Background: The purpose of this research is to identify the bowel symptoms and self-care strategies for rectal cancer survivors during the recovery process following low anterior resection surgery. Methods: A total of 100 participants were investigated under the structured interview guide based on the dimensions of “symptom management theory”. Results: 92% of participants reported changes in bowel habits, the most common being the frequent bowel movements and narrower stools, which we named it finger-shaped consistency stools. The 6 most frequently reported bowel symptoms were excessive flatus (93%), clustering (86%), urgency (77%), straining (62%), bowel frequency (57%) and anal pendant expansion (53%). Periodic bowel movements occurred in 19% participants. For a group of 79 participants at 6 to 24 months post-operation, 86.1% reported a significant improvement of bowel symptoms. Among 68 participants of this subgroup with significant improvements, 70.5% participants reported the length of time it took was at least 6 months. Self-care strategies adopted by participants included diet, bowel medications, practice management and exercise. Conclusions: It is necessary to educate patients on the symptoms experienced following low anterior resection surgery. Through the process of trial and error, participants have acquired self-care strategies. Healthcare professionals should learn knowledge of such strategies and help them build effective interventions. Keywords: Quality of life, Colorectal Cancer, Bowel symptoms, Nursing, Interview Background not mean a better QOL in patients who do not require a With the overall 5-year overall survival rate of rectal permanent stoma . cancer increasing, more and more researches focus not Following SPS, bowel dysfunction, also called low only on the resection of tumor but also on postoperative anterior resection syndrome, is a common and trouble quality of life (QOL) after surgery. The application of problem. It is characterized by frequency, urgency, stapling technique and total mesorectal excision facili- incontinence, and clustering (another bowel movement tates the increased proportion of sphincter-saving within one hour of last bowel movement), affecting more surgery (SPS). The main reason for its higher rates arises than 90% of patients who undergo a low anterior resec- from the conviction that the QOL of patients undertak- tion (LAR) . However, within the clinical practice, we ing SPS is better than that of patients with a permanent discovered some patients experienced periodic bowel stoma. But a systematic review concluded that SPS does movements (i.e. stool being hard at first then mushy or liquid occurs every few days), which is not reported in * Correspondence: firstname.lastname@example.org previous studies [3–8]. Risk factors for developing bowel Lishi Yin and Ling Fan contributed equally to this work. dysfunction are low-level anastomosis, end-to-end anasto- Department of Emergency and the Intensive Care Unit, Chongqing Hospital mosis, anastomotic leakage, acute or chronic inflammation, of Traditional Chinese Medicine, No. 6 Road Panxi seven branch, Chongqing City 400000, China surgical autonomic denervation, loss of the rectal reservoir Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Yin et al. BMC Surgery (2018) 18:35 Page 2 of 6 function and preoperative radiotherapy. The level of anas- Data collection tomosis is the most important factor [2, 9–11]. The participants’ bowel symptoms and self -care strategies The outcome of the above bowel symptoms varied. after surgery were investigated with the structured inter- For some patients, the symptoms can improve over time, view guide based on the “symptom management theory” and other patients find it difficult to treat and leave a dimensions . The guide comprises symptom experi- permanent colostomy. There is scant data on the length ence and symptom management strategies. Based upon of time it takes patients to report an improved bowel previous data, both fixed-response and open-ended ques- function. Because of the lack of effective medical inter- tions were included. Most of the fixed-response questions ventions, the patients have to struggle with bowel prob- were rated on a Likert-type scale, ranging from 3 to 4 lems for a long term. They can provide rich information points, and sought information on the types and fre- for the management bowel symptoms through trial and quency of symptoms experienced in the past 1 month. error. Such information is vital to healthcare profes- From clinical observations, we found that some postoper- sionals