Summary of the best evidence for managing low anterior resection syndrome in patients after rectal cancer sphincter-saving surgery
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摘要:
目的 检索并总结国内外关于直肠癌保肛术后低位前切除综合征患者管理的相关最佳证据，为临床实践提供依据。 方法 采用PIPOST方法确立循证问题，按“6S”金字塔证据模型，系统检索UpToDate、BMJ Best practice、Cochrane Library、Web of Science、PubMed、Embase、CINAHL、英国国家临床医学研究所指南库(NICE)、美国结直肠外科医师协会(ASCRS)、美国医学会、中国生物医学文献数据库、医脉通、中国知网、万方和维普数据库中关于直肠癌保肛术后低位前切除综合征患者管理措施的相关研究，包括临床决策、指南、系统评价、专家共识和原始研究，由2位小组成员采用对应的文献质量评价工具独立完成文献的质量评价，提取相关证据并根据JBI循证卫生保健中心证据分级和推荐系统对证据进行汇总与分级。检索时限为建库至2024年8月。 结果 本研究系统检索有关数据库获得文献4 166篇，根据文献纳入和排除标准筛选，最终纳入13篇，包括1篇临床决策、4篇指南、2篇专家共识、3篇系统评价和3篇原始研究。提取内容包括多学科合作与评估、盆底康复管理、饮食管理、健康教育及监测与随访4个方面，共汇总出21条最佳证据。 结论 本研究对直肠癌保肛术后低位前切除综合征患者的管理进行了证据总结，为患者构建全面、科学的管理方案提供循证依据，促进患者的全面康复。 Abstract:Objective Retrieve and summarize the highest evidence from both domestic and international sources on the management of patients with LARS, in order to provide a basis for clinical practice. Methods The PIPOST was adopted to establish evidence-based problems, and the "6S" pyramid evidence model was adopted. The system conducted a comprehensive search across various databases including UpToDate, BMJ Best Practice, Cochrane Library, Web of Science, PubMed, Embase, CINAHL, NICE, ASCRS, American Medical Association, Chinese Biomedical Literature Database, Yimaitong, CNKI, Wanfang, and VIP, focusing on the management of patients experiencing low anterior resection syndrome after rectal preservation surgery, including clinical decisions, guidelines, systematic reviews, expert consensus, and original research. Two team members independently completed the literature quality evaluation using corresponding literature quality evaluation tools and extracted relevant evidence. The evidence was summarized and evaluated using the grading and recommendation system established by the JBI Evidence-Based Health Care Center. The search period is up to August 2024. Results In this study, 4 166 literature were obtained through a systematic search of relevant databases, and screening in accordance with inclusion and exclusion criteria, a total of 13 studies were definitively incorporated into the final analysis for medical evaluation, including 1 clinical decision, 4 guidelines, 2 expert consensus, 3 systematic reviews, and 3 original studies. The extraction content included multidisciplinary cooperation and evaluation, pelvic floor rehabilitation management, diet management, health education, monitoring, and follow-up, and a total of 21 best evidence were collected. Conclusion This study summarizes the evidence for managing patients with LARS. It aims to provide an evidence-based foundation for developing a comprehensive and scientific management protocol for patients, ultimately promoting their overall rehabilitation. -
表 1 纳入文献的一般特征
