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Kim YM, Oh EG. Effectiveness of Pelvic Floor Muscle Training for Patients Following Low Anterior Resection: A Systematic Review and Meta-analysis. J Wound Ostomy Continence Nurs 2023; 50:142-150. [PMID: 36867038 DOI: 10.1097/won.0000000000000958] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE The purpose of this systematic review was to identify the effects of pelvic floor muscle training (PFMT) on bowel function and health-related quality of life among patients who have undergone low anterior resection. METHODS A systematic review and meta-analysis of pooled findings was conducted according to PRISMA guidelines. SEARCH STRATEGY A literature search was completed using PubMed, EMBASE, Cochrane, and CINAHL electronic databases; we searched studies published in English and Korean languages. Two reviewers independently selected relevant studies, evaluated their methodological quality, and extracted data. Meta-analysis was conducted of pooled findings. FINDINGS Thirty-six of 453 articles retrieved were read in full and 12 articles were included in the systematic review. In addition, pooled findings from 5 studies were selected for meta-analysis. Analysis revealed that PFMT reduced bowel dysfunction (mean difference [MD] -2.39, 95% confidence interval [CI] -3.79 to -0.99) and improved several domains of health-related quality of life: lifestyle (MD 0.49, 95% CI 0.15 to 0.82), coping (MD 0.36, 95% CI 0.04 to 0.67), depression (MD 0.46, 95% CI 0.23 to 0.70), and embarrassment (MD 0.24, 95% CI 0.01 to 0.46). IMPLICATIONS Findings suggested PFMT is effective for improving bowel function and enhancing multiple domains of health-related quality of life after low anterior resection. Further well-designed studies are required to confirm our conclusions and provide stronger evidence for the effects of this intervention.
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Affiliation(s)
- Young Man Kim
- Young Man Kim, PhD, RN , College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju-si, South Korea
- Eui Geum Oh, PhD, RN, FAAN , Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, and Yonsei Evidence Based Nursing Center of Korea: A Joanna Briggs Institute Affiliated Group, Seoul, South Korea
| | - Eui Geum Oh
- Young Man Kim, PhD, RN , College of Nursing, Research Institute of Nursing Science, Jeonbuk National University, Jeonju-si, South Korea
- Eui Geum Oh, PhD, RN, FAAN , Mo-Im Kim Nursing Research Institute, Yonsei University College of Nursing, and Yonsei Evidence Based Nursing Center of Korea: A Joanna Briggs Institute Affiliated Group, Seoul, South Korea
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Burch J, Swatton A, Taylor C, Wilson A, Norton C. Managing Bowel Symptoms After Sphincter-Saving Rectal Cancer Surgery: A Scoping Review. J Pain Symptom Manage 2021; 62:1295-1307. [PMID: 34119617 DOI: 10.1016/j.jpainsymman.2021.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 11/26/2022]
Abstract
CONTEXT Rectal cancer is common and it is often treated by surgery with or without chemoradiation. Cancer treatment frequently results in bowel symptoms. OBJECTIVES The review aim was to chart the management options for bowel symptoms following rectal cancer surgery. METHODS A scoping review was undertaken searching nine healthcare databases, using relevant search terms and Boolean operators following PRISMA-ScR guidance. Data were extracted into an Excel spreadsheet using headings from the United Kingdom Department of Health guidance and are reported narratively. RESULTS 30 heterogeneous studies met the inclusion criteria, including 853 patients. The most commonly reported bowel symptom was fecal incontinence; the most frequent management strategy was sacral nerve stimulation. Most studies reported on a single management option, often used to manage more than one bowel symptom. Often failure to satisfactorily improve symptoms using options such as medication was needed prior to progressing to other management options. In some studies more than one management option was used, such as rehabilitation programmes. CONCLUSION It is likely that to effectively manage the bowel symptoms experienced after rectal cancer treatment, more than one management option may be used-. Additionally, different management options may need to be tried concurrently.
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Affiliation(s)
- Jennie Burch
- St Mark's Hospital, Harrow, Middlesex; HA1 3UJ part of London North West University Healthcare NHS Trust, Harrow, Middlesex.
| | - Anna Swatton
- St Mark's Hospital, Harrow, Middlesex; HA1 3UJ part of London North West University Healthcare NHS Trust, Harrow, Middlesex
| | - Claire Taylor
- St Mark's Hospital, Harrow, Middlesex; HA1 3UJ part of London North West University Healthcare NHS Trust, Harrow, Middlesex
| | - Ana Wilson
- St Mark's Hospital, Harrow, Middlesex; HA1 3UJ part of London North West University Healthcare NHS Trust, Harrow, Middlesex; Imperial College, London
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Asnong A, D'Hoore A, Van Kampen M, Devoogdt N, De Groef A, Sterckx K, Lemkens H, Wolthuis A, Van Molhem Y, Van Geluwe B, Debrun L, Geraerts I. Randomised controlled trial to assess efficacy of pelvic floor muscle training on bowel symptoms after low anterior resection for rectal cancer: study protocol. BMJ Open 2021; 11:e041797. [PMID: 33483444 PMCID: PMC7831707 DOI: 10.1136/bmjopen-2020-041797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Radical surgery after a total mesorectal excision (TME) for rectal cancer often results in a significant decrease in the patient's quality of life, due to functional problems such as bowel, urinary and sexual dysfunction. The effect of pelvic floor muscle training (PFMT) on these symptoms has been scarcely investigated. We hypothesise that the proportion of successful patients will be significantly higher in the intervention group, receiving 12 weeks of PFMT, compared with the control group without treatment. The primary outcome of this trial is the severity of bowel symptoms, measured through the Low Anterior Resection Syndrome questionnaire, 4 months after TME or stoma closure. Secondary outcomes are related to other bowel and urinary symptoms, sexual function, physical activity and quality of life. METHODS AND ANALYSIS This research protocol describes a multicentre single blind prospective, randomised controlled trial. Since January 2017, patients treated for rectal cancer (n=120) are recruited after TME in three Belgian centres. One month following surgery or, in case of a temporary ileostomy, 1 month after stoma closure, patients are randomly assigned to the intervention group (n=60) or to the control group (n=60). The assessments concern the preoperative period and 1, 4, 6, 12 and 24 months postoperatively. ETHICS AND DISSEMINATION The study will be conducted in accordance with the Declaration of Helsinki. Ethics approval was granted by the local Ethical Committee of the University Hospitals Leuven (s59761) and positive advice from the others centres has been obtained. Dissemination of the results will be accomplished via guidelines and (non-)scientific literature for professionals as well as organisation of patient symposia. TRIAL REGISTRATION NUMBER NTR6383.
