生物反馈联合盆底肌锻炼对直肠癌低位保肛患者低位前切除综合征的作用

Intervention effect of biofeedback combined with pelvic floor muscle exercise on low anterior resection syndrome in patients with low anus-preserving rectal cancer

目的探讨生物反馈训练联合盆底肌锻炼对中低位直肠癌行低位保肛患者肛门直肠功能恢复的效果,寻求预防其低位前切除综合征的最佳方法.方法采用单中心前瞻性随机对照研究方法,将2015年6月至2016年12月在中山大学附属肿瘤医院接受诊治的109例拟接受术前放化疗后行低位保肛术和预防性造口的中低位直肠癌患者纳入研究,按随机数字表法分为空白对照、盆底肌锻炼和生物反馈训练联合盆底肌锻炼共3组,进行16个月的干预和随访追踪.采用高分辨肛门直肠测压测量患者的客观肛门直肠压力、感觉指标,采用中文版纪念斯隆-凯特林癌症中心(MSKCC)肠道功能问卷评价患者的肠道功能状况,比较3组患者客观的肛门直肠测压指标和主观肠道功能状况的差异;并评价患者直肠低位前切除综合征的发生情况.结果在干预结束时,生物反馈训练联合盆底肌锻炼组患者肛管静息压、直肠静息压、肛管最大收缩压、肛管最大收缩时间、直肠初始容量、直肠便意感觉容量、直肠最大耐受容量、直肠顺应性、肛管高压带和肠道功能总分分别为(44.8±9.0)mmHg(1mmHg=0.133kPa)、(4.3±1.6)mmHg、(130.5±10.0)mmHg、(19.9±4.3)s、(32.7±5.0)ml、(74.3±8.3)ml、(188.4±12.7)ml、(5.7±1.2)ml/kPa、(3.31±0.96)cm和(68.1±6.4)分.肛管静息压、直肠静息压、肛管最大收缩压、肛管最大收缩时间和肛管高压带5个指标变化的主效应为时间.组间差异显著的指标为直肠初始容量、直肠便意感觉容量、直肠最大耐受容量、直肠顺应性和肠道功能总分,生物反馈训练联合盆底肌锻炼组患者在治疗后的各个测量时间点显著高于空白对照组(P<0.05);生物反馈训练联合盆底肌锻炼组患者在根治术后1个月、造口回纳术围手术期及造口回纳术后3个月时显著高于盆底肌锻炼组(P<0.05).生物反馈训练联合盆底肌锻炼能降低直肠低位前切除综合征的发生率(P<0.05).结论生物反馈训练联合盆底肌锻炼能显著改善中低位直肠癌患者的感觉指标,促进其肠道功能的恢复,减轻直肠癌患者低位前切除综合征,值得推广应用.

Objective To explore the effect of biofeedback training combined with pelvic floor muscle exercise on the recovery of anorectal function in patients with middle and low rectal cancer undergoing sphincter-preserving surgery, and to find the best way to prevent low anterior resection syndrome. Methods A single-center prospective randomized controlled study was conducted. One hundred and nine patients with mid-low rectal cancer in Sun Yat-sen University Cancer Centre from June 2015 to December 2016 were enrolled in the study, who were going to undergo sphincter-preserving surgery or preventive ostomy after preoperative chemoradiotherapy. They were divided into three groups: blank control group, pelvic floor muscle exercise group and biofeedback training combined with pelvic floor muscle exercise group. Intervention and follow-up were conducted for 16 months. High-resolution anorectal manometry was used to measure the objective anorectal pressure and sensory index of patients, and the Chinese version of MSKCC Intestinal Function Questionnaire was used to evaluate the intestinal function of patients. The differences of objective anorectal manometry index and subjective intestinal function between the three groups were compared, and the occurrence of low anterior rectal resection syndrome was evaluated. Results At the end of the intervention, the total scores of anal resting pressure, rectal resting pressure, anal maximum systolic pressure, anal maximum systolic time, initial rectal volume, rectal fecal sensory capacity, rectal maximum tolerance capacity, rectal compliance, anorectal hypertensive zone and total score of intestinal function in the biofeedback training combined with pelvic floor muscle exercise group were (44.83±9.01) mmHg,(4.31±1.75) mmHg,(130.46±10.00) mmHg,(19.94±4.30) s,(32.71±5.00) ml,(74.26±8.30) ml,(188.4±12.68) ml,(5.69±1.18) ml/kPa,(3.31±0.96) cm and (68.09±6.38) points respectively. The main effects of the changes of five indices, including anal resting pressure, rectal resting pressure, anal maximum systolic pressure, anal maximum systolic time and anal high pressure zone, were time. Significant differences were found in initial rectal capacity, sensory capacity of rectal defecation, maximum tolerance capacity of rectum, rectal compliance and total score of intestinal function in every time point of measurement in the biofeedback training group combined with pelvic floor muscle exercise group. They were significantly higher than those in the blank control group (P<0.05);the score of the biofeedback training group combined with pelvic floor muscle exercise group at one month after operation, perioperative period and 3 months after operation were significantly higher than those in pelvic floor muscle exercise group (P<0.05). Biofeedback training combined with pelvic floor muscle exercise reduced the incidence of low anterior resection syndrome of rectum (P<0.05). Conclusion Biofeedback training combined with pelvic floor muscle exercise can significantly improve the sensory indicators of patients with mid-low rectal cancer, promote the recovery of intestinal function, and alleviate low anterior resection syndrome of rectal cancer patients, which is worthy of popularization and application.