Therapeutic Evaluation of Biofeedback Therapy in the Treatment of Anterior Resection Syndrome After Sphincter-Saving Surgery for Rectal Cancer

Treatment of anterior resection syndrome: A systematic review and network meta-analysis

INTRODUCTION

There has been a lack of research comparing the efficacy of various treatments for low anterior resection syndrome (LARS).

METHODS

We conducted a comprehensive search across six electronic databases and a paired meta-analysis was undertaken to assess the effectiveness of the interventions. Furthermore, a network meta-analysis was utilized to compare the efficacy of different treatments for LARS.

RESULTS

This study encompassed nine randomized controlled trials, involving a total of 450 patients. Compared to routine care, 5-HT3 receptor antagonists (follow-up<3 months) and percutaneous tibial nerve stimulation (3 months ≤ follow-up <6 months) were effective in reducing the LARS score. Pelvic floor rehabilitation (follow-up≤3 months) was effective in decreasing daily number of bowel movements when compared to routine care. The network meta-analysis indicated that 5-HT3 receptor antagonists (follow-up<3 months) were the most effective in reducing both the LARS score and the daily number of bowel movements. Transanal irrigation (3 months ≤ follow-up ≤ 12 months) was most effective in reducing the LARS score. Additionally, 5-HT3 receptor antagonists demonstrated relative efficacy in improving patients' quality of life (follow-up ≤ 1 month).

CONCLUSIONS

This review indicates that 5-HT3 receptor antagonists and anal irrigation show significant promise in the treatment of LARS. Nevertheless, the contributions of percutaneous tibial nerve stimulation and pelvic floor rehabilitation to LARS treatment should not be overlooked. Given the clinical heterogeneity observed among the studies, the results should be interpreted with caution.

Challenges in evaluating pelvic floor physiotherapy based strategies in low anterior resection syndrome: a systematic review and qualitative analysis

AIM

Physiotherapy is an established treatment strategy for low anterior resection syndrome (LARS). However, data on its efficacy are limited. This is in part due to the inherent challenges in study design in this context. This systematic review aims to analyse the methodology of studies using pelvic floor physiotherapy for treatment of LARS to elucidate the challenges and limitations faced, which may inform the design of future prospective trials.

METHODOLOGY

A systematic review of the literature was undertaken through MEDLINE, Embase and Cochrane Library, yielding 345 unique records for screening. Five studies were identified for review. Content thematic analysis of study limitations was carried out using the Braun and Clarke method. Line-by-line coding was used to organize implicit and explicit challenges and limitations under broad organizing categories.

RESULTS

Key challenges fell into five overarching categories: patient-related issues, cancer-related issues, adequate symptomatic control, intervention-related issues and measurement of outcomes. Adherence, attrition and randomization contributed to potential bias within these studies, with imbalance in the baseline patient characteristics, particularly gender and baseline pelvic floor function scores. Outcome measurements consisted of patient-reported measures and quality of life measures, where significant improvements in bowel function according to patient-reported outcome measures were not reflected in the quality of life scores.

CONCLUSION

Upcoming trial design in the area of pelvic floor physiotherapy for faecal incontinence related to rectal cancer surgery can be cognisant of and design around the challenges identified in this systematic review, including the reduction of bias, exclusion of the placebo effect and the potential cultural differences in attitude towards a sensitive intervention.

Long term persistence and risk factors for anorectal symptoms following low anterior resection for rectal cancer

BACKGROUND

Rectal cancer is commonly treated by chemoradiation therapy, followed by the low anterior resection anal sphincter-preserving surgery, with a temporary protecting ileostomy. After reversal of the stoma a condition known as low anterior resection syndrome (LARS) can occur characterized by a combination of symptoms such as urgent bowel movements, lack of control over bowel movements, and difficulty fully emptying the bowels. These symptoms have a significant negative impact on the quality of life for individuals who have survived the cancer. Currently, there is limited available data regarding the presence, risk factors, and effects of treatment for these symptoms during long-term follow-up.