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Affiliation(s)
- Anne Asnong
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - André D'Hoore
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
- Department of Oncology, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Marijke Van Kampen
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Nele Devoogdt
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - An De Groef
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Kim Sterckx
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Hilde Lemkens
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Albert Wolthuis
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
- Department of Oncology, KU Leuven, Leuven, Vlaams-Brabant, Belgium
| | - Yves Van Molhem
- Department of Abdominal Surgery, OLVZ, Aalst, Oost-Vlaanderen, Belgium
| | - Bart Van Geluwe
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
- Department of Abdominal Surgery, AZ Groeninge - Campus Kennedylaan, Kortrijk, West-Vlaanderen, Belgium
| | - Lynn Debrun
- Department of Abdominal Surgery, KU Leuven University Hospitals Leuven Gasthuisberg Campus, Leuven, Vlaams-Brabant, Belgium
| | - Inge Geraerts
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Vlaams-Brabant, Belgium
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Chan KYC, Suen M, Coulson S, Vardy JL. Efficacy of pelvic floor rehabilitation for bowel dysfunction after anterior resection for colorectal cancer: a systematic review. Support Care Cancer 2020; 29:1795-1809. [PMID: 33111180 DOI: 10.1007/s00520-020-05832-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 10/13/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Bowel dysfunction is common after anterior resection for colorectal cancer (CRC). Pelvic floor rehabilitation (PFR) may improve functional outcomes after surgery. This review aimed to evaluate the efficacy of PFR for patients with bowel symptoms after anterior resection. METHODS MEDLINE, CINHAL, PUBMED, EMBASE, Scopus, PsycINFO, Web of Science, PEDRO and Cochrane Library were searched from inception to June 2019. A final search was performed on 11 July 2020. Randomised controlled trials (RCTs), cohort studies, case-control studies and case series of bowel dysfunction after CRC surgery and PFR were eligible for review. Outcome measures were bowel function changes measured by patient-reported outcomes and manometric measurement. Risk of bias assessments using Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle Ottawa Scale (NOS) were conducted. RESULTS Eleven trials met eligibility criteria: four retrospective studies and seven prospective, non-randomised controlled studies. A total of 516 participants were included, of which 455 received PFR. Functional outcomes were measured by bowel functional outcome questionnaires, patient diary, anorectal manometry and three studies measured quality of life. Faecal incontinence was improved in seven studies, and bowel frequency also decreased in five studies. The mean MINORS score was 10 (8-13) out of 16 in non-comparative groups and 18 (16-22) out of 24 in comparative groups; the NOS was 4.2 (3-7) out of 9. The overall risk of bias was high in most studies. CONCLUSIONS PFR appears to be beneficial for improving bowel function after anterior resection for CRC. However, the studies included had methodological limitations, so further investigation on the effectiveness of PFR is warranted.
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Affiliation(s)
- K Y C Chan
- Concord Cancer Centre, Concord Repatriation & General Hospital, Hospital Road, Sydney, NSW, 2139, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - M Suen
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Colorectal Surgery, Concord Repatriation & General Hospital, Concord, NSW, 2139, Australia
| | - S Coulson
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Janette L Vardy
- Concord Cancer Centre, Concord Repatriation & General Hospital, Hospital Road, Sydney, NSW, 2139, Australia.
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
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Fomenko OY, Kashnikov VN, Alekseev MV, Veselov AV, Belousova SV, Aleshin DV, Morozov SV, Kozlov VA, Reutova AA, Rumiantsev AS, Nafedzov IO. [Rehabilitation program for patients with low anterior resection syndrome]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2020; 97:52-59. [PMID: 33054009 DOI: 10.17116/kurort20209705152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED Surgical treatment of rectal cancer and sphincter-preserving low anterior resection results to evacuation disorders («low anterior resection syndrome» - LARS). There are no clinical recommendations for the treatment of patients with LARS as well as a rehabilitation program for them. OBJECTIVE To develop a rehabilitation program for patients with low anterior resection syndrome. MATERIAL AND METHODS The investigation was performed at 2 stages. During the first stage, 29 patients with LARS (17 (58.6%) men, mean age of the participants' 61.5±9.5 years), 12 (41.4%) women (mean age 61.2±7.8 years) were examined and received the course of conservative treatment with the use of biofeedback-therapy performed by the standard protocol. On the second stage, 17 patients (mean age 61.4±12.7 years) - 9 (52.9%) men, 8 (47.1%) women received biofeedback therapy in combination with tibial neuromodulation (TNM). Functional state of the rectum and the locking apparatus in all patients were evaluated by anorectal manometry: sphincterometry and studies of the reservoir function of the rectum before and after treatment. RESULTS The developed complex of rehabilitation measures led to improved treatment results for patients with rectal cancer by improving the quality of life after low anterior resection, reducing the manifestations of LARS (by 47.8%). Stable positive results of treatment were maintained in 36.4% of patients, positive dynamics from the treatment according to the LARS scale decreased slightly in 54.5%, deterioration of indicators in 3-6 months after conservative rehabilitation was registered in 9.1% of cases. At the first stage maximal squeeze pressure improvement was reached in the whole cohort (p=0.047), at the second stage these trend was seen only for women for the pressure values at rest (p=0.01) and during squeeze (p=0.025). The data obtained allowed us to recommend a repeat course of treatment to 63.6% of patients. The authors modified and optimized a special complex of physical therapy for the rehabilitation of patients both in a medical institution and at home. These exercises are aimed at improving the functional state of the pelvic floor muscles and sphincter apparatus. CONCLUSION Rehabilitation program for patients with low anterior resection syndrome should include: 1) biofeedback therapy to improve the holding function; 2) biofeedback therapy aimed at improving the reservoir function and sensitivity of the rectum to filling; 3) tibial neuromodulation. This program may help improving the contractility of the anal sphincter and reservoir function of the rectum, as well as the appearance of the urge to defecate.
