Colorectal cancer is the second most common cancer in women and the third most common cancer in men. Nearly 40% of these tumours are located in the rectum. Standard of surgical care is a nerve and sphincter sparing total mesorectal excision (TME). This technique consists of excising the rectum, together with the total mesorectal envelope. By performing a TME, the rectal reservoir as such is lost and different techniques have been described to allow reconstruction, such as a straight coloanal anastomosis or a type of rectal neoreservoir reconstruction: colonic J-pouch or side-to-end coloanal anastomosis. However, negative consequences such as a wide range of bowel symptoms remain present in 25-80% of patients.[1] Postoperative physical activity also remains decreased. The aims of the present study were to assess the impact of the type of reconstruction and bowel symptoms on total physical activity level, sports, occupational and household activity levels of rectal cancer survivors, preoperatively to 1, 4, 6 and 12 months after surgery (or after stoma closure).

Patients who had a TME for rectal cancer between January 2017 and February 2021 (in three different hospitals) were eligible, but were excluded if they: (1) had another type of surgery for colorectal cancer: a Hartmann procedure, abdominoperineal excision, transanal endoscopic microsurgical resection, or sigmoid resection, (2) were incontinent for faeces before surgery, (3) had neurological diseases, (4) already had previous pelvic surgery, previous pelvic radiation or LAR for non-cancer reasons. After consent, patients were asked to fill out the LARS-questionnaire (maximum score of 42; 3 categories) and COREFO-questionnaire (maximum score of 100) to evaluate bowel symptoms.[2] Physical activity was evaluated using the the Flemish Physical Activity Computerized Questionnaire (FPACQ), which has been proven to be a reliable and valid questionnaire.[3] Patients were included if their TME (or stoma closure) took place at least 12 months prior to inclusion. All measurement methods were completed concerning the preoperative period (retrospectively) and at 1, 4, 6 and 12 months after surgery. From the FPACQ total physical activity level, sports, occupational and household activity level (MET-hours/week) were calculated. The influence on these parameters was investigated at the different time points for type of surgery and bowel complaints.
A linear model for repeated measures was used to evaluate the evolution of various continuous variables (total, sports, occupational and household activity levels) over time and to assess the relationship between the predictor variables and these outcome variables.

In total, 125 patients were included in this study. A straight coloanal anastomosis, a side-to-end coloanal anastomosis or a J-pouch was used for reconstruction in 58.4%, 26.4% and 15.2% of patients, respectively. Mean age for all patients was 58.5 (± 11.1) years. Bowel complaints according to the LARS- and COREFO-questionnaire are presented in Table 1. Scores on the LARS- and COREFO-questionnaire were highest at one month after surgery/stoma closure.
Total and occupational activity levels decreased significantly (with the exception of occupational activity levels one year after surgery/stoma closure) and remained lower than the preoperative values (Figure 1a/1b). Sports activity levels were significantly decreased at one and four months compared to preoperative values (Figure 1b). For household activity levels, no significant results were found over time.
The analyses showed no significant interaction between time and the type of reconstruction on physical activity levels (total, sports, occupational, household). However, there was a main trend showing better total physical activity levels for patients with a side-to-end coloanal anastomosis, compared to a straight coloanal anastomosis (p = 0.0518) or a J-pouch (p = 0.0661). 
Concerning bowel complaints - as represented by the LARS-score - no association was found for any type of physical activity level. However, a main effect was found between COREFO-scores and total physical activity level, indicating that a higher score on the COREFO-questionnaire was associated with lower total physical activity levels. Moreover, a higher score on the COREFO-questionnaire was significantly associated with time for occupational physical activity levels, at four months postoperatively/after stoma closure. Lastly, for sports and household physical activity levels, no effects were found for type of reconstruction or bowel complaints.

Total and occupational activity levels decreased in the first year after surgery/stoma closure and remained lower than preoperative levels. Sports activity levels decreased in the first four months postoperatively. The type of reconstruction had no significant influence on postoperative activity levels. Scores of the COREFO-questionnaire were correlated with total physical activity and predictive for a decrease in occupational physical activity levels at four months after surgery/stoma closure.

To the best of our knowledge, this is the first study to investigate the evolution of different levels of physical activity and predictive factors during the first year after TME for rectal cancer. This study showed that total and occupational physical activity levels remained lower than preoperative levels during the first year. Higher scores on the COREFO-questionnaire indicated lower levels of occupational physical activity at four months after surgery/stoma closure. Furthermore, higher COREFO-scores were associated with lower total physical activity levels in general. Type of reconstruction and the LARS-scores were no predictive factors for physical activity levels. The results of this study showed that preoperative physical activity levels were not reacquired in rectal cancer patients within the first year after surgery/stoma closure. With this in mind, patients should be steered and supported in their efforts to resume their physical activities after rectal cancer treatment.

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Liapi A, Mavrantonis C, Lazaridis P, et al. Validation and comparative assessment of low anterior resection syndrome questionnaires in Greek rectal cancer patients. Ann Gastroenterol 2019;32(2):185-92. doi: 10.20524/aog.2019.0350 [published Online First: 2019/03/07]
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