AIMS

To evaluate long term outcomes of low anterior resection surgery and its correlation to baseline anorectal manometry (ARM) parameters and physiotherapy with anorectal biofeedback (BF) treatment.

METHODS

One hundred fifteen patients (74 males, age 63 ± 11) who underwent low anterior resection surgery for rectal cancer were included in the study. Following surgery, patients were managed by surgical and oncologic team, with more symptomatic LARS patients referred for further evaluation and treatment by gastroenterologists. At follow up, patients were contacted and offered participation in a long term follow up by answering symptom severity and quality of life (QOL) questionnaires.

RESULTS

80 (70%) patients agreed to participate in the long term follow up study (median 4 years from stoma reversal, range 1-8). Mean time from surgery to stoma closure was 6 ± 4 months. At long term follow up, mean LARS score was 30 (SD 11), with 55 (69%) patients classified as major LARS (score > 30). Presence of major LARS was associated with longer time from surgery to stoma reversal (6.8 vs. 4.8 months; p = 0.03) and with adjuvant chemotherapy (38% vs. 8%; p = 0.01). Patients initially referred for ARM and BF were more likely to suffer from major LARS at long term follow up (64% vs. 16%, p < 0.001). In the subgroup of patients who underwent perioperative ARM (n = 36), higher maximal squeeze pressure, higher maximal incremental squeeze pressure and higher rectal pressure on push were all associated with better long-term outcomes of QOL parameters (p < 0.05 for all). 21(54%) of patients referred to ARM were treated with BF, but long term outcomes for these patients were not different from those who did not perform BF.

CONCLUSIONS

A significant number of patients continue to experience severe symptoms and a decline in their quality of life even 4 years after undergoing low anterior resection surgery. Prolonged time until stoma reversal and adjuvant chemotherapy emerged as the primary risk factors for a negative prognosis. It is important to note that referring patients for anorectal physiology testing alone tended to predict poorer long-term outcomes, indicating the presence of selection bias. However, certain measurable manometric parameters could potentially aid in identifying patients who are at a higher risk of experiencing unfavorable functional outcomes. There is a critical need to enhance current treatment options for this patient group.

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.

Clinical Management of Low Anterior Resection Syndrome: Review of the Current Diagnosis and Treatment

BACKGROUND

Low anterior resection syndrome (LARS) is a series of bowel dysfunction symptoms, including altered bowel frequency, irregular bowel rhythms, fecal incontinence, and constipation. LARS occurs in 80% of patients undergoing sphincter-preserving surgery, affecting patients' quality of life along with social avoidance. Different measurements and treatments have been raised to deal with LARS, but no systematic standard has been developed.

OBJECTIVE AND METHODS

To promote the standardization of clinical trials and clinical management of LARS, this review summarizes the latest findings up until 2023 regarding the diagnostic criteria, assessment protocols, and treatment modalities for postoperative LARS in rectal cancer.

RESULTS

The diagnostic criteria for LARS need to be updated to the definition proposed by the LARS International Collaborative Group, replacing the current application of the LARS score. In both clinical trials and clinical treatment, the severity of LARS should be assessed using at least one symptom assessment questionnaire, the LARS score or MSKCC BFI, and at least one scale related to quality of life. Anorectal manometry, fecoflowmetry, endoscopic ultrasonography, and pelvic floor muscle strength testing are recommended to be adopted only in clinical trials. After analysis of the latest literature on LARS treatment, a stepwise classification model is established for the standardized clinical management of LARS. Patients with minor LARS can start with first-line treatment, including management of self-behavior with an emphasis on diet modification and medication. Lamosetron, colesevelam hydrochloride, and loperamide are common antidiarrheal agents. Second-line management indicates multi-mode pelvic floor rehabilitation and transanal irrigation. Patients with major LARS should select single or several treatments in second-line management. Refractory LARS can choose antegrade enema, neuromodulation, or colostomy.