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Affiliation(s)
- O Yu Fomenko
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - V N Kashnikov
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - M V Alekseev
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - A V Veselov
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - S V Belousova
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - D V Aleshin
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - S V Morozov
- Federal Research Center of Nutrition, Biotechnology and Food Safety, Moscow, Russia
| | - V A Kozlov
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
| | - A A Reutova
- State clinical hospital No. 67 named after L.A. Vorokhobov, Moscow, Russia
| | - A S Rumiantsev
- State clinical hospital No. 67 named after L.A. Vorokhobov, Moscow, Russia
| | - I O Nafedzov
- National Medical Research Centre for Coloproctology named after A.N Ryzhikh, Moscow, Russia
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Yamada K, Saiki Y, Takano S, Iwamoto K, Tanaka M, Fukunaga M, Noguchi T, Nakamura Y, Hisano S, Fukami K, Kuwahara D, Tsuji Y, Takano M, Usuku K, Ikeda T, Sugihara K. Long-term results of intersphincteric resection for low rectal cancer in Japan. Surg Today 2019; 49:275-285. [PMID: 30604217 DOI: 10.1007/s00595-018-1754-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/01/2018] [Indexed: 12/18/2022]
Abstract
Intersphincteric resection (ISR) is the ultimate sphincter-preserving procedure for low rectal cancer. A questionnaire about the standardization of ISR was given to 2125 patients who underwent curative ISR for low rectal cancer between 2005 and 2012 at 127 affiliated institutions of the Japanese Society for Cancer of the Colon and Rectum (JSCCR), and the results were compared with the results of a systematic review. The findings revealed that although mortality and morbidity were relatively low and the survival rate after ISR was good, the rates of local recurrence and postoperative fecal incontinence were relatively high. The radicality of ISR was compared with that of abdominoperineal resection and low anterior resection using the propensity score matching prognosis analysis of patients in the JSCCR nationwide registry. The local recurrence rate was significantly higher after ISR, and especially high in patients with T3 (invasion into the external anal sphincter) and T4 disease. These results provide evidence about the factors related to fecal incontinence after ISR. As measures for the standardization of ISR, it is important to reconfirm that ISR is not indicated for patients with cT3 and cT4 disease and those with poor preoperative defecatory function, based on the ISR indication criteria.
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Affiliation(s)
- Kazutaka Yamada
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan.
| | - Yasumitsu Saiki
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Shota Takano
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Kazutsugu Iwamoto
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Masafumi Tanaka
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Mitsuko Fukunaga
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Tadaaki Noguchi
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Yasushi Nakamura
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Saburo Hisano
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Kensaku Fukami
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Daisaku Kuwahara
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Yoriyuki Tsuji
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Masahiro Takano
- Department of Surgery, Coloproctology Center Takano Hospital, 3-2-55 Oe, Chuo-ku, Kumamoto, 862-0971, Japan
| | - Koichiro Usuku
- Department of Medical Information Sciences and Administration Planning, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Tokunori Ikeda
- Department of Medical Information Sciences and Administration Planning, Kumamoto University Hospital, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Kenichi Sugihara
- The Japanese Society for Cancer of the Colon and Rectum, 2 Sanbancho, Chiyoda-ku, Tokyo, 102-0075, Japan
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Croese AD, Whiting S, Vangaveti VN, Ho YH. Using sacral nerve modulation to improve continence and quality of life in patients suffering from low anterior resection syndrome. ANZ J Surg 2018; 88:E787-E791. [PMID: 30347509 DOI: 10.1111/ans.14871] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/19/2018] [Accepted: 08/23/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Sphincter preserving surgery for the treatment of rectal cancer is very often feasible, avoiding a permanent colostomy. It is well recognized that a large proportion of patients will experience altered bowel habit following low anterior resection (LAR). Faecal incontinence is a common symptom associated with LAR syndrome. The aim of this study is to evaluate the long-term improvement in continence and quality of life (QoL) in LAR patients treated with sacral nerve modulation. METHODS Patients with ongoing faecal incontinence for >1 year after reversal of diverting ileostomy post ultra-LAR were selected for the study. Eligible patients underwent sacral nerve modulator implantation as a two-stage procedure. Bowel diaries and the Cleveland Clinic Faecal Incontinence Score were used to measure faecal incontinence and QoL. RESULTS Twelve patients underwent permanent implantation of a sacral nerve stimulator. Median follow-up was 34 months (interquartile range (IQR) 20.25-62.5 months). The median improvement in faecal incontinence was 90% (IQR 76.25-98.75%) and the median improvement in patient QoL was 80% (IQR 71.25-93.75%). Patients who had previously been treated with biofeedback showed a median improvement in incontinence of 75% compared to 90% which was found in patients who had not had prior biofeedback treatment. The mean percentage improvement in patients with an internal anal sphincter defect was 80% compared to 90% seen in patients with an intact sphincter. CONCLUSIONS The results of this study suggest that sacral nerve modulation should be more widely considered as an effective treatment strategy for patients with faecal incontinence following LAR.
