Care of Post-Operative Altered Bowel Function in Colorectal Cancer Patients

Abstract

Rectal cancer patients with postoperative altered bowel function have poorer quality of life than colon rectal cancer patients with it. The altered bowel function symptoms were named low anterior resection syndrome. Mechanisms of these symptoms associated with removing rectum and receptors on its internal wall, creating neorectum, and destroying pelvic neuro-plexus by analsaving surgery. Due to the low anterior resection syndrome, patients suffered from physical, psychological and social impacts on quality of life. Three options are used to treat low anterior resection syndrome, including self-care strategies, clinician-initiated interventions, and creating a permanent stoma. The self-care strategies contain diet modification, lifestyle changes, and spiritual sublimation. The clinician-initiated interventions include prescribed medication, trans-anal irrigation, pelvic floor rehabilitation, neuromodulation, and so on. Creating a permanent stoma is the eventual choice due to anastomotic restriction. Altered bowel function may follow postoperative rectal cancer patients for whole life; however, flexibly using these care strategies may help them adjust.

1. Introduction

Altered bowel function is a common consequence in postoperative colorectal cancer patients and may impact patients’ quality of life for years [1, 2, 3]. In the population, rectal cancer patients had worse long-term quality of life than colon cancer patients, which may relate to severer bowel dysfunction after they received anal-saving surgery [2, 4]. Improving the dysfunction in rectal cancer patients may effectively promote the quality of life in colorectal cancer patients [5]. The postoperative altered bowel function in rectal cancer patients with anal-saving surgery was named low anterior resection syndrome [6, 7]. This chapter will focus on definition of low anterior resection syndrome, the mechanisms of the dysfunction, its impactions on quality of life, and management strategies of low anterior resection.

2. Definition of low anterior resection syndrome

Under a consensus combined in the 17th European Colorectal Congress, low anterior resection syndrome was defined as a series of bowel dysfunction symptoms after patients received anal-saving surgery, such as anterior resection, low anterior resection, ultralow anterior resection, total mesorectal excision, and so forth [4, 6]. These symptoms and their incidence included small frequent stool (70–94.4%), altered anal sense (12–98%), fecal incontinence (12–97%), fecal urgency (67%), evacuator dysfunction (47%), varied stool forms (37.6%), and gas-stool discrimination (34%) [4, 6, 7, 8, 9]. These symptoms gradually spontaneously improved in the postoperative period but seldom totally recovered over years [4, 8, 9, 10, 11].

3. Mechanisms of low anterior resection syndrome

A mechanism of defecation includes a series of processes (see Figure 1): (1) When feces move into and distend the rectum, they stimulate stretch receptors in the wall of rectum, and the receptors transmit signals along afferent fibers to spinal cord neurons; (2) A spinal reflex is initiated in which parasympathetic motor fibers (efferent fibers) stimulate the contraction of the rectum and sigmoid colon and relaxation of the internal anal sphincter; (3) When it is convenient to defecate, voluntary motor neurons are inhibited, which allow the external anal sphincter to relax, and then feces may pass [12].

Figure 1.

The mechanism of defecation. (1) When feces move into and distend the rectum, they stimulate stretch receptors in the wall of rectum, and the receptors transmit signals along afferent fibers to spinal cord neurons, (2) A spinal reflex is initiated in which parasympathetic motor fibers (efferent fibers) stimulate the contraction of the rectum and sigmoid colon, and relaxation of the internal anal sphincter, (3) When it is convenient to defecate, voluntary motor neurons are inhibited, which allow the external anal sphincter to relax, and then feces may pass.

