Department of Gastrointestinal Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, P. R. China.
Department of Colorectal Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, P. R. China.
BJS Open. 2022 Nov 2;6(6). doi: 10.1093/bjsopen/zrac127.
Neoadjuvant radiation has been increasingly associated with postoperative bowel dysfunction, including low anterior resection syndrome (LARS). Although permanent stoma often results from severe bowel dysfunction and significantly impacts quality of life, the presence of stoma paradoxically excludes patients from functional follow-up. Hence, stoma status is rarely reported along with LARS, while assessment of both is essential for the comprehensive evaluation of bowel dysfunction in long-term survivors of rectal cancer.
Patients enrolled into the Neoadjuvant FOLFOX6 Chemotherapy with or without Radiation in Rectal Cancer (FOWARC) multicentre randomized clinical trial were randomized to receive long-course neoadjuvant chemoradiotherapy (nCRT) or chemotherapy (nCT) followed by sphincter-saving proctectomy and longitudinal follow-up. The primary outcome of the trial was disease-free survival. LARS score and stoma status were assessed secondarily for postoperative bowel function in the largest single-centre cohort of the trial.
Overall, 327 patients with locally advanced rectal cancer were enrolled in the original trial and 203 responded after a median follow-up of 83.4 months, of whom 24 (11.8 per cent) had persistent stoma, and 48 patients (23.6 per cent) reported major LARS. Compared with the nCT group, the nCRT group reported more persistent stomas (16.5 per cent versus 4.9 per cent, P = 0.014), and more major LARS in patients without persistent stoma (34.7 per cent versus 16.7 per cent, P = 0.003). The combined prevalence of persistent stoma and major LARS was significantly higher in the nCRT group (45.5 per cent versus 20.7 per cent, P < 0.001). Long-course neoadjuvant radiation (OR 2.20, 95 per cent c.i. 1.10 to 4.40, P = 0.027), height of anastomosis (OR 0.74, 95 per cent c.i. 0.61 to 0.91, P = 0.004), and anastomotic leak (OR 4.97, 95 per cent c.i. 2.24 to 11.05, P < 0.001) were associated with persistent stoma and major LARS in multivariate analysis.
More than one-third of patients receiving sphincter-saving proctectomy reported major LARS or persistent stoma at long-term follow-up. Long-course neoadjuvant radiation, low anastomosis, and postoperative leak are independent risk factors for persistent stoma and major LARS.
新辅助放疗与术后肠道功能障碍（包括低位前切除综合征，LARS）的关系日益密切。尽管永久性造口术通常是由严重的肠道功能障碍引起的，并且会显著影响生活质量，但造口术却使患者无法进行功能随访。因此，在直肠癌的长期生存者中，造口术的存在通常不会与 LARS 一起报告，而对两者的评估对于全面评估肠道功能障碍至关重要。
参加新辅助 FOLFOX6 化疗联合或不联合放疗治疗直肠癌（FOWARC）多中心随机临床试验的患者被随机分为接受长程新辅助放化疗（nCRT）或化疗（nCT），然后进行保肛直肠切除术和纵向随访。该试验的主要结局是无病生存率。次要终点为试验中最大的单中心队列评估术后肠道功能的 LARS 评分和造口术状态。
总体而言，327 例局部晚期直肠癌患者参加了原始试验，中位随访 83.4 个月后，203 例患者有反应，其中 24 例（11.8%）有持续的造口术，48 例（23.6%）患者报告有主要的 LARS。与 nCT 组相比，nCRT 组报告的持续造口术更多（16.5%对 4.9%，P=0.014），且无持续造口术的患者中更严重的 LARS 更多（34.7%对 16.7%，P=0.003）。nCRT 组的持续造口术和主要 LARS 的联合患病率明显更高（45.5%对 20.7%，P<0.001）。长程新辅助放疗（OR 2.20，95%CI 1.10 至 4.40，P=0.027）、吻合口位置（OR 0.74，95%CI 0.61 至 0.91，P=0.004）和吻合口漏（OR 4.97，95%CI 2.24 至 11.05，P<0.001）是多变量分析中持续造口术和主要 LARS 的独立危险因素。
接受保肛直肠切除术的患者中有超过三分之一在长期随访中报告有严重的 LARS 或持续的造口术。长程新辅助放疗、低位吻合口和术后漏是持续造口术和主要 LARS 的独立危险因素。
