Cengiz et al. report functional outcomes after rectal endoscopic submucosal dissection (ESD) in a retrospective cohort, finding a very low prevalence of minor low anterior resection syndrome (LARS) and no major LARS, with distal location and larger lesions associated with symptoms 1. This organ-preserving focus is clinically important, as LARS after rectal resection is common and can substantially impair quality of life. A key strength is the standardized technique (single experienced operator) and use of the validated LARS score framework 2, 3. However, several issues may influence interpretation. First, functional outcomes were assessed only post-procedure via telephone questionnaire; without baseline bowel function, it is difficult to attribute symptoms solely to ESD or quantify change from pre-ESD status. Baseline dysfunction is not rare in older populations and may be influenced by medications (e.g., laxatives/antidiarrheals), metabolic disease, or pelvic floor disorders not fully captured in retrospective records. Second, selection may have favored functionally well patients: those unreached, deceased, or requiring additional surgery were excluded. This could underestimate symptom burden in real-world practice where salvage surgery and complications occur 1. Third, lesion “size” alone may be an incomplete surrogate for functional impact; future work could incorporate resection circumference/area, extent of submucosal fibrosis, and objective physiology (anorectal manometry and rectal compliance) to test the proposed mechanisms of reduced reservoir function and altered motility 4. Despite these limitations, the study supports the hypothesis that avoiding mesorectal dissection and pelvic autonomic nerve injury may reduce LARS risk compared with rectal cancer surgery, where persistent major LARS is frequently reported 5. Prospective, multicenter studies with pre- and post-ESD assessments (including quality-of-life instruments and objective measures) would help define which distal/large lesions merit enhanced counseling and structured follow-up. Sushma Narsing Katkuri: methodology, writing – original draft, writing – review and editing. Varshini Vadhithala: writing – original draft, writing – review and editing. Sachin Kumar: conceptualisation, validation, writing – review and editing. Sushma Verma: writing – original draft, writing – review and editing. Jeffrin Reneus Paul: validation, writing – review and editing. The authors have nothing to report. The authors received no specific funding for this work. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. The authors have nothing to report. This letter discusses functional outcomes after rectal endoscopic submucosal dissection, highlighting the low prevalence of major low anterior resection syndrome while addressing key methodological limitations and implications for patient selection, counseling, and future prospective research.
Katkuri et al. (Tue,) studied this question.