Table 1. General characteristics of the included literature
纳入文献 文献来源 文献类型 文献主题 发表年份 JACOPO M[9] UpToDate 临床决策 低位前切除综合征 2020 CHRISTENSEN P等[10] Pubmed 指南 低位前切除综合征的管理指南 2021 HARDIMAN K M等[11] ASCRS 指南 美国结直肠外科医师协会临床实践指南：结直肠癌根治后患者的监测和生存护理 2021 PIERI C等[12] Medline 指南 低位前切除综合征的临床护理管理-了解和处理症状的实用指南 2020 BENSON A B等[13] NICE 指南 结直肠癌 2020 KEANE C等[14] Pubmed 专家共识 低位前切除综合征的国际共识定义 2020 中华医学会外科学分会结直肠外科学组等[15] 万方 专家共识 直肠癌经肛全直肠系膜切除中国专家共识及临床实践指南(2019版) 2019 HAAS S等[16] Embase 系统评价 结直肠癌后治疗相关后遗症的处理 2022 CHAN K Y C等[17] Embase 系统评价 盆底康复治疗对结直肠癌前切除术后肠功能障碍影响的系统评价 2021 BULFONE G等[18] Pubmed 系统评价 低位前切除综合征康复策略的系统评价 2020 LI C等[19] Pubmed RCT 保留括约肌手术后中下直肠癌患者肠道功能障碍自我管理计划的有效性：一项随机对照试验 2023 GARFINKLE R等[20] Pubmed RCT 以患者为中心的低位前切除综合征计划的制定和评估：随机对照试验的方案 2020 YIN L等[21] Pubmed RCT 直肠癌低位前切除术后幸存者恢复过程中的肠道症状及自我护理策略 2018 
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表 2 指南的质量评价
Table 2. Quality evaluation of the guidelines
纳入文献 范围和目的(%) 牵涉人员(%) 指南开发的严格性(%) 指南呈现的清晰性(%) 指南的适用性(%) 指南编撰的独立性(%) ≥30%领域数(个) ≥60%领域数(个) 推荐级别 CHRISTENSEN P等[10] 97.22 61.11 51.88 55.56 64.58 79.16 6 4 B HARDIMAN K M等[11] 100.00 66.67 67.71 72.22 54.17 83.33 6 5 B PIERI C等[12] 88.89 47.22 54.17 83.33 77.08 91.67 6 4 B BENSON A B等[13] 100.00 88.24 78.13 94.44 79.17 95.83 6 6 A
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表 3 直肠癌保肛术后低位前切除综合征患者管理的最佳证据总结
Table 3. Summary of the best evidence for managing low anterior resection syndrome in patients after rectal cancer sphincter-saving surgery
类别 证据内容 证据等级 推荐级别 多学科合作与评估 1.组建胃肠外科医生、护士、盆底康复治疗师、营养专科师及心理咨询师等多学科团队[10] Level 1 A 2.基于患者详细病史询问和体格检查评估肛门功能，采用直肠肛管测压评估直肠肛管的生理、病理状态[15] Level 5 A 3.建议使用LARS量表评估患者的严重程度，根据LARS评分将患者分为无、轻度和重度[10, 15-16] Level 1 A 4.建议使用纪念斯隆-凯特琳癌症中心功能量表(MSKCC-BFI评分)评估患者的肠道功能[10, 12] Level 5 A 5.建议使用直肠癌保肛术后患者肠道症状自我管理问卷评估患者的肠道症状的自我管理能力[10] Level 5 A 盆底康复管理 6.推荐患者居家每天做盆底肌修复训练，包括凯格尔运动和肛门括约肌运动[16-17] Level 2 A 7.提肛运动：术后肛周水肿消退后做提肛运动，下蹲时放松肛门，站立时收缩肛门，每日3~4次，每次连续做30次[17] Level 1 A 8.缩肛运动：术后1周指导患者缩肛运动训练，将食指插入肛门，呼气时使肛门上提，肛门括约肌收缩，吸气时放松，使手指能感受到紧缩感，每日2组，每组10次[18] Level 1 B 9.Kegel运动：术后1周指导患者做Kegel运动，每天训练时间15~20 min，训练时收紧盆底肌肉5~10 s，然后放松10 s，肌肉收紧与放松交替、反复进行[10-11, 17] Level 1 A 10.排便反射训练：术后3~4周开始，有便意时立即收缩肛门，通过深呼吸、变换体位等方式缓解便意，持续10 s，养成定时排便的习惯[16] Level 1 B 饮食管理 11.建议为患者制定科学、合理的饮食计划，规律进食以易消化的食物为主[21] Level 1 A 12.少食豆类、萝卜、洋葱等易产气食物[10] Level 5 A 13.避免摄入油炸、辛辣刺激性食物、酒、咖啡、浓茶、碳酸饮料等[10, 21] Level 5 A 14.建议患者采用高纤维、低脂饮食模式，首选西红柿、苹果等可溶性纤维[10, 14] Level 1 A 15.建议患者补充膳食纤维剂，如小麦糊精、洋前子草壳、瓜尔胶和甲基纤维素[12] Level 2 A 16.建议便秘患者每天摄入纤维量25~40 g，多吃水果、蔬菜、粗粮，富含果胶的水果如李子、香蕉等[13] Level 5 A 健康教育与随访 17.建议为患者发放LARS管理手册，包括信息手册、患者日记和护理支持[20] Level 1 B 18.建议患者便后采用柔软纸巾或使用不含酒精的湿巾擦拭，每天温水坐浴2~3次，使用氧化锌等保护肛周皮肤[10, 16] Level 5 A 19.建议患者外出当日降低食物的摄入量、出门尽可能前排空肠道，根据排便规律计划出行并事先了解活动地点的厕所分布情况[12, 19] Level 5 A 20.建议为患者提供延续护理[11, 13] Level 1 A 21.建议患者记录食物/症状日记：记录每天饮食情况和排便情况[12, 20] Level 1 B
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