Evaluation and Treatment for Fecal Incontinence after Sphincter-Preserving Operation for Middle and Low Rectal Cancer_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

 PIYan-na ¹ , XIAOYi ² ,  FANGXiu-cai ¹

1. Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100730, China;
2. Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100730, China;

Corresponding author：

FANGXiu-cai, Email: fangxiucai2@aliyun.com

Keywords：

Rectal cancer; Fecal incontinence; Anorectal function; Treatment

DOI：

10.7507/1007-9424.20140155

Video：

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Objective To understand the incidence of fecal incontinence after sphincter-preserving operation for middle and low rectal cancer, the factors influencing fecal incontinence, the relationship of fecal incontinence to anorectal manometry, and treatment. Method The literatures about fecal incontinence after sphincter-preserving operation for middle and low rectal cancer were reviewed. Results The incidence of fecal incontinence after sphincter-preserving operation for middle and low rectal cancer was about 35.3%. Wexner fecal incontinence score was the most popular scale in assessing the severity of fecal incontinence, which had high validity and utility. When Wexner score≥9, the fecal incontinence-related quality of life was seriously damaged. Closer the anastomosis to the anal margin, the fecal incontinence was more likely to happen and much severer if it appeared. Surgeon could improve the anorectal function through some kinds of surgeries, like ultralow anterior resection with levator-sphincter reinforcement when the tumor site was rather low. The effect of chemoradiotherapy on fecal incontinence was uncertain now. Age itself was a risk factor for fecal incontinence, for elderly patients underwent sphincter-preserving operation needed to be careful. The relationship of fecal incontinence to anorectal function was not completely clear. The anal sphincter nerve function was a predicting factor whether neurogenic fecal incontinence was going to happen or not. Even though the retrograde colonic irrigation, sacral nerve stimulation, and biofeedback therapy had been proved to alleviate the symptoms and improve the quality of life after sphincter-preserving operation, much more prospective and controlled studies were needed to validate their efficacy and explore other new solutions. Conclusions We still need to come up with the objective criterion to assess fecal incontinence. Much more prospective studies are needed to analyze the influencing factors and to find effective prevention and treatment.

Citation： PIYan-na, XIAOYi, FANGXiu-cai. Evaluation and Treatment for Fecal Incontinence after Sphincter-Preserving Operation for Middle and Low Rectal Cancer. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2014, 21(5): 641-645. doi: 10.7507/1007-9424.20140155 Copy

