Review of bowel dysfunction of rectal cancer patients during the first five years after sphincter-preserving surgery: A population in need of nursing attention
Introduction
Colorectal cancer is the third most common cancer in the world (Ferlay et al., 2010). Besides the high incidence rate, the prevalence rate of colorectal cancer is also high. It is estimated that around 3.2 million people have been living with colorectal cancer within the past five years, which makes it the third most prevalent cancer globally (Bray et al., 2013). Treatment for colorectal cancer may involve surgery, chemotherapy, radiotherapy or biological therapy (National Cancer Institute, 2012). Surgery is the corner stone of the treatment which varies according to the location and extent of disease. Surgery for rectal cancer can be simply classified into sphincter-preserving surgery and abdominoperineal resection (APR). The continuity of the intestine is maintained after sphincter-preserving surgery, which means that patients can still evacuate feces from the anus. By contrast, for patients undergoing APR, the continuity of the intestine is damaged and a permanent colostomy must be created on the abdomen for fecal evacuation. With the advancement of surgical techniques, the use of sphincter-preserving surgery has increased. An American study reported a 10% decrease (from 60.1% to 49.9%) in the use of APR from 1989 to 2001 (Abraham et al., 2005). In another German rectal cancer trial, APR was used in less than 30% of patients (Sauer et al., 2004). Nowadays, most patients with rectal cancer can maintain the continuity of the intestine.
Despite the lack of accurate data regarding its prevalence, it is believed that bowel dysfunction is a frequent complication of sphincter-preserving resection (Böhm et al., 2008), and it significantly impairs the quality of life (QOL) of patients with rectal cancer (Bruheim et al., 2010, Pietrzak et al., 2007, Vironen et al., 2006). In the past, nursing professionals might not have paid sufficient attention to patients with rectal cancer suffering from bowel dysfunction. Few articles can be found on this issue from the perspective of nursing (Desnoo and Faithfull, 2006, Landers et al., 2011a, Landers et al., 2011b, Mizuno et al., 2007, Nikoletti et al., 2008, Pan et al., 2011). Greater awareness of bowel dysfunction is needed among nursing professionals, and accurate knowledge of the condition is essential if nursing professionals are to be able to provide care for patients with rectal cancer.
Therefore, this review article aims to summarize the research evidence to facilitate our understanding of bowel dysfunction among patients with rectal cancer undergoing sphincter-preserving resection. The initial two objectives of this review article were to review the longitudinal changes in bowel dysfunction within the first five years after sphincter-preserving surgery, and to identify factors associated with bowel dysfunction. However, while this review was in preparation, a review article was published that summarized research on the factors contributing to the bowel dysfunction of patients with rectal cancer (Kwann, 2011). Thus, this critical review focused on the longitudinal changes in the bowel dysfunction of patients with rectal cancer within the first five years after sphincter-preserving surgery.
Section snippets
Search strategy
A series of literature searches were conducted on six English-language electronic databases: the British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health literature (CINAHL), OVID, PsycINFO, PubMed, and Scopus. The following combination of key words was used: (colorectal OR rectum) AND (cancer OR neoplasm OR carcinoma) AND (bowel OR anorectal) AND (symptom OR dysfunction OR problem OR consequence OR sequelea). Articles published between January 1990 and January 2013 were
Study design & settings
Of the 29 articles (see Table 1), a longitudinal design was adopted in 14 articles, and a cross-sectional design was adopted in 15 articles. One study including two articles was conducted in multiple countries (Fazio et al., 2007, Parc et al., 2009), while the others were each conducted in one country. The majority of studies were conducted in Europe, including Finland, France, Germany, Italy, Norway, Poland, Serbia, Sweden, the Netherlands, and the United Kingdom. Some studies were conducted
Discussion
To our knowledge, this review is one of the first attempts to summarize the changes in bowel dysfunction among patients with rectal cancer over time, although several review articles have been published describing bowel dysfunction from other perspectives. For example, two review articles analyzed the impacts of different treatments on bowel function (Emmersten and Laurberg, 2008, Kwaan, 2011). One focused on the effects of various anastomotic techniques (Murphy et al., 2007). Based on the
Implications for nursing
Bowel dysfunction includes an array of problems that have profound impacts on rectal cancer patients. It is necessary to provide supportive care to patients to help them learn self-care strategies and minimize the impact of their condition. Supportive care for bowel dysfunction should include the provision of information and psychological support, which should be delivered in multiple steps over an extended period of time. The first step should be taken before surgery, when patients are
Limitations and future research
Several limitations exist, which should be noted when generalizing the findings of this review. First, the subjects in the included studies were patients with rectal cancer. Among them, the subjects in 16 studies were patients with middle or low rectal cancer, who were more likely to have bowel dysfunction. Therefore, the findings of this review mainly reflect the situation of patients with rectal cancer, and one should be cautious about generalizing them to the whole population of patients
Conclusion
This critical review summarized longitudinal changes in the bowel dysfunction of patients with rectal cancer within the first five years following surgery. Bowel dysfunction is especially common among patients with rectal cancer. It includes altered bowel frequency, incontinence, abnormal sensations, and evacuation difficulties. These problems are most frequent and severe within the first year, especially the first six months, and stabilize after one year. For some, the problems may last for
Conflict of interest
None declared.