when advising patients on the possible benefits. ative patients reported a finger-shaped consistency stools In 2008, Hunphreys’ teamwork developed the “symptom that was not shown in Bristol stool scale. Therefore, this management theory” followed by two revisions. It is a paper added this category to this scale. middle-range theory, providing guidelines for symptom At the start of the study, most of participants were management . outside the hospital, and only a few returned for some The purpose of this article is to explore the bowel reasons, such as postoperative chemotherapy and symptoms and self-care strategies for survivors of rectal follow-up visit. With this in mind, interviews were con- cancer during LAR postoperative recovery using a struc- ducted by two ways: by telephone and face to face. tured interview guideline based on the “Symptom Management Theory” dimension. Data analysis Data analysis was guided by the principles of deductive Methods content analysis . This analysis is used when the struc- Sample ture of analysis is operationalized on the basis of previous The sample across one tertiary teaching hospital in knowledge. Data were quantized by the way of frequencies China was chosen for the study. Including individuals and percentages as well as central tendency and dispersion. were if they were 3 to 24 months after the LAR (tumors located at a maximum of 8 cm from the anal verge) for Results rectal cancer. The operative steps were en bloc rectal A total of 102 patients were invited to participate in the excision including (1) ligation of the inferior mesenteric study. Two patients refused, and finally enrolled 100 artery at its origin, (2) complete mobilization of the patients. 69 of the respondents participated in the tele- splenic flexure, (3) transection of the proximal left colon, phone interview and 31 participants participated in a (4) sharp dissection in the avascular plane into the face-to-face interview. The effective rate is 98.0%. A sam- pelvis—anterior to the presacral fascia—parietal fascia ple of 100 participants (56 men) with a mean age of 60.3 and outside the fascia propria or enveloping visceral ± 10.0 years was available for data. 46% participants were fascia, (5) division of lymphatics and middle from rural area and 54% participants from urban area. hemorrhoidal vessels anterolaterally at the level of the The average interval between LAR or closure of the tem- pelvic floor, and (6) inclusion of all pelvic fat and lymph- porary stoma and interview was 11.9 ± 6.6 months. 21% of atic material to the level of the anorectal ring or all fat participants were in 3–5 months, 40% of participants were and lymphatic material at least 2 cm below the level of in 6–11 months and 39% of participants were in 12– the distal margin. Exclusion criteria included anasto- 24 months. The length of tumor from anal verge was 6.4 motic leakage, recurrence of rectal cancer, adjuvant ± 1.3 cm. 75% participants had received adjuvant chemo- radiation, pelvic exenteration, palliative care, acute or therapy. All the participants had received both the chronic inflammation and language barriers. end-to-end anastomosis and double stapled technique. Ethical consideration Symptom experience Approval was gained from all the relevant ethics com- With reference to symptom experience, symptom mittees prior to the study. All interviews were conducted perception, symptom evaluation and symptom responses and documented by the same researcher. Provides indi- were adapted. viduals with information about research and documenta- tion goals. After receiving the consent, start the Bowel habits interview. In the process, they can withdraw from the 92% of participants reported changes in bowel habits study at any time or refuse to answer the question. (Table 1). Fifty-seven percent of subjects had > 3 bowel Yin et al. BMC Surgery (2018) 18:35 Page 3 of 6 Table 1 Bowel habits before and after surgery (n = 100) (60.0%) participants, inability to consciously control bowel movements by 6/40 (15.0%) participants and Before surgery After surgery physical activities by 4/40 (10.0%) participants. n% n % Frequency of defecation Bowel evaluation (1–3)times/day 44 44 23 23 For a group of 79 participants 6 to 24 months postoper- (4–7)times/day 41 41 32 32 atively, 68 (86.1%) participants reported a significant > 7times/day 12 12 25 25 improvement in bowel symptoms (Table 3). In this (2–3)times/week 3 3 1 1 significantly improved subgroup, 48 (70.5%) participants reported the length of time it took improvement was at Periodic bowel movements 0 0 19 19 least 6 months. Stool consistency Hard lumps 14 14 9 9 Social and physical responses Sausage-shaped 32 32 4 4 Restriction of leisure activities was seen in 73% partici- Finger-shaped 1 1 52 52 pants. They avoided going out and exercised in a specific Soft blobs 20 20 12 12 area. The availability of toilets was considered by 77% participants. 