Abstract
Purpose: Low anterior resection (LAR) is the preferred surgical treatment of rectosigmoid or rectal cancers. However, it is often associated with bowel dysfunction, which is termed low anterior resection syndrome (LARS). Daily bowel dysfunction symptoms have a detrimental effect on quality of life (QOL). Pelvic floor rehabilitation (PFR) can improve pelvic floor function and QOL among patients with LARS. This quality improvement (QI) project seeks to assess the prevalence of LARS and develop and incorporate PFR for the treatment and prevention of LARS. Methods: A convenience sample of 20 patients met project inclusion. Thirteen patients participated. Individuals were categorized by diagnostic risk: low risk, high risk, and established. The intervention included 1-hour PFR sessions with the physical therapist (PT) and 5 minutes of daily self-led pelvic floor muscle exercises. Outcomes questionnaires included the LARS Score and Fecal Incontinence Quality of Life (FIQOL) Scale. Data were collected both pre- and post–colorectal cancer treatment. Results: The overall prevalence of LARS was 76.9%, which was significantly higher than the retrospective cohort comparison rate of 21.8% (p < .001). The prevalence of major LARS was 89%, 83%, and 50% at the initial, second, and third sessions, respectively, representing a 44% relative decrease. Embarrassment was significantly affected among individuals with major LARS, although ongoing PFR facilitated improvement. Conclusion: PFR is a valuable adjunct therapy for LARS, with continued sessions decreasing the overall prevalence among the cohort. Major LARS negatively impacts QOL measures early on in treatment but improves with continued PFR.
References
American Cancer Society. (2022). Colorectal Cancer Facts & Figures 2023-2025. https://www.cancer.org/research/cancer-facts-statistics/colorectal-cancer-facts-figures.html
Badic, B., Joumond, A., Thereaux, J., Gancel, C. H., & Bail, J. P. (2018). Long-term functional and oncological results after sphincter-saving resection for rectal cancer - cohort study. International Journal of Surgery, 52, 1–6. https://doi.org/10.1016/j.ijsu.2018.02.003
Bernard, S., Ouellet, M.-P., Moffet, H., Roy, J.-S., & Dumoulin, C. (2016). Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: A systematic review. Journal of Cancer Survivorship, 10(2), 351–362. https://doi.org/10.1007/s11764-015-0481-8
Bohlok, A., Mercier, C., Bouazza, F., Galdon, M. G., Moretti, L., Donckier, V.,…Liberale, G. (2020). The burden of low anterior resection syndrome on quality of life in patients with mid or low rectal cancer. Supportive Care in Cancer, 28(3), 1199–1206. https://doi.org/10.1007/s00520-019-04901-2
Bregendahl, S., Emmertsen, K. J., Lous, J., & Laurberg, S. (2013). Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: A population-based cross-sectional study. Colorectal disease, 15(9), 1130–1139. https://doi.org/10.1111/codi.12244
Bulfone, G., Del Negro, F., Del Medico, E., Cadorin, L., Bressan, V., & Stevanin, S. (2020). Rehabilitation strategies for low anterior resection syndrome. A systematic review. Annali Dell’Istituto Superiore Di Sanità, 56(1), 38–47. https://doi.org/10.4415/ANN_20_01_07
Chan, K. Y., Suen, M., Coulson, S., & Vardy, J. L. (2021). Efficacy of pelvic floor rehabilitation for bowel dysfunction after anterior resection for colorectal cancer: A systematic review. Supportive Care in Cancer, 29(4), 1795–1809. https://doi.org/10.1007/s00520-020-05832-z
Croese, A. D., Lonie, J. M., Trollope, A. F., Vangaveti, V. N., & Ho, Y.-H. (2018). A meta-analysis of the prevalence of low anterior resection syndrome and systematic review of risk factors. International Journal of Surgery, 56, 234–241. https://doi.org/10.1016/j.ijsu.2018.06.031
Dulskas, A., Smolskas, E., Kildusiene, I., & Samalavicius, N. E. (2018). Treatment possibilities for low anterior resection syndrome: A review of the literature. International Journal of Colorectal Disease, 33(3), 251–260. https://doi.org/10.1007/s00384-017-2954-x