The purpose of anal-saving surgery is to save the anal sphincters and to avoid receiving abdominoperineal resection with permanent stoma [13]. When patients received anal-saving surgery, it may resect distal sigmoid, whole rectum, total mesorectum and partial or/and total internal sphincter or/and external sphincter, as well as straight down the stump of colon to create a colon-to-colon or coloanal anastomosis for bowel continuum [13, 14, 15]. Potential points of pelvic nerve injury during rectal dissection include (see Figure 2): (1) Damage to the superior hypogastric plexus from tension or high division of the inferior mesenteric artery, (2) Injury to the main trunks of the hypogastric nerve during retrorectal dissection; (3) Injury to the inferior hypogastric plexus and nervi erigentes during the mobilization of lateral stalks, and (4) injury to the periprostatic plexus during the dissection of Denonvilliers’ fascia [16, 17, 18].

Figure 2.

Potential points of pelvic nerve injury during rectal dissection include. (1) Damage to the superior hypogastric plexus from tension or high division of the inferior mesenteric artery. (2) Injury to the main trunks of the hypogastric nerve during retrorectal dissection. (3) Injury to the inferior hypogastric plexus and nervi erigentes during the mobilization of lateral stalks. (4) Injury to the periprostatic plexus during the dissection of Denonvilliers’ fascia.

When rectum was resected, the stump of colon was straightdown to form a neorectum [19]. Because of the neorectum with smaller volume and with decreasing available eastability following chemoradiotherapy, the mechanic change may induce small frequent stool and varied stool forms; smaller volume of neorectum and resection of the stretch receptors in the wall of rectum may lead to fecal urgency, evacuator dysfunction, altered anal sense, and gas-stool discrimination; resection of rectal receptors, destroying of pelvic neuro-plexus and resection of anal sphincter may cause fecal incontinence [13, 15, 19].

4. The symptom distress and impactions on quality of life related to low anterior resection syndrome

After rectal cancer patients received anal-saving surgery or reversal of temporary stoma, they experienced varied symptoms of altered bowl function [20, 21, 22]. They were often preoccupied with these uncontrolled excrement symptoms, which easily disturb their physical function, compel them to experience emotional distress, and interfere with their social activities [7, 20, 21, 22, 23, 24]. Additionally, a multicenter correctional study revealed patients with the major low anterior resection syndrome had significantly worse quality of life than the those with minor and moderate syndrome [25].

In the domain of physical function, interruption of daily activities (e.g., eating, householding, and sleep), consequent distraction in daytime, and decreased sexual behavior often related to small frequent defection, urgency, and fecal incontinence [20, 22]. Under the disturbance of sleep, there may be difficulty in falling asleep, interruption of sleep due to intent to defecate, difficulty in falling asleep post broken sleep at midnight, and poor quality of sleep [7, 20]. On the intimacy behaviors, patients and their couples may choose other methods (e.g. hug, kiss, and spiritual empathy, etc.) to replace sexual behaviors [7].

In the domain of psychological function, patients often develop varied negative moods due to uncontrolled excrement, such as distress, depress, upset, botheration, irritation, helplessness, loneness, hopelessness, and so on [7, 20, 23]. They feel tie to toilet due to frequent go to restroom, experience struggle in living because of relieving from stoma but falling in destructive bowel habits, though it is a price to survive from cancer, and mark stigma related to uncontrolled incontinence [20, 26, 27]. They often fear the spread of poor odor and feel embarrassment due to fecal incontinence [27], which lead to concern over the availability of restroom [7].

In the domain of social function, patients do not dare to go outside or dinning, compete to go to restroom with family members, are forced to change mode of work, decrease travel, and give up enjoyment [7, 20]. Their lifestyle changes may bother their family, and they may suffer from loneness because their family cannot totally understand their feeling [7, 23]. Their life style changed, thus, they feel they become a different person, in the other ward, their body image was changed [7, 26, 28]. At the same time, they also suffered from social isolation [20, 21, 26].

5. The management strategies of low anterior resection syndrome

Although management of low anterior resection syndrome remains equivocal, some strategies are mentioned [5, 29, 30, 31, 32, 33, 34]. The strategies involve in three options: self-care strategies, clinician-initiated interventions, and creating a permanent stoma [29, 30, 31, 35].

