Functional disorders after rectal cancer resection: does a rehabilitation programme improve anal continence and quality of life?

The Effect of Pelvic Floor Muscle Exercises on Bowel Evacuation and Quality of Life in Following Intestinal Ostomy Closure: Randomized Controlled Trial

PURPOSE

This purpose of this study was to evaluate the effect of pelvic floor muscle exercises (PFMEs) on bowel evacuation problems and health-related quality of life (HRQOL) following ostomy closure.

DESIGN

Randomized controlled trial.

SUBJECTS AND SETTING

Forty individuals following ostomy closure consented to participate in the study; 6 participants (15%) did not complete the trial (2 died and 2 required a second ostomy) yielding a study sample of 34. Participants were randomly allocated to an Exercise Group (EG, n = 17) and Control Group (CG, n = 17). The mean age of the EG was 55.7 (SD 12.6) years, whereas the mean age of the CG was 62.0 (SD 12.1) years. The study setting was the surgery clinic of 4 hospitals in Ankara, Turkey. Data were collected between December 2018 and May 2020.

METHODS

The study intervention, PFME training by a clinician, was administered to participants in the EG; CG participants received no information regarding PFME. Data were collected during face-to-face interviews on the day before discharge and by phone at the first, second, third, and sixth months after surgery. A questionnaire was used for data collection that queried a demographic and pertinent clinical questions, along with the Assessment Form for Bowel Evacuation Habits and Psychosocial Problems, Wexner Scale, and the Short Form (SF-36) Health-related Quality of Life Scale. Descriptive statistics and Mann-Whitney U test, t-test, Pearson-χ2 test, Fisher's Exact test, Friedman test, and Cochran-Q test statistical analysis according to normal distribution were used in data evaluation.

RESULTS

The number of defecations in the EG was statistically significantly lower than the CG at the second, third, and sixth months (P = .002, P = .002, P = .001, respectively). In addition, the number of individuals experiencing night defecation was statistically significantly less in the EG compared to the CG at the second-, third-, and sixth-month follow-ups (P = .001, P = .001, P = .028, respectively). HRQOL scores were also significantly higher in the EG.

CONCLUSION

Pelvic floor exercises applied after ostomy closure are effective in reducing bowel evacuation and increasing quality of life. Given these findings, PFMEs are recommended for patients after ostomy closure.

Effects of a bowel function improvement program for patients with rectal cancer surgery: A randomized controlled trial

OBJECTIVES

This study aimed to examine the effectiveness of a bowel function improvement program for male patients with rectal cancer who underwent low anterior resection.

METHODS

A prospective, unblinded, and randomized controlled trial was conducted. The enrolled 42 patients were assigned to the experimental or control group at a 1:1 ratio. The bowel function improvement program comprised a 4-week intensive program (face-to-face education and telephone coaching) and an 8-week maintenance program (text messages). Self-efficacy, bowel function, health-related quality of life, and healthcare resource utilization were measured. Collected data were analyzed using independent t-tests, chi-square tests, analysis of covariance, and generalized estimation equations to evaluate the effects of the program based on intention-to-treat.

RESULTS

The bowel function improvement program was effective in improving bowel function 3 months after discharge. Additionally, the number of unplanned pharmacy visits was lower in the experimental group than in the control group. Health-related quality of life, self-efficacy, and utilization of other healthcare resources were not statistically or clinically significant.

CONCLUSION

These findings indicated that the bowel function improvement program for male patients with rectal cancer was effective in improving bowel function and reducing unplanned healthcare resource utilization. The bowel function improvement program can be delivered as a nurse-led program in clinical practice to promote early recovery after low anterior resection.

TRIAL REGISTRATION NUMBER

KCT0003505. https://cris.nih.go.kr/cris/search/detailSearch.do/13708.

Patient-reported Bowel Function and Bowel-related Quality of Life After Pelvic Radiation for Rectal Adenocarcinoma: The Impact of Radiation Fractionation and Surgical Resection

INTRODUCTION

Multimodality treatment for locally advanced rectal cancer (LARC) can include long-course radiotherapy (LCRT) or short course radiotherapy (SCRT). Nonoperative management is increasingly pursued for those achieving a complete clinical response. Data regarding long-term function and quality-of-life (QOL) are limited.

METHODS

Patients with LARC treated with radiotherapy from 2016 to 2020 completed the Functional Assessment of Cancer Therapy- General (FACT-G7), the Low Anterior Resection Syndrome Score (LARS) and the Fecal Incontinence QOL Scale (FIQOL). Univariate and multivariable linear regression analyses identified associations between clinical variables including radiation fractionation and the use of surgery versus non-operative management.

RESULTS

Of 204 patients surveyed, 124 (60.8%) responded. Median (interquartile range) time from radiation to survey completion was 30.1 (18.3-43) months. Seventy-nine (63.7%) respondents received LCRT, and 45 (36.3%) received SCRT; 101 (81.5%) respondents underwent surgery, and 23 (18.5%) pursued nonoperative management. There were no differences in LARS, FIQoL or FACT-G7 between patients receiving LCRT versus SCRT. On multivariable analysis, only nonoperative management was associated with lower LARS score signifying less bowel dysfunction. Nonoperative management and female sex were associated with a higher FIQoL score signifying less disruption and distress from fecal incontinence issues. Finally, lower BMI at the time of radiation, female sex, and higher FIQoL score were associated with higher FACT-G7 scores signifying better overall QOL.

CONCLUSIONS

These results suggest long-term patient-reported bowel function and QOL may be similar for individuals receiving SCRT and LCRT for the treatment of LARC, but nonoperative management may lead to improved bowel function and QOL.

Postoperative inpatient exercise facilitates recovery after laparoscopic surgery in colorectal cancer patients: a randomized controlled trial

BACKGROUND

Early mobilization is an integral part of an enhanced recovery program after colorectal cancer surgery. The safety and efficacy of postoperative inpatient exercise are not well known. The primary objective was to determine the efficacy of a postoperative exercise program on postsurgical recovery of stage I-III colorectal cancer patients.

METHODS

We randomly allocated participants to postoperative exercise or usual care (1:1 ratio). The postoperative exercise intervention consisted of 15 min of supervised exercise two times per day for the duration of their hospital stay. The primary outcome was the length of stay (LOS) at the tertiary care center. Secondary outcomes included patient-perceived readiness for hospital discharge, anthropometrics (e.g., muscle mass), and physical function (e.g., balance, strength).

RESULTS

A total of 52 (83%) participants (mean [SD] age, 56.6 [8.9] years; 23 [44%] male) completed the trial. The median LOS was 6.0 days (interquartile range; IQR 5-7 days) in the exercise group and 6.5 days (IQR 6-7 days) in the usual-care group (P = 0.021). The exercise group met the targeted LOS 64% of the time, while 36% of the usual care group met the targeted LOS (colon cancer, 5 days; rectal cancer, 7 days). Participants in the exercise group felt greater readiness for discharge from the hospital than those in the usual care group (Adjusted group difference = 14.4; 95% CI, 6.2 to 22.6; P < 0.01). We observed a small but statistically significant increase in muscle mass in the exercise group compared to usual care (Adjusted group difference = 0.63 kg; 95% CI, 0.16 to 1.1; P = 0.03).

CONCLUSION

Postsurgical inpatient exercise may promote faster recovery and discharge after curative-intent colorectal cancer surgery.

TRIAL REGISTRATION

The study was registered at WHO International Clinical Trials Registry Platform (ICTRP; URL http://apps.who.int/trialsearch ); Trial number: KCT0003920 .

Effectiveness of Pelvic Floor Muscle Training for Patients Following Low Anterior Resection: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this systematic review was to identify the effects of pelvic floor muscle training (PFMT) on bowel function and health-related quality of life among patients who have undergone low anterior resection.

METHODS

A systematic review and meta-analysis of pooled findings was conducted according to PRISMA guidelines.

SEARCH STRATEGY

A literature search was completed using PubMed, EMBASE, Cochrane, and CINAHL electronic databases; we searched studies published in English and Korean languages. Two reviewers independently selected relevant studies, evaluated their methodological quality, and extracted data. Meta-analysis was conducted of pooled findings.

FINDINGS

Thirty-six of 453 articles retrieved were read in full and 12 articles were included in the systematic review. In addition, pooled findings from 5 studies were selected for meta-analysis. Analysis revealed that PFMT reduced bowel dysfunction (mean difference [MD] -2.39, 95% confidence interval [CI] -3.79 to -0.99) and improved several domains of health-related quality of life: lifestyle (MD 0.49, 95% CI 0.15 to 0.82), coping (MD 0.36, 95% CI 0.04 to 0.67), depression (MD 0.46, 95% CI 0.23 to 0.70), and embarrassment (MD 0.24, 95% CI 0.01 to 0.46).

IMPLICATIONS

Findings suggested PFMT is effective for improving bowel function and enhancing multiple domains of health-related quality of life after low anterior resection. Further well-designed studies are required to confirm our conclusions and provide stronger evidence for the effects of this intervention.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

Pelvic Floor Rehabilitation After Rectal Cancer Surgery: A Multicenter Randomized Clinical Trial (FORCE Trial)

OBJECTIVE

To investigate the effects of PFR after LAR compared to usual care without PFR.

