ABSTRACT
Resumen Durante las últimas décadas los avances en técnicas quirúrgicas, radioterapia y quimioterapia han logrado de forma significativa aumentar la sobrevida y disminuir la recidiva local en el cáncer de recto evitando una colostomía definitiva; sin embargo, este trascendental progreso médico no ha ido acompañado de una mejoría en los resultados funcionales de los pacientes sometidos a una cirugía conservadora de esfínter, siendo el conjunto de síntomas defecatorios posterior a la resección rectal, conocido como síndrome de resección anterior baja (LARS), una secuela prácticamente inevitable, que generalmente se asocia a disfunción sexual, urinaria, dolor crónico, altos costos en rehabilitación y control sintomático, además de una alteración importante en la calidad de vida. En este artículo presentamos una revisión completa y actualizada de las características clínicas y alternativas de tratamiento del LARS, finalizando con una propuesta de manejo integral multidisciplinario que destaca la importancia de la prehabilitación, evaluación objetiva de los síntomas, educación e información adecuada del paciente y su familia, además del trabajo en equipo en unidades especializadas de rehabilitación de piso pélvico, requisito fundamental a la hora de manejar adecuadamente esta patología.
During the last decades, advances in surgical techniques, radiotherapy and chemotherapy have significantly increased survival and reduced local recurrence in rectal cancer, avoiding a definitive colostomy. However, this transcendental medical progress has not been accompanied by an improvement in the functional results of patients after sphincter-preserving rectal resection, being the set of defecatory symptoms after rectal resection, known as low anterior resection syndrome (LARS), a practically inevitable sequel, which is usually associated with sexual or urinary dysfunction, chronic pain, high costs and an important alteration in the quality of life. In this article, we will present a complete and updated review of the clinical and alternative characteristics of LARS treatment, ending with a proposal for multidisciplinary and integral management that highlights the importance of prehabilitation, objective evaluation of symptoms, education and adequate information of the patient and his family, in addition to teamwork in units specialized in pelvic floor rehabilitation, a fundamental requirement when properly managing this pathology.
Subject(s)
Humans , Rectal Neoplasms/surgery , Organ Sparing Treatments/adverse effects , Low Anterior Resection Syndrome , Postoperative Complications/etiology , Postoperative Complications/therapy , Quality of Life , Rectal Neoplasms/therapyABSTRACT
Objetivo: Identificar fatores relacionados à ocorrência de disfunção intestinal e de impacto negativo na Qualidade de vida (QV) de mulheres submetidas à ressecção segmentar (RS) ou em disco (RD) por endometriose intestinal. Método: Estudo retrospectivo com mulheres submetidas à RS ou RD para tratamento de endometriose intestinal,com registro medico consecutivo, em hospital terciário (Biocor, Instituto) por equipe multidiciplinar no período 2008-2018. Os critérios de inclusão foram: anastomose até 15cm da margem anal, confirmação histológica de endometrioses intestinal, seguimento pós-operatório mínimo de 12 meses,sem cirurgia colorretal anterior e assinatura do termo de consentimento. Foram excluídas aquelas com doença inflamatória intestinal ou com doença sistêmica ou outra condição patológica grave capaz de comprometer a qualidade de vida. Foram utilizados questionários validados para avaliar a função intestinal Low Anterior Resection Syndrome Score (LARS score) e qualidade de vida (Short Form Health Survey SF 36). Dados clínicos cirúrgicos e sócio-demográficos foram também registrados. Variáveis que poderiam estar relacionadas à disfunção intestinal foram investigadas. A análise de associação das variáveis do estudo com a variável resposta LARS foi feita pela regressão logística e o p<0.05 foi considerado como significativo. O estudo foi aprovado pelo comitês de ética local. Resultados: Foram estudadas 144 mulheres com idade média 34 anos, sendo a dor a principal indicação cirúrgica (n=130;90,3%), seguida de infertilidade (n=74; 51,4%) todas as cirurgias forma por videolaparoscopia e realizadas pelo mesmo coloprotctologista sendo a RS realizada em 91 pacientes (63,2%), enquanto 53 (35,8%) foram submetidas a RD.A incidência de LARS foi de 42,36% (61pacientes) sendo 20,8% LARS leve e 21,5% de LARS grave. Não houve diferença significativa na incidência de LARS entre pacientes submetidos a RS 47% e RD 34% (p=0,120) Na análise das variáveis do questionário LARS escore, as pacientes que foram submetidas a RD apresentaram constipação, e quanto às submetidas a RS, um pequeno grupo apresentou frequência evacuatória de 4 a 7 vezes ao dia (p=0,011), e o restante de 1 a 3 vezes. As únicas variáveis responsáveis pela ocorrência de LARS foram: histerectomia prévia ou concomitante (OR 2,94 95% IC 1,24;6,97, p=0,014), distância a anastomose ≤ 5 cm e RS associada a distância a anastomose ≤ 5 cm da margem anal (OR 4,22 95% IC 1,70;10,50 p=0,002). A ocorrênca de LARS em pacientes submetidas a RS foi maior naquela com anastomose ≤ 5 cm da margem anal (37,6% versus 6,2% p < 0,001), sendo também significativamente maior quando comparada com RD (p=0,006). As pacientes, apresentaram boa QV, independente da técnica cirúrgica utilizada com todos os domínios acima de 60. Em relação a QV versus LARS, as pacientes que apresentaram LARS tiveram impacto significativo nos domínios aspectos emocional p=0,006) e saúde mental (p=0,011) comparado aos sem LARS. A taxa de morbidade geral foi de 10,3% sendo 6,3% complicações menores e 4,2% maiores, segundo classificação de Clavien-Dindo. As complicações não impactaram a QV e nem o LARS escore (p=0,655). Conclusão: Pacientes submetidas a cirurgia para tratamento da endometriose desenvolveram disfunção intestinal independente da técnica cirúrgica, com impacto na QV nos domínios aspectos emocional e saúde mental. A realização da histerectomia e anastomose baixa associada a RS aumentaram significamente o risco de disfunção intestinal.
