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Physical function and quality of life after
multimodality treatment for rectal cancer
Anneleen Maris
Department of Rehabilitation Sciences
Katholieke Universiteit Leuven
Overview
• Background
• Functional outcome & impact on quality of life
• Rehabilitation options
• Pelvic floor muscle training
• Conclusion
Overview
• Background
• Functional outcome & impact on quality of life
• Rehabilitation options
• Pelvic floor muscle training
• Conclusion
Colorectal cancer
Ferlay J et al, 2010
Background
Rectal carcinoma (30%)
• Distance to anal verge
Upper third: 11-15 cm
Middle third: 6-10 cm
Lower third: 0-5 cm
• TNM classification
Tumor
Lymph nodes
Metastasis
• Stage 0, I, II, III, IV
Background
Treatment
• Radiation and/ or chemotherapy (CT)
- Neoadjuvant
- Adjuvant
• Surgery
- Abdomino-perineal resection (APR)
- Partial mesorectal excision (PME)
- Total mesorectal excision (TME)
Low anterior resection (LAR)
Ultralow anterior resection (ULAR)
Background
• Restoration
- Straight colorectal anastomosis (CRA)
- Straight coloanal anastomosis (CAA)
- Reservoir reconstruction
Side-to-end CAA
J-pouch CAA
Coloplasty CAA
Background
Sphincter and/ or (autonomic) nerve injury
Distance of anastomosis to the anal verge
Suture technique
Diminished anal canal resting pressure
Limited (neo)rectal compliance & capacity
Affected postoperative continence and defecation
Background
Overview
• Background
• Functional outcome & impact on quality of life
• Rehabilitation options
• Pelvic floor muscle training
• Conclusion
• Potential anorectal side-effects
~ Anterior resection syndrome (90%)
• Frequency of daily bowel movements
• Nocturnal bowel movements
• Diarrhea
• Tenesmus
• Urgency
• Fecal incontinence (flatus, liquid, solid stool)
• Evacuation difficulties
- Incomplete evacuation
- Anorectal blockage
- Clustered defecation Peeters KC et al, 2005
Functional outcome
Better oncologic results &
survival rates
Long-term anorectal problems?
Functional outcome
Improvement during the first postoperative year:
• Spontaneous recovery ~ colonic adaptation
• Expansion of neorectal capacity Paty PB et al, 1994; van Duijvendijk P et al, 2002
Some anorectal symptoms:
• Progressive ~ radiation Andreyev J et al, 2007
Functional outcome
• Aim
Evaluation of anorectal function including symptom-related discomfort, fear
and embarrassment with a minimum follow-up of one year.
• Subjects
45 men and 34 women
Median age of 69 years (Q1=62; Q3=74)
Median follow-up of 22 months (Range: 12 - 37) .
• Procedure
COREFO, Vaizey incontinence score, ANBOF questionnaire
Rectal cancer patients
(n=79)
Age- and gender-matched control group
(n=79)
Functional outcome
Functional outcome
Functional outcome
Anal Bowel Function questionnaire
• Results
Significant at .01 level
0
10
20
30
40
50
60
70
80
90
100
%
Rectal cancer
Control
Functional outcome
Vaizey incontinence score
Functional outcome
0
10
20
30
40
50
60
70
80
90
100
%
Rectal cancer
Control
Functional outcome
- Impact on well-being: 78%
- Low correlation with FU
Functional outcome
Conclusion
Compared with control subjects, patients with rectal cancer have
significant worse anorectal function
Irradiated patients have worse anorectal function than patients who
underwent surgery alone
Majority of patients report moderate to severe impact of anorectal
dysfunction on well-being and self-confidence
Need for: Attention to these adverse effects
Individually adapted care
Functional outcome
Overview
• Background
• Functional outcome & impact on quality of life
• Rehabilitation options
• Pelvic floor muscle training
• Conclusion
- Postoperative anorectal dysfunction
- First-line treatment (vs second-line treatment)
Lundby L et al, 2010
Treatment options to improve anorectal function after rectal surgery
Systematic Review
1796 unique articles
1755 studies excluded based on
title and abstract
26 articles excluded based on
eligibility criteria
15 trials included in
systematic review by
consensus of 3 reviewers
41 relevant articles
assessed for eligibility
• Search
Systematic Review
• Results
Included trials (15)
- Irrigation techniques (2)
- Sacral neuromodulation (6)
- Pelvic floor reeducation (7)
Systematic Review
• Results
Included trials (15)
- Irrigation techniques (2)
- Sacral neuromodulation (6)
- Pelvic floor reeducation (7)
Systematic Review
• Results
Included trials (15)
- Irrigation techniques (2)
- Sacral neuromodulation (6)
- Pelvic floor reeducation (7)
Systematic Review
• Results
Included trials (15)
- Irrigation techniques (2)
- Sacral neuromodulation (6)
- Pelvic floor reeducation (7)
Systematic Review
Fecal incontinence
Evacuation difficulties
Quality of life
Incontinence score (WIS, MSKCC, MCIS, Pescatori)
Incontinence episodes
Anal manometry (Ps, Pr)
Pelvic floor reeducation (n=4) (n=3) (n=5)
Colonic irrigation (n=1) (n=1)
Sacral nerve stimulation (n=3) (n=5) (n=3)
Systematic Review
Stool frequency
Pelvic floor reeducation (n=1)
Satisfaction / SF36 / FIQL
Pelvic floor reeducation (n=3)
Sacral nerve stimulation (n=4)
Reference N Mean duration of
symptoms before
start intervention
Intervention Mean
follow-up
Chiang (1997) 6 18.5 6w BF 3.0
Ho (1996) 7 27.9 4w BF 10.6
Ho (1997) 11 33.3 4w BF 12.0
Laforest (2011) 46 1.0 15w PFME + BF 21.0 *
Kim (2011) 70 25.5 10w BF 2.5
Pucciani (2008) 88 22.4 4w PFME + BF + electro 4.0
Allgayer (2005) 95 1.5 * 3w PFME + BF 12.0
Systematic Review
>18 months vs <18 months * (Kim, 2011)
RT (n=41) vs nRT (n=54) (Allgayer, 2005)
LAR vs CAA (Pucciani, 2008)
men vs women (Pucciani, 2008)
PFMT vs control (Laforest, 2011)
Systematic Review
Functional outcome & Quality of life
Conclusion
Promising results: improvement of anorectal symptoms
Conservative therapy recommended first
Limitations
- Methodological quality
- Sample size
- No control group
- Intervention heterogenity
- Follow-up period
Need for high qualitative research!