SUMMARY OF BACKGROUND DATA

Functional complaints, including fecal incontinence, often occur after LAR for rectal cancer. Controversy exists about the effectiveness of PFR in improving such postoperative functional outcomes.

METHODS

This was a multicenter, randomized controlled trial involving 17 Dutch centers. Patients after LAR for rectal cancer were randomly assigned (1:1) to usual care or PFR and stratified by sex and administration of neoadjuvant therapy. Selection was not based on severity of complaints at baseline. Baseline measurements were taken 3 months after surgery without temporary stoma construction or 6 weeks after stoma closure. The primary outcome measure was the change in Wexner incontinence scores 3 months after randomization. Secondary outcomes were fecal incontinence-related quality of life, colorectal-specific quality of life, and the LARS scores.

RESULTS

Between October 2017 and March 2020, 128 patients were enrolled and 106 randomly assigned (PFR n = 51, control n = 55); 95 patients (PFR n = 44, control n = 51) were assessable for final analysis. PFR did not lead to larger changes in Wexner incontinence scores in nonselected patients after LAR compared to usual care [PFR: -2.3, 95% confidence interval (CI) -3.3 to -1.4, control: -1.3, 95% CI -2.2 to -0.4, P = 0.13]. However, PFR was associated with less urgency at follow-up (odds ratio 0.22, 95% CI 0.06-0.86). Patients without near-complete incontinence reported larger Wexner score improvements after PFR (PFR: -2.1, 95% CI -3.1 to -1.1, control: -0.7, 95% CI -1.6 to 0.2, P = 0.045). For patients with at least moderate incontinence PFR resulted in relevant improvements in all fecal incontinence-related quality of life domains, while the control group deteriorated. These improvements were even larger when patients with near-complete incontinence were excluded. No serious adverse PFR-related events occurred.

CONCLUSION

No benefit was found of PFR in all patients but several subgroups were identified that did benefit from PFR, such as patients with urgency or with at least moderate incontinence and no near-complete incontinence. A selective referral policy (65%-85% of all patients) is suggested to improve postoperative functional outcomes for patients after LAR for rectal cancer.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5469, registered on 3 September 2015.

Impact of Definitive Chemoradiation on Quality-of-Life Changes for Patients With Anal Cancer: Long-term Results of a Prospective Study

BACKGROUND

Maintaining and improving quality of life (QOL) are important goals of anal cancer management. This disease is generally curable, with many long-term survivors.

OBJECTIVE

Long-term QOL after chemoradiation for patients with anal cancer was evaluated.

DESIGN

This was a prospective cohort study.

SETTINGS

This study used data from a prospective study of patients with anal cancer who were treated with chemoradiation between 2008 and 2013.

PATIENTS

Patients with anal cancer who were treated with image-guided intensity-modulated radiation therapy were included.

INTERVENTIONS

English-speaking patients completed European Organization for Research and Treatment of Cancer cancer-specific (C30) and site-specific (CR29) QOL questionnaires at baseline, at end of radiation, at 3 and 6 months, and then annually.

MAIN OUTCOMES MEASURES

Long-term QOL was evaluated clinically (a change in score of ≥10 points was considered clinically significant) and statistically (using repeated-measurement analysis) by comparing the subscale scores at 1, 2, and 3 years with baseline scores. Subanalysis compared patients who received a radiation dose of 45 to 54 Gy versus 63 Gy.

RESULTS

Ninety-six patients were included (median follow-up of 56.5 months). The symptom and functional scales showed a clinically significant decline at the end of treatment with improvement by 3 months after treatment. There was a long-term statistically significant decline in dyspnea, body image, bowel embarrassment, fecal incontinence, and hair loss, and there was long-term statistically and clinically significant worsening of impotence. Higher radiation dose (63 Gy) was not associated with significantly worse QOL.

LIMITATIONS

Limitations included single-institution, single-arm study design, and lack of dose reconstruction (ie, analyses were based on prescribed, rather than delivered, dose).

CONCLUSIONS

Patients with anal cancer treated with chemoradiation reported recovery of overall QOL to baseline levels. Specific symptoms remained bothersome, emphasizing the need to address and manage the chemoradiation-induced symptoms, during treatment and in the long term. See Video Abstract at http://links.lww.com/DCR/B905.

IMPACTO DE LA QUIMIORRADIACIN DEFINITIVA EN CAMBIOS EN LA CALIDAD DE VIDA DE LOS PACIENTES CON CNCER ANAL RESULTADOS A LARGO PLAZO DE UN ESTUDIO PROSPECTIVE

ANTECEDENTES:Mantener y mejorar la calidad de vida son objetivos importantes del tratamiento del cáncer anal, ya que esta enfermedad generalmente es curable, con muchos sobrevivientes a largo plazo.OBJETIVO:Se evaluó la calidad de vida a largo plazo después de la quimiorradiación en pacientes con cáncer anal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Utilizamos datos de un estudio prospectivo en pacientes con cáncer anal tratados con quimiorradiación entre 2008-2013.PACIENTES:Los pacientes con cáncer anal fueron tratados con radioterapia de intensidad modulada guiada por imágenes.INTERVENCIONES:Los pacientes de habla inglesa completaron los cuestionarios de calidad de vida específicos de cáncer (C30) y específicos del sitio (CR29) de la Organización Europea para la Investigación y el Tratamiento del Cáncer al inicio, al final de la radiación, 3 y 6 meses, y luego anualmente.PRINCIPALES MEDIDAS DE RESULTADOS:Se evaluó a largo plazo la calidad de vida clínicamente (un cambio en la puntuación de ≥10 puntos se consideraron clínicamente significativo) y estadísticamente (usando análisis de medición repetida) comparando las subescalas de puntuación al 1, 2, y 3 años. Con puntuaciones de referencia. El subanálisis comparó pacientes que recibieron 45-54 Gy versus 63 Gy.RESULTADOS:Se incluyeron un total de 96 pacientes (mediana de seguimiento: 56,5 meses). La mayoría de las escalas funcionales y de síntomas mostraron una disminución clínicamente significativa al final del tratamiento con una mejoría a los 3 meses posteriores al tratamiento. Hubo una disminución estadísticamente significativa a largo plazo en disnea, imagen corporal, vergüenza intestinal, incontinencia fecal y pérdida de cabello; y hubo un empeoramiento a largo plazo estadística y clínicamente significativo en impotencia. La dosis de radiación más alta (63 Gy) no se asoció con una calidad de vida significativamente peor.LIMITACIONES:Institución única, diseño de estudio de un solo brazo y falta de recomposición de la dosis (es decir, los análisis se basan en la dosis prescrita, en lugar de la administrada).CONCLUSIÓNES:Los pacientes con cáncer anal tratados con quimiorradiación reportaron una recuperación de la QOL en general a los niveles de base. Síntomas específicos siguieron siendo molestos, lo que enfatiza la necesidad de resolver y tartar los síntomas inducidos por la quimiorradiación no solo durante el tratamiento, sino a largo plazo. Consulte Video Resumen en http://links.lww.com/DCR/B905. (Traducción- Dr. Francisco M. Abarca-Rendon).

Effectiveness of Biofeedback Therapy in Patients with Bowel Dysfunction Following Rectal Cancer Surgery: A Systemic Review with Meta-Analysis

Objective

To identify, systematically review and synthesize the evidence on the effectiveness of biofeedback therapy in patients with bowel dysfunction following rectal cancer surgery.

Data Sources

Four electronic databases (PubMed 1974–2021; Embase1980–2021; Cochrane databases and the trial registers) were systematically searched by reviewers from inception through March 2021.

Study Selection

Randomized controlled trials (RCTs), cohort studies, and case series studies were included for adults with bowel dysfunction following rectal cancer surgery. All participants received an intervention of biofeedback treatment. Any outcomes that can evaluate the patient’s bowel function were the primary research endpoint, while the quality of life was the second endpoint. The disagreements between the two reviewers were resolved after discussion and the third independent reviewer’s ruling. As a result, 12 of 185 studies met selection criteria and were included in the review.

Data Extraction

We designed an electronic data extraction form and data were extracted independently. The methodological quality of included studies was assessed using the Cochrane Risk of Bias, the MINORS scale, and the Institute of Health Economics scale.

Data Synthesis

Meta-analyses were conducted for case series only and narrative syntheses were completed. Key findings included significant improvements in bowel function as well as health-related quality of life after biofeedback therapy. (Wexner score: t=7, MD=3.33; 95% CI [2.48, 4.18]) and (Vaizey score: t=3, MD=2.46; 95% CI [1.98, 2.93]). Subgroup analysis of Wexner score: receiving electrical stimulation therapy (t=3, MD=2.36; 95% CI [1.51, 3.22]), not receiving electrical stimulation (t=4, MD=3.79;95% CI[2.66, 4.93]); not receiving adjuvant chemoradiotherapy (t=3, MD=2.42;95% CI[1.61, 3.24]), chemotherapy and radiotherapy (t=1, MD=4.10; 95% CI [2.90, 5.30]), radiotherapy and chemotherapy on parts of patients (t=2, MD=3.46;95% CI [1.41, 5.51]), chemotherapy (t=1, MD=4.81; 95% CI [3.38, 6.24]); performing ISR (t=2, MD=3.32;95% CI [0.37, 6.27]), performing AR (t=4, MD=3.08; 95% CI [2.12, 4.04]), performing PLRAS surgery (t=1, MD=4.10;95% CI[2.90, 5.30]).