Objective: To identify factors related to the occurrence of bowel dysfunction and negative impact on the Quality of life (QoL) of women undergoing segmental (SR) or disc resection (RD) for intestinal endometriosis. Method: This was a retrospective study with women undergoing RS or RD for the treatment of intestinal endometriosis,with consecutive medical record, in a tertiary hospital (Biocor, Instituto) by a multidisciplinary team from 2008 to 2018. Inclusion criteria were: anastomosis up to 15 cm above anal margin histological confirmation of intestinal endometriosis, minimum postoperative follow-up of 12 months,no previous colorectal surgery and signature of the consent form. Those with inflammatory bowel disease or with systemic disease or other serious pathological condition affecting quality of life were excluded. Validated questionnaires were used to assess bowel function: (Low Anterior Resection Syndrome Score (LARS score) and quality of life (Short Form Health Survey SF 36). Clinical, surgical and socio-demographic data were also recorded. Variables that could be related to bowel dysfunction were investigated. Statistical analysis included logistic regression to study the association of the study variables with the response variable LARS and p<0.05 w considered significant. The study was approved by the local ethics committee.Results: 144 women with an average age of 34 years were studied, with pain being the main indication for surgery (n= 130;90.3%), followed by infertility (n=74; 51.4%). All surgeries were laparoscopies performed by the same coloproctologist: RS was performed in 91 patients (63.2%), while 53 (35.8%) were submitted to DR. The incidence of LARS was 42.36% (n=61) with 20.8% classified as mild and 21. 5% severe. There was no significant difference in the incidence of LARS between patients who underwent either RS (47%) or RD (34%) (p=0.120). As for those submitted to RS, a small group presented evacuation frequency from 4 to 7 times a day (p=0.011), and the rest from 1 to 3 times. The only variables responsible for the occurrence of LARS were: previous or concomitant hysterectomy (OR 2.94 95% CI 1.24;6.97, p=0.014), distance to anastomosis ≤ 5 cm and RS associated with distance to anastomosis ≤ 5 cm from the anal margin (OR 4.22 95% CI 1.70; 10.50 p=0.002). The occurrence of LARS in patients undergoing RS was higher in those with anastomosis ≤ 5 cm from the anal margin (37.6% versus 6.2%; p < 0.001), being also significantly higher when compared to DR (p = 0.006). Patients, in general, had good QoL, regardless of the surgical technique used, with all domains above 60. Regarding QoL versus LARS, patients who had LARS had a significant impact on the emotional aspects (p=0.006) and mental health domains (p=0.011) compared to those without LARS. The overall morbidity rate was 10.3%, with 6.3% minor complications and 4.2% major complications, according to the Clavien-Dindo classification. Complications did not impact QoL nor the LARS score (p= 0.655). Conclusion: Patients undergoing surgery for endometriosis developed bowel dysfunction regardless of the surgical technique, with an impact on QoL in the emotional aspects and mental health domains. Hysterectomy and anastomosis ≤ 5 cm with RS significantly increase the risk of bowel dysfunction.
Subject(s)
Quality of Life , Endometriosis , Inflammatory Bowel Diseases , Colectomy , Academic DissertationABSTRACT
Introducción: El tratamiento en el cáncer de recto ha progresado en la última década. Hoy es factible ofrecer una cirugía con preservación de esfínteres, realizando anastomosis colorrectales bajas o anastomosis coloanales. Esto ha determinado que muchos pacientes desarrollen disfunción intestinal que puede llegar a ser severa, agrupando una serie de alteraciones que se conocen como síndrome de resección anterior baja. Objetivo: Efectuar una adaptación cultural de la versión 1.0 en español neutro del cuestionario acerca de la función intestinal o Low Anterior Resection Syndrome Score (LARS Score), efectuando traducción, comparación de traducciones, traducción inversa y prueba piloto. Resultados: Los resultados obtenidos de la prueba piloto revelan que la población encuestada logró comprender el instrumento, por lo que no se realizaron modificaciones posteriores. Conclusión: Se cuenta con una versión adaptada del cuestionario LARS para ser usada en Chile, la cual puede someterse a procesos de validación y establecer las características psicométricas para ser usada en pacientes con cáncer de recto operados.
Introduction: The treatment of rectal cancer has progressed in the past decade. Nowadays, it's feasible to provide sphincter sparing surgery with low colorectal anastomosis or coloanal anastomosis. This has determined that many patients develop intestinal dysfunctions that can become severe, grouping a number of disorders known as low anterior resection syndrome. Objective: To perform a cultural adaptation of the version 1.0 questionnaire about bowel function or Low Resection Syndrome Score (LARS Score) in neutral Spanish, making a translation, comparing translations, back translation and pilot test. Results: The results of the pilot test showed that the population surveyed understood the instrument, so that no further modifications were made. Conclusion: We now have an adapted version of the LARS questionnaire for use in Chile, which can undergo validation processes to establish the psychometric characteristics for use in patients with rectal cancer surgery.