Síndrome de resección anterior baja en pacientes con cáncer de recto medio e inferior ¿Qué más podemos hacer? / Low anterior resection syndrome in patients with medium and low rectal cancer. What else can we do?

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.

Avaliação da Função Intestinal e da Qualidade de Vida de Pacientes com Endometriose Pélvica Profunda Submetidas à Ressecção Colorretal / Evaluation of Intestinal Function and Quality of Life in Patients with Deep Pelvic Endometriosis Undergoing Colorectal Resection

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.

Clinical application and focus of lars ligament in anterior cruciate ligament reconstruction / 中国组织工程研究

BACKGROUND: Although there are three main types of graft selection for anterior cruciate ligament reconstruction: Autograft, allogeneic graft and synthetic graft, graft selection is still the focus of current research and controversy. OBJECTIVE: To review the early, mid-term and long-term clinical effects of LARS ligament in the reconstruction of arthroscopic anterior cruciate ligament. METHODS: The related literatures published before April 2019 in CNKI database and PubMed database were searched by computer with the search terms “LARS ligament, anterior cruciate ligament, artificial ligament, anterior cruciate ligament reconstruction” in Chinese and English respectively. After preliminary screening by reading titles and abstracts, irreverent literatures were excluded. Forty-six eligible literatures were included. RESULTS AND CONCLUSION: LARS ligament had excellent biocompatibility and mechanical properties. Its unique structure allowed fibroblasts to grow in the forms of wrapping and penetration, and there was no inflammatory reaction around the ligament and fewer macrophages were observed. Because the growing tissue increased the viscoelasticity of the ligament and reduced the friction between the fibers, so it can effectively prevent the biological reaction caused by detritus. LARS ligament had good elastic modulus, anti-torsion and fatigue resistance properties. LARS ligament was suitable for anterior cruciate ligament reconstruction because of its rapid recovery, low failure rate, and few complications.

Síndrome de la resección anterior baja: un alto precio del tratamiento del cáncer de recto / Low anterior resection syndrome: a high cost of rectal cancer treatment

En los últimos 30 años el tratamiento del cáncer del recto ha mejorado significativamente gracias al manejo multidisciplinario y a la introducción del concepto de resección total del mesorrecto (RTM), logrando disminuir las tasas de recidiva local y aumentar la sobrevida. Si bien los avances oncológicos y técnicos en términos de tasas de conservación del esfínter anal son innegables, las secuelas funcionales son significativas, especialmente las relacionadas a la función intestinal, sexual y urinaria. Hasta un 90% de los pacientes sometidos a una RTM refiere secuelas intestinales cuyos síntomas se conocen como el síndrome de la resección anterior baja (SRAB). Recientemente se han diseñado sistemas de valoración específicos que han evidenciado su alta incidencia y prevalencia. En esta revisión se entrega una mirada actualizada de la fisiopatología, factores de riesgo, formas de presentación, evaluación clínica y las distintas alternativas de prevención y tratamiento del SRAB.

In the last 30 years, oncologic outcomes of rectal cancer treatment have been significantly improved due to multimodal management and the introduction of the concept of total mesorectum excision. Although the improvements in oncological treatment and surgical techniques are undeniable, multimodal treatment results in the onset of disorders of the intestinal, sexual and urinary function in a high proportion of these patients. Up to 90% of patients undergoing a low anterior resection refer bowel disorders such as fecal incontinence, urgency, increased frequency and fragmentation of defecation. These elements are included in an entity known as the low anterior resection syndrome and specific assessment tools have been designed recently, evidencing the high incidence and prevalence of this syndrome. In the present review, we update the pathophysiology, risk factors, clinical presentation, evaluation and the alternatives of prevention and treatment of low anterior resection syndrome.

