After Anterior Resection Research Articles

Low anterior resection syndrome phenotypes-Different symptom profiles for different patients.

Attention is increasingly being turned to functional outcomes as being central to colorectal cancer (CRC) survivorship. The current literature may underestimate the impact of evacuatory dysfunction on patient satisfaction with bowel function after anterior resection (AR) for CRC. The aim of this study was to investigate the impact of post-AR symptoms of storage and evacuatory dysfunction on patient satisfaction and health-related quality of life (HRQoL). A cross-sectional study was performed at an Australian hospital of patients post-AR for CRC (2012-2021). The postoperative bowel function scores used were: low anterior resection syndrome (LARS), St Mark's incontinence, Cleveland Clinic constipation and Altomare obstructive defaecation syndrome scores. Eight 'storage' and 'evacuatory' dysfunction symptoms were derived. A seven-point Likert scale measured patient satisfaction. The SF36v2® measured HRQoL. Linear regression assessed the association between symptoms, patient satisfaction and HRQoL. Overall, 248 patients participated (mean age 70.8 years, 57.3% male), comprising 103 with rectal cancer and 145 with sigmoid cancer. Of the symptoms that had a negative impact on patient satisfaction, six reflected evacuatory dysfunction, namely excessive straining (p < 0.001), one or more unsuccessful bowel movement attempt(s)/24 h (p < 0.001), anal/vaginal digitation (p = 0.005), regular enema use (p = 0.004), toilet revisiting (p = 0.004) and >10 min toileting (p = 0.004), and four reflected storage dysfunction, namely leaking flatus (p = 0.002), faecal urgency (p = 0.005), use of antidiarrhoeal medication (p = 0.001) and incontinence-related lifestyle alterations (p < 0.001). A total of 130 patients (53.5%) had 'no LARS', 56 (23.1%) had 'minor LARS' and 57 (23.4%) had 'major LARS'. Fifty-seven (44.5%) patients classified as having 'no LARS' had evacuatory dysfunction. Postoperative storage and evacuatory dysfunction symptoms have an adverse impact on patient satisfaction and HRQoL post-AR. The importance of comprehensively documenting symptoms of evacuatory dysfunction is highlighted. Further research is required to develop a patient satisfaction-weighted LARS-specific HRQoL instrument.

Low Anterior Resection Syndrome and Quality of Life of Patients After Sphincter Preservation Surgery: A Prospective Study.

Background After anterior resection (AR), one of the most debilitating complications is low anterior resection syndrome (LARS) seenin about 64% of patients. The severity of the LARS score wassignificantly correlated with neoadjuvant treatment, the extent of rectal surgery, complication by the anastomotic leak, female gender, and age < 64 years. In this study, weanalyzed the impact of various clinical factors on LARS and also the various domains of quality of life (QoL). Purpose To assess the incidence of LARS in patients undergoing sphincter-sparing surgery for rectal cancer after the patient starts long-term defecating per anus, change in the QoL, and relation to LARS and factors affecting it. Methods One year before, 72 patients who had undergone AR in the Regional Cancer Centre were interviewed by a trained interviewer and data was collected from the file. Thequestionnairesused were the Wexner Incontinence score, LARS Malayalam Questionnaire, and European Organisation For Research and Treatment of Cancer (EORTC) QLQ C30 Malayalam translations. Statistical measures The LARS score wasused to categorize patients into three grades. The scores werecompared with clinical and social factors using the χ2 test for association. Continuous variables were compared by the Spearman Rho test. Results Details of patients were studied(male: 55.6% (40) andfemale: 44.4% (32)). Fifty patientsunderwent low anterior resection (LAR). The mean LARSscore was 25.61, with 47.2% of patients having severe LARS score. The mean Wexner score was 6.84. The relation withtype of surgery, approach (laparoscopic vs open), or type of neoadjuvant therapy was not found to be significant. A higher LARS score did not impact overall QoL as assessed by FACT-C. Insomnia and diarrhea symptoms scores were significantly worsened. The pain score was worse for those undergoing stapler anastomosis. Wexner's score was worse for those who had received adjuvant chemotherapy. Role functioning score was better for AR compared to low anterior resection (LAR). Only distance from the anal verge was found to be a significant cause of LARS and was negatively correlated. Discussion LARS of severe degrees were seen in most patients. No modifiable risk factors were significantly found to affect the chance of LARS. However, LARS did not have a significant impact on QoL, neither did the type of surgery. So sphincter preservation can be offered to the patients, but all patients undergoing LAR should be counseled well about the risk ofLARS before surgery.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR. Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed. Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%). The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

421P Ghost stoma – solving the dilemma of diversion after anterior resection: A single centre experience from India

