Continued Care in Palliative Bowel Surgery: An Invited Brief Commentary on “Long-Term Functional Outcome After Internal Delorme's Procedure for Obstructed Defecation Syndrome and the Role of Post-Operative Rehabilitation”

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Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation

In Long-term functional outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome and the role of postoperative rehabilitation, the authors and investigators aim to examine the role of postoperative rehabilitation on the outcomes of patients who did not respond to conservative treatment [1]. This study focused specifically on the Internal Delorme's Procedure (IDP), a modified rectosigmoidectomy which removes prolapsed or intussuscepted portions of the rectum, to provide relief from Obstructed Defecation Syndrome (ODS).

While rarely life-threatening, ODS is a form of functional constipation which can burden one's quality of life [2, 3]. The root cause of ODS is often an anatomical defect and therefore conservative treatment methods may not be effective. These conservative treatments generally consist of bulking agents and fiber supplements added to the diet of the patient, or laxatives and stool softeners [4]. Since the cause is anatomical in nature, patients would have to either consistently and continuously adhere to the conservative therapy or undergo surgery to repair the defect [5].

Ultimately, due to the fact that the participants selected did not have any life-threatening conditions [1], this study may be viewed as an examination of the effectiveness of IDP as a palliative treatment. In these circumstances, IDP falls within the American College of Surgeon's (ACS) definition of palliative treatment, especially considering the expansion of its meaning to include all interventions aiming “to relieve physical pain and psychological, social and spiritual suffering” beyond its traditional use to describe end-of-life care [6]. Even palliative surgery can come with its own risks, complications, and pains which surgeons aim to minimize. The effectiveness of IDP on ODS and the related rehabilitation should then be analyzed in terms of complications, functional outcome, and satisfaction, just as the authors of this paper have done [1].

In this paper, the authors effectively describe how most patients are satisfied with the IDP, and how there is a loss of functional outcome in patients who have not been exposed to rehabilitation [1]. Their course of rehabilitation included “evacuatory technique training, biofeedback, electric stimulation and volumetric stimulation” [1]. Biofeedback therapy has been known to be effective in treating fecal incontinence [7]. A recent study in the Indian Journal of Gastroenterology also shows that biofeedback improves the symptoms and physiology of patients with fecal evacuation disorder [8]. Additionally, volumetric and electrical stimulation can be used together to address evacuatory dysfunction and rectal hyposensitivity [9]. It stands to reason that, when combined, these therapies would be effective in enhancing or preserving the functional outcomes of IDP, which has been demonstrated in this paper [1].

The high level of patient satisfaction demonstrates that IDP for ODS on its own is an effective palliative intervention. Additionally, the authors highlight the importance of post-operative rehabilitation by showing a statistically significant correlation of loss of functional outcome associated with lack of rehabilitation. This may indicate postoperative rehabilitation after IDP to ensure a reduced risk of recurrence. However, there is always a question of ease-of-access and affordability when it comes to new measures or protocols. We are not made aware of the cost and specific content of the appropriate rehabilitation, so we cannot hope to judge the feasibility of postoperative rehabilitation as part of the gold-standard of care for palliative ODS intervention. The question of access also weighs heavy due to the fact that the rehabilitation was only available to the patients at one of the hospitals included in the study. Nevertheless, it is important and appreciated that the investigators of this study determined that their methods of rehabilitation are useful in achieving desirable results after IDP.

We also do not know with any degree of specificity if special instructions were given to the patients, both immediately after the IDP and during the rehabilitation. Following colorectal surgery at Morristown Medical Center, patients are instructed to consume a “modified fiber diet.” This diet is high in water soluble fibers and low in water insoluble fibers with the intent to slow intestinal transit and promote recovery. It is not mentioned in this study whether or not patients were instructed to modify their diet after IDP. If this is the case, yet it is not reported in the study, then diet may be a source of confounding. We know that diet is closely related with intestinal function, and that a change in diet is part of the conservative therapy for ODS [4]. If patients undergoing post-IDP rehabilitation therapy were more likely to adhere to the diet (which is not an unreasonable hypothesis to posit, since this cohort is consistently in contact with healthcare professionals), then the rehabilitation program may be confounding the relationship between diet and functional outcome.

At the end of the day, this study is enlightening, and like most enlightening studies leaves us asking more questions. The authors did show with a high level of significance the relationship between post-IDP rehabilitation and long-term functional outcome, despite a relatively small population of patients. Since it appears that rates of complication and failure are low, it would be interesting to see a study with a larger population that could tease out any measures which may be associated with complications. It may also be worthwhile to repeat a similar study design accounting for different causes of ODS and the surgical treatments which address them. The patients in this study presented with tenesmus, rectocele, prolapse, intussusception, or a combination of these causes [1]. This same rehabilitation program should be tested for other specific causes and their appropriate surgical treatments [4, 10]. It is likely that the methods would transfer well, given their effectiveness on their own [7–9], yet they should be tested thoroughly for each set of causes before claims are made. Another study could potentially determine which aspects of the rehabilitation contribute significantly to positive long-term functional outcome. This could help determine which methods are absolutely necessary for a rehabilitation program and not only lower the cost of care but also spare patients from redundant or unnecessary exercises which they may consider to be intrusive or embarrassing. Despite these new questions which we may be asking about ODS and IDP, this study does demonstrate and frame an important aspect of palliative surgery and the care which follows. We hope to see additional studies in the future examining the role of rehabilitation and continued care in enhancing recovery, and for the results of these studies to be sincerely applied in practice to improve the lives of patients.

DECLARATION OF INTEREST

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.