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.
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