Anastomotic leak is one of the most dreaded complication after anterior resection(AR) with leak rates ranging from 3 - 20 %. To avoid such leaks, many surgeons routinely perform diversion stoma after AR. However, stomas are associated with their own set of complications leading to decreased quality of life. Thus, to do prophylactic stoma or not is a matter of constant dilemma that most surgeons face. Ghost Stoma is a technique where in unnecessary prophylactic stoma can be avoided while ensuring that a diversion stoma can be created if need arises without the need of general anaesthesia. Surgical Technique: Ghost Stoma techniques done by pulling a loop of intestine up to parietal peritoneal layer of anterior abdominal wall with the help of silicone/ plastic tube at the time of anterior resection. If an anastomotic leak is detected in postoperative period, same loop of bowel can be pulled out and fashioned into stoma under local anaesthesia. Study Design: A retrospective analysis of all the cases who underwent this procedure between January 2015 to December 2019 was done. Total 68 patients underwent AR with ghost stoma at our institute during specified time period. Total 7 patients required creation of functional stoma post-operatively for suspected or confirmed leak and was done under local anesthesia in all patients. One patient had congestion of stoma due to rotation of mesentery and required refashioning of stoma under regional anesthesia. Rest of the patients had the plastic tube removed at around 2 weeks. However, none of the patients required re-laparotomy or peritoneal wash under general anaesthesia. None of the patients had any complication due to plastic tube like bowel rotation, obstruction, strangulation, adhesion, stricture or tube migration. Ghost Stoma is a very simple & safe procedure which can decrease the need of prophylactic diversion stoma in most cases of AR. It is technically easy, oncologically safe, decreases intraoperative time & also prevents patient from morbidity as well as psychological and financial burden of stoma. Using this technique unnecessary stoma could be avoided in >80 % patients of AR in this series.

TH3.7 Is There a Benefit for Routine Doughnuts Histopathological Examination After Anterior Resection (AR) in Colorectal Cancer Surgery?

Abstract Aim To evaluate the oncological benefits and cost-effectiveness of routine histological examination of the doughnuts from stapled anastomoses in patients undergoing colorectal cancer surgery. Methods A retrospective chart auditing was performed on all consecutive rectal cancer surgery (RCAS) patients performed in NGH from January 2019 till August 2021. Data collected included patients' demographic, procedure performed and postoperative histopathological analysis including doughnuts examination. Results Fifty-two patients underwent AR during the given period. 37 (71%) patients had doughnuts histopathological examination. median age was 68.59 (±11) years old and 62.1% were male. The histopathology of all resected specimens was adenocarcinoma. 48.6% and 51.4% underwent low anterior resection and high anterior resection respectively. Proximal doughnuts sent in 70.2% patients whereas distal doughnuts were sent in all resections. Mean distal resection margin from tumour was 21.7 mm and the shortest distance from the tumour to resection margin was 6 mm. All the doughnuts as well as resection margin were negative for any malignancy. Additionally, each doughnut costs our pathology laboratory around 150 pounds with total preparation time of 72hours and around 10 mins of microscopic examination. This makes total costs and time of examining all specimens of around 9,300 pound and 4,470 hours in resources. Conclusion There was no additional oncological benefit in sending routine examination of doughnuts. It should only be sent in those deemed of a higher risk of a positive margin. This will result in significant reduction in cost and time burdens on our resources.

Radiological findings in anastomotic leakage after anterior resection may predict a permanent stoma.

BackgroundPermanent stoma (PS) is common following treatment of anastomotic leakage (AL) after anterior resection (AR) and ways of predicting successful treatment outcome are missing.PurposeTo explore radiological variables in rectal contrast studies in their relation to end-result of PS following treatment for AL after AR.Material and MethodsThe Swedish Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the region of Skåne from 1 January 2001 to 31 December 2011. Among identified AL cases, patients subjected to radiological imaging consistent with AL were evaluated according to a predetermined set of radiological variables. Information of PS as the end-result after AL treatment were retrieved from medical records.ResultsThirty-two patients had radiological imaging available for analysis confirming AL after AR; PS rate after a median follow-up of 87 months (range = 21–165) after AR was 62%. Radiological findings compatible with abscess (P = 0.023) and a leak size ≤6 mm (P = 0.049) were significantly associated with PS.ConclusionIn this limited explorative study, our findings suggest that abscess status and leak size could correspond to outcome of PS in treatment for AL after AR. Additional studies are warranted to further explore this subject.

