September’s paper of the month looks at the FORCE trial, a randomized control trial aiming to improve the intestinal function (LARS score) and the quality of life (QoL) of patients who had undergone a low anterior resection for rectal cancer.

Pelvic floor rehabilitation after rectal cancer surgery. A multicenter randomized clinical trial (FORCE trial)
J.A.G. van der Heijden, A.J. Kalkdijk-Dijkstra, J.P.E.N. Pierie, et al.

Annals of Surgery, July 2022

What is known about the subject?
Pelvic floor rehabilitation (PFR) has shown to improve QoL of patients with faecal incontinence, with a success rate between 50 and 80%. Previous studies reported improvement in stool frequency, incontinence episodes, severity of faecal incontinence and QoL after PFR and biofeedback.

What the study adds?
This study randomized 106 patients from 17 different Ducth centres, diagnosed with rectal cancer who had undergone a low anterior resection with primary anastomosis with or without a temporary stoma. Patients in the control group continued with the usual care with conservative measures and patients in the study group participated in weekly treatment sessions for 3 months led by a certified pelvic floor physiotherapist.

Overall, no improvement in incontinence scores was found. However, two subgroups of patients who could benefit from PFR were identified: 1) patients with urgency, 2) patients with a baseline Wexner (incontinence) score lower than 16 without complete incontinence. In both instances, better functional outcomes were found when compared to usual care. The authors hypothesized that only patients with some remaining control over the continence system can benefit from PFR. Those with a severe damage to the continence system are unlikely to respond to PFR.

Implications for colorectal practice
The current standard of care for LARS treatment after rectal cancer surgery includes conservative treatment with diet, laxatives and/or constipating agents. However, conservative measures often yield inconsistent results. Their impact on patients QoL is still doubtful.

Although few studies have been published yet about PFR for the treatment of LARS, results are promising. A standardized training program on PFR seems to be the key to improve postoperative functional results. Thus, in case of urgency problems or moderate incontinence, it seems justified to refer patients for PFR.

ESCP Affiliates