Physical function and quality of life after multimodality

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!