Prospective evaluation of bowel dysfunction after rectal cancer surgery

Effects of low anterior resection syndrome after colorectal cancer resections on health-related quality of life: a systematic review and meta-analysis

BACKGROUND

Low anterior resection syndrome (LARS) is a term that encompasses multidimensional bowel dysfunction that typically occurs following resections of rectum and distal parts of the colon. We aimed to systematically assess the available literature on the effects of bowel dysfunction after colorectal cancer (CRC) surgeries on health-related quality of life (HRQOL) and conduct a meta-analysis.

METHODS

Studies were included if they assessed patients who had undergone sphincter-preservation surgeries for CRC. Studies were eligible if they assessed bowel dysfunction using the LARS score and HRQOL using the European Organization for Research and Treatment Core Quality-of-Life Questionnaire (EORTC QLQ-C30).

RESULTS

Of 1410 reports, 28 studies were included. According to the analyses, patients with major LARS had lower global health status [weighted mean differences (WMD) = - 10.98; 95% confidence interval (CI) - 13.18, - 8.79], physical functioning (WMD = - 5.96; 95% CI - 7.40, - 4.52), role functioning (WMD = - 10.59; 95% CI - 12.54, - 8.63), emotional functioning (WMD = - 11.09; 95% CI - 14.34, 7.84), cognitive functioning (WMD = - 9.27; 95% CI - 12.22, - 6.32), and social functioning (WMD = - 15.73; 95% CI - 18.82, - 12.63) and higher scores of symptoms compared to patients with minor/no LARS.

CONCLUSIONS

The study findings suggest that patients with major LARS experience worse HRQOL compared to those with minor/no LARS.

REGISTRATION

PROSPERO, CRD42023479657.

Body image as a mediator between bowel dysfunction symptoms and psychological outcomes among patients with colorectal cancer

BACKGROUND

Colorectal cancer (CRC) survivors commonly experience bowel dysfunction symptoms because of treatment, leading to psychological distress. While previous studies have focused on managing physical symptoms and the impact of a stoma on psychological outcomes, CRC patients without a stoma may also suffer from psychological distress, including body image distress due to their bowel dysfunction symptoms. Body image distress may mediate the relationship between bowel dysfunction symptoms and psychological outcomes in CRC patients.

OBJECTIVES

This study aims to (1) identify bowel dysfunction symptoms, body image distress, and psychological outcomes in CRC survivors and (2) examine the mediating role of body image in the relationship between bowel dysfunction symptoms and psychological outcomes.

METHODS

A cross-sectional and correlational design was employed, and CRC survivors completed the Low Anterior Resection Syndrome (LARS) Score, Body Image Scale (BIS), and Hospital Anxiety and Depression Scale (HADS) questionnaires. The mediated role of body image was examined using Hayes' PROCESS macro.

RESULTS

A total of 193 CRC patients provided data, with 65.8% reporting experiencing bowel dysfunction symptoms, 44.6% reporting body image distress, and 40.4% experiencing anxiety and depression. Body image was found to partially mediate the effect of bowel dysfunction symptoms on both anxiety (β = 0.0446, 95% CI = 0.0061, 0.0968) and depression (β = 0.0411, 95% CI = 0.0034, 0.0941).

CONCLUSION AND IMPLICATIONS

The significant mediating role of body image underscores the importance of addressing both bowel dysfunction symptoms and body image distress. Healthcare professionals should integrate both physical and psychological aspects to promote psychological well-being.

A word of caution in the functional monitoring of patients after rectal cancer surgery: a multicentre observational study

BACKGROUND

Patients with rectal cancer often experience adverse effects on urinary, sexual, and digestive functions. Despite recognised impacts and available treatments, they are not fully integrated into follow-up protocols, thereby hindering appropriate interventions. The aim of the study was to discern the activities conducted in our routine clinical practice outside of clinical trials.

METHODS

This multicentre, retrospective cohort study included consecutive patients undergoing rectal cancer surgery between January 2016 and January 2020 at six tertiary Spanish hospitals.

RESULTS

A total of 787 patients were included. Two years post surgery, gastrointestinal evaluation was performed in 86% of patients. However, bowel movements per day were only recorded in 242 patients (46.4%), and the values of the Low Anterior Resection Syndrome (LARS) questionnaire were recorded in 106 patients (20.3%); 146 patients received a diagnosis of fecal incontinence (28.2%), while 124 patients were diagnosed with low anterior resection syndrome (23.8%). Urogenital evaluation was recorded in 21.1% of patients. Thirty-seven patients (5.1%) were detected to have urinary dysfunction, while 40 patients (5.5%) were detected to have sexual dysfunction. A total of 320 patients (43.9%) had their quality of life evaluated 2 years after surgery, and only 0.8% completed the Quality of Life questionnaire. Medication was the most used treatment for sequelae (26.9%) followed by referral to other specialists (15.1%).

CONCLUSIONS

There is a significant deficit in clinical follow-ups regarding the functional assessment of patients undergoing rectal cancer surgery. It is crucial to implement a postoperative functional follow-up protocol and to utilize technologies such as Patient-Reported Outcome Measures (PROMs) to enhance the evaluation and treatment of these sequelae, thereby ensuring an improved quality of life for patients.

The bowel function instrument for rectal cancer survivors with anastomosis and ostomy

OBJECTIVE

Rectal cancer is often treated with surgery such as ostomy or anastomosis. The Bowel Function Instrument (BFI) is a valid and reliable 18-item measure of physical bowel symptoms. Some items on the BFI do not apply to those with ostomies. We reanalyzed data from a previous validation study to inform the best method for scoring the BFI for both people with ostomies and anastomosis.