CONCLUSIONS

In clinical trials of LARS treatment between 2020 and 2022, the eligibility criteria and evaluation system have been variable. Therefore, it is urgent to create a standard for the diagnosis, assessment, and treatment of LARS. Failure to set placebos and differentiate subgroups are limitations of many current LARS studies. Randomized controlled trials comparing diverse therapies and long-term outcomes are absent, as well. Moreover, a new scale needs to be developed to incorporate the patient's perspective and facilitate outpatient follow-up. Though the establishment of a stepwise classification model for LARS treatment here is indispensable, the refinement of the guidelines may be improved by more standardized studies.

Advances in diagnosis and treatment of low anterior resection syndrome

Rectal cancer is one of the most common cancers. As much as 90% of patients with low rectal cancer complain of increased frequency of defecation, fecal incontinence, and evacuation problems after surgery, which is termed as low anterior resection syndrome (LARS). LARS detrimentally affects the quality of life for patients with rectal cancer. In this paper, we review the pathogenesis, risk factors, assessment tools, and treatment strategies for LARS.

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.

Pelvic floor muscle exercises alleviate symptoms and improve mental health and rectal function in patients with low anterior resection syndrome

Background

Pelvic floor rehabilitation has been reported to be effective in improving fecal incontinence. The aim of this study was to prospectively evaluate the effectiveness of combined pelvic floor muscle exercises (PFMEs) and loperamide treatment on rectal function and mental health for low anterior resection syndrome (LARS) patients after sphincter-saving operation (SSO) for rectal cancer.

Methods

A total of 60 inpatients diagnosed with LARS were enrolled and randomly assigned to one of two groups: patients in Group A (n = 30) were treated with a PFME intervention and those in Group B (n = 30) with a control intervention for 4 weeks. High-resolution anorectal manometry (HRAM) was performed for all LARS patients. Demographic information was collected for all patients, and they subsequently also completed several questionnaires, including the Hospital Anxiety and Depression Scale (HADS), a measure of Wexner score, a measure of stool frequency per day, and the Bristol Stool Form Scale (BSFS).

Results

No significant differences between the groups were observed in baseline data. With regard to rectal function, we found significant improvements at week 4 in maximal resting pressure (MRP) (39.93 ± 5.02 vs. 28.70 ± 5.40 mmH₂O, p < 0.001) and maximal squeeze pressure (MSP) (132.43 ± 8.16 mmH₂O vs. 113.33 ± 9.87 mmH₂O, p < 0.001) among Group A patients compared to Group B patients. Additionally, Wexner scores were significantly lower in Group A than in Group B at week 4 (8.10 ± 1.24 vs. 9.87 ± 1.29 ml, p = 0.018), as were stool frequency (6.47 ± 0.90 vs. 7.83 ± 0.93, p < 0.001) and BSFS scores (5.17 ± 0.65 vs. 6.10 ± 0.80, p = 0.020). Notably, HADS scores were also significantly lower in Group A than in Group B at week 4 (8.25 ± 2.36 vs. 10.48 ± 3.01, p < 0.001). Additionally, both anxiety scores (4.16 ± 1.38 vs. 5.33 ± 1.69, p < 0.001) and depression scores (4.09 ± 1.56 vs. 5.15 ± 1.89, p < 0.001) were significantly lower in Group A than in Group B at week 4.

Conclusion

Pelvic floor muscle exercises are an effective treatment that can alleviate symptoms and improve rectal function and mental health in patients with low anterior resection syndrome.

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.

Biofeedback therapy combined with Baduanjin on quality of life and gastrointestinal hormone level in patients with colorectal cancer

BACKGROUND

With the change in people’s lifestyles, the incidence of colorectal cancer (CRC) is increasing. It is essential to study the efficacy of various treatment methods for CRC patients to prevent and treat CRC.

AIM

To investigate the efficacy of biofeedback therapy combined with Baduanjin in improving the quality of life and gastrointestinal hormone levels of patients with CRC.