References (56)
- et al.
Functional outcome after intersphincteric resection of the rectum with coloanal anastomosis in low rectal cancer
European Journal of Surgical Oncology
(2004) - et al.
Late side effects and quality of life after radiotherapy for rectal cancer
International Journal of Radiation Oncology • Biology • Physics
(2010) - et al.
Recurrence and survival after total mesorectal excision for rectal cancer
Lancet
(1986) Bowel function after rectal cancer surgery: a review of the evidence
Seminars in Colon & Rectal Surgery
(2011)- et al.
Impact of short-course radiotherapy and low anterior resection on quality of life and bowel function in primary rectal cancer
The American Journal of Surgery
(2008) - et al.
Quality of life, anorectal and sexual functions after preoperative radiotherapy for rectal cancer: report of a randomized trial
Radiotherapy and Oncology
(2007) - et al.
Increased use of low anterior resection for veterans with rectal cancer
Alimentary Pharmacology & Therapeutics
(2005) - et al.
Function after intersphincteric resection for low rectal cancer and its influence on quality of life
Colorectal Cancer
(2011) - et al.
Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer
Techniques in Coloproctology
(2011) - et al.
Anorectal, bladder, and sexual function in females following colorectal surgery for carcinoma
International Journal of Colorectal Disease
(2008)
Global estimates of cancer prevalence for 27 sites in the adult population in 2008
International Journal of Cancer
Comparison of functional results and quality of life between intersphincteric resection and conventional coloanal anastomosis for low rectal cancer
Diseases of the Colon & Rectum
Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients
International Journal of Colorectal Disease
The challenges of colorectal cancer survivorship
Journal of the National Comprehensive Cancer Network
Risk factors for fecal incontinence after intersphincteric resection for rectal cancer
Diseases of the Colon & Rectum
A qualitative study of anterior resection syndrome: the experiences of cancer survivors who have undergone resection surgery
European Journal of Cancer Care
Bowel function after treatment for rectal cancer
Acta Oncologica
A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers
Annals of Surgery
GLOBOCAN 2008 v2.0: Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 [Internet]
Neorectal reservoir is not the functional principle of the colonic J-pouch
Diseases of the Colon & Rectum
Anorectal function after partial intersphincteric resection in ultra-low rectal cancer
Colorectal Disease
Functional outcome after low anterior resection with low anastomosis for rectal cancer using the colonic J-pouch
Diseases of the Colon & Rectum
Long-term functional outcome of low anterior resection with colonic J-pouch reconstruction for rectal cancer in the elderly
Diseases of the Colon & Rectum
Comparison of J-pouch and coloplasty pouch for low rectal cancers
Annals of Surgery
Lever of the anastomosis does not influence functional outcome after anterior rectal resection for rectal cancer
The American Journal of Surgery
Transabdominal anastomosis after low anterior resection: a prospective, randomized, controlled trial comparing long-term results between side-to-end anastomosis and colonic J-pouch
Diseases of the Colon & Rectum
Influence of intra-operative and postoperative radiotherapy on functional outcome in patients undergoing standard and deep anterior resection for rectal cancer
Diseases of the Colon & Rectum
Effectiveness of biofeedback therapy in the treatment of anterior resection syndrome after rectal cancer surgery
Diseases of the Colon & Rectum
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