Comparasion of clinical outcomes of reconstruction by LARS and conservative treatment for patients older than 50 years with chronic forward instability of knee joint / 中国综合临床

Objective To compare the outcomes between conservative treatment and reconstruction with LARS in patients over 50 years old with chronic forward instability of knee joint.Methods Forty patients with chronic forward instability of knee joint from May,2005 to September,2013 in Shengjing Hospital of China Medical University were included in this study and were divided into conservative treatment group(16 cases) and LARS group(19 cases) besides that were ineligible according to different treatment methods.All patients were followed up for two years.The evaluation indicators included Lysholm,IKDC,Tegner,ROM,Kneelax and Kellgren-Lawrence rating.Results At the end of two-year follow-up,the knee joint function score of conservative treatment group was significantly higher than that before treatment (Lysholm score after treatment (83.4± 12.5) points,before treatment (69.6 ± 10.4) points,t =-11.502,P =0.00;IKDC after treatment,abnormal 2 cases,and before treatment,abnormal 10 cases,P =0.00;Tegner after treatment 6 (1,9) points,before treatment 3 (1,5) points,Z =-3.471,P =0.01).The knee joint function score and Kneelax measurement in the LARS ligament reconstruction group were significantly improved after operation(Lysholm score after treatment (80.0±14.2) points,before treatment (68.7±9.6) points,t =-7.875,P =0.00;IKDC score after treatment,abnormal 2 cases,and before treatment,abnormal 13 cases,P =0.00;Tegener score after treatment 8 (1,9) points,before treatment 3 (1,5) points,Z =-3.879,P=0.00;Kneelax score after treatment (1.5 ± 0.8) mm,before treatment (4.2 ± 0.8) mm,t =9.955,P =0.00).At the end of two-year follow-up,kneelax and Tegner scores in LARS ligament reconstruction group were significantly higher than those in conservative treatment group (Z =6.109,P=0.00;Z =2.672,P =0.01).Conclusion Compared with conservative treatment,LARS ligament reconstruction is more conducive to the stability and functional recovery of knee joint in patients over 50 years old with chronic anterior instability of knee joint.

Effectiveness of patellar tendon reconstruction with LARS artificial ligament for old patellar tendon rupture / 中国修复重建外科杂志

Objective: To explore the effectiveness of patellar tendon reconstruction by using LARS artificial ligament in treatment of old patellar tendon rupture. Methods: A clinical data of 12 patients with old patellar ligament ruptures, who met the inclusive criteria and reconstructed with LARS artificial ligament between December 2011 and December 2017, was retrospectively analyzed. There were 8 males and 4 females with an average age of 33.5 years (range, 18-55 years). The cause of injury included traffic accident injury in 4 cases, sport injury in 5 cases, and violent injury in 3 cases. There were 5 cases in the left knee and 7 cases in the right knee. The disease duration was 2-12 weeks (mean, 2.5 weeks). The preoperative Lysholm score and Kujala score were 43.2±3.2 and 43.9±2.6, respectively. The knee range of motion was (106.5±14.7)°. The thigh circumference which was measured at 10 cm above the upper end of the patella was (40.92±1.93) cm. There were 4 cases of patellar ligament body rupture, 1 case of patella distal pola rupture, and 7 cases of tibial tuberosity attachment rupture. Preoperative Caton-Deschamps index was 1.47±0.13. Results: All patients were followed up 12-30 months (mean, 20.5 months). All incisions healed by first intention. And no complication such as infection, recurrent rupture, and neurovascular injury occurred. At 1 year after operation, the knee range of motion was (131.0±10.2)°, Lysholm score was 87.4±2.4, Kujala score was 88.3±4.8, the thigh circumference which was measured at 10 cm above the upper end of the patella was (42.58±1.93) cm; all showing significant differences when compared with preoperative values ( P<0.05). The effectiveness results were excellent in 9 cases and good in 3 cases according to the Insall evaluation criteria. The Caton-Deschamps index was 1.09±0.11, which was significantly lower than preoperative one ( t=8.155, P=0.000). Conclusion: Patellar tendon reconstruction with LARS artificial ligament is an effective method for the old patellar ligament rupture, which can effectively repair the knee extension device and restore knee function.