The Aortic Calcification Index is a risk factor associated with anastomotic leakage after anterior resection of rectal cancer

Anastomotic leakage (AL) is one of the most feared postoperative complications after anterior resection (AR) of rectal cancer. An adequate blood supply at the anastomotic site is regarded as a prerequisite for healing. We hypothesize that the Aortic Calcification Index (ACI) might reflect the severity of atherosclerosis in patients, and thereby be a risk factor for AL. AL was investigated retrospectively according to the definition of the International Study Group of Rectal Cancer in 423 rectal cancer patients who underwent anterior rectal resection. The ACI was measured by preoperative abdominal CT scan. The cross-section of the aorta was evenly divided into 12 sectors, the number of calcified sectors was counted as the calcification score of each slice. Lasso logistic regression and multivariate regression analysis were used to identify risk factors for AL. The percentage of AL after AR was 7.8% (33/423); the mortality of patients who sustained a leak was 3.0% (1/33). Patients with a high ACI had a significantly higher percentage of AL than patients with low ACI (11.2% vs 5.6%, P=0.04). Among patients with AL, a higher ACI was associated with greater severity of AL (the ACI of patients with grade A leakage, grade B leakage and grade C leakage was 0.5%±0.2%, 11.5%±9.2% and 24.2%±21.7%, respectively; P=0.008). After risk adjustment, multivariate regression analysis showed that a higher ACI was an independent risk factor for AL (OR 2.391, P=0.04). A high ACI might be an important prognostic factor for AL after AR for rectal cancer. Confirmatory studies are required.

Long-term oncologic outcomes following anastomotic leak after anterior resection for rectal cancer: does the leak severity matter?

The evidence regarding the impact of anastomotic leak (AL) after anterior resection (AR) for rectal cancer on oncologic outcomes is controversial, and there are no data about the prognostic relevance of the International Study Group of Rectal Cancer (ISREC) AL classification. The aim was to evaluate the oncologic outcomes in patients with AL after AR for rectal cancer. The prognostic value of the ISREC AL grading system was also investigated. It is a retrospective analysis of a prospectively collected database including all patients undergoing curative elective AR for rectal cancer (April 1998-September 2013). AL severity was defined according to the ISREC criteria. A multivariable analysis was performed to identify predictors of poor survival. A total of 532 patients underwent curative AR (69% laparoscopic) for rectal cancer. The overall AL rate was 7.9%: 15 grade B and 27 grade C ALs. With a median follow-up of 80 (range 12-266) months, 5-year overall survival (OS) was 67.2% in patients with AL and 86.5% in those without AL (P = 0.001). Five-year disease-free survival (DFS) was 50.5% and 80.3%, respectively (P < 0.001). Local recurrence and distant metastases developed more frequently in AL patients (P < 0.05). Grade B AL and no administration or delay of adjuvant chemotherapy were independent predictors for poorer OS and DFS. Grade B AL independently affected also the administration of adjuvant chemotherapy. Circulating C-reactive protein levels at 2weeks after AL treatment were higher in grade B than grade C patients (P = 0.006) and in patients with tumor relapse (P = 0.011). AL after curative AR for rectal cancer and impaired use of adjuvant chemotherapy are associated with poor survival. Postoperative systemic inflammation seems to be more sustained in grade B than that in grade C AL patients, with possible adverse impact on long-term survival.

Late leakage after anterior resection: a defunctioning stoma alters the clinical course of anastomotic leakage.

Anastomotic leakage (AL) is common after anterior resection (AR). Long term clinical outcomes of AL including late presenting leakage (LL) are not well studied. This study was undertaken to assess clinical features of LL with respect to incidence, association with predisposing factors and need for re-intervention. The Swedish Colorectal Cancer Registry (SCRCR) was explored for AL cases after AR for rectal cancer in patients operated in the south of Sweden from 1 January 2001 to 31 December 2011. Demographic data, surgical technical details, number of postoperative days (POD) until diagnosis of AL, presenting symptoms, methods of diagnosis and treatment were retrieved from medical records. LL was defined according to different cut-offs as leakages occurring after hospital discharge (LLAHD), after 30 POD (LL≥POD 30) and after 90 POD (LL≥POD 90). In total, 1442 patients were operated on with AR of whom 144 cases of AL (10%) were identified. Median time from operation to follow-up was 87months (range 21-162). LLAHD, LL≥POD 30 and LL≥POD 90 were present in 51%, 24% and 9% respectively. All categories of LL were associated with a defunctioning stoma. Relaparotomy was significantly less often employed in LLAHD, but not in other categories of LL. LL constitutes a substantial portion of all AL after AR for rectal cancer. The large proportion of LLAHD calls for awareness in the outpatient setting.

Abdominoperineal Excision: Technical Challenges in Optimal Surgical and Oncological Outcomes after Abdominoperineal Excision for Rectal Cancer.