Conclusion

Although biofeedback therapy may improve intestinal function and quality of life as well as anal function reflected by ARM after surgery, patient satisfaction is still unclear. Due to the scarcity of data, good-quality research is required to delve deeper.

Clinical Trial Registration Number

CRD42020192658.

Managing Bowel Symptoms After Sphincter-Saving Rectal Cancer Surgery: A Scoping Review

CONTEXT

Rectal cancer is common and it is often treated by surgery with or without chemoradiation. Cancer treatment frequently results in bowel symptoms.

OBJECTIVES

The review aim was to chart the management options for bowel symptoms following rectal cancer surgery.

METHODS

A scoping review was undertaken searching nine healthcare databases, using relevant search terms and Boolean operators following PRISMA-ScR guidance. Data were extracted into an Excel spreadsheet using headings from the United Kingdom Department of Health guidance and are reported narratively.

RESULTS

30 heterogeneous studies met the inclusion criteria, including 853 patients. The most commonly reported bowel symptom was fecal incontinence; the most frequent management strategy was sacral nerve stimulation. Most studies reported on a single management option, often used to manage more than one bowel symptom. Often failure to satisfactorily improve symptoms using options such as medication was needed prior to progressing to other management options. In some studies more than one management option was used, such as rehabilitation programmes.

CONCLUSION

It is likely that to effectively manage the bowel symptoms experienced after rectal cancer treatment, more than one management option may be used-. Additionally, different management options may need to be tried concurrently.

Low anterior resection syndrome: can it be prevented?

Surgery remains the cardinal treatment in colorectal cancers but changes in bowel habits after rectal cancer surgery are common and disabling conditions that affect patients' quality of life. Low anterior resection syndrome is a disorder of bowel function after rectal resection resulting in a lowering of the QoL and recently has been defined by an international working group not only by specified symptoms but also by their consequences. This review aims to explore an extensive bibliographic research on preventive strategies for LARS. All "modifiable variables," quantified by the LARS Score, such as type of anastomosis, neoadjuvant therapy, surgical strategy, and diverting stoma, were evaluated, while "non-modifiable variables" such as age, sex, BMI, ASA, preoperative TMN, tumor height, and type of mesorectal excision were excluded from the comparative analysis. The role of defunctioning stoma, local excision, neoadjuvant radiotherapy, and non operative management seems to significantly affect risk of LARS, while type of anastomosis and surgical TME approach do not impact on LARS incidence or gravity in the long term period. Although it is established that some variables are associated with a greater onset of LARS, in clinical practice, technical difficulties and oncological limits often make difficult the application of some prevention plans. Transtomal irrigations, intraoperative neuromonitoring, pelvic floor rehabilitation before stoma closure, and early transanal irrigation represent new arguments of study in preventive strategies which could, if not eliminate the symptoms, at least mitigate them.

A novel bowel rehabilitation programme after total mesorectal excision for rectal cancer: the BOREAL pilot study

AIM

Low anterior resection syndrome (LARS) following sphincter-preserving surgery for rectal cancer has a high prevalence, with an impact on long-term bowel dysfunction and quality of life. We designed the bowel rehabilitation programme (BOREAL) as a proactive strategy to assess and treat patients with LARS. The BOREAL programme consists of a stepwise approach of escalating treatments: medical management (steps 0-1), pelvic floor physiotherapy, biofeedback and transanal irrigation (step 2), sacral nerve neuromodulation (step 3), percutaneous endoscopic caecostomy and anterograde enema (step 4) and definitive colostomy (step 5).

METHODS

A pilot study was undertaken to assess the feasibility of collecting LARS data routinely with the parallel implementation of the BOREAL programme. All patients who underwent total mesorectal excision for rectal cancer between February 2017 and March 2019 were included. LARS was assessed using the LARS score and the Wexner Faecal Incontinence score at 30 days and 3, 6, 9 and 12 months postoperatively. A good functional result was considered to be a combined LARS score <20 and/or a Wexner score <4.

RESULTS

In all, 137 patients were included. Overall compliance with the BOREAL programme was 72.9%. Major LARS decreased from 48% at 30 days postoperatively to 12% at 12 months, with a concomitant improvement in overall good function from 33% to 77%, P < 0.001. The majority of patients (n = 106, 77%) required medical management of their LARS.

CONCLUSION

The BOREAL programme demonstrates the acceptability, feasibility and effectiveness of implementing a responsive, stepwise programme for detecting and treating LARS.

Better quality of life and reduced fecal incontinence in rectal cancer patients with the watch-and-wait follow-up strategy

INTRODUCTION

The watch-and-wait (WW) strategy is an alternative to anterior resection in patients with rectal cancer (RC) that have had a complete clinical response to neoadjuvant treatment. Few reports describe the quality of life and functional anorectal disorders (FADs) in that population.

AIM

To analyze and compare the FADs and quality of life in patients with locally advanced adenocarcinoma of the rectum treated with neoadjuvant therapy, divided into two different strategy groups: group 1 (G1), WW; and group 2 (G2), anterior resection.

MATERIALS AND METHODS

Thirty patients (G1: n = 20 and G2: n = 10) that had finished neoadjuvant therapy at least 12 months prior were included. Mean patient age was 59.5 years (range: 41-79) and 15 of the patients were men. The FADs were evaluated through: a) clinical history, b) 21-day bowel diary, c) Jorge and Wexner fecal incontinence scale, d) anorectal manometry (ARM), and fecal incontinence quality of life scale (FIQL).

RESULTS

Bowel diary: fecal incontinence (40%) and urge to defecate (45%) in G1 vs. fecal incontinence (60%) and urge to defecate (30%) in G2, with no significant differences (p = NS). Fecal incontinence scale: fecal incontinence in G1 was significantly less severe than that in G2 (median 6.5 points vs. 13 points [p = 0.0142]). ARM: no differences between the two groups. Quality of life: significantly different between the two groups (FIQL/G1: 3.7 vs. FIQL/G2: 2.8; p < 0.03).

CONCLUSIONS

The WW follow-up strategy in patients with locally advanced rectal cancer was associated with better quality of life and reduced fecal incontinence.

Randomised controlled trial to assess efficacy of pelvic floor muscle training on bowel symptoms after low anterior resection for rectal cancer: study protocol

INTRODUCTION

Radical surgery after a total mesorectal excision (TME) for rectal cancer often results in a significant decrease in the patient's quality of life, due to functional problems such as bowel, urinary and sexual dysfunction. The effect of pelvic floor muscle training (PFMT) on these symptoms has been scarcely investigated. We hypothesise that the proportion of successful patients will be significantly higher in the intervention group, receiving 12 weeks of PFMT, compared with the control group without treatment. The primary outcome of this trial is the severity of bowel symptoms, measured through the Low Anterior Resection Syndrome questionnaire, 4 months after TME or stoma closure. Secondary outcomes are related to other bowel and urinary symptoms, sexual function, physical activity and quality of life.

METHODS AND ANALYSIS

This research protocol describes a multicentre single blind prospective, randomised controlled trial. Since January 2017, patients treated for rectal cancer (n=120) are recruited after TME in three Belgian centres. One month following surgery or, in case of a temporary ileostomy, 1 month after stoma closure, patients are randomly assigned to the intervention group (n=60) or to the control group (n=60). The assessments concern the preoperative period and 1, 4, 6, 12 and 24 months postoperatively.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki. Ethics approval was granted by the local Ethical Committee of the University Hospitals Leuven (s59761) and positive advice from the others centres has been obtained. Dissemination of the results will be accomplished via guidelines and (non-)scientific literature for professionals as well as organisation of patient symposia.

TRIAL REGISTRATION NUMBER

NTR6383.

Efficacy of pelvic floor rehabilitation for bowel dysfunction after anterior resection for colorectal cancer: a systematic review

PURPOSE

Bowel dysfunction is common after anterior resection for colorectal cancer (CRC). Pelvic floor rehabilitation (PFR) may improve functional outcomes after surgery. This review aimed to evaluate the efficacy of PFR for patients with bowel symptoms after anterior resection.

METHODS

MEDLINE, CINHAL, PUBMED, EMBASE, Scopus, PsycINFO, Web of Science, PEDRO and Cochrane Library were searched from inception to June 2019. A final search was performed on 11 July 2020. Randomised controlled trials (RCTs), cohort studies, case-control studies and case series of bowel dysfunction after CRC surgery and PFR were eligible for review. Outcome measures were bowel function changes measured by patient-reported outcomes and manometric measurement. Risk of bias assessments using Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle Ottawa Scale (NOS) were conducted.