A comparative study on the effect of reconstruction of posterior cruciate ligament with Autogenous hamstring tendon plus Peroneus longus tendon anterior bundle and LARS ligament / 实用医学杂志

Objective To investigate the effect of the use of autologous hamstring tendon plus peroneal longus tendon and the application of LARS artificial ligament reconstruction of posterior cruciate ligament (PCL) knee function and recovery of mechanical stability. Methods Forty-three patients with posterior cruciate ligament rupture were divided into two groups according to the type of graft used during the operation : the LARS artificial ligament group (22 cases) and the autologous hamstring tendon plus peroneal longus tendon group (21 cases). The postoperative follow-up time was at least two years. The knee joint function was evaluated using the knee joint Lysholm score, IKDC score, and Tegner score. The post-drawer test evaluated mechanical stability. Results After 43 cases were followed up completely, the knee joint stability and function indexes of the two groups were significantly improved compared with preoperative ones. The differences were statistically significant (P < 0.05).At the same time, for all postoperative scores, two There was no significant difference between groups (P> 0.05).Conclusion The application of autologous hamstring tendons plus peroneal longus tendon anterior bundle and LARS artificial ligament reconstruction posterior cruciate ligament can achieve satisfactory clinical curative effect.

Clinical effects of arthroscopic reconstruction of anterior cruciate ligament with LARS artifical ligamennt / 中国综合临床

Objective To explore the operating methods and clinical effects of reconstruction of anterior cruciate ligament with LARS artifical ligament. Methods From October 2012 to June 2015,the clinical data of twenty-four patients with arthroscopic reconstruction of anterior cruciate ligament with LARS artifical ligamennt in Capital Medical University Beijing Friendship Hospital Pinggu Hospital were analyzed retrospectively. All patients underwent anatomical and isometric reconstruction of anterior cruciate ligament to drill femoral and tibial tunnel. The recovery of knee joint function was evaluated by Lysholm scoring system,and the clinical effect was observed. Results All 24 patients were available for follow-up with an average of ( 22. 5 ± 1. 5) months. No wound infection occurred during the period. Joint instability and weak leg symptoms and knee pain were obviously improved,the scope of joint activities was increasing. The Lysholm scores improved from a preoperative score of (40.20±1.26) points to postoperative (92.20±2.18)points,and the difference between the two groups was statistically significant (t＝2. 156,P＜0. 05). According to the modified Lysholm scoring standard,among 24 cases,15 cases were excellent,7 cases were good,2 cases were fair,and the excellent and good rate was 91. 6%(22/24). Conclusion The reconstruction of the anterior cruciate ligament with LARS artificial ligament has the advantages of small trauma, definite curative effect and less complications. It can achieve the purpose of anatomic reconstruction of the anterior cruciate ligament and can effectively restore the stability of the knee joint.

Adaptación transcultural del cuestionario acerca de la función intestinal (LARS Score) para su aplicación en pacientes operados de cáncer de recto medio y bajo / Cross-cultural adaptation of a bowel function questionnaire (LARS Score) for application in patients operated on for medium and low rectal cancer

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.

Early clinical outcomes of anterior cruciate ligament reconstruction by LARS artificial ligament versus hamstring tendon autograft / 医学研究生学报

Objective Clinically, the anterior cruciate ligament ( ACL) can be reconstructed by either ligament advanced reinforcement system ( LARS) artificial ligament or hamstring tendon autograft ( HTAG) . This study aims to compare the early clinical outcomes of LARS versus HTAG in the treatment of ACL. Methods This study included 38 cases of ACL injury treated in our de-partment from March 2012 to August 2014, 18 by LARS artificial ligament and the other 20 by HTAG. Before and at 18 months after surgery, we evaluated the clinical outcomes of the tow strategies using the Lysholm knee scoring scale and International Knee Documen-tation Committee ( IKDC) scoring systems, and conducted statistical analysis on the follow-up findings. Results Statistically signifi-cant differences were not observed preoperatively between the LARS and HTAG groups either in the Lyshrolm scores (46.78±1.52 vs 46.80 ±1.89, P>0.05) or in the IKDC scores (42.83±1.47 vs 42.20±1.61, P>0.05), nor at 18 months postoperatively in the Lyshrolm scores (93.52±3.19 vs 94.10±1.37, P>0.05) or the IKDC scores (92.11± 1.45 vs 93.15±1.76, P>0.05). However, both the LARS and HTAG groups showed significant differences in the Lyshrolm and IKDC scores at the baseline as compared with those at 18 months after oper-ation ( P<0.05) . Conclusion Both LARS artificial ligament ham-string tendon autograft can achieve good early clinical outcomes in ACL reconstruction.

