Rectal cancer is one the most common malignant neoplasms of the GI tract. Rectal excision with total mesorectal excision (TME) remains the cornerstone of curative treatment for rectal cancer.1 Up to 80% of patients who have rectal excision with sphincter-preserving surgery will have a subsequent change in bowel habit and quality of life (QoL).2 The combination of increased stool frequency, urgency, clustering, and fecal incontinence after anterior resection with anastomosis is often referred to as low anterior resection syndrome (LARS). Recently, a simple scoring system to grade LARS has been developed and validated and can be used to assess patients who have had a rectal resection with preservation of bowel continuity.3 , 4 The incidence of definitive stoma was higher than 20% after low or ultralow resection for rectal cancer, mainly because of poor functional outcomes.5
Antegrade continence enema has been reported as an acceptable treatment of functional constipation, fecal incontinence (FI), and after perineal colostomy across several analyses.6–11 However, such surgical techniques are burdened by the need for surgical revisions due to stenosis or stoma leakage.12 , 13 To overcome such limitations, novel mini-invasive techniques have been developed using radiological or endoscopic approaches. In particular, the feasibility and preliminary results of percutaneous endoscopic cecostomy (PEC) have been assessed in previous studies.14 However, there is no study about antegrade continence enema after PEC for the treatment of LARS and FI after rectal excision for cancer. The aim of this study was to assess the functional results and QoL of patients after PEC for antegrade colonic enema for refractory LARS and FI after TME.
MATERIALS AND METHODS
From March 2012 to September 2016, of 319 patients who underwent TME for low rectal cancer, 25 were treated by PEC and antegrade enema for refractory LARS and FI in Bordeaux University Hospital. Data from these patients were prospectively collected and analyzed. After TME, patients were followed up by both surgeon and gastroenterologist, and the decision to perform PEC was discussed in multidisciplinary meetings. The PEC procedure was proposed after the failure of previous medical or surgical treatments such as mucilage and antidiarrheal drugs, biofeedback, retrograde enema, and sacral neurostimulation.
Colonic cleansing before the PEC procedure included 7 days of fiber-free diet and 3 days of oral polyethylene glycol. Antibiotic prophylaxis (either amoxicillin-clavulanic acid 1 g or ofloxacine 200 mg with metronidazole 500 mg) was administered intravenously 1 hour before the PEC. In both centers, the colonoscopy was performed under general anesthesia (propofol) and CO2 insufflation in the left lateral or supine position. Cecal position was confirmed using digital pressure and transillumination, and the cecum insufflated. The puncture site was disinfected with an antiseptic solution. Then, 3 to 4 anchors (Chait trapdoor suture set, Cook Medical, Bloomington IN, or Harpon T-fasteners, Balt Extrusion, Montmorency, France) were placed under endoscopic guidance to fix an area in the cecum. In the center of this area, an 80-cm-long guidewire was introduced through a trocar, and served to pass several dilatators from 6F to 10F and create the ministoma. Then, the final catheter (Chait trapdoor catheter, Cook Medical) was introduced into the cecum over the guidewire and a rigid introducer and released to place the external button in contact with the skin, and the pigtail curved into the cecum (Fig. 1). All the previous steps were performed under endoscopic guidance, and the colonoscope was then retrieved with gradual exsufflation. After the procedure, patients received on-demand pain killers according to the intensity of pain. Antibiotics were continued for 72 hours. Patients were discharged 1 to 7 days after the procedure, ie, when they were able to eat normally and had minimal difficulty with their daily tasks. Two to 3 weeks after the procedure, patients spent 1 day in the ambulatory care unit to remove anchors, perform the first antegrade colonic enema with a nurse’s assistance, and receive educational advice and material to facilitate the autonomous use of the Chait catheter at home. In particular, they were asked to use 1 liter of standard tap water every day, then to adapt the timing and volume of water infusion according to the efficacy and tolerance of enemas.
We assessed postoperative morbidity and the rate of definitive colostomy, and we compared functional outcomes and QoL before and after the use of antegrade enema. Postoperative morbidity was defined according to the Dindo classification.15 Details regarding complications such as local pain, sweating, and local abscess were also collected.