RESULTS

Eleven trials met eligibility criteria: four retrospective studies and seven prospective, non-randomised controlled studies. A total of 516 participants were included, of which 455 received PFR. Functional outcomes were measured by bowel functional outcome questionnaires, patient diary, anorectal manometry and three studies measured quality of life. Faecal incontinence was improved in seven studies, and bowel frequency also decreased in five studies. The mean MINORS score was 10 (8-13) out of 16 in non-comparative groups and 18 (16-22) out of 24 in comparative groups; the NOS was 4.2 (3-7) out of 9. The overall risk of bias was high in most studies.

CONCLUSIONS

PFR appears to be beneficial for improving bowel function after anterior resection for CRC. However, the studies included had methodological limitations, so further investigation on the effectiveness of PFR is warranted.

Better quality of life and reduced fecal incontinence in rectal cancer patients with the watch-and-wait follow-up strategy

INTRODUCTION

The watch-and-wait (WW) strategy is an alternative to anterior resection in patients with rectal cancer (RC) that have had a complete clinical response to neoadjuvant treatment. Few reports describe the quality of life and functional anorectal disorders (FADs) in that population.

AIM

To analyze and compare the FADs and quality of life in patients with locally advanced adenocarcinoma of the rectum treated with neoadjuvant therapy, divided into two different strategy groups: group 1 (G1), WW; and group 2 (G2), anterior resection.

MATERIALS AND METHODS

Thirty patients (G1: n = 20 and G2: n = 10) that had finished neoadjuvant therapy at least 12 months prior were included. Mean patient age was 59.5 years (range: 41-79) and 15 of the patients were men. The FADs were evaluated through: a) clinical history, b) 21-day bowel diary, c) Jorge and Wexner fecal incontinence scale, d) anorectal manometry (ARM), and fecal incontinence quality of life scale (FIQL).

RESULTS

Bowel diary: fecal incontinence (40%) and urge to defecate (45%) in G1 vs. fecal incontinence (60%) and urge to defecate (30%) in G2, with no significant differences (p = NS). Fecal incontinence scale: fecal incontinence in G1 was significantly less severe than that in G2 (median 6.5 points vs. 13 points [p = 0.0142]). ARM: no differences between the two groups. Quality of life: significantly different between the two groups (FIQL/G1: 3.7 vs. FIQL/G2: 2.8; p < 0.03).

CONCLUSIONS

The WW follow-up strategy in patients with locally advanced rectal cancer was associated with better quality of life and reduced fecal incontinence.

Long-term functional results and quality of life after redo rectal surgery: delayed versus immediate colo-anal anastomosis

AIM

To compare the functional results and quality of life after delayed colo-anal anastomosis (DCAA) or immediate colo-anal anastomosis (ICAA) following redo rectal surgery.

METHOD

Twenty-six patients with DCAA between 2014 and 2018 were studied retrospectively (group A). Two control groups were used: 26 ICAA after redo surgery (group B) and 52 colo-anal anastomosis (CAA) after anterior resection (group C). Control groups were matched for age, sex, pelvic radiotherapy and time to surgery. Low Anterior Resection Syndrome (LARS) and Gastrointestinal Quality of Life Index (GIQLI) scores were used to assess function and quality of life.

RESULTS

The indications for surgery were comparable for groups A and B: anastomotic failure with chronic sepsis (38% vs 50%, P = 0.40), vaginal fistula (42% vs 42%, P = 1) and urinary fistula (20% vs 8%, P = 0.22) as well as the number of previous abdominal operations (1.3 ± 0.9 vs 1.1 ± 0.6, P = 0.19). The median LARS score in the first 2 years was 30 [interquartile range (IQR) 14-41] for group A, 23 (IQR 0-41) for group B and 22 (IQR 11-37) for group C. After 2 years, the median LARS score improved in each group [A, 21 (IQR 11-35); B, 18 (IQR 5-26); C, 13 (IQR 9-20)], but was still high in group A. There was a tendency toward more major LARS in group A than in group B (46% vs 27%; P = 0.149). There was no difference in the mean GIQLI score between groups A and B (120 ± 16 vs 117 ± 19; P = 0.53) at the end of the follow-up period. Time after stoma closure (< 2 years) and previous radiotherapy were risk factors for major LARS in all populations.

CONCLUSION

ICAA should be the procedure of choice where possible in redo surgery as it has better functional outcomes.

Optimising functional outcomes in rectal cancer surgery

Background

By improved surgical technique such as total mesorectal excision (TME), multimodal treatment and advances in imaging survival and an increased rate of sphincter preservation have been achieved in rectal cancer surgery. Minimal-invasive approaches such as laparoscopic, robotic and transanal-TME (ta-TME) enhance recovery after surgery. Nevertheless, disorders of bowel, anorectal and urogenital function are still common and need attention.

Purpose

This review aims at exploring the causes of dysfunction after anterior resection (AR) and the accordingly preventive strategies. Furthermore, the indication for low AR in the light of functional outcome is discussed. The last therapeutic strategies to deal with bowel, anorectal, and urogenital disorders are depicted.

Conclusion

Functional disorders after rectal cancer surgery are frequent and underestimated. More evidence is needed to define an indication for non-operative management or local excision as alternatives to AR. The decision for restorative resection should be made in consideration of the relevant risk factors for dysfunction. In the case of restoration, a side-to-end anastomosis should be the preferred anastomotic technique. Further high-evidence clinical studies are required to clarify the benefit of intraoperative neuromonitoring. While the function of ta-TME seems not to be superior to laparoscopy, case-control studies suggest the benefits of robotic TME mainly in terms of preservation of the urogenital function. Low AR syndrome is treated by stool regulation, pelvic floor therapy, and transanal irrigation. There is good evidence for sacral nerve modulation for incontinence after low AR.

Tools for fecal incontinence assessment: lessons for inflammatory bowel disease trials based on a systematic review

BACKGROUND

Fecal incontinence is a disabling condition affecting up to 20% of women.

OBJECTIVE

We investigated fecal incontinence assessment in both inflammatory bowel disease and non-inflammatory bowel disease patients to propose a diagnostic approach for inflammatory bowel disease trials.

METHODS

We searched on Pubmed, Embase and Cochrane Library for all studies on adult inflammatory bowel disease and non-inflammatory bowel disease patients reporting data on fecal incontinence assessment from January 2009 to December 2019.

RESULTS

In total, 328 studies were included; 306 studies enrolled non-inflammatory bowel disease patients and 22 studies enrolled inflammatory bowel disease patients. In non-inflammatory bowel disease trials the most used tools were the Wexner score, fecal incontinence quality of life questionnaire, Vaizey score and fecal incontinence severity index (in 187, 91, 62 and 33 studies). Anal manometry was adopted in 41.2% and endoanal ultrasonography in 34.0% of the studies. In 142 studies (46.4%) fecal incontinence evaluation was performed with a single instrument, while in 64 (20.9%) and 100 (32.7%) studies two or more instruments were used. In inflammatory bowel disease studies the Wexner score, Vaizey score and inflammatory bowel disease quality of life questionnaire were the most commonly adopted tools (in five (22.7%), five (22.7%) and four (18.2%) studies). Anal manometry and endoanal ultrasonography were performed in 45.4% and 18.2% of the studies.

CONCLUSION

Based on prior validation and experience, we propose to use the Wexner score as the first step for fecal incontinence assessment in inflammatory bowel disease trials. Anal manometry and/or endoanal ultrasonography should be taken into account in the case of positive questionnaires.

Pelvic floor rehabilitation to improve functional outcome and quality of life after surgery for rectal cancer: study protocol for a randomized controlled trial (FORCE trial)

BACKGROUND

After low anterior resection (LAR), up to 90% of patients develop anorectal dysfunction. Especially fecal incontinence has a major impact on the physical, psychological, social, and emotional functioning of the patient but also on the Dutch National Healthcare budget with more than €2000 spent per patient per year. No standardized treatment is available to help these patients. Common treatment nowadays is focused on symptom relief, consisting of lifestyle advices and pharmacotherapy with bulking agents or antidiarrheal medication. Another possibility is pelvic floor rehabilitation (PFR), which is one of the most important treatments for fecal incontinence in general, with success rates of 50-80%. No strong evidence is available for the use of PFR after LAR. This study aims to prove a beneficial effect of PFR on fecal incontinence, quality of life, and costs in rectal cancer patients after sphincter-saving surgery compared to standard treatment.

METHODS

The FORCE trial is a multicenter, two-armed, randomized clinical trial. All patients that underwent LAR are recruited from the participating hospitals and randomized for either standard treatment or a standardized PFR program. A total of 128 patients should be randomized. Optimal blinding is not possible. Stratification will be done in variable blocks (gender and additional radiotherapy). The primary endpoint is the Wexner incontinence score; secondary endpoints are health-related and fecal-incontinence-related QoL and cost-effectiveness. Baseline measurements take place before randomization. The primary endpoint is measured 3 months after the start of the intervention, with a 1-year follow-up for sustainability research purposes.