Curative effect analysis of arthroscopic transtibial single-bundle posterior cruciate ligament residual reconstruction using artificial ligament compared with hamstring tendon autograft / 中国综合临床

Objective To compare the curative effect of arthroscopic transtibial single-bundle posterior cruciate ligament(PCL) reconstruction using LARS artificial ligament and hamstring tendon autograft.Methods Thirty-seven patients who underwent isolated single-bundle PCL reconstruction with remnant preservation technique were evaluated.They were divided into LARS group(n=19) and 4-strand hamstring tendon autograft (4SHG) group (n =18).Minimum follow-up was 2 years.Patients were evaluated preoperatively and postoperatively at the latest follow-up with several parameters,including the international knee documentation committee(IKDC) score,Lysholm knee score,Tegner activity rating and physical examination.Results After operation,in LARS group,Lysholm sorce was 89 (51,100) points,Tegner sorce was 6 (1,9) points,IKDC sorces were normal of 5 cases,nearly normal of 10 cases,abnormal of 3 cases,and obviously abnormal of 1 case,significantly improved compared with before operation (62 (28,98) points,2 (1,5) points,abnormal IKDC score of 8 cases,obviously abnormal of 11 cases;P＜0.001).In 4SHG group,Lysholm sorce was 84(36,100) points,Tegner sorce was 6(1,9) points,IKDC sorces were normal of 5 cases,nearly normal of 9 cases,abnormal of 3 cases,and obviously abnormal of 1 case,better than before operation (64 (28,98) points,2 (1,5) points,IKDC score abnormal of 8 cases,obviously abnormal of 10 cases;P＜0.001).There was significant difference about Lysholm sorce between two groups after operation (P=0.037).The drawer test results show that,after operation,there were 15 case of grade 0,4 cases of grade 1 in LARS group,3 cases of grade 0,11 cases of grade 1,4 cases of grade 2 in 4SHG group,all improved significantly compared with before operation,and the differences were statistically significant(LARS group:x2 =38.000,P＜0.001;4SHG group:x2 =29.143,P＜0.001),and the grade of patients in LARS group were superior to 4SHG group after operation (x2 =15.251,P ＜0.001).Conclusion The clinical effect of using a LARS ligament for PCL reconstruction is more useful than using a 4SHG.

Comparison between LARS system and autografts in anterior cruciate ligament reconstruction: A meta analysis / 第二军医大学学报

Objective To compare the clinical efficacy and safety between LARS system and autografts in anterior cruciate ligament (ACL) reconstruction. Methods The PubMed database, China. National Knowledge Infrastructure (CNKI), Chinese biomedical literature database (CBMdisc), and Wanfang database were searched to obtain the published article comparing the LARS and autografts for ACL reconstruction. The references, of the retrieved articles were also read for related articles. Results A total of 9 articles with 456 cases were included in this study. The results showed that Lysholm and Tegner scores were improved significantly after LARS replacement (Lysholm: MD=50. 05, 95% CI 48. 41-51. 68; Tegner: MD = 4. 41; 95% CI 3. 40-5. 42). Compared with autografts, the improvements of Lysholm and Tegner scores for LARS replacement were more significant 2 years postoperatively (Lysholm: MD=0. 20, 95% CI 0. 04-0. 35; Tegner: MD=0. 18, 95% CI 0. 040. 32). Meanwhile, complication (such as synovitis) rate of LARS replacement was low2 years postoperatively, showing no notable difference with that of autograft techniques. Conclusion The LARS artificial ligament is effective and safe for ACL reconstruction. LARS has more advantages than autografts concerning the stability 2 years postoperatively. However, high] quality studies with long-term follow-up are required for further confirmation.

