Bowel dysfunction after rectal cancer treatment: a study comparing the specialist's versus patient's perspective

Abstract

ObjectivesTo investigate how bowel dysfunction after sphincter-preserving rectal cancer treatment, known as low anterior resection syndrome (LARS), is perceived by rectal cancer specialists, in relation to the patient's experience.DesignQuestionnaire study.SettingInternational.Participants58 rectal cancer specialists (45 colorectal surgeons and 13 radiation oncologists).Research procedureThe Low Anterior Resection Syndrome Score (LARS score) is a five-item instrument for evaluation of LARS, which was developed from and validated on 961 patients. The 58 specialists individually completed two LARS score-based exercises. In Exercise 1, they were asked to select, from a list of bowel dysfunction issues, five items that they considered to disturb patients the most. In Exercise 2, they were given a list of scores to assign to the LARS score items, according to the impact on quality of life (QOL).Outcome measuresIn Exercise 1, the frequency of selection of each issue, particularly the five items included in the LARS score, was compared with the frequency of being selected at random. In Exercise 2, the answers were compared with the original patient-derived scores.ResultsFour of the five LARS score issues had the highest frequencies of selection (urgency, clustering, incontinence for liquid stool and frequency of bowel movements), which were also higher than random. However, the remaining LARS score issue (incontinence for flatus) showed a lower frequency than random. Scores assigned by the specialists were significantly different from the patient-derived scores (p<0.01). The specialists grossly overestimated the impact of incontinence for liquid stool and frequent bowel movements on QOL, while they markedly underestimated the impact of clustering and urgency. The results did not differ between surgeons and oncologists.ConclusionsRectal cancer specialists do not have a thorough understanding of which bowel dysfunction symptoms truly matter to the patient, nor how these symptoms affect QOL.

Aspectos fisiopatológicos da síndrome pós-ressecção anterior do reto para o tratamento de câncer retal

“…While the number of patients that survived rectal cancer surgery with definitive stoma decreases, the number of patients submitted to sphincter preserving surgeries increase, with severe functional disturbances of intestine 9 . Colo-rectal anastomosis performed to avoid definitive colostomy is the preferred choice of most surgeons, but is not always the best option for the patient 9 .…”

“…Colo-rectal anastomosis performed to avoid definitive colostomy is the preferred choice of most surgeons, but is not always the best option for the patient 9 . Some studies have shown that patients submitted to abdominal-perineal amputation and definitive colostomy have better quality of life than patients submitted to ARR, due to the symptoms caused by colon-anal anastomosis 9,33 . Although most studies of LARS focus on structural changes of rectum and anus, evidences point to the important role in this condition on colon motility alteration and inhibitory reflex and anal sensitivity disturbances that must be more studied in the future.…”

“…In that study, patients submitted to stapled anastomosis presented reduced anal rest pressure at anal-rectal manometry and higher incidence of fragmentation of internal anal sphincter at endo-anal ultrasonography after six months of surgery. Regarding EAS, it was not demonstrated until the present any structural damage directly related to surgical technique, and its dysfunction probably is secondary to pudendal nerve lesion 9 .…”

“…Several questionnaires (specific for intestinal function evaluation) are used to try to identify and measure how those functional alterations affect quality of life after ARR (9,23 28 was the first specifically proposed to evaluate intestinal function of patients submitted to sphincter preserving surgeries for the treatment of colon-rectal cancer. However, its use is restricted due to high number of items and lack of practicality.…”

“…In spite of surgical technical evolution and attention to preservation of pelvic nerves, many patients develop severe urinary, sexual and intestinal disturbances following ARR [6][7][8][9] . The group of functional alterations of intestine following ARR is known as low anterior resection syndrome -LARS 10,11 .…”