Functional outcome was assessed by both the LARS score3 and the Wexner score.16 The LARS score ranges from 0 to 42 and is stratified into 3 categories: no LARS (LARS score from 0 to 20), minor LARS (score from 21 to 29), and major LARS (score from 30 to 42).3 Wexner score was used to specifically evaluate the severity of FI (0 is perfect continence and 20 is major incontinence). Major FI was defined by an incontinence score higher than 10.16 Rates of major LARS and major FI before and after PEC were compared.
The QoL of patients was assessed using the French version of the previously validated Gastrointestinal Quality of Life Index (GIQLI) score, ranging from 0 to 144 (excellent).17 This score comprises 36 items, including GI symptoms, physical status, emotions, social integration, and the effect of medical treatment.
The rate of definitive stoma formation and failure of the procedure were also analyzed. The reasons for procedure failures were recorded. Catheter removal was considered a failure of the procedure.
Data were prospectively collected in a computer database. Quantitative data were given as median (ranges). Qualitative data are expressed as a percentage. Comparison between before and after treatment scores were assessed using the Wilcoxon signed-rank test. A p value of <0.05 was considered to be statistically significant.
Of the 25 patients with PEC, 6 (24%) had a low anterior resection (LAR) with a stapled anastomosis, 18 (72%) had a TME with handsewn coloanal anastomosis, half with a J-pouch, and 1 (4%) had a perineal colostomy.
Preoperative radiotherapy for the rectal cancer was used in 22 patients (88%). Rates of anastomotic leakage and stenosis were 16% (n = 4) and 24% (n = 6). Details of the population are given in Table 1.
Percutaneous endoscopic cecostomy was only performed after the failure of other treatments. These were as follows; biofeedback for 14 (56%), mucilage for 25 (100%), retrograde enema 16 (64%), and neuromodulation for 2 (8%). The time between ileostomy closure and PEC was 22 months (3–199).
Procedure and Morbidity
The duration of the procedure was 33 (range 25–60) minutes and length of hospital stay was 3 days (range 1–13). The frequency of irrigation was 1 per day (range 0.5–2) requiring 1000 mL (range 800–1500) of liquid for each irrigation.
Postoperative complications within 30 days of the procedure were reported in 4 patients (16%). The rate of local abscess was 8% (n = 2), all treated by antibiotics and classified Dindo II. Details of morbidity are given in Table 2. At the end of follow-up, the 2 main symptoms reported by patients were sweating for 7 patients (28%) and local pain for 9 patients (36%).
After a median follow-up of 8 (range 1–33) months, 4 (16%) catheters had been removed. Removal was considered to be a failure of the procedure. Among the 4 patients who required catheter removal, 3 went on to have a definitive stoma (12%). The reasons for catheter removal were as follows: 2 of the 4 patients did not have an effective response to the antegrade lavage, 1 patient had locally recurrent rectal cancer, and 1 patient had local sweating and pain. Four patients (15%) died during the follow-up but none of the deaths were catheter related. All patients (n = 25) were considered for the functional assessment.
The LARS score was 33 (range 12–41) before the PEC procedure. There was a significant improvement in LARS after PEC and antegrade enema, the LARS score decreasing to 4 (range 0–41) (p < 0.001). The rate of major LARS decreased significantly from 73% (16/22) to 9% (2/22) (p < 0.001). The redistribution of patients according to the severity of LARS score over time is given in Figure 2.
The severity of FI decreased significantly from a Wexner score of 16 (range 4–20) before PEC, to 4 (range 0–16) after PEC and antegrade enema (p < 0.001). Major incontinence was reported by 92% of patients (23/25) before PEC, versus 16% (4/25) after the procedure (p < 0,001) (Fig. 2).
The patients’ QoL was also improved by antegrade enema with a significant increase of the GIQLI score (73 vs 104; p < 0.001) (Fig. 2).