METHODS

A total of 120 patients with CRC who were admitted to our hospital from June 2020 to June 2021 were included in the study. They were randomly divided into four groups (n = 30): the control group (group A), the biofeedback therapy intervention group (group B), the Baduanjin exercise intervention group (group C), and the combination group (group D). Patients in group A adopted the standard nursing mode and necessary health education. Patients in group B were treated with biofeedback therapy based on routine nursing care. Patients in group C were given Baduanjin intervention for 12 wk based on conventional drug treatment and care. Patients in group D were treated with biofeedback therapy and Baduanjin exercise. In this study, patients’ quality of life, gastrointestinal hormone levels, and clinical efficacy in the four groups were observed at baseline and 12 wk after intervention. Meanwhile, the correlation between gastrointestinal hormone levels and various functional areas of quality of life was analyzed. By comparing the observed indicators of patients in the four groups, the efficacy of biofeedback therapy combined with Baduanjin in improving the quality of life and gastrointestinal hormone levels of patients with CRC was explored.

RESULTS

At baseline, there were no significant differences in quality of life, gastrointestinal hormone levels, or clinical efficacy among the four groups (P > 0.05). Twelve weeks after the intervention, the combination group’s quality of life, gastrointestinal hormone levels, and clinical effectiveness were better than those of the three other groups.

CONCLUSION

On the basis of routine nursing care, patients with CRC combined with biofeedback therapy and Baduanjin exercise can improve the quality of life of patients with CRC and the efficacy of gastrointestinal hormone levels.

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.

Low Anterior Resection Syndrome in Adults with Rectal Cancer in China: a Case Series Analysis

Low anterior resection syndrome (LARS) comprises a collection of symptoms affecting patients’ defecation after restorative surgery for rectal cancer. The aim of this work was to study the incidence and risk factors for LARS in China. Rectal cancer patients undergoing total mesorectal excision and colorectal anastomosis between May 2012 and January 2015 were identified from a single center. The patients completed the LARS score questionnaire through telephone. The clinical and pathological factors that may influence the occurrence of LARS were analyzed using univariate and multivariate logistic regression analysis. The influence of postoperative recovery time and pelvic dimensions on the occurrence of LARS was also analyzed. This study included 337 patients, at an average age of 61.03 SD11.32. The mean LARS score of the patients was 14.08 (range 0–41). A total of 126 patients (37.4%) developed LARS after surgery, including 63 (18.7%) severe cases. Compared with the scores within the initial 6 postoperative months, the LARS scores of the patients in 6~18 months after the surgery showed significant reductions (p < 0.01). In multivariate analysis, lower locations of anastomosis, pre-surgery radiotherapy, and shorter postoperative recovery time were significant predisposing factors for LARS. A subgroup analysis revealed that patients suffering from LARS over 18 months after surgery were found to have a significantly shorter interspinous distance than those without LARS (p < 0.05). LARS could improve over time after surgery. Lower anastomotic level and pre-surgery radiotherapy are risk factors for LARS.

Using transanal irrigation in the management of low anterior resection syndrome: a service audit

Low anterior resection syndrome (LARS) is a collection of symptoms that can occur as a result of a low anterior resection for bowel cancer. Transanal irrigation (TAI) can be used to manage these symptoms. This article describes a retrospective audit of 15 patients who were using TAI to manage symptoms of LARS. The aim of the audit was to ascertain whether the use of TAI improved outcomes for these patients. The data suggest that TAI has reduced both the frequency of bowel movements and episodes of faecal incontinence. Those patients using higher volumes of water seem to have experienced more benefit than those patients using lower volumes of water. These findings are consistent with current literature around TAI for LARS and suggest research into optimum volume of water would be beneficial.

