A comparative study of acupuncture combined with rehabilitation gymnastics on postoperative anal function of lower rectal cancer

Abstract

BACKGROUND

From the anal function, inflammatory response and other indicators, acupuncture combined with rehabilitation gymnastics was applied to patients with cancer undergoing low resection, aiming to improve the prognosis of patients.

AIM

To explore the effects of acupuncture combined with rehabilitation gymnastics on anal function after lower rectal cancer surgery.

METHODS

From January 2020 to December 2022, 128 patients who underwent rectal cancer surgery in the Department of Oncology of Hebei Provincial Hospital of Traditional Chinese Medicine Hospital were selected and divided into two groups using the random number table method, with 64 patients in each group. Patients in the control group were not treated with acupuncture or rehabilitation gymnastics and served as blank controls. Patients in the study group were treated with acupuncture and rehabilitation gymnastics from the 7th postoperative day. The anal incontinence scores, changes in serum interleukin-4, interleukin-6, and interleukin-10 Levels, and serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels were compared.

RESULTS

There were no significant differences in serum interleukin-4, interleukin-6, and interleukin-10 Levels between the groups before treatment (P > 0.05). After treatment, these levels were better than those of the control group (P < 0.05). There was no significant difference in the anal incontinence scores between the groups before and 7 d after surgery (P > 0.05). Anal incontinence scores in the study group were lower than those in the control group at 14 d, 21 d, and 28 d postoperatively (P < 0.05). There were no significant differences in serum motilin, 5-hydroxytryptamine, or vasoactive intestinal peptide levels between the groups before treatment (P > 0.05). After treatment, these levels were higher in the study group than in the control group, and vasoactive intestinal peptide level was lower in the study group than in the control group (P < 0.05).

CONCLUSION

Acupuncture combined with rehabilitation gymnastics can promote the recovery of anal function and reduce the inflammatory response in patients with lower rectal cancer after surgery.

Key Words: Low rectal cancer; Anal function; Acupuncture; Rehabilitation gymnastics

Core Tip: Acupuncture combined with rehabilitation gymnastics applied to patients with low rectal cancer surgery can significantly improve anal function, which can also reduce the level of inflammatory factors and improve gastrointestinal function. This study observed the changes of gastrointestinal function in patients with low rectal cancer after surgery, which can be correlated with the anal function of patients, and confirms the effectiveness of acupuncture combined with rehabilitation gymnastics applied to patients with low rectal cancer surgery.

INTRODUCTION

Lower rectal cancers occur within 8 cm of the anal verge. The most common symptom is rectal irritation and severe symptoms such as tenesmus and stool bleeding may occur[1]. Rectal cancer is a malignant tumor of the digestive system with a high incidence, and the most effective clinical treatment is surgery. Currently, minimally invasive sphincter-preserving surgery is widely used. However, while improving the rate of anal preservation in patients with lower rectal cancer, it is easy to neglect the recovery of anal function after surgery. Hence the physiological and psychological needs of patients are not met, resulting in poor quality of life after surgery, anal incontinence, and night fecal leakages are common. To promote postoperative anal recovery, it is necessary to develop an effective and safe treatment plan[2]. To date, the postoperative treatment of patients with lower rectal cancer, mainly through drugs and biofeedback methods, has achieved some therapeutic effects, although the expected goal remains unattained. Traditional Chinese medicines, such as hip baths, acupuncture, and massage, have great advantages in promoting anal recovery with significant therapeutic effects[3]. Acupuncture treatment has a good effect on postoperative anal function recovery in patients with lower rectal cancer and is simple to perform, inexpensive, and safe. However, previous studies lacked objective indicators, and theoretical guidance and standardized treatment processes have not yet been developed. Rehabilitation gymnastics also plays a role in promoting the recovery of postoperative anal function. Patients can complete it independently with little influence of time and space, simple operations, and good outcomes. Consequently, 128 patients who underwent rectal cancer surgery at Hebei Provincial Hospital of Traditional Chinese Medicine Hospital between January 2020 and December 2022 were selected as controls to explore the effect of acupuncture therapy combined with rehabilitation gymnastics on anal function after lower rectal cancer surgery.