1.	郑荣寿, 张思维, 吴良有, 等.中国肿瘤登记地区2008年恶性肿瘤发病和死亡分析[J].中国肿瘤, 2012, 21(1):1-12.
2.	Shibata D, Guillem JG, Lanouette N, et al.Functional and qualityof-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation[J].Dis Colon Rectum, 2000, 43(6):752-758.
3.	Emmertsen KJ, Laurberg S.Bowel dysfunction after treatment for rectal cancer[J].Acta Oncol, 2008, 47(6):994-1003.
4.	Parés D, Vial M, Bohle B, et al.Prevalence of faecal incontinence and analysis of its impact on quality of life and mental health[J].Colorectal Dis, 2011, 13(8):899-905.
5.	Bryant CL, Lunniss PJ, Knowles CH, et al.Anterior resection syndrome[J].Lancet Oncol, 2012, 13(9):e403-e408.
6.	Rao SS.American College of Gastroenterology Practice Parameters Committee.Diagnosis and management of fecal incontinence[J].Am J Gastroenterol, 2004, 99(8):1585-1604.
7.	Scheer AS, Boushey RP, Liang S, et al.The long-term gastrointestinal functional outcomes following curative anterior resection in adults with rectal cancer:a systematic review and meta-analysis[J].Dis Colon Rectum, 2011, 54(12):1589-1597.
8.	Vaizey CJ, Carapeti E, Cahill JA, et al.Prospective comparison of faecal incontinence grading systems[J].Gut, 1999, 44(1):77-80.
9.	Bols EM, Hendriks HJ, Berghmans LC, et al.Responsiveness and interpretability of incontinence severity scores and FIQL in patients with fecal incontinence:a secondary analysis from a randomized controlled trial[J].Int Urogynecol J, 2013, 24(3):469-478.
10.	Rothbarth J, Bemelman WA, Meijerink W, et al.What is the impact of fecal incontinence on quality of life?[J].Dis Colon Rectum, 2001, 44(1):67-71.
11.	Lynne B, Nowak M, Yik-Hong H.Impact of fecal incontinence on quality of life[J].World J Gastroenterol, 2009, 15(26):3276-3282.
12.	Matzel KE, Stadelmaier U, Muehldorfer S, et al.Continence after colorectal reconstruction following resection:impact of level of anastomosis[J].Int J Colorectal Dis, 1997, 12(2):82-87.
13.	马骏, 冯勇, 丛进春, 等.低位直肠癌保肛术后的吻合口水平对排便功能及生活质量的影响[J].世界华人消化杂志, 2009, 17(2):221-224.
14.	Gross E, Möslein G.Colonic pouch and other procedures to improve the continence after low anterior rectal resection with TME[J].Zentralbl Chir, 2008, 133(2):107-115.
15.	Zhang YC, Jin XD, Zhang YT, et al.Better functional outcome provided by short-armed sigmoid colon-rectal side-to-end anastomosis after laparoscopic low anterior resection:a match-paired retrospective study from China[J].Int J Colorectal Dis, 2012, 27(4):535-541.
16.	Bittorf B, Stadelmaier U, Göhl J, et al.Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer[J].Eur J Surg Oncol, 2004, 30(3):260-265.
17.	Tilney HS, Tekkis PP.Extending the horizons of restorative rectal surgery:intersphincteric resection for low rectal cancer[J].Colorectal Dis, 2008, 10(1):3-16.
18.	Bretagnol F, Rullier E, Laurent C, et al.Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer[J].Dis Colon Rectum, 2004, 47(6):832-838.
19.	Vorobiev GI, Odaryuk TS, Tsarkov PV, et al.Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma[J].Br J Surg, 2004, 91(11):1506-1512.
20.	Kim JC, Kim CW, Yoon YS, et al.Levator-sphincter reinforcement after ultralow anterior resection in patients with low rectal cancer:the surgical method and evaluation of anorectal physiology[J].Surg Today, 2012, 42(6):547-553.
21.	Benson ABⅢ, Bekaii-Saab T, Chan E, et al.Rectal cancerclinical practice guidelines in oncology[J].J Natl Compr Canc Netw, 2012, 10(12):1528-1564.
22.	Pucciarelli S, Del Bianco P, Efficace F, et al.Patient-reported outcomes after neoadjuvant chemoradiotherapy for rectal cancer:a multicenter prospective observational study[J].Ann Surg, 2011, 253(1):71-77.
23.	Canda AE, Terzi C, Gorken IB, et al.Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients[J].Int J Colorectal Dis, 2010, 25(2):197-204.
24.	Lange MM, den Dulk M, Bossema ER, et al.Risk factors for faecal incontinence after rectal cancer treatment[J].Br J Surg, 2007, 94(10):1278-1284.
25.	Swedish Rectal Cancer Trial.Improved survival with preoperative radiotherapy in resectable rectal cancer[J].N Engl J Med, 1997, 336(21):980-987.
26.	Peeters KC, van de Velde CJ, Leer JW, et al.Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer:increased bowel dysfunction in irradiated patients-a Dutch colorectal cancer group study[J].J Clin Oncol, 2005, 23(25):6199-6206.
27.	Pollack J, Holm T, Cedermark B, et al.Long-term effect of preoperative radiation therapy on anorectal function[J].Dis Colon Rectum, 2006, 49(3):345-352.
28.	鲁兵, 傅传刚, 刘连杰, 等.高龄低位直肠癌患者保肛手术后控便功能分析[J].癌症, 2005, 24(10):1257-1260.
29.	Lee SJ, Park YS.Serial evaluation of anorectal function following low anterior resection of the rectum[J].Int J Colorectal Dis, 1998, 13(5/6):241-246.
30.	刘宝华, 张胜本, 王亚旭, 等.肛肠测压在直肠癌术后肛门功能评价中的价值[J].第三军医大学学报, 1999, 21(4):279-281.
31.	Tomita R, Igarashi S, Fujisaki S.Studies on anal canal sensitivity in patients with or without soiling after low anterior resection for lower rectal cancer[J].Hepatogastroenterology, 2008, 55(85):1311-1314.
32.	Koda K, Yasuda H, Hirano A, et al.Evaluation of postoperative damage to anal sphincter/levator ani muscles with three-dimensional vector manometry after sphincter-preserving operation for rectal cancer[J].J Am Coll Surg, 2009, 208(3):362-367.
33.	Kauff DW, Kempski O, Koch KP, et al.Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection:an innovative approach for observation of functional nerve integrity in pelvic surgery[J].Langenbecks Arch Surg, 2012, 397(5):787-792.
34.	Kneist W, Kauff DW, Gockel I, et al.Total mesorectal excision with intraoperative assessment of internal anal sphincter innervation provides new insights into neurogenic incontinence[J].J Am Coll Surg, 2012, 214(3):306-312.
35.	Rosen H, Robert-Yap J, Tentschert G, et al.Transanal irrigation improves quality of life in patients with low anterior resection syndrome[J].Colorectal Dis, 2011, 13(10):e335-e338.
36.	Koch SM, Rietveld MP, Govaert B, et al.Retrograde colonic irrigation for faecal incontinence after low anterior resection[J].Int J Colorectal Dis, 2009, 24(9):1019-1022.
37.	Matzel KE, Kamm MA, Stösser M, et al.Sacral spinal nerve stimulation for faecal incontinence:multicentre study[J].Lancet, 2004, 363(9417):1270-1276.
38.	Tomita R.Sacral nerve function in patients with soiling more than 10 years after low anterior resection for lower rectal cancer[J].Hepatogastroenterology, 2009, 56(89):120-123.
39.	de Miguel M, Oteiza F, Ciga MA, et al.Sacral nerve stimulation for the treatment of faecal incontinence following low anterior resection for rectal cancer[J].Colorectal Dis, 2011, 13(1):72-77.
40.	Kim KH, Yu CS, Yoon YS, et al.Effectiveness of biofeedback therapy in the treatment of anterior resection syndrome after rectal cancer surgery[J].Dis Colon Rectum, 2011, 54(9):1107-1113.
41.	Bartlett L, Sloots K, Nowak M, et al.Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer[J].Tech Coloproctol, 2011, 15(3):319-326.

