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

Abstract

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.

The Longitudinal Course of Low-anterior Resection Syndrome

“…Patients with major LARS at 3-to 6-months are likely to continue to suffer persisting dysfunction. The bowel rehabilitation programme (BOREAL) pilot programme has demonstrated that ''preventative'' care can be instituted on discharge (with bowel continuity) for all patients undergoing rectal resection, 48 but few institutions have such a programme. Therefore, these data suggest that all patients should have a functional follow-up assessment between 3 and 6 months and those with major LARS should have more intensive supportive care instituted with escalation as required.…”

Perianal/perineal rhabdomyosarcoma: Results of the SIOP MMT 95, Italian RMS 96, and EpSSG RMS 2005 studies

“…26 There are now a variety of treatments that might benefit patients, such as pelvic floor physiotherapy and sacral nerve stimulation. 27 These interventions could improve long-term quality of life for PRMS survivors.…”

“…Up to 80% of patients following surgery for rectal cancer report symptoms when this assessment tool is used and it may be that more focused questioning of PRMS survivors would uncover morbidity due to unpredictability and frequency of bowel motions 26 . There are now a variety of treatments that might benefit patients, such as pelvic floor physiotherapy and sacral nerve stimulation 27 . These interventions could improve long‐term quality of life for PRMS survivors.…”

Preliminary functional results after transanal irrigation in patients undergoing SHiP procedure for low rectal cancer

“…The BOREAL programme [ 8 ] consists of five sequential therapeutic steps starting from an approach as conservative as possible and up to surgery. The first one is medical management (steps 0–1), in case of persistence of symptomatology, the patients undergo pelvic floor physiotherapy, biofeedback and transanal irrigation (step 2), sacral nerve neuromodulation (step 3), percutaneous endoscopic cecostomy and anterograde enema (step 4), definitive colostomy (step 5).…”