Low Anterior Resection Syndrome: Predisposing Factors and Treatment

Bowel dysfunction after restorative proctectomy, commonly referred to as Low Anterior Resection Syndrome (LARS), is a common long-term sequela of rectal cancer treatment that has a significant impact on quality of life. While the pathophysiology of LARS is poorly understood, its underlying cause is likely multifactorial, and there are numerous patient, tumor, and treatment-level factors associated with its development. In accordance with these risk factors, several strategies have been proposed to mitigate LARS postoperatively, including modifications in the technical approach to restorative proctectomy and advancements in the multidisciplinary care of rectal cancer. Furthermore, a clinically applicable pre-operative nomogram has been developed to estimate the risk of LARS postoperatively, which may help in counseling patients before surgery. The management of LARS begins with identifying those who manifest symptoms, as postoperative bowel dysfunction often goes unrecognized. This goal is best achieved with the systematic screening of patients using validated Patient-Reported Outcome Measures. Once a patient with LARS is identified, conservative management strategies should be implemented. When available, a dedicated LARS nurse and/or multidisciplinary team can be an invaluable resource in engaging patients and educating them regarding LARS self-care. If symptoms of LARS persist or worsen over time despite conservative measures, second-line interventions, such as transanal irrigation or pelvic floor rehabilitation, can be initiated. A small proportion of patients will ultimately require an intervention such as sacral neuromodulation or permanent colostomy for refractory, major LARS symptoms.

A nomogram to predict risk factors of frequent defecation early after ileostomy reversal for rectal cancer patients

Background

Defecation disorders after ileostomy reversal are among the most common complications for rectal cancer patients, and significantly diminish their quality of life. The aim of this study was to identify the risk factors associated with frequent defecation early after ileostomy reversal for rectal cancer patients.

Methods

We retrospectively collected the data of rectal cancer patients who underwent ileostomy reversal from January 2018 to December 2019 at the Sixth Affiliated Hospital of Sun Yat-sen University. We divided patients into two groups: a no frequent defecation group (≤7 times/day) and a frequent defecation group (>7 times/day).

Results

Of the 264 included patients, 59 patients (22.35%) had frequent defecation within 1 month after ileostomy closure and were defined as the frequent defecation group. There were no significant differences between the two groups in terms of gender, age, hypertension, and diabetes. Univariate and multivariate analyses showed that proctitis (P=0.04) and anastomotic stenosis (P=0.02) were independent risk factors for frequent defecation. Four factors, including proctitis, anastomotic stenosis, hypertension, and age were included to construct the nomogram. The consistency index of the nomogram was 0.949 and the area under the curve value was 0.623.

Conclusions

For rectal cancer patients, proctitis and anastomotic stenosis were correlated with frequent defecation within 1 month after ileostomy closure. Surgeons should pay attention to the rectal examination before ileostomy reversal surgery.

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.

A randomized clinical trial to assess the effectiveness of pre- and post-surgical pelvic floor physiotherapy for bowel symptoms, pelvic floor function, and quality of life of patients with rectal cancer: CARRET protocol

Background

There is scarcity of trials about preventative strategies for low anterior resection syndrome (LARS) in rectal cancer patients. The aim of this study is to evaluate the effectiveness of a pre- and post-surgical pelvic floor rehabilitation program on the bowel symptoms, pelvic floor function, and quality of life of rectal cancer patients.

Methods

A randomized controlled trial with parallel groups (pelvic floor rehabilitation versus control group), with a blinded evaluator. Participants and setting: 56 stage I to III rectal cancer patients aged from 18 to 80 years old undergoing sphincter preservation surgery at Hospital del Salvador and who have a sufficient knowledge of Spanish. Main outcome measures: ICIQ-B questionnaire for intestinal symptoms, high-resolution anorectal manometry (Alacer Multiplex 24-channel manometry equipment) for anorectal function, pelvic floor muscle strength test with Oxford Modified Scale, and a quality of life test with the EORTC QLQ C30 questionnaire. The evaluations will be carried out at five stages: before surgery, before and after the pelvic floor rehabilitation, and during a 3-month and 1-year follow-up. Interventions: one pre-rehabilitation session and 9 to 12 sessions of pelvic floor rehabilitation, including patient education, pelvic floor muscle exercises, pelvic floor electromyography biofeedback, and capacitive and sensory rectal training with a balloon probe. Rehabilitation will begin 3–5 weeks before the ileostomy is removed (four sessions) and around 3 weeks after stoma removal (5–8 sessions).

