Partial longitudinal resection of the anorectum and sphincter for very low rectal adenocarcinoma: a surgical approach to avoid permanent colostomy

Effectiveness of Biofeedback Therapy in Patients with Bowel Dysfunction Following Rectal Cancer Surgery: A Systemic Review with Meta-Analysis

Objective

To identify, systematically review and synthesize the evidence on the effectiveness of biofeedback therapy in patients with bowel dysfunction following rectal cancer surgery.

Data Sources

Four electronic databases (PubMed 1974–2021; Embase1980–2021; Cochrane databases and the trial registers) were systematically searched by reviewers from inception through March 2021.

Study Selection

Randomized controlled trials (RCTs), cohort studies, and case series studies were included for adults with bowel dysfunction following rectal cancer surgery. All participants received an intervention of biofeedback treatment. Any outcomes that can evaluate the patient’s bowel function were the primary research endpoint, while the quality of life was the second endpoint. The disagreements between the two reviewers were resolved after discussion and the third independent reviewer’s ruling. As a result, 12 of 185 studies met selection criteria and were included in the review.

Data Extraction

We designed an electronic data extraction form and data were extracted independently. The methodological quality of included studies was assessed using the Cochrane Risk of Bias, the MINORS scale, and the Institute of Health Economics scale.

Data Synthesis

Meta-analyses were conducted for case series only and narrative syntheses were completed. Key findings included significant improvements in bowel function as well as health-related quality of life after biofeedback therapy. (Wexner score: t=7, MD=3.33; 95% CI [2.48, 4.18]) and (Vaizey score: t=3, MD=2.46; 95% CI [1.98, 2.93]). Subgroup analysis of Wexner score: receiving electrical stimulation therapy (t=3, MD=2.36; 95% CI [1.51, 3.22]), not receiving electrical stimulation (t=4, MD=3.79;95% CI[2.66, 4.93]); not receiving adjuvant chemoradiotherapy (t=3, MD=2.42;95% CI[1.61, 3.24]), chemotherapy and radiotherapy (t=1, MD=4.10; 95% CI [2.90, 5.30]), radiotherapy and chemotherapy on parts of patients (t=2, MD=3.46;95% CI [1.41, 5.51]), chemotherapy (t=1, MD=4.81; 95% CI [3.38, 6.24]); performing ISR (t=2, MD=3.32;95% CI [0.37, 6.27]), performing AR (t=4, MD=3.08; 95% CI [2.12, 4.04]), performing PLRAS surgery (t=1, MD=4.10;95% CI[2.90, 5.30]).

Conclusion

Although biofeedback therapy may improve intestinal function and quality of life as well as anal function reflected by ARM after surgery, patient satisfaction is still unclear. Due to the scarcity of data, good-quality research is required to delve deeper.

Clinical Trial Registration Number

CRD42020192658.

[Low anterior resection syndrome-Causes and treatment approaches]

BACKGROUND

With improvement of the oncological prognosis and more sphincter-preserving procedures for rectal cancer of the lower third, the functional sequelae of anterior rectal resection become more and more predominant and are summarized under the term low anterior resection syndrome (LARS).

MATERIAL AND METHODS

In this narrative review the causes, associated factors, prevalence, diagnostics and treatment strategies are presented based on an evaluation of the international literature.

RESULTS

The central role of the rectum in the physiology of defecation and continence explains the frequency of symptoms following anterior rectal resection. In an unselected patient population a major LARS is to be expected in approximately 40% and a minor LARS in approximately 20%. The most important factor is the length of the remaining rectal stump. The diagnosis of LARS is made clinically and can be quantified by scores, especially by the LARS score. Treatment options range from patient counselling to stoma construction and a symptom-related, stepwise approach is generally accepted.

CONCLUSION

While the evidence for the causes, the quantification and determination of associated factors of LARS is good, the treatment options are based either on experience or on only few studies.

Long-term changes in physical capacity after colorectal cancer treatment

Older patients with colorectal cancer are faced with the dilemma of choosing between the short-term risks of treatment and the long-term risks of insufficiently treated disease. In addition to treatment-related morbidity and mortality, patients may suffer from loss of physical capacity. The purpose of this review was to gather all available evidence regarding long-term changes in physical functioning and role functioning after colorectal cancer treatment, by performing a systematic Medline and Embase search. This search yielded 27 publications from 23 studies. In 16 studies addressing physical functioning after rectal cancer treatment, a median drop of 10% (range -26% to -5%) in the mean score for this item at three months. At six months, mean score was still 7% lower than baseline (range -18% to 0%) and at twelve months 5% lower (range -13% to +5%). For role functioning (i.e. ability to perform daily activities) after rectal cancer treatment, scores were -18% (range -39% to -2%), -8% (range -23% to +6%) and -5% (range -17% to +10%) respectively. Elderly patients experience the greatest and most persistent decline in self-care capacity (up to 61% at one year). This systematic review demonstrates that both physical functioning and role functioning are significantly affected by colorectal cancer surgery. Although initial losses are recovered partially during follow-up, there is a permanent loss in both aspects of physical capacity, in patients of all ages but especially in the elderly. This aspect should be included in patient counselling regarding surgery.