61% participants reported a sleep disturb- Fluffy pieces 28 28 10 10 ance. For a group of 10 participants aged of ≦55 years at Liquid 5 5 1 1 the 12–24 months of surgery, 7 participants continued Miscellaneous 0 0 12 12 to work and 5 of them came from rural area. movements / day after surgery and > 7 / day for 25% of Psychological responses the subjects. 19% of participants had periodic bowel With psychological responses to open-ended questions, movements. Almost all participants reported fewer the deductive content analysis produced 2 categories stools after surgery. The most common (52%) fecal comprising 5 subcategories (Table 4). Negative psycho- consistency was finger-shaped with a small amount. logical responses were found in 72% participants. A secondary theme running throughout all these categories was the feeling of confidence and normality. Bowel symptoms The bowel symptoms reported are shown in Table 2. Symptom management strategies The 6 most frequently symptoms were excessive flatus, Self-care strategies adopted by participants included diet, clustering, urgency, straining, bowel frequency (> 3 bowel medications, practice management and exercise. times/day) and anal pendant expansion. Participants reported multiple precipitating factors associated with Diet soiling, 68 responses from 40 participants. The most 96% of participants reported a change in diet. The frequently reported was passing wind by 34/40 (85.0%) change was described by high fiber, low fat, no offending participants, not immediate access to toilet by 24/40 food such as wine, cold beverage, reduced spicy food and stimulating food (i.e. chicken, mutton, seafood and Table 2 Bowel symptoms after surgery (n = 100) ginger) that may induce or aggravate cancer. The 2 most Number Percent common types of postsurgical diet were high fiber and Excessive flatus 93 93 Table 3 Length of time for patients reporting a significant Clustering 86 86 improvement of bowel symptoms Urgency 77 77 Significant Patients at 6–11 Patients at 12-24 Straining 62 62 improvement months (n = 40) months (n = 39) Bowel frequency 57 57 n% n % Anal pendant expansion 53 53 NO 7 17.5 4 10.3 Incomplete evacuation 42 42 YES 33 35 Soiling 40 40 3–5 months 14 35.0 6 15.4 Perianal soreness/itching 36 36 6 months 13 32.5 16 41.0 Abdominal/rectal pain 31 31 7–11 months 6 15.0 2 5.1 Periodic bowel movements 19 19 12 months 9 23.1 Inability to distinguish between 11 11 13–24 months 2 5.1 passing feces/wind Yin et al. BMC Surgery (2018) 18:35 Page 4 of 6 Table 4 Length of time for patients reporting a significant out with spare underpants, sought the location of toilets improvement of bowel symptoms and filled papers or pads in the anus. Physical activities Significant Patients at 6–11 Patients at 12-24 were focused mainly on walking and dancing. Some par- improvement months (n = 40) months (n = 39) ticipants reported a desire to defecate after meal or phys- n% n % ical activities which were not perceived before surgery. NO 7 17.5 4 10.3 Discussion YES 33 35 Symptom experience 3–5 months 14 35.0 6 15.4 Most of participants reported a change in bowel habits 6 months 13 32.5 16 41.0 with increased bowel movements and finger-shaped 7-11 months 6 15.0 2 5.1 consistency stools. This change may be due to loss of 12 months 9 23.1 the rectal reservoir function for the decreased ability to 13–24 months 2 5.1 store feces and surgical autonomic denervation for the altered bowel motions. Periodic bowel movements re- low fat. In the subsequent 50-person interview, 33 ported by participants is not found in previous studies (66.0%) had greasy food and 32(64.0%) participants had [3–8], which may be due to the rigid neorectum around cold drinks developed diarrhea. the anastomosis where feces is hard to pass until a certain amount of it produces an enough pressure. Bowel medications The type of bowel symptom identified in this paper is Two types of bowel medications reported by participants similar to the findings of earlier studies [4, 7], but its fre- are presented in Table 5. More than two-fifths participants quency rankings are higher. It could be due to the lower had used the medications for bowel control in the past height of tumor resulting in poor bowel function. During 1 month, the most common