1. 郑荣寿, 张思维, 吴良有, 等.中国肿瘤登记地区2008年恶性肿瘤发病和死亡分析[J].中国肿瘤, 2012, 21(1):1-12.
2. Shibata D, Guillem JG, Lanouette N, et al.Functional and qualityof-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation[J].Dis Colon Rectum, 2000, 43(6):752-758.
3. Emmertsen KJ, Laurberg S.Bowel dysfunction after treatment for rectal cancer[J].Acta Oncol, 2008, 47(6):994-1003.
4. Parés D, Vial M, Bohle B, et al.Prevalence of faecal incontinence and analysis of its impact on quality of life and mental health[J].Colorectal Dis, 2011, 13(8):899-905.
5. Bryant CL, Lunniss PJ, Knowles CH, et al.Anterior resection syndrome[J].Lancet Oncol, 2012, 13(9):e403-e408.
6. Rao SS.American College of Gastroenterology Practice Parameters Committee.Diagnosis and management of fecal incontinence[J].Am J Gastroenterol, 2004, 99(8):1585-1604.
7. Scheer AS, Boushey RP, Liang S, et al.The long-term gastrointestinal functional outcomes following curative anterior resection in adults with rectal cancer:a systematic review and meta-analysis[J].Dis Colon Rectum, 2011, 54(12):1589-1597.
8. Vaizey CJ, Carapeti E, Cahill JA, et al.Prospective comparison of faecal incontinence grading systems[J].Gut, 1999, 44(1):77-80.
9. Bols EM, Hendriks HJ, Berghmans LC, et al.Responsiveness and interpretability of incontinence severity scores and FIQL in patients with fecal incontinence:a secondary analysis from a randomized controlled trial[J].Int Urogynecol J, 2013, 24(3):469-478.
10. Rothbarth J, Bemelman WA, Meijerink W, et al.What is the impact of fecal incontinence on quality of life?[J].Dis Colon Rectum, 2001, 44(1):67-71.
11. Lynne B, Nowak M, Yik-Hong H.Impact of fecal incontinence on quality of life[J].World J Gastroenterol, 2009, 15(26):3276-3282.
12. Matzel KE, Stadelmaier U, Muehldorfer S, et al.Continence after colorectal reconstruction following resection:impact of level of anastomosis[J].Int J Colorectal Dis, 1997, 12(2):82-87.
13. 马骏, 冯勇, 丛进春, 等.低位直肠癌保肛术后的吻合口水平对排便功能及生活质量的影响[J].世界华人消化杂志, 2009, 17(2):221-224.
14. Gross E, Möslein G.Colonic pouch and other procedures to improve the continence after low anterior rectal resection with TME[J].Zentralbl Chir, 2008, 133(2):107-115.
15. Zhang YC, Jin XD, Zhang YT, et al.Better functional outcome provided by short-armed sigmoid colon-rectal side-to-end anastomosis after laparoscopic low anterior resection:a match-paired retrospective study from China[J].Int J Colorectal Dis, 2012, 27(4):535-541.
16. Bittorf B, Stadelmaier U, Göhl J, et al.Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer[J].Eur J Surg Oncol, 2004, 30(3):260-265.
17. Tilney HS, Tekkis PP.Extending the horizons of restorative rectal surgery:intersphincteric resection for low rectal cancer[J].Colorectal Dis, 2008, 10(1):3-16.
18. Bretagnol F, Rullier E, Laurent C, et al.Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer[J].Dis Colon Rectum, 2004, 47(6):832-838.
19. Vorobiev GI, Odaryuk TS, Tsarkov PV, et al.Resection of the rectum and total excision of the internal anal sphincter with smooth muscle plasty and colonic pouch for treatment of ultralow rectal carcinoma[J].Br J Surg, 2004, 91(11):1506-1512.
20. Kim JC, Kim CW, Yoon YS, et al.Levator-sphincter reinforcement after ultralow anterior resection in patients with low rectal cancer:the surgical method and evaluation of anorectal physiology[J].Surg Today, 2012, 42(6):547-553.
21. Benson ABⅢ, Bekaii-Saab T, Chan E, et al.Rectal cancerclinical practice guidelines in oncology[J].J Natl Compr Canc Netw, 2012, 10(12):1528-1564.
22. Pucciarelli S, Del Bianco P, Efficace F, et al.Patient-reported outcomes after neoadjuvant chemoradiotherapy for rectal cancer:a multicenter prospective observational study[J].Ann Surg, 2011, 253(1):71-77.