Discussion

We expect the program to improve the bowel symptoms, pelvic floor function, and quality of life of rectal cancer patients.

Trial registration

Australian New Zealand Clinical Trials Register ACTRN12620000040965. Registered on 21 January 2020.

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.

Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer

Many patients develop a variety of bowel dysfunction after sphincter preserving surgeries (SPS) for rectal cancer. The bowel dysfunction usually manifests in the form of low anterior resection syndrome (LARS), which has a negative impact on the patients’ quality of life. This study reviewed the LARS after SPS, its mechanism, risk factors, diagnosis, prevention, and treatment based on previously published studies. Adequate history taking, physical examination of the patients, using validated questionnaires and other diagnostic tools are important for assessment of LARS severity. Treatment of LARS should be tailored to each patient. Multimodal therapy is usually needed for patients with major LARS with acceptable results. The treatment includes conservative management in the form of medical, pelvic floor rehabilitation and transanal irrigation and invasive procedures including neuromodulation. If this treatment failed, fecal diversion may be needed. In conclusion, Initial meticulous dissection with preservation of nerves and creation of a neorectal reservoir during anastomosis and proper Kegel exercise of the anal sphincter can minimize the occurrence of LARS. Pre-treatment counseling is an essential step for patients who have risk factors for developing LARS.

Nurse-led standardized intervention for low anterior resection syndrome. A population-based pilot study

AIM

Our aim was to study the implementation of the low anterior resection syndrome (LARS) score in a clinical setting and to evaluate a nurse-led standardized intervention for bowel dysfunction following rectal cancer surgery.

METHOD

All patients who underwent curatively intended, restorative rectal cancer resection in a single centre between 2012 and 2016 were screened using the LARS score. At clinical follow-up, patients with major LARS were offered treatment in a nurse-led clinic. Data were retrospectively collected from patients' electronic medical records.

RESULTS

In total, 190 out of 286 (66%) patients were screened with the LARS score of whom 89 had major LARS. A total of 86 patients requested treatment for their bowel dysfunction and the majority obtained acceptable function after nurse-led optimized conservative treatment. Seventeen patients went on to transanal irrigation, and seven patients were treated with biofeedback. Five patients were referred for surgery, three for gastroenterological evaluation. After treatment in the clinic, patients achieved a statistically significant decrease in median LARS score from 37 (interquartile range 34-39) to 31 (interquartile range 23-34) (P < 0.001), and the prevalence of major LARS fell from 95% to 53% (P < 0.001).

CONCLUSION

Screening for LARS was not optimal as one-third of patients were not screened. The majority of patients with major LARS requested treatment for their symptoms and could be successfully treated with standardized interventions managed in a nurse-led setting.

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.

Low Anterior Resection Syndrome

PURPOSE OF REVIEW

Low anterior resection syndrome is a highly prevalent condition that can develop after anal sphincter-sparing surgery for rectal cancer and impair quality of life. In this review, we summarize the major features and pathophysiology of this syndrome and discuss treatment approaches.

RECENT FINDINGS

Quality of life correlates significantly with severity of low anterior resection syndrome. Prompt assessment and initiation of therapy are essential to rehabilitating damaged mechanical and neural structures. Anorectal manometry demonstrates a global decrease in sphincteric function postoperatively, though in many patients, function does recover. Transanal irrigation, pelvic floor rehabilitation, and biofeedback are the mainstays of the treatment of major LARS. Definitive stoma can be considered in therapy refractory LARS > 2 years. The development of low anterior resection syndrome likely involves an interplay between mechanical and neural pathways. Clinically, patients present at varying levels of severity, and scoring systems are available to help assess patient symptoms and guide therapy. Treatment approaches range from conservative therapies to biofeedback and sacral nerve stimulation. Future randomized controlled trials aimed at risk stratification of patients and development of severity-based treatment algorithms are warranted.

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.