being Imodium. Minority the interview, we found that some participants confused participants required long-term use of medications to the term “clustering” with “incomplete evacuation”, control stool elimination. Less than two-fifths participants which may increase the frequency of the latter. A study had used medications for perianal soreness or itching, by  Emmertsen and Laurberg (2012) have shown that with sitz bath being the most common reported. incontinent of flatus is one of the most common bowel dysfunction, which is not identified this paper because Practice management and exercise participants did not have a try to hold flatus. Abdominal 36% of participants reported perianal soreness or itching or rectal pain was a sort of dull or distending. Perianal after frequent bowel movements, which promoted them soreness or itching was caused by bowel frequency, to use moist wipes and irrigation to clean the anal area. In incomplete evacuation and intake of spicy food. order to prevent leakage of feces, some participants went Soiling is a concern for participants. Leaking faces was mainly mushy or liquid. It was associated with the following factors: passing wind due to incomplete clos- Table 5 Bowel habits before and after surgery (n = 100) ure of anal canal consequent upon the internal anal Before surgery After surgery sphincter dysfunction; not immediate access to toilet n% n % due to lack of control over feces resulted from the exter- Frequency of defecation nal anal sphincter weaknesses; physical activities due to (1–3)times/day 44 44 23 23 the consequent increase of intra-abdominal pressure and (4–7)times/day 41 41 32 32 inability to consciously control bowel movements due to > 7times/day 12 12 25 25 the damage of transitional epithelium above dentate line. The two most common causes were passing wind and (2–3)times/week 3 3 1 1 not immediate access to toilet. This is in contrast to the Periodic bowel movements 0 0 19 19 observations of  Nikoletti et al. (2008), in which phys- Stool consistency ical activities and after going to the toilet were the most Hard lumps 14 14 9 9 common. Sausage-shaped 32 32 4 4 Finger-shaped 1 1 52 52 Bowel evaluation Research on the time it takes patients to report improved Soft blobs 20 20 12 12 bowel function is limited. In our study, almost all partici- Fluffy pieces 28 28 10 10 pants admitted that the bowel symptoms were improved Liquid 5 5 1 1 with time. The majority of (86.1%) subjects reported a Miscellaneous 0 0 12 12 significant improvement in their bowel symptoms from 6 Yin et al. BMC Surgery (2018) 18:35 Page 5 of 6 to 24 months, concentrating on soiling, anal pendant exacerbate diarrhea and bloating. Spicy food can cause expansion and urgency. The most frequently reported im- perianal soreness, constipation and diarrhea. Due to the provements are at least 6 months. This is similar to the development of traditional Chinese medicine, some par- findings of an earlier study , where QOL improved ticipants reported avoiding stimulating food. Norton and over time and significantly after the first 6 months. The Chelvanayagam (2001)  concluded the bowel func- predictability of bowel symptoms varied. For some partici- tion was affected by artificial sweeteners, tea, cola drinks pants, the symptoms were predicted so that they planed and chocolates, which was not confirmed in this paper. evacuation at a convenient time. Through interview, the current study concluded that bowel medications should be a conservative measure Bowel responses aimed at controlling symptoms. Three participants More than half of participants reported bowel frequency, reported that Medilac-Vita comprising Bacillus subtilis but less than two-fifths participants considered the sp. and Enterococcus faecium sp. was better than Imo- extent of disturbance of leisure activities as ‘often’. This dium in case of frequency bowel movements and softer discrepancy between the symptom prevalence and the stool. As Western medicine failed to treat bowel prob- bother rating may be explained by participants’ good lems, some participants sought help from traditional control of the feces, knowing the location of the toilets Chinese medicine. For perianal soreness, some partici- and sacrificing QOL. For most of participants, the con- pants reported sitz bath with water or saline solution sequence of resection of tumor was a small price to pay was available and effective. Inappropriate use of bowel for their life. As a result, their QOL were underesti- medications can cause unnecessary adverse effects. In mated. This phenomenon is an example of response