Functional results after treatment for rectal cancer / Resultados funcionais após tratamento de câncer retal

INTRODUCTION: With improving survival of rectal cancer, functional outcome has become increasingly important. Following sphincter-preserving resection many patients suffer from severe bowel dysfunction with an impact on quality of life (QoL) - referred to as low anterior resection syndrome (LARS). STUDY OBJECTIVE: To provide an overview of the current knowledge of LARS regarding symptomatology, occurrence, risk factors, pathophysiology, evaluation instruments and treatment options. RESULTS: LARS is characterized by urgency, frequent bowel movements, emptying difficulties and incontinence, and occurs in up to 50-75% of patients on a long-term basis. Known risk factors are low anastomosis, use of radiotherapy, direct nerve injury and straight anastomosis. The pathophysiology seems to be multifactorial, with elements of anatomical, sensory and motility dysfunction. Use of validated instruments for evaluation of LARS is essential. Currently, there is a lack of evidence for treatment of LARS. Yet, transanal irrigation and sacral nerve stimulation are promising. CONCLUSION: LARS is a common problem following sphincter-preserving resection. All patients should be informed about the risk of LARS before surgery, and routinely be screened for LARS postoperatively. Patients with severe LARS should be offered treatment in order to improve QoL. Future focus should be on the possibilities of non-resectional treatment in order to prevent LARS. (AU)

INTRODUÇÃO: Com o aumento da sobrevida após câncer retal, o resultado funcional se tornou cada vez mais importante. Após ressecção com preservação do esfíncter, muitos pacientes sofrem de disfunção intestinal com um impacto sobre a qualidade de vida (QdV) - denominada síndrome da ressecção anterior baixa (LARS). OBJETIVO DO ESTUDO: Fornecer uma visão geral do conhecimento atual da LARS com relação à sintomatologia, à ocorrência, aos fatores de risco, à fisiopatologia, aos instrumentos de avaliação e às opções de tratamento. RESULTADOS: A LARS é caracterizada por movimentos intestinais repentinos e frequentes, dificuldades de esvaziamento e incontinência e ocorre em até 50-75% dos pacientes em longo prazo. Os fatores de risco conhecidos são anastomose baixa, radioterapia, lesão direta do nervo e anastomose direta. A fisiopatologia parece multifatorial, com elementos de disfunção anatômica, sensorial e da motilidade. O uso de instrumentos validados para avaliação da LARS é essencial. Atualmente, não há comprovações de tratamento da LARS. Ainda hoje, a irrigação transanal e a estimulação do nervo sacral são comprometidas. CONCLUSÃO: A LARS é um problema comum após ressecção com preservação do esfíncter. Todos os pacientes devem ser informados sobre o risco de LARS antes da cirurgia, e o rastreamento da LARS deve ser rotineiro após a cirurgia. Pacientes com LARS severa devem receber tratamento para melhorar a QdV. O foco futuro deve ser nas possibilidades de tratamento sem ressecção a fim de evitar a LARS. (AU)

Melancolia: sintoma contemporâneo? / Melancholy: a contemporary symptom?

A partir de uma interpretação do filme Melancolia, do diretor Lars von Trier, o artigo atravessa várias figuras da melancolia ao longo da tradição do pensamento ocidental até encontrar a psicanálise, que, além de conceber a neurose depressiva como o sintoma que marca o contemporâneo, rompeu, desde Sigmund Freud - Luto e Melancolia, 1915 -, a associação tradicional, proposta por Aristóteles, entre melancolia e gênio criador. Doravante, na psicanálise, a melancolia é parte das psicoses. É Carl Gustav Jung quem recupera, por meio da noção-guia de individuação, atrelada que é a uma crítica da cultura, um lugar contemporâneo para a tradicional associação rompida com a psicanálise.

By an interpretation of Lars von Trier's Melancholia movie, the article analyzes several figures of melancholia in Western thinking tradition up to psychoanalysis. This science conceives depressive neurosis as a symptom that stamps contemporary era and splits since Sigmund Freud's Mourning and Melancholia (1915) the traditional association proposed by Aristotle between melancholy and creative genius. From then on melancholy is on psychoanalysis part of the psychosis. Carl Gustav Jung recovers the contemporary role of the traditional association ruptured by psychoanalysis through the guiding notion of the individuation linked to cultural critics.