Postoperative Bowel Function After Anal Sphincter-Preserving Rectal Cancer Surgery: Risks Factors, Diagnostic Modalities, and Management

Low anterior resection syndrome (LARS) refers to a disturbance of bowel function that commonly manifests within 1 month after rectal cancer surgery. A low level of anastomosis and chemoradiotherapy have been consistently found to be risk factors for developing LARS. Thorough history taking and physical examination with adjunctive procedures are essential when evaluating patients with LARS. Anorectal manometry, fecoflowmetry, and validated questionnaires are important tools for assessing the quality of life of patients with LARS. Conservative management (medical, physiotherapy, transanal irrigation), invasive procedures (neuromodulation), and multimodal therapy are the mainstay of treatment for patients with LARS. A stoma could be considered when other treatment modalities have failed. An initial meticulous surgical procedure for rectal cancer, creation of a neorectal reservoir during anastomosis, and proper exercise of the anal sphincter muscle (Kegel’s maneuver) are essential to combat LARS. Pretreatment counseling is a crucial step for patients who have risk factors for developing LARS.

Application value of nursing intervention combined with early nutritional support in preventive stoma reversion of low rectal cancer

Application value of nursing intervention combined with early nutritional support treatment in preventive stoma reversion of low rectal cancer was explored. Ninety-two cases of low rectal cancer patients undergoing preventive stoma reversion from January 2014 to December 2016 were retrospectively analyzed. All the patients had closed fistula 3 months after neostomy. Forty-four cases with routine nursing care were the control group; 48 cases with early nutritional support and nursing intervention were the experimental group. Nutritional status, psychological status, incidence of adverse reactions, wound infection rate, number of shaped and regular defecation were compared in the two groups. The levels of albumin, prealbumin and serum total protein in the experimental group were significantly higher than those in the control group after operation (P<0.05); the levels of albumin in the two groups after operation were significantly lower than those before operation (P<0.001). The SAS and SDS scores in the experimental group were significantly lower than those in the control group after operation (P<0.001); the SAS and SDS scores in the two groups after operation were significantly lower than those before operation (P<0.001). The number of abdominal pain, abdominal distention, diarrhea, incision infection and abdominal infection in the experimental group were less than those in the control group (P<0.05). The number of shaped and regular defecation cases in the experimental group was more than that in the control group (P<0.05). Nursing intervention combined with early nutritional support can improve the nutritional status, psychological anxiety-depression of the patients undergoing preventive stoma reversion, decrease the incidence of adverse reactions, and wound infection rate. It can also increase the shaped and regular defecation cases and is helpful for the recovery of intestinal function.

Before and after Anorectal Surgery: Which Information Is Needed from the Functional Laboratory?

Background

Anorectal surgery covers a wide spectrum of surgery. Diagnostic workup of anorectal disease is based on clinical examination with basic functional tests followed by more elaborate diagnostic tests. Since the incidence of anorectal disorders increases with age, more patients will present in outpatient clinics, thus underlining the relevance of this topic.

Methods

A PubMed literature search was performed using the terms 'anal incontinence', 'anal and rectal surgery', 'functional diagnostics', and combinations of these terms. No restriction regarding publication year or publication type was applied but randomized trials, 'metanalyses', or guidelines were ranked higher. Only articles in English or German were included.

Results

The diagnostic value of digital rectal examination, anal manometry and endosonography, the water holding procedure, contrast enema, and incontinence scores is summarized.

Conclusion

The article focusses on basic clinical and functional diagnostic tests which can be easily applied in the pre- and postoperative setting to evaluate the postoperative outcome.

Alterations of anal physiological features after surgery for low rectal cancer and management strategies

The sphincter preserving operation has improved the quality of life (QOL) of patients with low rectal cancer. However, some patients complain of having postoperative fecal incontinence and low QOL due to sphincter injury, nerve injure, and decreased rectal capacity. Therefore, anal physiology evaluation must be done preoperatively, the sphincter muscle and nerve should be preserved in operation, and biofeedback treatment should be administered postoperatively.

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.