MATERIALS AND METHODS

General information

A total of 128 patients who underwent rectal cancer surgery at Hebei Provincial Hospital of Traditional Chinese Medicine between January 2020 and December 2022 were selected and divided into control and study groups using the random number table method, with 64 cases in each group. The control group consisted of 35 males and 29 females. The oldest was 68 years, the youngest was 27 years, and the average age was 45.64 ± 4.45 years. Body mass index ranged between 21.2-24.7 kg/m², with an average of 22.68 ± 1.02 kg/m². The study group consisted of 34 males and 30 females. The oldest was 67 years, the youngest was 26 years old, and the average age was 45.68 ± 4.42 years. Body mass index was 21.5-24.5 kg/m², with an average of 22.61 ± 1.05 kg/m². There was no significant difference in the baseline data between the two groups (P > 0.05). The application was submitted to the Ethics Committee, and the study was conducted after approval.

Inclusion criteria: (1) Meet the diagnostic criteria of lower rectal cancer in "Rectal Cancer"[4]; (2) all patients underwent surgical treatment; (3) good spirit and cognition; (4) stable vital signs; and (5) complete case data. The exclusion criteria were as follows: (1) Contraindications to surgery or anesthesia; (2) serious postoperative infection; and (3) discharge or transfer during the study period.

Methods

Both groups underwent laparoscopic radical resection according to the 2019 NCCN Clinical Practice Guidelines for Rectal Cancer. All surgeries were performed by the same surgical team. The control group did not receive any acupuncture treatment or rehabilitation gymnastics after the operation and was used as a blank control. Only routine postoperative treatment was administered to the patients. The team administered acupuncture and rehabilitation exercise combination therapy. Acupuncture aims to clear turbidity, remove poison, nourish qi, invigorate the spleen, raise yang, and lift depression. Acupuncture was applied to Zusanli (ST 36), Gongsun (ST 36), Qihai (SP 6), and Pishu (BL 23) using a reinforcing method. Acupuncture was applied at Tianshu (ST 25), Changqiang (CV 6), Baihui (GV 20), and Anthursa (CV 4) (1.5 cm away from the anal verge at points 3, 6, 9, and 12) using the method of flat reinforcement and reduction. Acupuncture was applied to Hegu (LI 4), Yinlingquan (SP 9), Shangjuxu (ST 37), and Fenglong (ST 40) using the filiform needling-reducing method. The needle was retained for 20 min after acupuncture at Deqi and the treatment was administered every other day. Treatment was initiated 7 d after surgery and continued until 28 d after surgery. Rehabilitation gymnastics: (1) Leg bending: Supine position, lifting both legs and knees simultaneously, repeat 10 times; (2) Lift leg: Supine position, lift both legs simultaneously and repeat the action 10 times; (3) Riding: Supine position, take turns to flexion-extension legs, do riding action, each time 20-30 s; and (4) Shrink the anus: In the supine position, close the legs to the buttocks and tighten the direction of the anus. Take a deep breath, repeat the levator ani, and clamp the anus–20-30 times. Perform rehabilitation gymnastics twice daily.

Indicators of observation

Changes in serum interleukin-4, 6, and 10 levels were compared. Patients were instructed to fast and abstain from water after 9 pm on the day before the examination. The following day, 10 mL of fasting venous blood was collected and centrifuged for 10 min (2500 r/min) to separate the serum. Serum levels of interleukin-4, 6, and 10 were detected using appropriate kits. Patients were tested once, before and after treatment.

To compare anal incontinence scores. The Wexner score for anal incontinence was used to evaluate the postoperative anal function. The frequencies of anal incontinence, stool shape, lifestyle changes, and sanitary pad use were also recorded. The scores ranged from 0 to 20, with higher scores indicating more severe anal incontinence. Anal incontinence scores were compared before surgery and 7 d, 14 d, 21 d, and 28 d after surgery.

Serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels were compared. They were measured before and after treatment.

Statistical analysis

All patient data were imported into SPSS25.0 software for processing. Measurement data in accordance with normal distribution were expressed by mean ± SD and analyzed by t-test. Count data were expressed as (n, %), χ² test was performed, and the test standard was 0.05. P < 0.05 indicated that the data difference was statistically significant.

RESULTS

Comparison of serum levels of interleukin-4, 6, and 10

There was no significant difference in the serum levels of interleukin-4, 6, and 10 between the study and control groups before treatment (P > 0.05). After treatment, the serum levels in the study group decreased than those in the control group (P < 0.05). The data and statistical results are presented in Table 1.

Table 1 compares serum levels of interleukin-4, interleukin-6, and interleukin-10 (mean ± SD).