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Affiliation(s)
- Alexander D Croese
- Institute of Surgery, Townsville Hospital, Townsville, Queensland, Australia
| | - Scott Whiting
- Division of Surgery, Mackay Base Hospital, Mackay, Queensland, Australia
| | - Venkat N Vangaveti
- School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Yik-Hong Ho
- School of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors. Int J Surg 2018; 56:234-241. [PMID: 29936195 DOI: 10.1016/j.ijsu.2018.06.031] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/10/2018] [Accepted: 06/20/2018] [Indexed: 12/16/2022]
Abstract
AIM To summarize the reported prevalence and causative factors of Low Anterior Resection Syndrome (LARS) from studies using the LARS score. METHODS A systematic literature search was conducted using Pubmed, Ovid Medline and the Cochrane database. Searches were performed using a combination of MeSH (medical subject headings) terms and key terms. Studies that were included used the LARS score as their primary collection tool. Studies were excluded if initial surgery was not for malignancy, or if the majority of LARS scores were from patients less than 1 year post initial surgery or closure of diverting stoma. Eligible studies were assessed with a validated quality assessment tool prior to performing a meta-analysis with quality effects model. Meta-analysis was conducted with prevalence estimates that had been transformed using the double arcsine method. RESULTS Following the initial search and implementation of inclusion and exclusion criteria 11 studies were deemed suitable for meta-analysis. Meta-analysis found the estimated prevalence of major LARS was 41% (95% CI 34 -48). Where possible outlier studies were excluded, the prevalence was 42% (95%CI 35-48). Radiotherapy and tumour height were the most consistently assessed variables, both showing a consistent negative effect on bowel function. Defunctioning ileostomy was found to have a statically significant negative impact on bowel function in 4 of 11 studies. The majority of reported data has been produced by groups in Denmark and the United Kingdom with limited numbers provided by other locations. Available data is heterogenous with some variables having limited numbers, making meta-analysis of certain variables impossible. CONCLUSIONS There is significant prevalence of Low Anterior Resection Syndrome following oncological rectal resection. A low anastomotic height or history of radiotherapy are major risk factors.
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Ridolfi TJ, Berger N, Ludwig KA. Low Anterior Resection Syndrome: Current Management and Future Directions. Clin Colon Rectal Surg 2016; 29:239-45. [PMID: 27582649 DOI: 10.1055/s-0036-1584500] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Outcomes for rectal cancer surgery have improved significantly over the past 20 years with increasing rates of survival and recurrence, specifically local recurrence. These gains have been realized during a period of time in which there has been an increasing emphasis on sphincter preservation. As we have become increasingly aggressive in avoiding resection of the anus, we have begun accepting bowel dysfunction as a normal outcome. Low anterior resection syndrome, defined as a constellation of symptoms including incontinence, frequency, urgency, or feelings of incomplete emptying, has a significant impact on quality of life and results in many patients opting for a permanent colostomy to avoid these symptoms. In this article, we will highlight the most recent clinical and basic science research on this topic and discuss areas of future investigation.
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Affiliation(s)
- Timothy J Ridolfi
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nicholas Berger
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kirk A Ludwig
- Department of Surgery, Division of Colorectal Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Hwang YH, Choi JS, Nam YS, Salum MR, Weiss EG, Nogueras JJ, Wexner SD. Biofeedback Therapy After Perineal Rectosigmoidectomy or J Pouch Procedure. Surg Innov 2016; 12:135-8. [PMID: 16034502 DOI: 10.1177/155335060501200211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to determine the outcome and to identify possible predictors of success for biofeedback therapy after perineal rectosigmoidectomy (PRS) or coloanal or ileoanal J pouch. A retrospective chart review of all patients with electromyography-based biofeedback therapy due to fecal incontinence after PRS or a J pouch procedure was undertaken. Follow-up was obtained by telephone survey. Fourteen patients (4 men and 10 women) were included in this study. In the 9 patients after PRS, the frequency of daily bowel movements was 3.6 2.8 preoperatively, 4.1 3.2 prebiofeedback, and 2.2 - 1.3 postbiofeedback (P < .05). The frequency of daily incontinent episodes was reduced from 2.4 2.2 preoperatively and 2.0 + 1.9 prebiofeedback to 0.26 0.3 postbiofeedback (P< .05). The incontinence scores decreased from 17 3.1 preoperatively to 16 + 2.1 prebiofeedback and to 8.2 5 postbiofeedback (P < .001). At a follow-up of 15.8 7.1 months, 5 patients after the J pouch had decreased daily bowel frequency from 6.6 4.2 prebiofeedback to 3.3 2 postbiofeedback and 3.1 2 at follow-up (P < .05). The frequency of daily incontinent episodes was reduced from 1.9 1.3 prebiofeedback to 0.9 0.7 postbiofeedback to 0.7 0.8 at followup (P < .05). The incontinence scores decreased from 13.4 2.7 prebiofeedback to 8.8 5.1 postbiofeedback to 6.8 5.5 at follow-up (P < 0.05). In both groups, the postbiofeedback incontinence score correlated with the prebiofeedback incontinence score. Furthermore, there was no correlation between outcome and age, interval between surgery and biofeedback therapy, frequency of biofeedback sessions, or manometry results in either group. Biofeedback therapy is an effective option for patients with fecal incontinence after perineal rectosigmoidectomy or colonic or ileal J pouch.
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Affiliation(s)
- Yong Hee Hwang
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA
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Kim JK, Jeon BG, Song YS, Seo MS, Kwon YH, Park JW, Ryoo SB, Jeong SY, Park KJ. Biofeedback Therapy Before Ileostomy Closure in Patients Undergoing Sphincter-Saving Surgery for Rectal Cancer: A Pilot Study. Ann Coloproctol 2015; 31:138-43. [PMID: 26361615 PMCID: PMC4564665 DOI: 10.3393/ac.2015.31.4.138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
Purpose This study prospectively investigated the effects of biofeedback therapy on objective anorectal function and subjective bowel function in patients after sphincter-saving surgery for rectal cancer. Methods Sixteen patients who underwent an ileostomy were randomized into two groups, one receiving conservative management with the Kegel maneuver and the other receiving active biofeedback before ileostomy closure. Among them, 12 patients (mean age, 57.5 years; range, 38 to 69 years; 6 patients in each group) completed the study. Conservative management included lifestyle modifications, Kegel exercises, and medication. Patients were evaluated at baseline and at 1, 3, 6, and 12 months after ileostomy closure by using anal manometry, modified Wexner Incontinence Scores (WISs), and fecal incontinence quality of life (FI-QoL) scores. Results Before the ileostomy closure, the groups did not differ in baseline clinical characteristics or resting manometric parameters. After 12 months of follow-up, the biofeedback group demonstrated a statistically significant improvement in the mean maximum squeezing pressure (from 146.3 to 178.9, P = 0.002). However, no beneficial effect on the WIS was noted for biofeedback compared to conservative management alone. Overall, the FI-QoL scores were increased significantly in both groups after ileostomy closure (P = 0.006), but did not differ significantly between the two groups. Conclusion Although the biofeedback therapy group demonstrated a statistically significant improvement in the maximum squeezing pressure, significant improvements in the WISs and the FI-QoL scores over time were noted in both groups. The study was terminated early because no therapeutic benefit of biofeedback had been demonstrated.