Maris A et al., Colorectal Dis 2012
Systematic Review
Overview
• Background
• Functional outcome & impact on quality of life
• Rehabilitation options
• Pelvic floor muscle training
• Conclusion
Pelvic floor muscle training
Pelvic floor training in patients with fecal incontinence after rectal
surgery -> 6/7 trials: rectal cancer (Maris A et al, 2012)
Köninger et al. (2004): affected muscle coordination <-> limited
neorectal capacity (Köninger JS et al, 2004)
Additional value of preoperative pelvic floor training?
• Aim
Evaluation of the short- and longterm effect of minimal preoperative
proprioceptive pelvic floor training on postoperative anorectal function
• Inclusion criteria Primary rectal cancer diagnosis, prognosis >1.5 year
• Protocol
- Standardised pelvic floor training ~ PPP-concept
- Evaluation: ANBOF questionnaire, satisfaction score
Pelvic floor muscle training
Position Remarks Repetitions
Side lying
- Legs extended - Hip/ knee 90°
3-5 repetitions in
each position
Sitting
-Hip/ knee 90°
-10 cm between feet
3-5 repetitions
Standing
-Legs extended
-Hips/ knees flexed
-10 cm between feet
3-5 repetitions in
each position
• PPP-concept
- 3x/ day (+/- 90 contractions)
- Single contraction duration: 6-10 sec
Pelvic floor muscle training
Rectal surgery
N=37
Non-stoma
NSTpre-group n=16
NSTpost-group n=10
Stoma ST-group
n=11
2M 6M 12M
Start PPP
Start PPP
Pelvic floor muscle training
• Results
Pelvic floor muscle training
0
10
20
30
40
50
60
70
80
90
100
2M (n=11)
6M (n=11)
12M (n=11)
ST
0
10
20
30
40
50
60
70
80
90
100
2M (n=16)
6M (n=15)
12M (n=16)
NSTpre
0
10
20
30
40
50
60
70
80
90
100
2M (n=8) 6M (n=10)
12M (n=10)
NSTpost
Diarrhea
FI liquid
Pelvic floor muscle training
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
ST NST
FI solid_discomfort
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
ST NST
FI solid_fear
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
ST NST
FI solid_embarrassment
Impact on well-being
2M: NSTpre = NSTpost
ST vs NST
Pelvic floor muscle training
Satisfaction score
Item ST (n=11) NSTpre (n=15) NSTpost (n=8)
Median IQR Median IQR Median IQR
Pelvic floor training profit 3 3 - 4 3 2 - 3 2 1.25 - 2.75
Pelvic floor muscle control 3 3 - 4 3 3 - 3.5 2 2 - 3
Distinction superficial/ deep 3 3 - 4 3 2 - 3.75 2 2 - 3.5
Satisfaction anorectal function 3 2 - 3 3 2 - 3 2 1.75 - 2.5
Distinction flatus - stool 3 3 - 4 3 3 - 3 3 2.75 - 4
Distinction solid - liquid stool 3 3 - 4 3 2 - 3 3 1.75 - 4
Pelvic floor muscle training
Conclusion
Basic pelvic floor muscle training can improve anorectal functional
outcome
ST > NSTpre > NSTpost
- Anorectal function
- Well-being
- Satisfaction with therapy
Similar muscle control – discrimination
Pelvic floor muscle training
Overview
• Background
• Functional outcome & impact on quality of life
• Rehabilitation options
• Pelvic floor muscle training
• Conclusion
Conclusion
Patients with rectal cancer have significant worse anorectal function
at long-term follow-up
Moderate to severe impact of anorectal dysfunction on well-being
and self-confidence
Promising results - conservative therapy recommended first
Need for high qualitative research!
Additional value of preoperative start pelvic floor muscle training
Thank you!