Nursing cooperation during posterior cruciate ligament reconstruction using LARS artificial ligament under arthroscopy / 现代临床护理

Objective To investigate the nursing experience during posterior cruciate ligament(PCL)reconstruction using LRAS artificial ligament under arthroscopy.Method The experience in nursing 51 cases of PCL reconstruction using LARS artificial ligament under arthroscopy from 2009 to 2012 was retrospectively summarized.Results It showed that KDC score of the 39 cases was excellent and 12 cases good,with the excellent and good rate of 100.0%.The average operation duration was(70.0±6.0)min and the average blood lose(50±3.6)ml.Conclusion Sufficient preparation before operation,much familiarity with LARS artificial ligament,skilled and accurate surgical cooperation are important factors for the success of PCL reconstruction using LARS artificial ligament under arthroscopy.

Mid-term clinical results of ligament advanced reinforcement system artificial ligament in anterior cruciate ligament reconstruction / 中华创伤杂志

Objective To evaluate the knee joint function at 3-7 years after anterior cruciate ligament (ACL) reconstruction with ligament advanced reinforcement system (LARS) artificial ligament and assess the morphologic changes of LARS artificial ligament in human tissues.Methods Fifty-seven patients (58 knees) undergone ACL reconstruction with LARS artificial ligament were recruited to this multi-factor retrospective study and divided into acute injury group and chronic injury group according to time between injury and operation.LARS artificial ligament harvested from the three patients (4 knees)who had an additional surgery were observed histologically.Results Knee joint function and range of movement were significantly improved after surgery (P ＜ O.O1),however subjective and objective estimation on knee joint function presented no statistical differences between the two groups (P ＞0.05).X-ray films and MRI revealed different degree of bone tunnel progressive augmentation in average 1.5 years,indistinctive correlation of knee joint stability with bone tunnel augmentation (P ＞ 0.5) as well as no statistical difference concerning incidence of tibial and femoral bone tunnel augmentation (P ＞ 0.05).Histological observation revealed well-arranged fiber tissue growth into LARS artificial ligament as well as fibrous joint among single-beam polyester fibers as well as a bundle of polyester fibers at postoperative 2 years.Conclusions (1) LARS artificial ligament gains a satisfactory knee joint stability and function in ACL reconstruction.(2) There exists bone tunnel augmentation that tends to stability at postoperative 1.5 years,but knee joint stability is not correlated to the extent of bone tunnel augmentation after surgery.(3) Postoperative data evaluation of acute injury and chronic injury is the same.(4) Human normal fibrous tissues grow into LARS artificial ligament regularly.

Clinical valure of C-arm fluoroscopy in arthroscopic reconstruction of anterior cruciate ligament with LARS artificial ligament / 中华创伤杂志

Objective To discuss the operation skills and clinical effects of C-arm fluoroscopy in arthroscopic reconstruction of anterior cruciate ligament(ACL)with the Ligament Advancement Reinforcement System(LARS)artificial ligaments.Methods The study involved 36 patients with acute ACL rupture treated with the LARS artificial ligaments from June 2006.There were 25 males and 11 females,at age range of 22-51 years(average 28.3 years),involving 19 left knees and 17 right knees.The results of preoperative MRI of all patients suggested discontinuation of ACL,with average score of Lysholm on knee joint for 50.The operation was completed under arthroscope.While the locations of the femoral tunnel portal and the tibial tunnel exit were mainly determined by the C-arm fluoroscopy.The diameter of the LARS artificial ligament was 7.5 mm while that of the interference screw 8 mm.Results All 36 patients were followed up for a mean duration of 18 months(9-20 months).The average Lysholm Score was 52 preoperatively and 92 at the 12th week after operation.The clinical results were graded as excellent in 23 patients,good in nine and fair in four according to the Lysholm's classification,with excellence rate of 89%.Conclusions Arthroscopic reconstruction of anterior cruciate ligament with LARS artifical ligament under C-arm fluoroscopy takes advantages of convenient operation,accurate location and satisfactory clinical effect.