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Affiliation(s)
- Jeong-Ki Kim
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Byeong Geon Jeon
- Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Yoon Suk Song
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Sun Seo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Yoon-Hye Kwon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Daejin Medical Center Bundang Jesaeng General Hospital, Seongnam, Korea. ; Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea. ; Cancer Research Institute, Seoul National University, Seoul, Korea. ; Colorectal Cancer Center, Seoul National University Cancer Hospital, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Lin KY, Granger CL, Denehy L, Frawley HC. Pelvic floor muscle training for bowel dysfunction following colorectal cancer surgery: A systematic review. Neurourol Urodyn 2014; 34:703-12. [PMID: 25156929 DOI: 10.1002/nau.22654] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/16/2014] [Indexed: 12/11/2022]
Abstract
AIMS To identify, evaluate and synthesize the evidence examining the effectiveness of pelvic floor muscle training (PFMT) on bowel dysfunction in patients who have undergone colorectal cancer surgery. METHODS Eight electronic databases (MEDLINE 1950-2014; CINAHL 1982-2014; EMBASE 1980-2014; Scopus 1823-2014; PsycINFO 1806-2014; Web of Science 1970-2014; Cochrane Library 2014; PEDro 1999-2014) were systematically searched in March 2014. Reference lists of identified articles were cross referenced and hand searched. Randomized controlled trials, cohort studies and case series were included if they investigated the effects of conservative treatments, including PFMT on bowel function in patients with colorectal cancer following surgery. Two reviewers independently assessed the risk of bias of studies using the Newcastle-Ottawa Scale (NOS). RESULTS Six prospective non-randomized studies and two retrospective studies were included. The mean (SD) NOS risk of bias score was 4.9 (1.2) out of 9; studies were limited by a lack of non-exposed cohort, lack of independent blinded assessment, heterogeneous treatment protocols, and lack of long-term follow-up. The majority of studies reported significant improvements in stool frequency, incontinence episodes, severity of fecal incontinence, and health-related quality of life (HRQoL) after PFMT. Meta-analysis was not possible due to lack of randomized controlled trials. CONCLUSIONS Pelvic floor muscle training for patients following surgery for colorectal cancer appears to be associated with improvements in bowel function and HRQoL. Results from non-randomized studies are promising but randomized controlled trials with sufficient power are needed to confirm the effectiveness of PFMT in this population.
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Affiliation(s)
- Kuan-Yin Lin
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Catherine L Granger
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia.,Department of Physiotherapy, Royal Melbourne Hospital, Melbourne, Australia
| | - Linda Denehy
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Helena C Frawley
- Department of Physiotherapy, School of Health Sciences, The University of Melbourne, Melbourne, Australia.,Allied Health Research, Cabrini Health, Melbourne, Australia
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A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome. Updates Surg 2013; 65:257-63. [PMID: 23754496 DOI: 10.1007/s13304-013-0220-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 05/31/2013] [Indexed: 12/15/2022]
Abstract
The aim of this review is to characterize the functional results and "anterior resection syndrome" (ARS) after sphincter-saving surgery for rectal cancer. The purpose of sphincter-saving operations is to save the anal sphincters by avoiding the need for rectal abdomino-perineal resection with a permanent stoma. A variety of alternative techniques have been proposed and, today, ultra-low anterior resections of the rectum are commonplace. Inevitably rectal resections modify anorectal physiology. The backdrop of the functional asset for ultralow anterior resections is related to a small neorectal capacity with high endo-neorectal pressures that act together on a weakened sphincteric mechanism. Sometimes a defecation disorder called ARS may be induced and the patient experiences an extremely low quality of life. Impaired bowel function is usually provoked either by colonic dysmotility, neorectal reservoir dysfunction, anal sphincter damage or by a combination of these factors. Surgical technique defects can contribute to these possible causes: anastomotic ischemia, short length of the descending colon and stretching of neorectal mesentery may play a role. Unfortunately, there is no therapeutic algorithm or gold standard treatment that may be used for ARS. Nevertheless, it is rational to use conservative therapy first and then resort to surgery. Drugs, rehabilitative treatment and sacral neuromodulation may be used; after failure of conservative methods, surgical treatment can be considered.
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Maris A, Devreese AM, D'Hoore A, Penninckx F, Staes F. Treatment options to improve anorectal function following rectal resection: a systematic review. Colorectal Dis 2013; 15:e67-78. [PMID: 23017030 DOI: 10.1111/codi.12036] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery. METHOD Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life. RESULTS The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re-education (n=7), colonic irrigation (n=2) and sacral nerve stimulation (SNS) (n=6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re-education or SNS. Three studies reported improved quality of life after pelvic floor re-education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS. CONCLUSION Conservative therapies such as pelvic floor re-education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence-based conclusions.
