Reply on “Efficacy of biofeedback therapy for objective improvement of pelvic function in low anterior resection syndrome (Ann Surg Treat Res 2019;97:194–201)”

Thank you for your letter regarding our paper “Efficacy of biofeedback therapy for objective improvement of pelvic function fin low anterior resection syndrome [1]” published in the Annals of Surgical Treatment and Research, 2019, and congratulation your promising results.

Delivery of temperature-controlled radiofrequency energy to the anal canal has been studied for treatment of fecal incontinence. After Takeshi et al. [2] reported that anal radiofrequency safely improved Wexner and fecal incontinence-related quality of life scores in 2002, the Food and Drug Administration of the United States approved the Secca® System (Curon Medical, Inc., Fremont, CA, USA) for fecal incontinence. A multicenter trial demonstrates that the Secca procedure was safe and significantly improved the Cleveland Clinic Florida Fecal Incontinence score and the overall quality of life [3]. More recently, Felt-Bersma et al. [4] reported it seemed to be promising for patients with fecal incontinence with a persisting effect after 1 year. However, they reported there was no significant changes in tests. There was no comparative study which improved its superiority to another management, and although it has been almost 20 years from its introduction, the Secca procedure does not seem to become one of the main therapeutic strategy for fecal incontinence yet. Kim et al. [5] reported the Fecal Incontinence Severity Index score and the Fecal Incontinence-related Quality of Life scale were not improved significantly after the Secca procedure, and considerable complications were associated with the procedure.

Unlikely fecal incontinence as a distinct disease, low anterior resection syndrome generally has natural course of improvement after surgery and most of patients show improvement of symptoms after more than 1 year just only with conservative management. When we designed the study, we thought it is very important that not to confuse the natural improvement along time flow and patient's physiologic adaptation to postoperatively anatomical change and lifestyle to the efficacy of biofeedback. Therefore, we set the endpoints as objective results of manometry, not as questionnaire about quality of life, and performed the study as comparative study. Of course, there are also limitations including selection bias in our study.

Therefore, we recommend the comparative study for your further evaluation, as biofeedback alone versus biofeedback plus anal radiofrequency, and we hope your study help many patients who suffer from LARS syndrome.