DISCUSSION

The results of this study may substantially improve postoperative care for patients with fecal incontinence or anorectal dysfunction after LAR. This section provides insight in the decisions that were made in the organization of this trial.

TRIAL REGISTRATION

Netherlands Trial Registration, NTR5469, registered on 03-09-2015. Protocol FORCE trial V18, 19-09-2019. Sponsor Radboud University Medical Center, Nijmegen.

[Rehabilitation program for patients with low anterior resection syndrome]

Surgical treatment of rectal cancer and sphincter-preserving low anterior resection results to evacuation disorders («low anterior resection syndrome» - LARS). There are no clinical recommendations for the treatment of patients with LARS as well as a rehabilitation program for them.

OBJECTIVE

To develop a rehabilitation program for patients with low anterior resection syndrome.

MATERIAL AND METHODS

The investigation was performed at 2 stages. During the first stage, 29 patients with LARS (17 (58.6%) men, mean age of the participants' 61.5±9.5 years), 12 (41.4%) women (mean age 61.2±7.8 years) were examined and received the course of conservative treatment with the use of biofeedback-therapy performed by the standard protocol. On the second stage, 17 patients (mean age 61.4±12.7 years) - 9 (52.9%) men, 8 (47.1%) women received biofeedback therapy in combination with tibial neuromodulation (TNM). Functional state of the rectum and the locking apparatus in all patients were evaluated by anorectal manometry: sphincterometry and studies of the reservoir function of the rectum before and after treatment.

RESULTS

The developed complex of rehabilitation measures led to improved treatment results for patients with rectal cancer by improving the quality of life after low anterior resection, reducing the manifestations of LARS (by 47.8%). Stable positive results of treatment were maintained in 36.4% of patients, positive dynamics from the treatment according to the LARS scale decreased slightly in 54.5%, deterioration of indicators in 3-6 months after conservative rehabilitation was registered in 9.1% of cases. At the first stage maximal squeeze pressure improvement was reached in the whole cohort (p=0.047), at the second stage these trend was seen only for women for the pressure values at rest (p=0.01) and during squeeze (p=0.025). The data obtained allowed us to recommend a repeat course of treatment to 63.6% of patients. The authors modified and optimized a special complex of physical therapy for the rehabilitation of patients both in a medical institution and at home. These exercises are aimed at improving the functional state of the pelvic floor muscles and sphincter apparatus.

CONCLUSION

Rehabilitation program for patients with low anterior resection syndrome should include: 1) biofeedback therapy to improve the holding function; 2) biofeedback therapy aimed at improving the reservoir function and sensitivity of the rectum to filling; 3) tibial neuromodulation. This program may help improving the contractility of the anal sphincter and reservoir function of the rectum, as well as the appearance of the urge to defecate.

Efficacy of biofeedback therapy for objective improvement of pelvic function in low anterior resection syndrome

Purpose

There is no established treatment of choice for low anterior resection syndrome (LARS). To evaluate the efficacy of biofeedback therapy for objective improvement of pelvic function in LARS, we performed the present study.

Methods

The primary endpoint was the change of Wexner score. Consenting patients between 20 and 80 years old with major LARS at least 2 months after sphincter preserving proctectomy for rectal cancer were enrolled. After recommendation of biofeedback therapy, patients who accept it were enrolled in the biofeedback group and patients who refuse were enrolled in the control group. Initial and follow-up evaluations were performed and analyzed.

Results

Fifteen and sixteen patients were evaluated in the control group and the biofeedback group, respectively. There was no statistically significant difference of LARS score between both groups. Decrease in Wexner score and increase in rectal capacity were significantly higher in the biofeedback group (odds ratio [OR], 5.386; 95% confidence interval [CI], 1.194–24.287; P = 0.028 and OR, 1.061; 95% CI, 1.002–1.123; P = 0.042).

Conclusion

Biofeedback therapy was superior for objective improvement of pelvic function to observation in LARS. It can be considered to induce more rapid improvement of major LARS.

A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders

PURPOSE OF REVIEW

Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy.

RECENT FINDINGS

The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.

Physiotherapy and Anterior Resection Syndrome (PARiS) trial: feasibility study protocol

INTRODUCTION

Rectal cancer affects more than 600 patients per year in Wales, with a 5-year survival rate of around 60%. A recent report demonstrated that 19% of patients with bowel cancer had difficulty controlling their bowels after surgery, and these patients were twice as likely to report lower quality of life than those who had control. Nearly all patients will experience bowel dysfunction initially following surgery and up to 25% will experience severe bowel dysfunction on a long-term basis. The aim of this study is to test the feasibility of introducing a simple intervention in an attempt to improve bowel function following surgery for rectal cancer. We propose the introduction of an educational session from specialist nurses and physiotherapists prior to surgery and a subsequent physiotherapy programme for 3 months to teach patients how to strengthen their pelvic floor.

METHODS AND ANALYSIS

All patients with rectal cancer planned to receive an anterior resection will be approached for the study. The study will take place in three centres over 12 months, and we expect to recruit 40 patients. The primary outcome measure is the proportion of eligible patients approached who consent to and attend the educational session. The secondary outcomes include patient compliance to the pelvic floor rehabilitation programme (assessed by patient paper or electronic diary), the acceptability of the intervention to the patient (assessed using qualitative interviews) and preoperative and postoperative pelvic floor tone (assessed using the Oxford Grading System and the International Continence Society Grading System), patient bowel function and patient quality of life (assessed using validated questionnaires).

ETHICS AND DISSEMINATION

Ethics approval was granted. This feasibility study is in progress. If patients find the intervention acceptable, the next stage would be a trial comparing outcomes after anterior resection in those who have and do not have physiotherapy.

TRIAL REGISTRATION NUMBER

ISRCTN77383505; Pre-results.

Long-term assessment of anorectal function after extensive resection of the internal anal sphincter for treatment of low-lying rectal cancer near the anus

Objectives: Intersphincteric resection (ISR) for low-lying rectal cancer (LRC) may induce major problems associated with anorectal function. In this study, we assessed the severity of ISR-induced impairment in anorectal function. Methods: In total, 45 patients followed up regularly ≥2 years after diverting ileostoma closure were eligible. The patients underwent ISR (n=35) or conventional coloanal anastomosis without resection of the internal anal sphincter (IAS) (n=10) for treatment of LRC from January 2000 to December 2011. We retrospectively compared anorectal function [stool frequency, urgency, Wexner incontinence scale (WIS) score, and patient satisfaction with bowel movement habits on a visual analog scale (VAS) score] for ≥2 years after stoma closure between the two groups. Results: The median follow-up period was 4.0 years (range, 2.0-6.5 years). Of the total, 17 (48.6%) patients who underwent ISR had poor anorectal function, including two with complete incontinence. Significant differences were found between the groups in the incidence of urgency (p=0.042), WIS score (p=0.024), and defecation disorder with a WIS score of ≥10 (p=0.034) but not in stool frequency. Based on the VAS score, 45.7% of patients who underwent ISR were dissatisfied with their bowel movement habits (p=0.041). Conclusions: Extensive resection of the IAS has negative short- and long-term effects on anorectal function.

Effectiveness of Pelvic Floor Rehabilitation for Bowel Dysfunction After Intersphincteric Resection for Lower Rectal Cancer

BACKGROUND

The aim of this study was to evaluate the effectiveness of pelvic floor rehabilitation (PFR) for patients with bowel dysfunction after intersphincteric resection (ISR) and to compare the treatment response to that of patients after low anterior resection (LAR).

METHODS

Thirty patients with postoperative bowel dysfunction for more than 6 months were enrolled and treated with PFR for 6 months.

RESULTS

In the ISR group, significant improvements in the number of bowel movements and the use of antidiarrheal medications were observed, but no significant improvement was observed in the Wexner score (WS) and the fecal incontinence severity index (FISI). Meanwhile, in the LAR group, WS and FISI were better post-treatment than pre-treatment (WS: 10.7-5.7; p = 0.01, FISI: 28-11; p = 0.01). In the assessment of fecal incontinence quality of life (FIQL), only the Coping/Behavior category was improved in the ISR group (1.56 before, 2.16 after PFR; p = 0.01), while all four categories were improved significantly in the LAR group. The anorectal manometric examination showed no significant increase in sphincter pressure and the tolerable volume in patients after ISR.

CONCLUSIONS

PFR improved several clinical symptoms of patients after ISR. Compared with patients after LAR, patients after ISR showed an insufficient response to PFR in improving fecal incontinence. Considering the result of the generalized assessment of the quality of life scale, PFR may offer a therapeutic effect for several symptoms of patients after ISR.

Treatment possibilities for low anterior resection syndrome: a review of the literature

AIM

Up to 80% of patients after low anterior resection, experience (low) anterior resection syndrome (ARS/LARS). However, there is no standard treatment option currently available. This systemic review aims to summarize treatment possibilities for LARS after surgical treatment of rectal cancer in the medical literature.