Groups	Time	Interleukin-4 (pg/mL)	Interleukin-6 (pg/mL)	Interleukin-10 (pg/mL)
Research group (n = 64)	Before treatment	10.24 ± 1.15	10.11 ± 1.24	14.24 ± 2.15
	After treatment	4.11 ± 0.45	5.05 ± 0.47	7.04 ± 0.61
Control group (n = 64)	Before treatment	10.22 ± 1.16	10.09 ± 1.22	14.22 ± 2.18
	After treatment	6.64 ± 0.57	6.68 ± 0.51	9.64 ± 0.75
t/P value Research group (before and after treatment)		39.711/0.000	30.526/0.000	25.773/0.000
t/P value Control group (before and after treatment)		22.159/0.000	20.631/0.000	15.893/0.000
t/P value Between-group values (before treatment)		0.098/0.922	0.092/0.927	0.052/0.958
t/P value Between-group values (post-treatment)		27.870/0.000	18.802/0.000	21.515/0.000

Comparison of anal incontinence scores

There was no significant difference in the anal incontinence scores between the two groups before and 7 d after surgery (P > 0.05). At 14 d, 21 d, and 28 d after surgery, the anal incontinence score of the intervention group was lower than that of the control group (P < 0.05). The data and statistical results are presented in Table 2.

Table 2 compares anal incontinence scores (mean ± SD).

Groups	Before surgery	7 d after surgery	14 d after surgery	21 d after surgery	28 d after surgery
Research group (n = 64)	4.05 ± 0.54	11.24 ± 1.15	7.24 ± 0.54	5.11 ± 0.48	4.05 ± 0.78
Control group (n = 64)	4.03 ± 0.55	11.22 ± 1.12	9.05 ± 0.64	8.24 ± 0.51	6.28 ± 0.81
t value	0.208	0.100	17.292	35.753	15.865
P value	0.836	0.921	0.000	0.000	0.000

Comparison of levels of serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide

There were no significant differences in the levels of serum motilin, 5-hydroxytryptamine, or vasoactive intestinal peptide between the two groups before treatment (P > 0.05). After treatment, the levels of serum motilin and 5-hydroxytryptamine in the study group were higher than those in the control group, and the level of vasoactive intestinal peptides was lower than that in the control group (P < 0.05). Serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels in the study and control groups after treatment were significantly different from those before treatment (P < 0.05). The data and statistical results are presented in Table 3.

Table 3 Comparison results of serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels between groups (mean ± SD).

Groups	Time	Serum motilin (ng/L)	5-hydroxytryptamine (pg/mL)	Vasoactive intestinal peptide (pg/mL)
Research group (n = 64)	Before treatment	253.24 ± 25.54	63.54 ± 2.18	75.54 ± 5.54
	After treatment	312.24 ± 28.68	82.54 ± 6.45	48.04 ± 2.15
Control group (n = 64)	Before treatment	252.87 ± 25.68	63.64 ± 2.17	75.61 ± 5.49
	After treatment	284.64 ± 26.05	70.55 ± 6.54	58.64 ± 3.24
t/P value Research group (before and after treatment)		12.291/0.000	22.325/0.000	37.021/0.000
t/P value Control group (before and after treatment)		6.948/0.000	8.023/0.000	21.296/0.000
t/P value Between-group values (before treatment)		0.082/0.935	0.260/0.795	0.072/0.943
t/P value Between-group values (post-treatment)		5.699/0.000	10.443/0.000	21.808/0.000

DISCUSSION

The incidence of rectal cancer is gradually increasing and is related to changes in living habits, binge eating, staying up late, and alcohol abuse. The age of onset of the disease is gradually decreasing, and the trend in younger patients is obvious, which has a significant impact on physical and mental health[5]. Middle and lower rectal cancers account for 60%-75%, and surgical treatment is the main treatment for patients in clinical practice[6]. Low-anterior sphincter-preserving surgery for rectal cancer is widely used in the treatment of lower rectal cancer, with the advantage of sphincter preservation, which has good efficacy and high safety. However, patients have a high probability of anal dysfunction after surgery, with anal incontinence, delayed emptying, and frequent defecation as the main symptoms, which seriously affect their quality of life[7]. In the postoperative treatment of patients with lower rectal cancer, conventional symptomatic treatment has been used, and biofeedback and physical therapy have been used to promote the recovery of anal function. The short-term effect was good, but the long-term effect was not ideal, and symptoms were prone to relapse, which increased pain and economic burden on patients[8]. Therefore, it is important to explore effective treatment options to promote postoperative anal function recovery in patients with lower rectal cancer. Western and traditional Chinese medicines have advantages and disadvantages, and appropriate treatment should be selected according to the actual situation of the patient.