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Affiliation(s)
- A Maris
- Department of Rehabilitation Sciences, Neuromotor Rehabilitation Research Group, KU Leuven, Belgium
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15
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Bartlett L, Sloots K, Nowak M, Ho YH. Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer. Tech Coloproctol 2011; 15:319-26. [DOI: 10.1007/s10151-011-0713-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Accepted: 06/26/2011] [Indexed: 12/17/2022]
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Boselli AS, Pinna F, Cecchini S, Costi R, Marchesi F, Violi V, Sarli L, Roncoroni L. Biofeedback therapy plus anal electrostimulation for fecal incontinence: prognostic factors and effects on anorectal physiology. World J Surg 2010; 34:815-21. [PMID: 20108095 DOI: 10.1007/s00268-010-0392-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The current literature does not provide unequivocal data on prognostic factors in conservative management of fecal incontinence. Moreover, the physiopathologic effects of pelvic floor rehabilitation on anorectal function are not well understood. Our aim is to identify some prognostic parameters and assess their effects on anorectal physiology of biofeedback therapy plus anal electrostimulation for fecal incontinence. METHODS We studied prospectively 45 consecutive adult patients with fecal incontinence treated at our institution with biofeedback plus electrostimulation. The outcome parameter was modification of the Wexner Incontinence Score (WIS) at the end of treatment. In addition, we studied the modifications of anorectal manometry and the rectal sensitivity threshold after treatment. RESULTS At univariate analysis, age, the pretreatment WIS, and the pretreatment resting and maximum squeeze pressures were correlated with the clinical outcome. Patients showed a significant reduction in the rectal sensitivity threshold but no significant change in manometric parameters after treatment. CONCLUSIONS We identify good sphincter function and mild to moderate symptomatology as favorable prognostic factors in biofeedback and anal electrostimulation therapy. Improvement in rectal sensitivity can be implicated in symptomatic improvement. The impossibility of correlating the clinical results with the effects on anorectal physiology suggests a nonspecific effect of conservative treatment.
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Affiliation(s)
- Adamo Stefano Boselli
- Department of Surgical Sciences, Section of General Surgical Clinics and Surgical Therapy, Parma University Medical School, Via Gramsci 14, Parma, 43100, Italy
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Park JS, Kang SB, Kim DW, Namgung HW, Kim HL. The efficacy and adverse effects of topical phenylephrine for anal incontinence after low anterior resection in patients with rectal cancer. Int J Colorectal Dis 2007; 22:1319-24. [PMID: 17569063 DOI: 10.1007/s00384-007-0335-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anal incontinence is experienced by some patients with rectal cancer who received low anterior resection. This study was to examine the efficacy and adverse effects of the alpha-1 adrenergic agonist phenylephrine, which causes contraction of the internal anal sphincter and raises the resting pressure in these patients. PATIENTS AND METHODS Thirty-five patients with anal incontinence were treated with 30% phenylephrine or a placebo randomly allocated in a double-blind study. The efficacy of the drug was assessed by changes in the following standardized questionnaire scores: the fecal incontinence severity index (FISI), fecal incontinence quality of life (FIQL) scales, and a global efficacy question. Anal sphincter function was evaluated using anorectal manometry. RESULTS Phenylephrine did not improve either the FISI score or any of the four FIQL scores. Five of 17 (29%) patients reported subjective improvement after phenylephrine compared with 4 of 12 (33%) using the placebo. The maximum resting anal pressure did not differ between baseline and after 4 weeks application of phenylephrine (30.0 to 27.3 mmHg). In the phenylephrine group, allergic dermatitis was developed in five patients and headache in two. CONCLUSION In the patients with anal incontinence after low anterior resection for rectal cancer, phenylephrine gel did not seem to be helpful in relieving symptoms with some adverse effects.
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Affiliation(s)
- Jun-Seok Park
- Department of Surgery, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, 463-707, Sungnam, South Korea
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Abstract
A very low local recurrence rate of 3%-6% (associated with improved 5 year survival) is possible when proper oncological surgery is performed of mid and distal rectal adenocarcinoma. Restoration of bowel continuity is possible in most cases, without compromise of cancer clearance. Re-anastomosis can be performed with stapled, transabdominal hand-sewn or coloanal pull-through techniques. However after a direct (straight) anastomosis of the colon to the distal rectum/anus, up to 33% of patients have 3 or more bowel movements/d; some can be troubled with up to 14 stools a day. Construction of a 6-cm colonic J-pouch is likely to cause some reversed peristalsis which improves postoperative bowel frequency without causing neo-rectum evacuation problems. Colonic J-pouch-anal anastomosis patients have a median of 3 bowel movements a day compared with a median of 6 a day for straight anastomoses, at 1 year after surgery. In the longer term, bowel adaptation may enable the function after a straight anastomosis to approximate that of a colonic J-pouch-anal anastomosis. This probably depends in the former, upon whether the more rigid sigmoid colon or more distensible descending colon is used. An additional advantage of the colonic J-pouch-anal anastomosis is the lower risk of anastomotic complications. A more vascularized side-to-end (colonic J-pouch-anal) anastomosis is likely to heal better than an end-to-end (straight) anastomosis. Where the pelvis is too narrow for a bulky colonic J-pouch anal anastomosis, a coloplasty-anal-anastomosis is an option. The latter results in postoperative bowel function comparable with the colonic J-pouch. However, the risk of anastomotic complications is higher possibly related to its end-to-end anastomotic configuration. Laparoscopic techniques for accomplishing all the above are being proven to be effective. Restorative surgery for rectal cancer can be safely and effectively performed with methods to improve bowel function very acceptably; the future advances are likely in laparoscopy.
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Chiarioni G, Ferri B, Morelli A, Iantorno G, Bassotti G. Bio-feedback treatment of fecal incontinence: Where are we, and where are we going? World J Gastroenterol 2005; 11:4771-5. [PMID: 16097042 PMCID: PMC4398720 DOI: 10.3748/wjg.v11.i31.4771] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fecal incontinence is a disabling disease, often observed in young subjects, that may have devastating psycho-social consequences. In the last years, numerous evidences have been reported on the efficacy of bio-feedback techniques for the treatment of this disorder. Overall, the literature data claim a success rate in more than 70% of cases in the short term. However, recent controlled trials have not confirmed this optimistic view, thus emphasizing the role of standard care. Nonetheless, many authors believe that this should be the first therapeutic approach for fecal incontinence due to the efficacy, lack of side-effects, and scarce invasiveness. Well-designed randomized, controlled trial are eagerly awaited to solve this therapeutic dilemma.