METHODS

Embase, PubMed, and the Cochrane Library were searched using the terms anterior resection syndrome, low anterior resection, colorectal/rectal/rectum, surgery/operation, pelvic floor rehabilitation, biofeedback, transanal irrigation, sacral nerve stimulation, and tibial nerve stimulation. All English language articles presenting original patient data regarding treatment and outcome of LARS were included. We focused on the effects of different treatment modalities for LARS. The Jadad score was used to assess the methodological quality of trials. The quality scale ranges from 0 to 5 points, with a score ≤ 2 indicating a low quality report, and a score of ≥ 3 indicating a high quality report.

RESULTS

Twenty-one of 160 studies met the inclusion criteria, of which 8 were reporting sacral nerve stimulation, 6 were designed to determine pelvic floor rehabilitation, 3 studies evaluated the effect of transanal irrigation, 2-percutaneous tibial nerve stimulation, and the rest of the studies assessed probiotics and 5-HT₃ receptor antagonists for LARS in patients who had undergone rectal resection. All except one study were poor quality reports according to the Jadad score.

CONCLUSIONS

LARS treatment still carries difficulties because of a lack of well-conducted, randomized multicenter trials. Well-performed randomized controlled trials are needed.

The lived experiences of patients with post-operative rectal cancer who suffer from altered bowel function: A phenomenological study

PURPOSE

Altered bowel function is a common consequence of anal sphincter-saving surgery in rectal cancer patients, and bowel symptoms influence patients' daily life and psychosocial status. Patients have inadequate professional support because care specialists fail do fully appreciate the impact of the patients' symptoms. In-depth exploration of the individual's experience is essential to improve the quality of patient care. The purpose of this study was to explore the lived experiences of post-operative rectal cancer patients with altered bowel function.

METHODS

This Husserlian descriptive phenomenological study recruited 16 post-operative rectal cancer patients with altered bowel function. Data was collected through purposive sampling and one-on-one in-depth, semi-structured interviews. Narratives were analyzed thematically using Colaizzi's seven-step method.

RESULTS

Three themes emerged, namely: "living in the restroom", "never backward", and "rebalancing on a new road". "Living in the restroom" described how patients frequent the restroom due to post-operative physical changes. "Never backward" outlined that such changes disturbed their mood, interrupted their daily activities, and affected their family life. "Rebalancing on a new road" described the patients' coping strategies, which included spiritual reconstruction, a new excrement model, an adjusted lifestyle, and peer support.

CONCLUSIONS

Post-operative rectal cancer patients with altered bowel function frequent the restroom for prolonged periods, which disturbs their psychosocial status. However, they are forced to develop coping methods by themselves. Specialists can offer effective early post-operative interventions by thoroughly understanding each patient's symptomatic experience, symptom-related interferences, and primary concerns.

Sacral nerve stimulation can alleviate symptoms of bowel dysfunction after colorectal resections

AIM

Poor functional results, such as faecal incontinence (FI), low anterior resection syndrome (LARS) or high stool frequency, can occur after colorectal resections, including proctocolectomy with ileal pouch-anal anastomosis (IPAA), rectal resection and left hemicolectomy. Management of such patients is problematic, and some case reports have demonstrated the effectiveness of sacral nerve stimulation (SNS) in these situations. Our aim was to analyse the effectiveness of SNS on poor functional results and on quality of life in patients after treatment with different types of colorectal resection.

METHOD

At five university hospitals from 2006 to 2014, patients with poor functional results after rectal resection, IPAA or left hemicolectomy underwent a staged SNS implant procedure. Failure was defined by the absence or insufficient improvement (< 50%) of FI episodes.

RESULTS

SNS for bowel dysfunction was performed in 16 patients after rectal resection with coloanal anastomosis, left hemicolectomy with colorectal anastomosis or IPAA. Two (13%) cases of primary failure were observed after the percutaneous stimulation test. Median frequency of stool, FI episodes and urgency were significantly improved in 14 patients. Wexner and LARS scores were also significantly improved for 14 patients. When we compared results according to the type of colorectal surgery (IPAA, rectal resection or left hemicolectomy), median frequencies of stool and urgency, Wexner and LARS scores were still significantly improved. Overall success rate was 75% (12/16 patients) in intention-to-treat analysis and 86% (12/14 patients with permanent electrode) in per-protocol analysis.

CONCLUSION

SNS seems to improve bowel dysfunction following rectal resection, left hemicolectomy or IPAA.

Sacral neuromodulation for the treatment of faecal incontinence following proctectomy

AIM

This study assessed the effectiveness of sacral neuromodulation (SNM) for faecal incontinence (FI) following proctectomy with colorectal or coloanal anastomosis.

METHODS

An Institutional Review Board (IRB)-approved database identified patients treated for FI following proctectomy (SNM-P) for benign or malignant disease, who were matched 1:1 according to preoperative Cleveland Clinic Florida Faecal Incontinence Scores (CCF-FIS) with patients without proctectomy (SNM-NP). Primary outcome was change in CCF-FIS.

RESULTS

Twelve patients (seven women) were in the SNM-P group and 12 (all women) were in the SNM-NP group. In the SNM-P group, six patients underwent proctectomy for low rectal cancer and five received neoadjuvant chemoradiation. Five patients had handsewn anastomosis, and one had stapled coloanal anastomosis. One lead explantation occurred after a failed 2-week SNM percutaneous trial. Six patients underwent proctectomy for benign conditions. Within-group analyses revealed significant improvement in CCF-FIS in the SNM-P group (reduction from a score of 18 to a score of 14; P = 0.02), which was more profound for benign disease (reduction from 14.5 to 8.5) than for rectal cancer (reduction from 19.5 to 15). SNM was explanted in 66% and 33% of patients after proctectomy for malignant and benign conditions, respectively. In the SNM-NP group, 41% underwent overlapping sphincteroplasty. One patient received chemoradiation for anal cancer. Within-group analysis for the SNM-NP group showed significant improvement in CCF-FIS (a reduction from 17.5 to 4.0; P = 0.003). There was significant improvement in CCF-FIS in patients without previous proctectomy (mean delta CCF-FIS: 11.1 vs 4.7; P = 0.011). Analysis of covariance (ANCOVA) reaffirmed that controls outperformed proctectomy patients (P = 0.006).

CONCLUSION

SNM for FI after proctectomy appears less effective than SNM in patients without proctectomy, with high device explantation rates, particularly after neoadjuvant chemoradiation and proctectomy for low rectal cancer.

Survivorship care plans for people with colorectal cancer: do they reflect the research evidence?

AIM

In the present study, we synthesized the published literature about the psychosocial aspects of colorectal cancer (crc) survivorship to support an update of the evidentiary base of the survivorship care plans (scps) created in our jurisdiction.

METHODS

The psychosocial topics identified in the crc scps created by two different initiatives in our province were used as search criteria: quality of life (qol), sexual function, fatigue, and lifestyle behaviors. An umbrella review was conducted to retrieve the best possible evidence. Only reviews that investigated the intended outcomes in crc survivors and those with moderate-to-high methodologic quality scores were included.

RESULTS

Of 462 retrieved reports, eight reviews met the inclusion criteria for the synthesis. Of those eight, six investigated the challenges of crc survivors and two investigated the effect of physical activity on survivor well-being. Our results indicate that emotional and physical challenges are common in crc survivors and that physical activity is associated with clinically important benefits for the fatigue and physical functioning of crc survivors.

CONCLUSIONS

Our study findings update the evidence and indicate that existing scps in our province concerning the physical and emotional challenges of crc survivors reflect the evidence at the time of their issue. However, the literature concerning cancer risks specific to crc survivors is lacking. Although systematic reviews are considered to be the "gold standard" in knowledge synthesis, our findings suggest that much remains to be done in the area of synthesis research to better guide practice in cancer survivorship.

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.

Pelvic floor muscle exercise for fecal incontinence quality of life after coloanal anastomosis

AIMS AND OBJECTIVES

To assess the efficacy of pelvic floor muscle exercise for enhancing fecal incontinence quality of life after coloanal anastomosis in colorectal cancer patients.

BACKGROUND

Methods of improving incontinence have been evaluated in many countries, but never in a Taiwan population.

DESIGN

A longitudinal experimental study.

METHODS

Fifty-two colorectal cancer patients who had received colostomy closure and coloanal anastomosis surgery were recruited from a general hospital in southern Taiwan and randomly assigned to an experimental group (n = 26) or a control group (n = 26). Both groups received routine postoperative care. However, the experimental group received private consultations, educational DVDs and pamphlets to instruct them in performing pelvic flow muscle exercise. In all participants, the Fecal Incontinence Quality of Life Scale was used to measure quality of life before discharge and at one, two, three, six and nine months after discharge. Generalised estimating equations were used to compare longitudinal effects between the two groups.

RESULTS

The generalised estimating equations revealed that all participants had significantly improved Fecal Incontinence Quality of Life Scale scores at two, three, six and nine months after discharge. Compared to the controls, however, the experimental group had significantly higher scores at two, three, and six months after discharge.

CONCLUSIONS

Patient education in pelvic floor muscle exercise positively affects Fecal Incontinence Quality of Life Scale scores in patients who have received coloanal anastomosis.