In this study, the levels of interleukin-4, 6, and 10 in the study group decreased more than those in the control group (P < 0.05). Acupuncture combined with rehabilitation gymnastics can reduce postoperative inflammatory responses in patients with lower rectal cancer. The reasons are as follows: interleukin-4 is secreted by activated Th2 Lymphocytes, which can inhibit Th1 activation, induce the release of many inflammatory transmitters, and promote local immune responses[9,10]. As a cytokine involved in immune regulation and inflammatory response, interleukin-6 reflects the severity of tissue trauma[11]. Interleukin-10 inhibits neutrophil production, downregulates inflammatory response, and inhibits inflammatory mediators. Traditional Chinese medicine believes that "the corporeal door is also the cause of the five Zang organs", and the anus is heaving and bloating, which is related to the rise and fall of the five Zang organs, deficiency and excess, and restraint of life[12,13]. Owing to the influence of surgical trauma, the patient's healthy qi is seriously injured, which leads to the inability of the body to remove turbidities and poisoning, leading to an imbalance in the five Zang organs and anal dysfunction, which is related to the poor coordination[14]. Based on the theory of turbidity and toxins, acupuncture therapy follows the therapeutic principle of supplementing qi, strengthening the spleen, clearing turbidity, and eliminating toxins, and adopting acupuncture and moxibustion techniques of deficiency and excess. Through stimulation of selected acupoints, acupuncture therapy can dredge meridians, balance the five Zang organs, and promote recovery of anal function in patients with lower rectal cancer after surgery[15]. Rehabilitation gymnastics can promote local blood circulation in the anus and improve the anal sphincter function. From the perspective of traditional Chinese medicine, rehabilitation gymnastics can improve middle qi and promote the recovery of anal function. In this study, there were no significant differences in the levels of serum motilin, 5-hydroxytryptamine, or vasoactive intestinal peptide between the two groups before treatment (P > 0.05). After treatment, the levels of serum motilin and 5-hydroxytryptamine in the study group were higher than those in the control group, and the level of vasoactive intestinal peptides was lower than that in the control group (P < 0.05). Serum motilin, 5-hydroxytryptamine, and vasoactive intestinal peptide levels in the study and control groups after treatment were significantly different from those before treatment (P < 0.05). The combination of acupuncture therapy and rehabilitation gymnastics can promote the recovery of gastrointestinal function in patients with low rectal cancer after surgery. Yuan et al[16] combined acupuncture with early enteral nutrition for patients after laparoscopic common bile duct exploration, and the results showed that the combination of the two could significantly improve the gastrointestinal function of patients, which was similar to the results of this study. Serum motilin is mainly distributed in the mucosa of the proximal jejunum and duodenum, which affects gastrointestinal motility and promotes the secretion of somatostatin and pepsin[17]. Patients with constipation due to surgical trauma have decreased serum motilin levels. Serotonin is mainly distributed in the human intestinal wall and small amounts are distributed in the neurons and mucosal cells of the intestinal wall. Its main effect is to promote the formation of gastrointestinal smooth muscle peristalsis and contraction. The 5-hydroxytryptamine level decreased in patients with postoperative constipation. The vasoactive intestinal peptide is distributed in all layers of the gastrointestinal tract, and its main role is to relax the gastrointestinal smooth muscles, prevent gastrointestinal emptying, and slow gastrointestinal peristalsis. Vasoactive intestinal peptide levels increased in patients with postoperative constipation[18,19]. Acupuncture and rehabilitation gymnastics can promote local blood circulation in the anus, alter gastrointestinal peristalsis, promote postoperative defecation, and reduce constipation, thereby reducing the vasoactive intestinal peptide levels and increasing motilin and 5-hydroxytryptamine levels. In general, acupuncture and rehabilitation gymnastics have positive effects on postoperative anal function recovery.

However, due to the small number of samples included in this study, there may be errors or biases in the research results. In the future, large sample, multi center randomized controlled studies can be carried out to obtain more accurate results.

CONCLUSION

In conclusion, the application of acupuncture combined with rehabilitation gymnastics in the postoperative treatment of patients with lower rectal cancer can promote the recovery of the anal function, improve gastrointestinal peristalsis, increase the frequency of defecation, improve the degree of constipation, and contribute to the postoperative rehabilitation of patients.