23. Canda AE, Terzi C, Gorken IB, et al.Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients[J].Int J Colorectal Dis, 2010, 25(2):197-204.
24. Lange MM, den Dulk M, Bossema ER, et al.Risk factors for faecal incontinence after rectal cancer treatment[J].Br J Surg, 2007, 94(10):1278-1284.
25. Swedish Rectal Cancer Trial.Improved survival with preoperative radiotherapy in resectable rectal cancer[J].N Engl J Med, 1997, 336(21):980-987.
26. Peeters KC, van de Velde CJ, Leer JW, et al.Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer:increased bowel dysfunction in irradiated patients-a Dutch colorectal cancer group study[J].J Clin Oncol, 2005, 23(25):6199-6206.
27. Pollack J, Holm T, Cedermark B, et al.Long-term effect of preoperative radiation therapy on anorectal function[J].Dis Colon Rectum, 2006, 49(3):345-352.
28. 鲁兵, 傅传刚, 刘连杰, 等.高龄低位直肠癌患者保肛手术后控便功能分析[J].癌症, 2005, 24(10):1257-1260.
29. Lee SJ, Park YS.Serial evaluation of anorectal function following low anterior resection of the rectum[J].Int J Colorectal Dis, 1998, 13(5/6):241-246.
30. 刘宝华, 张胜本, 王亚旭, 等.肛肠测压在直肠癌术后肛门功能评价中的价值[J].第三军医大学学报, 1999, 21(4):279-281.
31. Tomita R, Igarashi S, Fujisaki S.Studies on anal canal sensitivity in patients with or without soiling after low anterior resection for lower rectal cancer[J].Hepatogastroenterology, 2008, 55(85):1311-1314.
32. Koda K, Yasuda H, Hirano A, et al.Evaluation of postoperative damage to anal sphincter/levator ani muscles with three-dimensional vector manometry after sphincter-preserving operation for rectal cancer[J].J Am Coll Surg, 2009, 208(3):362-367.
33. Kauff DW, Kempski O, Koch KP, et al.Continuous intraoperative monitoring of autonomic nerves during low anterior rectal resection:an innovative approach for observation of functional nerve integrity in pelvic surgery[J].Langenbecks Arch Surg, 2012, 397(5):787-792.
34. Kneist W, Kauff DW, Gockel I, et al.Total mesorectal excision with intraoperative assessment of internal anal sphincter innervation provides new insights into neurogenic incontinence[J].J Am Coll Surg, 2012, 214(3):306-312.
35. Rosen H, Robert-Yap J, Tentschert G, et al.Transanal irrigation improves quality of life in patients with low anterior resection syndrome[J].Colorectal Dis, 2011, 13(10):e335-e338.
36. Koch SM, Rietveld MP, Govaert B, et al.Retrograde colonic irrigation for faecal incontinence after low anterior resection[J].Int J Colorectal Dis, 2009, 24(9):1019-1022.
37. Matzel KE, Kamm MA, Stösser M, et al.Sacral spinal nerve stimulation for faecal incontinence:multicentre study[J].Lancet, 2004, 363(9417):1270-1276.
38. Tomita R.Sacral nerve function in patients with soiling more than 10 years after low anterior resection for lower rectal cancer[J].Hepatogastroenterology, 2009, 56(89):120-123.
39. de Miguel M, Oteiza F, Ciga MA, et al.Sacral nerve stimulation for the treatment of faecal incontinence following low anterior resection for rectal cancer[J].Colorectal Dis, 2011, 13(1):72-77.
40. Kim KH, Yu CS, Yoon YS, et al.Effectiveness of biofeedback therapy in the treatment of anterior resection syndrome after rectal cancer surgery[J].Dis Colon Rectum, 2011, 54(9):1107-1113.
41. Bartlett L, Sloots K, Nowak M, et al.Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer[J].Tech Coloproctol, 2011, 15(3):319-326.

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Evaluation and Treatment for Fecal Incontinence after Sphincter-Preserving Operation for Middle and Low Rectal Cancer

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