this paper, some participants reported constipation and shift discovered by Sprangers and Schwartz (1999) . diarrhea after taking Imodium and Lactulose. Therefore, Five of seven participants who continued their work healthcare professionals should educate patients on how were from rural area, which demonstrated household to use them properly. income is a positive factor in ongoing work. Most (61%) The location and availability of toilets is necessary for participants reported a sleep disturbance due to frequency this group of participants. It is encouraged to follow the and night-time soiling and felt fatigue the next day. successful experience of Australia to establish National Most participants had a negative psychological reac- Public Toilet Map and Web site . Increased urgency tion. This may be because they did not recognize the to defecate after meal or physical activities may be expe- change in bowel anatomy, did not distinguish between rienced by some participants due to the altered bowel bowel symptoms caused by surgery and symptoms asso- anatomy. Loots and Bartlett (2009)  encouraged par- ciated with cancer recurrence, there was no effective ticipants to remain active or gradually increase their intervention. A substantial proportion of participants’ level of physical activity as the improved bowel control complaint their bowel function were neglected by health is associated with confidence improved. It is because professionals. This is in contrast to the findings of an more vigorous exercises such as running, swimming, earlier study  but is supported by another study . and cycling may stimulate bowel activity. Due to lack of information support, trial and error adapted by participants for managing bowel symptoms Implications for practice was aimed at gaining self-confidence and normality. Health professionals should help patients understand the nature and outcome of bowel symptoms, understand Symptom management strategies patients’ strategies for adapting to bowel symptoms, pro- The two most common types of diet after surgery were vide advice on possible benefits, and provide leadership in high fiber and low fat. Some participants followed a spe- addressing bowel problems. Close attention should be cific diet. Based on the principal of ensuring a nutrition- given to patients who developed with new rectal bleeding ally adequate diet, participants are encouraged to reduce for anastomotic recurrence (AR) of colonic cancer. AR oc- their food intake, but with increased frequency. Almost curred less than two years after radical resection of colon all participants admitted that bananas, sweet potatoes cancer. Its diagnosis can be confirmed by colonoscopy. and fresh vegetables facilitate stool elimination. High LAR followed by intensive careful endoscopic monitoring fiber is confusion for some participants. Depending on could result in long-term disease-free survival . the type of fiber ingested, it may exacerbate problems with soft stools and evacuation. This is consistent with Conclusion earlier studies [7, 18]. The two studies found that sup- Bowel symptoms can be significantly improved for most plementation with soluble dietary fiber improves the of survivors. The most frequently reported improvement water-holding capacity of stool solids, the consistency of is at least 6 months. This paper identifies a new bowel stools and fecal incontinence and insoluble fiber may symptom (i.e. periodic bowel movements). Rectal cancer Yin et al. BMC Surgery (2018) 18:35 Page 6 of 6 survivors following low anterior resection surgery felt 3. Emmertsen KJ, Laurberg S. Bowel dysfunction after treatment for rectal cancer. Acta Oncol. 2008;47:994–1003. https://doi.org/10.1080/ abandoned after surgery and lacked the information to manage bowel symptoms. Healthcare professionals 4. Emmertsen KJ, Laurberg S. Low anterior resection syndrome score: should provide relevant information to support them, in development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg. 2012; particular how to discriminate between the bowel symp- 255:922–8. https://doi.org/10.1097/SLA.0b013e31824f1c21. toms caused by surgery and the symptoms that might be 5. Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal associated the recurrence of cancer. excision for rectal cancer: functional assessment and factors affecting outcome. Color Dis. 2006;8:650–6. https://doi.org/10.1111/j.1463-1318.2006. Abbreviations 00992. QOL: quality of life; SPS: sphincter-saving surgery 6. Landers M, McCarthy G, Savage E. 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Published: Jun 4, 2018