As survival from rectal cancer has improved, attention has begun to focus on functional results and what can be done to improve QoL for these patients. Low anterior resection syndrome and FI are common problems in the early postoperative phase, with reports in the literature of as many as 60% to 90% of patients affected.18 , 19 Despite the frequency of FI and LARS after TME, there is a lack of consistent evidence for their effective treatment. This is the first study in the literature to report on the use of PEC for the treatment of LARS and FI after sphincter-preserving surgery for rectal cancer. We compared the rates of LARS and FI, in addition to QoL, before and after PEC was performed. This was done using 3 validated scoring systems: LARS, Wexner, and GIQLI scores. We were able to demonstrate a significant decrease in both the Wexner and LARS scores and a significant improvement in the QoL score. Our results are encouraging and suggest that PEC may offer an alternative to a permanent stoma in patients with poor functional outcomes after rectal excision for cancer.5
There is a lack of a standardized treatment strategy for the management of LARS. However, a conservative approach should be taken in the first instance. This includes dietary regulation and the use of medications such as loperamide, stool-bulking agents, amitryptylline, and smooth muscle relaxants. In those who do not respond, treatment can be escalated. A recent systematic review confirmed the efficacy of pelvic floor rehabilitation and biofeedback in improving function after LAR.20 However, these studies mainly focused on the symptoms of FI rather than those of urgency and clustering, which we have specifically assessed in our study by using the LARS score. Retrograde colonic irrigation has also been shown to be effective in treating patients with FI after LAR.21 An improved response was also reported with antegrade irrigation via an appendicostomy in a small number of patients after abdominoperineal excision and perineal colostomy.22 Sacral nerve stimulation has more recently emerged as a possible treatment, and a review article in 2015 reported an improvement in symptoms in more than 70%, although numbers are low.23 However, Mizrahi et al24 have more recently reported that sacral nerve stimulation is less effective with high explantation rates. In our study, patients were only considered for PEC if more conservative therapies that included biofeedback, retrograde irrigation, and neuromodulation had already failed.
This inconsistency in the successful treatment of LARS led us to considering the PEC procedure. The antegrade continence enema became a recognized technique after it was used by Malone et al25 in a pediatric series with chronic constipation and FI. In a recent meta-analysis of 17 studies assessing the antegrade enema in constipation and FI, 74% were successfully using the cecostomy after a median follow-up of 39 months.10 Its effectiveness in treating FI in those who have had rectal resection and perineal colostomy has also been reported in a small series.26 It is an invasive procedure, however, and stenosis of the stoma is one of the most commonly described complications.6 , 11 The percutaneously placed cecostomy has been suggested as a less invasive alternative. Its feasibility for treating severe constipation and pseudo-obstruction has been confirmed.27 In our study, assessing the antegrade enema with PEC, 84% had sustained efficacy at the end of the follow-up period. Our 30-day morbidity rate of 16% is similar to that described in previous literature reports of the PEC procedure.14 The main reports were of sweating and local pain requiring analgesia in 7 (28%) and 9 (36%) patients. Of 4 patients who required catheter removal, only 2 (8%) did not have a good response to the antegrade enema and one (4%) had major local pain and sweating. Local chronic pain has also been reported in other series of PEC. Currently, it is not possible to predict which individuals may be affected, and, therefore, patients should be adequately counseled before the procedure. At the end of the follow-up period, in a population with initially very poor functional outcomes, for whom a definitive stoma may be the only alternative, only 12% required a definitive colostomy. The only mortality during the follow-up was unrelated to the procedure or catheter.
Overall, our study has shown promising results for PEC in patients with poor bowel function after rectal cancer excision. We were able to demonstrate a significant improvement in LARS, FI, and QoL. We have confirmed the feasibility and safety of this procedure that may allow patients in this population to avoid a permanent stoma. Patients have to be cognizant of the potential for poor functional outcomes and their management after rectal excision for cancer. A bowel rehabilitation program, including PEC with antegrade enema, may be proposed, within a specialized multidisciplinary team taking care of rectal cancer. This may facilitate the optimization of the management of this patient group. It now warrants further evaluation in a larger prospective cohort of patients with longer follow-up.
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