METHODS

People (n = 575) with rectal cancer treated with ostomy (n = 181, 31 %) or anastomosis (n = 394, 69 %) completed the BFI and Short Form 12 (SF12) measure on a mailed survey. The full BFI has three subscales and a total score based on 14 items: soilage/urgency (4 items); frequency of bowel movements (6 items); and dietary changes (4 items). We used confirmatory factor analysis (CFA) to examine two versions (8-item, 11-item) of the BFI adapted for use with both ostomy and anastomosis. We also examined reliability and validity of the version supported by the CFA.

RESULTS

CFA results supported the 8-item BFI that included only the soilage/urgency items and dietary changes items but not the frequency items. The 8-item BFI was reliable (Cronbach's alpha of 0.788). The 8-item BFI score significantly correlated with all SF12 subscales with Pearson correlations ranging from 0.115 (Vitality) to 0.318 (social function).

CONCLUSIONS

The 8-item version of the BFI was valid and reliable as a total score for people with ostomy or anastomosis. The 8-item BFI may be useful for monitoring bowel function during and after treatment for rectal cancer.

Baseline characteristics and recruitment for SWOG S1820: altering intake, managing bowel symptoms in survivors of rectal cancer (AIMS-RC)

PURPOSE

Many survivors of rectal cancer experience persistent bowel dysfunction. There are few evidence-based symptom management interventions to improve bowel control. The purpose of this study is to describe recruitment and pre-randomization baseline sociodemographic, health status, and clinical characteristics for SWOG S1820, a trial of the Altering Intake, Managing Symptoms in Rectal Cancer (AIMS-RC) intervention.

METHODS

SWOG S1820 aimed to determine the preliminary efficacy, feasibility, and acceptability of AIMS-RC, a symptom management intervention for bowel health, comparing intervention to attention control. Survivors with a history of cancers of the rectosigmoid colon or rectum, within 6-24 months of primary treatment completion, with a post-surgical permanent ostomy or anastomosis, and over 18 years of age were enrolled. Outcomes included total bowel function, low anterior resection syndrome, quality of life, motivation for managing bowel health, self-efficacy for managing symptoms, positive and negative affect, and study feasibility and acceptability.

RESULTS

The trial completed accrual over a 29-month period and enrolled 117 participants from 34 institutions across 17 states and one US Pacific territory. At baseline, most enrolled participants reported self-imposed diet adjustments after surgery, persistent dietary intolerances, and bowel discomfort post-treatment, with high levels of constipation and diarrhea (grades 1-4).

CONCLUSIONS

SWOG S1820 was able to recruit, in a timely manner, a study cohort that is demographically representative of US survivors of rectal cancer. Baseline characteristics illustrate the connection between diet/eating and bowel symptoms post-treatment, with many participants reporting diet adjustments and persistent inability to be comfortable with dietary intake.

CLINICALTRIALS

GOV REGISTRATION DATE

12/19/2019.

CLINICALTRIALS

GOV IDENTIFIER

NCT#04205955.

Efficacy of Pelvic Floor Muscle Training for Postoperative Patients With Rectal Cancer: A Systematic Review and Meta-Analysis

This study aimed to assess the effectiveness of pelvic floor muscle training (PFMT) for fecal incontinence (FI) and health-related quality of life (HR-QOL) after colorectal cancer surgery. This systematic review (SR) and meta-analysis included randomized controlled trials (RCTs) that examined the effects of PFMT after colorectal cancer surgery, which were extracted from several databases in January 2023. The primary outcomes were FI (Wexner scores), HR-QOL, and adverse events. We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence (CoE). A total of seven RCTs were included. Our SR results suggested that PFMT showed little to no difference in FI (mean difference 0.62 higher; 95% CI: -1.26 to 2.5, low CoE) and adverse events (risk ratio 5.78; 95% CI: 0.28-117.22, low CoE). Two adverse events occurred in the PFMT group (anastomotic stenosis, suboptimal use of laxatives) and were not observed in controls. HR-QOL was measured in two RCTs using 12-item Short Form Survey (SF-12) and fecal incontinence quality of life (FIQL). Two RCTs found no trend toward a positive impact on HR-QOL. Higher quality RCTs on colorectal cancer after surgery are required. Furthermore, extending the duration of the PFMT intervention may be necessary to ensure its success.

The impact on health-related quality of a stoma or poor functional outcomes after rectal cancer surgery in Dutch patients: A prospective cohort study

BACKGROUND

As the survival of patients with rectal cancer has improved in recent decades, more and more patients have to live with the consequences of rectal cancer surgery. An influential factor in long-term Health-related Quality of Life (HRQoL) is the presence of a stoma. This study aimed to better understand the long-term consequences of a stoma and poor functional outcomes.

METHODS

Patients who underwent curative surgery for a primary tumor located in the rectosigmoid and rectum between 2013 and 2020 were identified from the nationwide Prospective Dutch Colorectal Cancer (PLCRC) cohort study. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, and the LARS-score at 12 months, 24 months and 36 months after surgery.

RESULTS

A total of 1,170 patients were included of whom 751 (64.2%) had no stoma, 122 (10.4%) had a stoma at primary surgery, 45 (3.8%) had a stoma at secondary surgery and 252 (21.5%) patients that underwent abdominoperineal resection (APR). Of all patients without a stoma, 41.4% reported major low-anterior resection syndrome (LARS). Patients without a stoma reported significantly better HRQoL. Moreover, patients without a stoma significantly reported an overall better HRQoL.

CONCLUSION

The presence of a stoma and poor functional outcomes were both associated with reduced HRQoL. Patients with poor functional outcomes, defined as major LARS, reported a similar level of HRQoL compared to patients with a stoma. In addition, the HRQoL after rectal cancer surgery does not change significantly after the first year after surgery.