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Affiliation(s)
- Giuseppe Chiarioni
- Division of Gastroenterological Rehabilitation, University of Verona, Valeggio sul Mincio Hospital, Azienda Ospedaliera of Verona, Verona, Italy
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Ratto C, Grillo E, Parello A, Petrolino M, Costamagna G, Doglietto GB. Sacral neuromodulation in treatment of fecal incontinence following anterior resection and chemoradiation for rectal cancer. Dis Colon Rectum 2005; 48:1027-36. [PMID: 15785890 DOI: 10.1007/s10350-004-0884-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Fecal incontinence may occur in patients who have undergone anterior resection for rectal cancer without presenting sphincter lesions. Chemoradiation may contribute to disrupting continence mechanisms. Treatment is controversial. Assessment of fecal incontinence in patients who agreed to integrate treatment for rectal cancer and treatment with sacral neuromodulation are reported. METHODS Fecal incontinence following preoperative chemoradiation and anterior resection for rectal cancer was evaluated in four patients. A good response was observed during the percutaneous sacral nerve evaluation test, and so permanent implant of sacral neuromodulation system was performed. Reevaluation was performed at least two months after implant. RESULTS After device implantation, the mean fecal incontinence scores decreased, and the mean number of incontinence episodes dropped from 12.0 to 2.5 per week (P < 0.05). Permanent implant resulted in a significant improvement in fecal continence in three patients, and incontinence was slightly reduced in the fourth. Manometric parameters agreed with clinical results: maximum and mean resting tone and the squeeze pressure were normal in three patients and reduced in one. In these same three patients, neorectal sensation parameters increased when the preoperative value was normal or below normal and decreased when the preoperative value was higher than normal, whereas in one patient in whom extremely low values were recorded all of the parameters decreased significantly. CONCLUSIONS Fecal incontinence following anterior resection and neoadjuvant therapy should be carefully evaluated. If a suspected neurogenic pathogenesis is confirmed, sacral neuromodulation may be proposed. If the test results are positive, permanent implant is advisable. Failure of this approach does not exclude the use of other, more aggressive treatment.
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Affiliation(s)
- Carlo Ratto
- Department of Clinica Chirurgica, Catholic University, 00168 Rome, Italy.
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23
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Ho YH, Muller R, Veitch C, Rane A, Durrheim D. Faecal incontinence: an unrecognised epidemic in rural North Queensland? Results of a hospital-based outpatient study. Aust J Rural Health 2005; 13:28-34. [PMID: 15720312 DOI: 10.1111/j.1440-1854.2004.00642.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES We explored the prevalence of faecal incontinence (FI) in a referral hospital outpatient population, to explore suspicions that FI is inadequately studied, underestimated and poorly appreciated in the rural North Queensland (NQ) community. DESIGN Prospective cross-sectional study using a specifically designed questionnaire. SETTING The Townsville Hospital, a referral centre serving rural NQ. SUBJECTS A total of 435 consecutive patients attending the gynaecology (n = 261) and colorectal clinics (n = 174) between 31 January and 12 June 2003 were enrolled (participating proportion 96.5%). MAIN OUTCOME MEASURES FI prevalence, severity, impact on patients' lives, and risk factors. RESULTS The prevalence of FI in the study population (median age 53 years) was 20.7%. Amongst affected patients (n = 90) the median duration of FI was 2 years with more than half of those affected soiling themselves at least once a month. Many patients with FI (42%) reported feeling hopeless at least some of the time. Rectal prolapse, chronic constipation, psychiatric problems, colon disease, and urinary incontinence were all significantly associated with FI. A CART analysis revealed that many patients (45%) with urinary incontinence and chronic constipation also experienced FI. CONCLUSIONS This FI prevalence in a clinical setting in NQ is, apart from nursing home studies, the highest reported in the literature. FI negatively impacted on affected persons' lives. In patients presenting with urinary incontinence and chronic constipation, physicians should specifically enquire whether FI is also present. Definitive community studies to determine the scale of this 'silent epidemic' in northern Australia are now required.
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Affiliation(s)
- Yik-Hong Ho
- School of Medicine and School of Public Health and Tropical Medicine, James Cook University, Townsville, Australia.
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Rao SSC. Diagnosis and management of fecal incontinence. American College of Gastroenterology Practice Parameters Committee. Am J Gastroenterol 2004; 99:1585-604. [PMID: 15307881 DOI: 10.1111/j.1572-0241.2004.40105.x] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Satish S C Rao
- Department of Neurogastroenterology & Motility, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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Matibag GC, Nakazawa H, Giamundo P, Tamashiro H. Trends and current issues in adult fecal incontinence (FI): Towards enhancing the quality of life for FI patients. Environ Health Prev Med 2003; 8:107-17. [PMID: 21432098 PMCID: PMC2723386 DOI: 10.1007/bf02897914] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2003] [Accepted: 07/24/2003] [Indexed: 12/14/2022] Open
Abstract
Our goals are to review the literature on the definition and epidemiology of fecal incontinence (FI), the risk factors involved, available treatment options, and measurement of the quality of life (QOL) of patients with this condition. Articles included for review were searched following the guidelines set by Cochrane Reviewers' Handbook. FI was defined variously depending upon the duration, type, and amount of leakage. About 17 published papers were reviewed on the prevalence of FI that ranged from 1.4% to 50%. Potential risk factors included perianal injury/surgery, and fair/poor general health. QOL assessment using various grading scales provided an objective method of evaluating patients before and after treatment. Management included medical, physiotherapy, and surgical options. Through the range of various references, a clear definition of FI should be specified, which reflects its epidemiology in the various studies. These differences in definition would significantly affect its prevalence. Many risk factors have been sited but further epidemiological studies are necessary to elucidate FI. Understanding the etiology of the disease is an important initial step to provide adequate treatment of FI. QOL assessment provides objective and subjective method in the analysis of effectiveness of therapy.
