Aim
Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the ...LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS.
Method
The ‘Management guidelines for low anterior resection syndrome’ (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face‐to‐face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project.
Results
The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts.
Conclusions
The MANUEL project provides an up‐to‐date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.
We describe two options for colorectal anastomosis suitable in cases when the colon would reach the pelvis under tension.
Deloyers procedure and the retro-ileal colorectal anastomosis are presented, ...focusing on practical tips and tricks to perform them. Insights on patients who underwent the procedures are provided to demonstrate the advantages and feasibility of the techniques.
Each step of both techniques is detailed. Ten patients underwent Deloyers procedure and nine underwent retro-ileal anastomosis at our unit. A minimally invasive approach was attempted in 13 patients, of whom five required conversion to open surgery due to the technical complexity of the abdominal procedure. Colorectal anastomosis was successfully performed in all patients. There were no major intra-operative complications, although five patients had postoperative complications requiring further treatment.
Both techniques are effective in patients at risk of receiving a colorectal anastomosis under tension, and a minimally invasive approach can be used. However, owing to the complexity of surgery in this group of patients, the perioperative morbidity is not negligible. Careful postoperative management is advisable, and patients should be informed of the risks. In expert hands, the outcomes are acceptable, avoiding an ileorectal anastomosis and its constraints.
Aim
Surgical site infections (SSIs) are common after colonic surgery. SSIs can cause relevant morbidity and increase costs of care. Preoperative oral antibiotics can reduce the incidence of SSIs ...after resection of the colon, but the role of mechanical bowel preparation (MBP) is debated. This study aims to assess the impact of a combined regimen of oral antibiotics and MBP on SSIs after colonic surgery.
Methods
An international, multicentre, pragmatic, adaptive, parallel‐group, randomized controlled trial will be conducted across Europe. Adult patients scheduled to undergo elective colonic resection will be assessed for inclusion. Patients will be randomized into one of two treatment arms: (1) preoperative oral antibiotics without MBP (control); (2) preoperative oral antibiotics with MBP (experimental). All patients will receive intravenous antibiotics at anaesthetic induction. The primary aim will be 30‐day SSI, assessed by a blinded nurse. Additional end‐points include safety, morbidity and mortality, satisfaction with the preparation, time to return of bowel function, time to complete recovery and time to discharge, long‐term results. Analyses will be performed with a modified intention‐to‐treat approach. Interim analyses are planned.
Discussion
This will be the first randomized clinical trial to assess the efficacy and safety of preoperative oral antibiotics plus MBP versus preoperative oral antibiotics only, before colonic surgery. The knowledge obtained could help to establish the ideal preparation for patients scheduled to undergo resection of the colon. Full protocol NCT04161599.
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