Hung, S.-L., Lin, Y.-H., Yang, H.-Y., Kao, C.-C., Tung, H.-Y., & Wei, L.-H. (2016). Pelvic floor muscle exercise for fecal incontinence quality of life after coloanal anastomosis. Journal of Clinical Nursing, 25(17–18), 2658–2668. https://doi.org/10.1111/jocn.13314
Juul, T., Battersby, N. J., Christensen, P., Janjua, A. Z., Branagan, G., Laurberg, S., Emmertsen, K. J., & Moran, B. (2015). Validation of the English translation of the low anterior resection syndrome score. Colorectal Disease, 17(10), 908–916. https://doi.org/10.1111/codi.12952
Keane, C., Wells, C., O’Grady, G., & Bissett, I. P. (2017). Defining low anterior resection syndrome: A systematic review of the literature. Colorectal Disease, 19(8), 713–722. https://doi.org/10.1111/codi.13767
Laycock, J., & Jerwood, D. (2001). Pelvic floor muscle assessment: The perfect scheme. Physiotherapy, 87(12), 631–642. https://doi.org/10.1016/s0031-9406(05)61108-x
Lin, Y.-H., Yang, H.-Y., Hung, S.-L., Chen, H.-P., Liu, K.-W., Chen, T.-B., & Chi, S.-C. (2016). Effects of pelvic floor muscle exercise on faecal incontinence in rectal cancer patients after stoma closure. European Journal of Cancer Care, 25(3), 449–457. https://doi.org/10.1111/ecc.12292
National Institute for Health and Care Excellence. (2021). Recommendations: Pelvic floor dysfunction: Prevention and non-surgical management: Guidance. NICE. https://www.nice.org.uk/guidance/ng210/chapter/Recommendations
Nishigori, H., Ishii, M., Kokado, Y., Fujimoto, K., & Higashiyama, H. (2018). Effectiveness of pelvic floor rehabilitation for bowel dysfunction after intersphincteric resection for lower rectal cancer. World Journal of Surgery, 42(10), 3415–3421. https://doi.org/10.1007/s00268-018-4596-8
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2020). Squire 2.0 guidelines. SQUIRE. http://www.squire-statement.org/index.cfm?fuseaction=page.viewpage&pageid=471
Paquette, I. M., Varma, M. G., Kaiser, A. M., Steele, S. R., & Rafferty, J. F. (2015). The American Society of Colon and Rectal Surgeons’ clinical practice guideline for the treatment of fecal incontinence. Diseases of the Colon & Rectum, 58(7), 623–636. https://doi.org/10.1097/dcr.0000000000000397
Qin, Q., Huang, B., Cao, W., Zhou, J., Ma, T., Zhou, Z.,…Wang, L. (2017). Bowel dysfunction after low anterior resection with neoadjuvant chemoradiotherapy or chemotherapy alone for rectal cancer: A cross-sectional study from China. Diseases of the Colon & Rectum, 60(7), 697–705. https://doi.org/10.1097/dcr.0000000000000801
Romeikienė, K. E., & Bartkevičienė, D. (2021). Pelvic-floor dysfunction prevention in prepartum and postpartum periods. Medicina, 57(4), 387. https://doi.org/10.3390/medicina57040387
Rosswurm, M. A., & Larrabee, J. H. (1999). A model for change to evidence-based practice. Image:
The Journal of Nursing Scholarship, 31(4), 317–322. https://doi.org/10.1111/j.1547-5069.1999.tb00510.x
Sacomori, C., Lorca, L. A., Martinez-Mardones, M., Salas-Ocaranza, R. I., Reyes-Reyes, G. P., Pizarro-Hinojosa, M. N., & Plasser-Troncoso, J. (2021). 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. Trials, 22(1), 448. https://doi.org/10.1186/s13063-021-05396-1
Sakr, A., Sauri, F., Alessa, M., Zakarnah, E., Alawfi, H., Torky, R.,…Kim, N. K. (2020). Assessment and management of low anterior resection syndrome after sphincter preserving surgery for rectal cancer. Chinese Medical Journal, 133(15), 1824–1833. https://doi.org/10.1097/cm9.0000000000000852
Tan, S. H., Liao, Y. M., Lee, K. C., Ko, Y. L., & Lin, P. C. (2019). Exploring bowel dysfunction of patients following colorectal surgery: A cohort study. Journal of Clinical Nursing, 28(9-10), 1577–1584. https://doi.org/10.1111/jocn.14757
Trenti, L., Galvez, A., Biondo, S., Solis, A., Vallribera-Valls, F., Espin-Basany, E.,…Kreisler, E. (2018). Quality of life and anterior resection syndrome after surgery for mid to low rectal cancer: A cross-sectional study. European Journal of Surgical Oncology, 44(7), 1031–1039. https://doi.org/10.1016/j.ejso.2018.03.025
