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THE IMPACT OF SURGICAL TOOLS AND TECHNIQUES ON LOW ANTERIOR RESECTION SYNDROME AFTER RECTAL SURGERY
Evan D. Adams
*, Sydney Castellanos, Chandler Lowe, Sidhant Kalsotra, Matthew Kalady, Mark Arnold, Alessandra Gasior, syed Husain
Surgery, The Ohio State University, Columbus, OH
Background:
Lower anterior resection syndrome (LARS) is a condition of disordered bowel function after rectal resection which negatively impacts quality of life after oncologic resections. Established risk factors include age, gender, radiation treatment, tumor location, mesorectal dissection, and need for fecal diversion.
The impact of operative techniques and the type/number of surgical staplers on outcomes remain unexplored. Endoscopic staplers used in laparoscopic/robotic surgeries often require multiple firings for rectal division, unlike the single firing of staplers used in open technique. This increased stapler load may lead to excessive scarring, impairing bowel function. We hypothesize that endoscopic stapler use and multiple firings during rectal division increase the risk of LARS compared to open staplers.
Methods:
We surveyed patients who underwent low anterior resection with stapled anastomosis within 10 years using the Memorial Sloan Kettering Cancer Center Bowel Function Instrument (MSK-BFI). This addresses 4 subscales of intestinal function (Frequency, Diet, Separate, and Urgency/Soilage). Higher scores indicate less severe symptoms.
Clinical data included operative approach, stapler type and number, tumor level, diversion, and neoadjuvant/adjuvant treatment. We calculated pre-operative low anterior resection syndrome score (POLARS).
We compared resections performed with an endoscopic stapler (endoGIA and SureFire) to open staplers (Contour, thoracoabdominal) by total score and subscale using two sampled t-tests.
Results:
We received 38 responses to 1,275 surveys (3%). 22 (58%) were performed using an endoscopic stapler and 16 (42%) with open stapler. Clinical data is shown (Table 1). There was no statistically significant difference between total MSK-BFI score or any sub-scale (Table 2). The ability to distinguish stool from flatus (separate subscale) was reported as better controlled in the endoscopic stapler group (14.1 ± 0.56) compared to the open stapler group (12.6 ± 0.51, p = 0.05). The endoscopic stapler group exhibited better POLARS scores (endoscopic stapler 24.9 ± 1.1 vs. open stapler 28.2 ± 1.4, p = 0.06). There was no association between the number of stapler firings used to divide the rectum and the MSK-BFI total score.
Conclusions:
This is an ongoing prospective survey-based study seeking to assess the impact of laparoscopic compared to open stapling techniques in low anterior resections. Our preliminary analysis revealed a trend favoring endoscopic staplers, approaching but not reaching statistical significance for both overall POLARS scores (p = 0.06) and the ability to distinguish flatus from stool (p = 0.05). This finding may be reflective of a minimally invasive compared to open approach, rather than the choice of stapler used. Additional data is required to fully evaluate our hypothesis.
Table 1: Clinical characteristics are shown for the overall cohort, and within the Endoscopic and Open Stapler groups. Continuous variables are compared with t-tests. Cateogrical variables are compared with chi-squared.
Table 2: MSK-BFI overall and subgroups, comparing endoscopic and open staplers.
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