav 
Published: June 2023

Abstract
Background
Rectal cancer is commonly treated by chemo-radiation therapy, followed by anal sphincter-preserving surgery, with a temporary protecting ileostomy. After the reversal of the stoma, a condition known as low anterior resection syndrome (LARS) can occur, characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up.Aims: To evaluate long term outcomes of sphincter-preserving surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment.
Methods
115 patients (74 males, age 63 ± 11) who underwent sphincter preserving surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, a cross sectional observational study was performed. Patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires.
Results
80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1–8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as severe LARS (score > 30). Presence of severe LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months, p = 0.03). Patients initially referred for ARM and BF were more likely to suffer from severe LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters as measured by questionnaires (p < 0.05 for all). 19 (53%) of these patients were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF.
Conclusions
A significant number of patients continue to experience severe symptoms and a decline in their quality of life even four years after undergoing sphincter-preserving surgery. Prolonged time until stoma reversal emerged as the primary risk factor for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group, which may involve implementing a more comprehensive anorectal bowel function protocol and considering sacral neuromodulation as potential interventions.