5.1 Self-care strategies

The self-care strategies for treating low anterior resection syndrome contain diet modification, lifestyle changes, and spiritual sublimation [29].

Diet modification is the commonest strategy to treat the altered bowel function in postoperative rectal cancer patients [32]. Some types of foods leading to aggravation of bowel dysfunction were advised, including greasy foods, liquid foods, gas-inducing foods, sweet foods, and stimulating foods [32, 33, 36]. These foods easily increase the frequency of defecation and possibly induce diarrhea, urgency, fecal incontinence, or/and gas-stool discrimination [32]. Notably, the mechanism may be supported by a correlative study, which revealed some nutrients aggravate bowel dysfunction; for example, the consumption of protein, cholesterol, and fruit increases the frequency and urgency of defecation; the consumption of fruit decreases the abnormal sense of defecation, but the interaction of wheats and milk leads to an abnormal sense of defecation [37]. The consumption of high-fiber foods remained equivocal; some studies mentioned that it may increase the risk of diarrhea and frequency of bowel movement, but it also may decrease the incidence of fecal incontinence when taken an amount of 25 g in a day [31, 32, 33]. Although patients’ motivation of diet modification is usually driven by burden of low anterior resection syndrome, they often have a trial-and-error process, need to overcome general habits, and face social interfering factors before forming new eating habits, such the availability of diet preparation, the time and amount of eating regularly, and so on [38].

Lifestyle change is a consequence of suffering from low anterior resection syndrome and also is a strategy of treating it [32, 39]. To have a supply of anal skin-care products and use sitz bath can decease perianal soreness related to frequent defecation [29]. When patients go outside, using wipes or pads, carrying spare clothes, and confirming the availability of restroom can help them to manage the embarrassment related to fecal incontinence [7, 29]. Participating some activities to divert patients’ attention from defecation is a useful method to control bowel symptoms, such as walking, jogging, going work, joining religion ceremony, and so on [33, 40]. Minor patients note that special body position can improve evacuator function; additionally, some patients change their schedule or mode of jobs for return-to-work [33].

In spiritual sublimation, building up a confidence of managing low anterior resection and feeling normality, constructing positive or thankful life attitude, accepting the dysfunction as part of them, and seeking reason to be strong usually help patients to adjust their altered bowel function and cancer disease [7, 23, 33]. In clinical practice, healthcare professionals can find that symptoms did not disappear, but positive attitude and thinking can promote patients’ perception and quality of life [7, 24]. Acceptability and sharing experiences with other rectal cancer patients with low anterior resection syndrome can decrease patients’ loneness and helplessness [23, 24].

5.2 Clinician-initiated interventions

The clinician-initiated interventions for managing low anterior resection syndrome include prescribed medication, trans-anal irrigation, pelvic floor rehabilitation (such as pelvis floor exercise, biofeedback, functional electrostimulation, and rectal balloon training), and neuromodulation (percutaneous/transcutaneous tibial nerve stimulation and sacral nerve stimulation), and so forth [29, 41].

Some prescribed medications are usually used to improve these altered bowel function [29, 32]. Phenylephrine gel twice a day or once every 8 hours may increase the anal sphincter resting pressure and decrease fecal incontinence, and Botox-A may relieve anal neuropathic pain [26, 38]. Loperamide is the most commonly prescribed oral anti-diarrhea agent to treat low anterior resection syndrome, which can activate the resting tone of internal anal sphincter and reduce episodes of defecation [31]. In clinical practice, the dose of anti-diarrhea medicine is often used by patients’ self-judgment [32].

Indication of trans-anal irrigation is suggested for use in postoperative rectal cancer patients with severe or chronic low anterior resection syndrome [31]. The procedure of irrigation is usually undertaken with a rectal catheter or an anal cone and using 500 to 1500 mL daily or three to four time a week; patients usually train by clinicians or using a training video, and then they are also supervised the outcomes at least 4 weeks to 6 months [29]. The volume of irrigation, intervals between irrigation procedure, and choice of irrigation device remained equivocal and depend on patients’ or educators’ judgment [31, 39]. Under patients’ perception, trans-anal irrigation can improve symptoms of low anterior resection, control the time of defecation, and promote their quality of life; however, patients may feel stressful and have intent of refusal due to conduct the procedure with catheterization [39].

