The role of biofeedback in improving anal continence after anterior resection

Abstract

Incorporation of routine biofeedback into the management of patients with rectal cancer who are undergoing anterior resection offers potential for improved anal continence compared with standard management. A multicentre randomised controlled trial was performed to investigate this and 121 participants undergoing major rectal resection were randomly assigned to receive biofeedback training. In the control group participants received standard management. Randomisation was stratified for preoperative radiotherapy exposure. The primary end point was Cleveland Clinic Incontinence (CCI) score at 1 year. Analysis was by intention to treat (ITT). Secondary end points were serial symptom-score, quality of life questionnaires and anorectal physiology measured during the first postoperative year. Follow-up to one year was completed by 89 participants. A mean CCI score of 4 was recorded at 1 year in both groups. Before anterior resection, 15 (17%) participants reported severe anal incontinence. At 3 months after anterior resection, 27% of participants reported severe anal incontinence, which caused a negative impact on their quality of life. Function improved in some participants but 15% complained of severe anal incontinence at one year. Anal continence after anterior resection is a poorly defined problem. Although no advantage was found by the addition of routine biofeedback to standard management, this study establishes a working definition for “Anterior Resection Syndrome” and evaluates methods for measuring the structural and functional abnormalities associated with it. Symptom-score and quality of life questionnaires, anorectal physiology and proctography are frequently used to evaluate pelvic floor patients but are also relevant to assess anterior resection patients. An additional study was carried out to compare Barium (BaP) and MR proctography. BaP reproduced rectal emptying and demonstrated structural abnormalities to a greater extent than MR proctography and would be the best test for assessing structural abnormalities after anterior resection

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