RELEVANCE TO CLINICAL PRACTICE

Early education in pelvic floor muscle exercise can improve management of fecal incontinence symptoms after coloanal anastomosis and can improve quality of life.

Low anterior resection syndrome: a survey of the members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP)

BACKGROUND

Low anterior resection syndrome (LARS) is frequent following sphincter-sparing procedures for rectal cancer.

OBJECTIVE

This study aims to assess surgeons' awareness of LARS.

DESIGN

This was a survey study.

SETTINGS

Members of the American Society of Colon and Rectal Surgeons (ASCRS), the Spanish Association of Surgeons (AEC), and the Spanish Society of Coloproctology (AECP).

PARTICIPANTS

Three hundred thirty-four surgeons from the ASCRS and 150 from the Spanish Societies completed a 23-item electronic questionnaire.

MAIN OUTCOME MEASURES

Surgeons' opinions regarding different aspects of LARS.

RESULTS

The proportion of rectal cancer patients undergoing sphincter-sparing operations ranged between 71 and 90 %. Low anterior resection with end-to-end anastomosis was the most frequently cited procedure after mesorectal excision. More than 80 % of participants were recognized to be moderately or extremely aware of the condition, but regarding the method used to assess LARS, the majority relied on clinical manifestations. Around 35 % of surgeons considered that severe LARS developed in less than 40 % of patients. The most important factor related to defecatory function impairment in the surgeons' opinion was the distance from the anal margin to anastomosis. Other factors thought to be involved were anastomotic leakage, preoperative radiation therapy, age, and postoperative radiotherapy, with similar percentages in the two groups of surgeons. Lifestyle changes and dietary measures associated with or without drug treatment was the modality of choice. The experience with transanal irrigation or sacral nerve stimulation was limited. It was considered that <30 % of patients chronically suffer from severe LARS with significant quality of life impairment.

LIMITATIONS

The limitations of this study are the international mix and expert status of the specialists.

CONCLUSIONS

The probability of patients suffering from LARS was underestimated despite reporting good knowledge of the syndrome. Validated methods for the assessment of LARS were rarely used. Deficient awareness regarding risk factors for LARS was documented. Knowledge of therapeutic options was also limited.

The functional results of radical rectal cancer surgery: review of the literature

Introduction For more than the last 20 years, low anterior resection with total mesorectal excision (TME) is a gold standard for rectal cancer treatment. Oncological outcomes have improved significantly and now more and more reports of functional outcomes appear. Due to the close relationship between the rectum and pelvic nerves, bowel, bladder, and sexual function are frequently affected during TME. Methods A search for published data was performed using the MEDLINE database (from 1 January 2005 to 31 January 2015) to perform a systematic review of the studies that described anorectal, bladder, and sexual dysfunction following rectal cancer surgery. Methodological quality of the included studies was assessed using the MINORS criteria. Results Eighty-nine studies were eligible for analysis. Up to 76% of patients undergoing sphincter preserving surgery will have changes in bowel habits, the so-called "low anterior resection syndrome" (LARS). The duration of LARS varies between a few months and several years. Pre-operative radiotherapy, damage of anal sphincter and pelvic nerves, and height of the anastomosis are the risk factors for LARS. There is no evidence-based treatment available for LARS. Sexual function is more commonly affected after rectal surgery than after urinary function. The main cause of dysfunction is damage to pelvic nerves. Sexual and bladder functional outcomes in females are less well reported. Laparoscopic and robotic surgery allows better visualization of autonomic nerves and, therefore, more precise dissection and preservation. Conclusions It is important that rectal resection is standardized as much as possible, and that new functional outcome research use the same validated outcome questionnaires. This would allow for a high-quality meta-analysis.

Validity and reliability of a Lithuanian version of low anterior resection syndrome score

BACKGROUND

Up to 90 % of patients undergoing low anterior resection complain of increased daily bowel movements, urgency, and a variable degree of incontinence. A symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer has recently been developed and validated. The aim of our study was to adapt the low anterior resection syndrome (LARS) scale questionnaire to the Lithuanian language, and assess its psychometric properties.

METHODS

The LARS questionnaire was translated into Lithuanian by the Scientific Advisory Committee of the Medical Outcomes Trust using a standard procedure of double-back translation. The Lithuanian version of the LARS (LARS-LT) questionnaire was completed by 111 patients who underwent low anterior resection with total mesorectal excision in the period from January 1, 2008, to December 31, 2012, at the National Cancer Institute. An anchor question from the Wexner score assessing the impact of bowel function on lifestyle was included. A subgroup of 20 patients completed the LARS-LT questionnaire twice. Validity was tested using a factor analysis, and internal reliability was estimated using the Cronbach's alpha and intraclass correlation coefficients.

RESULTS

Twenty-seven patients (25 %) had no LARS, 26 (24 %) had minor LARS, and 55 (56 %) had major LARS. The response rate was 60.7 %. The LARS-LT showed significantly high reliability and internal consistency [Cronbach's α = 0.88, interclass correlation coefficient-0.86 (0.71-0.98)]. The LARS score showed significant correlations with the lifestyle question (p < 0.05). It could not detect differences between female and male patient groups (p = 0.33), patients' age (p = 0.45), patients who had/had not undergone radiation therapy (p = 0.07), and those in whom the distal edge of the tumor was close to or far from the anal verge (p = 0.17).

CONCLUSIONS

The Lithuanian version of the LARS-LT shows acceptable psychometric properties and can be considered a valuable and specific instrument to assess bowel function in rectal cancer patients, both for research purposes and in clinical practice.

The risk of definitive stoma formation at 10 years after low and ultralow anterior resection for rectal cancer

AIM

The long-term risk of definitive stoma after sphincter-saving resection (SSR) for rectal cancer is underestimated and has never been reported for ultralow conservative surgery. We report the 10-year risk of definitive stoma after SSR for low rectal cancer.

METHOD

From 1994 to 2008, patients with low rectal cancer who were suitable for SSR were analysed retrospectively. Patients were divided into the following four groups: low colorectal anastomosis (LCRA); coloanal anastomosis (CAA); partial intersphincteric resection (pISR); and total intersphincteric resection (tISR). The end-point was the risk of a definitive stoma according to the type of anastomosis.

RESULTS

During the study period, 297 patients had SSR for low rectal cancer. The incidence of definitive stoma increased from 11% at 1 year to 22% at 10 years. The reasons were no closure of the loop ileostomy (4.7%), anastomotic morbidity (6.5%), anal incontinence (8%) and local recurrence (5.2%). The risk of definitive stoma was not influenced by type of surgery: 26% vs 18% vs 18% vs 19% (P = 0.578) for LCRA, CAA, pISR and tISR, respectively. Independent risk factors for definitive stoma were age > 65 years and surgical morbidity.

CONCLUSION

The risk of a definitive stoma after SSR increased two-fold between 1 and 10 years after surgery, from 11% to 22%. Ultralow conservative surgery (pISR and tISR) did not increase the risk of definitive stoma compared with conventional CAA or LCRA.

Health-related quality of life in patients with lower rectal cancer after sphincter-saving surgery: a prospective 6-month follow-up study

This longitudinal descriptive study examined whether rectal cancer patients report changes in health-related quality of life (HRQOL) over a 6-month period after different types of sphincter-saving surgery (SSS): intersphincteric resection (ISR), ultra-low anterior resection (ULAR) and low anterior resection (LAR). It also compares HRQOL among the three groups of patients. Seventy-three patients from two hospitals in Japan completed questionnaires on HRQOL and defecation symptoms immediately before surgery and 1 and 6 months afterwards. Results showed that ISR patients had significantly worse HRQOL scores than ULAR and LAR patients and more defecation symptoms that persisted during the 6 months post-SSS. Thus, patients undergoing ISR require psychological and social support, including skills in competent self-management, during the early post-operative period. Furthermore, defecation problems substantially influence HRQOL. The first month post-SSS is particularly challenging. The assumption that HRQOL is better after SSS compared to living with a permanent stoma might not be valid.

Diagnosis and treatment of faecal incontinence: Consensus statement of the Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists

Faecal incontinence is a common and disturbing condition, which leads to impaired quality of life and huge social and economic costs. Although recent studies have identified novel diagnostic modalities and therapeutic options, the best diagnostic and therapeutic approach is not yet completely known and shared among experts in this field. The Italian Society of Colorectal Surgery and the Italian Association of Hospital Gastroenterologists selected a pool of experts to constitute a joint committee on the basis of their experience in treating pelvic floor disorders. The aim was to develop a position paper on the diagnostic and therapeutic aspects of faecal incontinence, to provide practical recommendations for a cost-effective diagnostic work-up and a tailored treatment strategy. The recommendations were defined and graded on the basis of levels of evidence in accordance with the criteria of the Oxford Centre for Evidence-Based Medicine, and were based on currently published scientific evidence. Each statement was drafted through constant communication and evaluation conducted both online and during face-to-face working meetings. A brief recommendation at the end of each paragraph allows clinicians to find concise responses to each diagnostic and therapeutic issue.