The mechanism of pelvic floor muscle rehabilitation focuses on training coordination, sensory function, and strength of pelvis floor muscle to improve fecal incontinence [31]. The methods may consist of: (1) Pelvis floor muscle training depends on steady contraction of pelvis floor muscles to increase maximum strength, extend the duration of contractions, and improve coordination of pelvic floor muscles (a recommended frequency of the contraction is 25-40 times for three sections a day); (2) Biofeedback allows patients to directly visualize the effects of contraction and relaxation of the pelvis floor muscle and helps them to maintain habitually high-quality pelvic floor movement; (3) Functional electrostimulation induces construction of pelvis floor, and then, patients relearn and optimize the contractions by sensory feedback of this artificial contraction; and (4) Rectal balloon training depends on putting a balloon into rectum to stimulate intent of defecation, and then, patients are trained to resist the urge to defecate [29, 30, 42, 43, 44]. Varied studies validate the effectiveness of the contents of intervention, which include pelvis floor muscle training alone, biofeedback with pelvis floor muscle training, electromyography biofeedback, rectal balloon biofeedback, or all of them [45]. Although the better benefits seem to be proved on multimodalities than the single one, but the conclusion remained equivocal because of several risks of bias, including low quality across all studies due to small sample sizes, insufficient long-term follow-up, lack of randomized and blinding assessment, and heterogeneity of outcome [31, 45]. Additionally, patients’ satisfaction remained unclear [46].

Neuromodulation included percutaneous tibial nerve stimulation, transcutaneous tibial nerve stimulation, and sacral nerve stimulation, which can restore neural pathway by continuous neural stimulation to treating various forms of urinary and fecal incontinence by activating nerve potentials to contract anal sphincter [31]. Percutaneous tibial nerve stimulation is applying a needle electrical stimulation into the tibial nerve at ankle, and is undertaking for 12, 17, or 20 sessions each lasting for 30 minutes; the undertaken intervals are more frequently initially, either once or twice a week, decreasing to weekly, fortnightly, monthly or sixmonthly [29]. The transcutaneous tibial nerve stimulation is to undertake a similar method of transcutaneous one, but it is using a cutaneous pad to substitute the needle electrical stimulation [31]. The procedure of sacral nerve stimulation is to put a lead of temporary external stimulator at the level of S2, S3, or S4 under general anesthesia, connecting it to a sacral nerve stimulation device and fixing its positions in a subcutaneous gluteal pocket; the setting divides the test and permanent stage, and the permanent implementation is conducted after confirming effective response during test stage [47]. The benefits of neuromodulation were revealed in previous studies, however, they still remained biases due to the results from researches with small sample sizes and lack of long-term follow-up [29, 31].

5.3 Creating a permanent stoma

Anastomosis stricture may develop in postoperative rectal cancer survivor, which may relate to previous radiation and surgery and aggravate symptoms of altered bowel function [30, 35]. When reconstruction of anastomosis is a contraindication to patients, creating a permanent stoma should be the eventual choice [30].

6. Conclusion

Altered bowel function is a consequence of anal-saving surgery. The symptoms impact patients’ physical, psychological, and social domains of quality of life and may follow postoperative rectal cancer patients for whole life. Flexibly using these care strategies may help them rebalance on a new road.

Acknowledgments

I am sincerely thankful for the all kind help from our editing team and the opportunity to share knowledge. The figures in this chapter were created by Li-Hua Fang, a pharmacist from the Department of Pharmacy at the Koo-Foundation Sun Yet-Sen Cancer Centre in Taipei, Taiwan.

Conflict of interest

The author has no conflicts of interest relevant to this article.