Reconstruction of combined anterior cruciate ligament and posterior cruciate ligament injuries by using LARS artificial ligament under arthroscope / 中华创伤杂志

Objective To explore the treatment method and clinical effect of LARS artificial ligament in treatment of combined anterior cruciate ligament(ACL) and posterior crueiate ligament (PCL) injuries of the knee under arthroscope. Methods Thirteen cases of ACL and PCL injuries were reconstructed with LARS ligament. The patients were followed up for 12-36 months. The International Knee Documentation Committee (IKDC) and Lysholm knee score scale were used for functional evaluation. In the meantime, KT-1000 was employed to check anterior and posterior laxation of the knee. Results No knee infection or limitation of knee extension occurred. Knee flexion was 105° -125° (average 117°). At termination of follow up, 10 cases (77%) was graded as A and 3 (23%) as B according to IKDC. KT-1000 examination at 25° flexion showed that the difference of anterior laxation was less than 2 mm in 12 cases and 3-5mm in 1. KT-1000 examination at 70°flexion showed that the difference of anterior laxation was less than 2mm in 12 cases and 2-4 mm in 1. The Lysholm score was (63.8±2.9) points (49459 points) before operation and (91.1 ±2.7) points (88-95 points) at follow up, with statistical difference (P ＜0.01). Conclusion Reconstruction of ACL and PCL by using LARS ligament under arthroscope is a kind of minimally invasive, safe and effective method to treat ACL and PCL injuries of the knee, with good short term outcome.

Comparison of early clinical outcome between the ligament advanced reinforcement system and the ?-ray irradiation allograft for anterior cruciate ligament reconstruction under arthroscopy / 中国矫形外科杂志

[Objective]To compare the early clinical outcome of ACL reconstruction using the ligament advanced reinforcement system and the ?-ray irradiation allograft.[Method]From January 2006 to January 2008,55 cases of ACL reconstruction were studied.According to the indication of LARS ligament and allograft,suggestion from surgeon and patient's aspiration,one of them were chosen as grafts for ACL reconstruction,including 25 LARS ligaments with titanium screw fixation and 19 allografts with absorptive screw fixation.After reconstruction,both groups of patients carried on functional exercise.Each patient was evaluated with Lysholm-Tegner score and KT-2000 measurements preoperatively and postoperatively at 3 months,6 months,9 months,12 months,15 months and 18 months.[Result]Fifty-two cases were followed up,3 cases were dismissed.The Lysholm -Tegner score in cases using the LARS ligament were higher than that in cases using the allograft 3 months post-operation,6 months post-operation,9 months post-operation.Contemporary comparison of the score gap between the LARS ligament group and the allograft group showed a trend of decrease.During the follow up,the allograft group displayed significantly more laxity in KT-1000 measurements at all time points than the LARS ligament group.And the measurements gap between the two groups showed a trend of increase.[Conclusion]The knee anterior-posterior stability of the patients using the LARS ligament were better than that of patients using the allograft.The knee function of the patients using the LARS ligament recovered earlier than that of patients using allograft at nonage,but long-term effect is almost the same.

Experimental study on integration of artificial ligament with bone interface / 中国矫形外科杂志

[Objective]To reconstruct anterior cruciate ligament (ACL) by using ligament advanced reinforcement system(LARS),and to investigate the integration of LARS artificial ligament with bone interface in the animals with regard to imageology, biomechanics and histology.[Method]Twenty-four Boer goats were randomly divided into three groups. The animal mode of ACL reconstruction was established by clinical ACL reconstruction system. Gross observation was made, and histological, imageological and biomechanical changes were observed at 4, 8 and 12 weeks after surgery, respectively. Statistical analysis was performed.[Result](1)At 4 weeks after surgery,ligament-bone interface had great amount of loose bindweb and infiltration of chronic inflammation cells. At 8 weeks after surgery, there was new bone formation. Part of samples had Sharpey fibers. At 12 weeks after surgery, Sharpey fibers.and a large number of fibroblasts were noted in the interface between LARS artificial ligament and bone interface. But calcified cartilage was not founded.(2)The imageology examination for group 3 was made at 4, 8 and 12 weeks after surgery. The data were analyzed statistically by the image processing software of eflime,and there was evident statistical difference (P0.05 ) .[Conclusion]After ACL reconstruction by LARS artificial ligament, indirect connection developed via Sharpey fibers in bone tunnel at the end of LARS artificial ligament and bone interface. The integration of LARS artificial ligament with bone interface has been improved and its intensity is increased.