Improvement of fecal incontinence and quality of life by electrical stimulation and biofeedback for patients with low rectal cancer after intersphincteric resection

OBJECTIVE

To assess the efficacy and benefits of pelvic rehabilitation programs in terms of functional outcomes and quality of life for patients with fecal incontinence and defecation disorders after rectal cancer surgery.

DESIGN

Prospective, observational study.

SETTING

University hospital physiotherapy clinics.

PARTICIPANTS

Patients (N=32) who experienced fecal incontinence after sphincter-saving surgery with the intersphincteric resection (ISR) technique and could follow and cooperate with the treatment schedule were included in the present study.

INTERVENTIONS

Pelvic rehabilitation programs included electrical stimulation (ES) and biofeedback (BF).

MAIN OUTCOME MEASURES

Functional results, Wexner score, and anorectal manometry were used to assess the clinical outcomes of rehabilitation treatment.

RESULTS

Maximum squeeze pressure improved after rehabilitation training (P=.014). There were no statistical differences in resting pressure, resting muscle electromyography, and maximum squeeze electromyography (P=.061, P=.76, and P=.99, respectively). The mean stool frequency was 18.8 per 24 hours before the pelvic intervention program and 7.8 per 24 hours after ES and BF training (P<.001). Of the 32 patients, 27 required antidiarrheal medications before treatment, and after completion of the training, only 9 patients still needed antidiarrheal medications (P<.001). Significant improvements were observed in the Wexner score (17.74 vs 12.93; P<.001).

CONCLUSIONS

Our data show that ES and BF are effective in the treatment of fecal incontinence, leading to improvement of quality of life for patients with low rectal cancer after ISR.

Effects of pelvic floor muscle exercise on faecal incontinence in rectal cancer patients after stoma closure

The purpose of this study was to examine the effects of pelvic floor muscle exercise (PFME) on the faecal incontinence (FI) of rectal cancer patients following stoma closure. Participants were randomly distributed into an exercise group (n = 27) and non-exercise group (n = 26). An experimental design and longitudinal approach were implemented for data collection. Baseline data were collected at 1 day before discharge, and then PFME was taught before the patients were discharged from the hospital. We collected data and followed up with the patients at their pre-discharge visit and at 1, 2, 3, 6 and 9 months after discharge. The Cleveland Clinic Faecal Incontinence (CCI) score was used to measure patient outcome. PFME proved to effectively decrease the degree of FI in stoma closure recipients. The FI score of the exercise group significantly decreased from 8.37 to 2.27 after PFME compared with that of the non-exercise group (from 8.54 to 2.58). The generalised estimation equation tests showed that both group and time were significantly different. The tests also indicated that although PFME appeared to hasten the decline of incontinence, this effect was no longer detectable at 9 months; thus, it may be an effective intervention for FI when implemented up to half a year after discharge.

Pelvic floor rehabilitation in the treatment of fecal incontinence

Fecal incontinence (FI) is a prevalent problem that can drastically affect quality of life. Pelvic floor rehabilitation is an important first-line treatment for patients with FI, and many published case reports and a small number of randomized controlled trials (RCTs) provide limited evidence for its efficacy. Pelvic floor rehabilitation approaches to the treatment of FI include pelvic floor muscle training, biofeedback, and volumetric training with rectal balloon catheters. Various forms of external electrical stimulation have also been described and may be of added benefit. Behavioral bowel retraining is an important part of a good rehabilitative approach as well. Pelvic floor rehabilitation treatment for FI is thought to be effective and safe, with reported success rates in a majority of studies at 50 to 80%. Many more high-quality RCTs are needed to define optimal treatment protocols.

Pelvic floor muscle training for bowel dysfunction following colorectal cancer surgery: A systematic review

AIMS

To identify, evaluate and synthesize the evidence examining the effectiveness of pelvic floor muscle training (PFMT) on bowel dysfunction in patients who have undergone colorectal cancer surgery.

METHODS

Eight electronic databases (MEDLINE 1950-2014; CINAHL 1982-2014; EMBASE 1980-2014; Scopus 1823-2014; PsycINFO 1806-2014; Web of Science 1970-2014; Cochrane Library 2014; PEDro 1999-2014) were systematically searched in March 2014. Reference lists of identified articles were cross referenced and hand searched. Randomized controlled trials, cohort studies and case series were included if they investigated the effects of conservative treatments, including PFMT on bowel function in patients with colorectal cancer following surgery. Two reviewers independently assessed the risk of bias of studies using the Newcastle-Ottawa Scale (NOS).

RESULTS

Six prospective non-randomized studies and two retrospective studies were included. The mean (SD) NOS risk of bias score was 4.9 (1.2) out of 9; studies were limited by a lack of non-exposed cohort, lack of independent blinded assessment, heterogeneous treatment protocols, and lack of long-term follow-up. The majority of studies reported significant improvements in stool frequency, incontinence episodes, severity of fecal incontinence, and health-related quality of life (HRQoL) after PFMT. Meta-analysis was not possible due to lack of randomized controlled trials.

CONCLUSIONS

Pelvic floor muscle training for patients following surgery for colorectal cancer appears to be associated with improvements in bowel function and HRQoL. Results from non-randomized studies are promising but randomized controlled trials with sufficient power are needed to confirm the effectiveness of PFMT in this population.

Pelvic floor rehabilitation to improve functional outcome after a low anterior resection: a systematic review

PURPOSE

Impaired functional outcome is common after a low anterior resection (LAR). Pelvic floor rehabilitation (PFR) might improve functional outcome after a LAR. The aim of this systematic review is to evaluate the effectiveness of PFR in improving functional outcome.

METHODS

PubMed, Embase, and the Cochrane Library were searched using the terms fecal incontinence, colorectal neoplasm/surgery, LAR, rectal cancer, anterior resection syndrome, bowel habit, pelvic floor, training, therapy, physical therapy, rehabilitation and biofeedback. Of the 125 identified records, 5 articles were included.

RESULTS

The 5 included studies reported on 321 patients, of which 286 patients (89%) underwent pelvic floor training. Three studies included patients with anterior resection syndrome after a LAR while the remaining studies included a series of patients after a LAR. Functional outcome was mostly assessed by using the Wexner incontinence scale. Quality of life was assessed in one study, and in three studies, rectal manometry was performed. After PFR, the functional outcome was improved in four studies, as was the quality of life.

CONCLUSION

This systematic review demonstrated that PFR is useful for improving the functional outcome after a LAR. The data are extracted from studies of limited quality, but the available evidence points to the effectiveness of the procedure.

Smooth muscle enfoldment internal sphincter construction after intersphincteric resection for rectal cancer

Objective

To assess smooth muscle enfoldment and internal sphincter construction (SMESC) for improvement of continence after intersphincteric resection (ISR) for rectal cancer.

Methods

Twenty-four Bama miniature pigs were randomly divided into a conventional ISR group and experimental SMESC group, with 12 pigs in each group. The proximal sigmoid colon was anastomosed directly to the anus in the ISR group. In the SMESC group, internal sphincter construction was performed. At 12 weeks before and after surgery, rectal resting pressure and anal canal length were assessed. Three-dimensional ultrasound was used to determine the thickness of the internal sphincter. After the animals were sacrificed, the rectum and anus were resected and pathological examinations were performed to evaluate the differences in sphincter thickness and muscle fibers.

Results

All 24 animals in the SMESC group and the ISR group survived the surgery. Twelve weeks post-surgery, the rectal resting pressure, length of the anal high-pressure zone and the postoperative internal sphincter thickness for the ISR group were significantly lower than for the SMESC group. There was a thickened area (about 2 cm) above the anastomotic stoma among animals from the SMESC group; in addition, the smooth muscles were significantly enlarged and enfolded when compared to the ISR group.

Conclusion

This animal model study shows that the SMESC procedure achieved acceptable reconstruction of the internal anal neo-sphincter (IAN/S), without increasing surgical risk. However, the findings in this experimental animal model must be confirmed by clinical trials to determine the safety and efficacy of this procedure in clinical practice.

Quality of life after surgery for rectal cancer

Patients' health-related quality of life (HRQoL) is now considered a relevant clinical outcome. This study systematically reviewed articles published in the last 5 years, focusing on the impact of rectal cancer treatment on patients' HRQoL. Of the 477 articles retrieved, 56 met the inclusion criteria. The most frequently reported comparisons were between surgical procedures (21 articles), especially between sphincter-preserving and non-sphincter preserving surgery or between stoma and stoma-free patients (13 articles), and between multimodality therapies (11 articles). Additionally, twelve articles compared patients' and healthy controls' HRQoL as primary or secondary aim. The majority of the studies were observational (84 %), controlled (66 %), cross-sectional (54 %), prospective (100 %), with a sample of more than 100 patients (59 %), and with more than 60 % of patients treated with neoadjuvant therapy (50 %). The most frequently used instruments were the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (QLQ-C30), its colorectal cancer specific module QLQ-CR38, and the Medical Outcomes Study Short-Form 36 items questionnaire. Findings from the included articles are summarised and commented, with a special focus on the comparison between surgical treatments, between irradiated and not-irradiated patients, and between patients and the general population.