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Affiliation(s)
- Gino C. Matibag
- Department of Health for Senior Citizens, Division of Preventive Medicine, Social Medicine Cluster, Hokkaido University Graduate School of Medicine, Kita 15 Jo Nishi 7 Chome, Kita-ku, 060-8638 Sapporo, Japan
| | - Hiroshi Nakazawa
- Department of Health for Senior Citizens, Division of Preventive Medicine, Social Medicine Cluster, Hokkaido University Graduate School of Medicine, Kita 15 Jo Nishi 7 Chome, Kita-ku, 060-8638 Sapporo, Japan
| | - Paolo Giamundo
- Department of Surgery, Hospital S. Spirito, Via Vittorio Emanuele 2, Bra (CN), Italy
| | - Hiko Tamashiro
- Department of Health for Senior Citizens, Division of Preventive Medicine, Social Medicine Cluster, Hokkaido University Graduate School of Medicine, Kita 15 Jo Nishi 7 Chome, Kita-ku, 060-8638 Sapporo, Japan
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Función defecatoria y calidad de vida con la cirugía preservadora de esfínteres en el cáncer de recto. Cir Esp 2003. [DOI: 10.1016/s0009-739x(03)72091-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ho YH. Postanal sphincter repair for anterior resection anal sphincter injuries: report of three cases. Dis Colon Rectum 2001; 44:1218-20. [PMID: 11535866 DOI: 10.1007/bf02234648] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Treatment options are limited for intractable excessive stool frequency and incontinence after low anterior resection for rectal cancer. Fortunately, this is quite rare, but three such patients were reported. The patients did not respond to two years of expectant treatment, including medications and anorectal biofeedback. Anorectal physiologic tests and endoanal ultrasound findings were consistent with internal anal sphincter injuries, which are known to occur with transanal insertion of stapling instruments. After postanal sphincter repair, stool frequency was reduced from 5.7 (standard error of the mean, 1.3) to 1.7 (0.3) stools per day. Fecal incontinence requiring pads in all patients was reduced to full continence in two patients and gas incontinence in one. Continence score improved from 13.7 (2.2) to 1.3 (0.3). Mean follow-up was 3.2 (0.5) years. Postanal sphincter repair could be considered when persistent bowel dysfunction after anterior resection is caused by internal sphincter injury.
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Affiliation(s)
- Y H Ho
- Department of Colorectal Surgery, Singapore General Hospital, Outram Road, Singapore 169806
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Norton C, Kamm MA. Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults--a systematic review. Aliment Pharmacol Ther 2001; 15:1147-54. [PMID: 11472317 DOI: 10.1046/j.1365-2036.2001.01039.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Faecal incontinence is a common health care problem. Biofeedback is extensively used in clinical practice to treat faecal incontinence. AIM To systematically review and evaluate the evidence from clinical studies on the effectiveness of biofeedback as a treatment for faecal incontinence in adults. METHODS A systematic literature search was undertaken using electronic databases, with review of the retrieved references. RESULTS The search identified 46 studies published in English using biofeedback to treat adults complaining of faecal incontinence. Those studies included a total of 1364 patients. Of those studies with adequate data, 275 out of 566 patients (49%) were said to be cured of symptoms of faecal incontinence following biofeedback therapy and 617 out of 861 (72%) patients were reported to be cured or improved. Studies varied in the method of biofeedback used, criteria for success and the outcome measures used. Only eight of the 46 studies employed any form of control group. CONCLUSIONS The data suggest that biofeedback and exercises help a majority of patients with faecal incontinence. However, methodological variation, lack of controls and a lack of validated outcome measures are problems in evaluating these results.
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Affiliation(s)
- C Norton
- Physiology Unit, St Mark's Hospital, Harrow, UK.
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Ho YH, Tan M, Leong A, Eu KW, Nyam D, Seow-Choen F. Anal pressures impaired by stapler insertion during colorectal anastomosis: a randomized, controlled trial. Dis Colon Rectum 1999; 42:89-95. [PMID: 10211526 DOI: 10.1007/bf02235189] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The significance of anal sphincter injury from transanal inserted staplers was studied. A randomized, controlled comparison was made of anorectal manometry and clinical function after sigmoid colectomy (avoiding nerve injury from rectal mobilization), anastomosed by either transanal inserted stapler or biofragmentable anastomotic ring (avoiding anal manipulation). METHOD Fifty-eight consecutive patients with sigmoid adenocarcinoma were randomly assigned to transanal inserted stapler or biofragmentable anastomotic ring groups. Anorectal manometry and clinical bowel function assessment were performed by an independent blinded observer before surgery and six weeks and six months after surgery. RESULTS At six weeks after surgery, there was significant impairment of mean anal resting pressures (mean impairment, 23 percent; P < 0.001) and physiologic anal length (mean impairment, 31 percent; P < 0.01) in the transanal inserted stapler group (27 completed the trial), but not in the biofragmentable anastomotic ring group (18 completed the trial). Pressures remained impaired at six months. When changes in the anal pressures were compared between groups, the mean anal resting pressure (P < 0.001) and maximum squeeze pressure (P < 0.01) at six weeks and mean anal resting pressure at six months (P < 0.01) were significantly more impaired in the transanal inserted stapler group. Postoperative bowel function was not different between the two groups. Postoperative complications were similar. In the transanal inserted stapler group one patient died of anastomotic leak sepsis and one had wound infection; in the biofragmentable anastomotic ring group one patient died of myocardial infarct and one had wound infection. CONCLUSION Direct injuries to the internal anal sphincter occurred after transanal inserted stapler but not biofragmentable anastomotic ring anastomoses. Clinical function was not correspondingly affected, probably because of the adequate residual rectal reservoir after sigmoid colectomy.
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Affiliation(s)
- Y H Ho
- Department of Colorectal Surgery, Singapore General Hospital, Singapore
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