Treatment results in rectal cancer have improved significantly during the recent two decades, but local control and survival after abdominoperineal excision (APE) have not improved to the same degree as that seen after anterior resection (AR). The reason for this is an increased risk of inadvertent bowel perforations and tumor involved margins after APE as compared with AR. The conventional synchronous combined APE has not been a standardized procedure and consequently oncological outcomes have varied considerably between different institutions and in different reports. With the new concept of APE, based on well-defined anatomical structures, the procedure can be categorized as intersphincteric APE, extralevator APE, and ischioanal APE. This article discusses the technical aspects and results from this approach.

Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer.

BackgroundA generally acceptable definition and a severity grading system for anastomotic leakages (ALs) following rectal resection were not available until 2010, when the International Study Group of Rectal Cancer (ISGRC) proposed a definition and a grading system for AL.MethodsA search for published data was performed using the MEDLINE database (2000 to December 5, 2012) to perform a systematic review of the studies that described AL, grade AL according to the grading system, pool data, and determine the average rate of AL for each grade after anterior resection (AR) for rectal cancer.ResultsA total of 930 abstracts were retrieved; 40 articles on AR, 25 articles on low AR (LAR), and 5 articles on ultralow AR (ULAR) were included in the review and analysis. The pooled overall AL rate of AR was 8.58% (2,085/24,288); the rate of the asymptomatic leakage (Grade A) was 2.57%, that of AL that required active intervention without relaparotomy (Grade B) was 2.37%, and that of AL that required relaparotomy (Grade C) was 5.40%. The pooled rate of AL that required relaparotomy was higher in AR (5.40%) than in LAR (4.70%) and in ULAR (1.81%), which could be attributed to the higher rate of protective defunctioning stoma in LAR (40.72%) and ULAR (63.44%) compared with that in AR (30.11%).ConclusionsThe new grading system is simple that the ALs of each grade can be easily extracted from past publications, therefore likely to be accepted and applied in future studies.

Sacral nerve stimulation in patients with severe fecal incontinence after rectal resection

Oncologic resection of rectal cancer has been reported to be associated with a significant rate of fecal incontinence (FI). The risk is greater in patients with a resection less than 6–8 cm from the anal verge [1]. Sacral nerve stimulation (SNS) has been advocated as a safe and effective therapy for severe FI and shown to be associated with minimal morbidity [2]. In patients with FI after anterior resection (AR), SNS is has been used in few cases, with varying results [1, 3]. Between 2006 and 2009, four patients (one male, three female), with severe FI following neoadjuvant therapy and AR performed for rectal cancer, were treated in our hospital with SNS. The median age was 65.5 years (range 49–73 years). All patients had undergone chemoradiation before the operation. Total mesorectal excision and longitudinal coloplasty had been performed during the operation in all patients. The mean distance of the anastomosis from the anorectal ring was 5 cm (range 2–8 cm). The median history of FI following AR was 26.5 months (range 25–28 months). None presented tumor recurrence, local or distant. The incontinence status was classified according to the Wexner score [4]. All patients were treated with conservative treatment, including drugs, constipating diet and biofeedback physiotherapy for 2 years. Before surgery, in all patients, anorectal manometry and endoanal ultrasonography were performed (Table 1). The percutaneous test stimulation was performed under general anesthesia. The response of S2–S4 was tested on both sides. If contraction of the anal sphincters could be obtained by SNS, percutaneous electrodes (Medtronic 3050; Medtronic, Minneapolis, MN, USA) were implanted. The patients were subsequently tested by SNS for a 4-week period. Patients who became candidates for permanent implantation based on an improvement of their continence received the permanent stimulation generator (INTERSTIM II, 3058; Medtronic, Minneapolis, MN, USA) under general anesthesia. Differences were analyzed by the Wilcoxon test for paired data. All patients tested had contraction of the anal sphincters during the SNS 4-week test period. All patients had least a 50 % reduction in episodes of incontinence and were given a permanently implanted system. The Wexner score fell from a median score of 15.5 before SNS to 5.5 during permanent stimulation (p \ 0.005). There were no significant differences in sphincter pressures measured by anal manometry. The patients with associated urinary incontinence presented improvement in their symptoms. There was no cessation of clinical response during the follow-up, and no complications were observed. After colorectal or coloanal anastomoses at a lower location, about 30–60 % of patients develop anal dysfunction due to the loss of the rectum and internal sphincter. These patients develop clinical symptoms and signs, such as anterior resection syndrome, which includes stool frequency, urgency, fragmentation and soiling. These symptoms usually disappear approximately 1 year postoperatively [5]. Our results of SNS in patients with FI after P. Moya A. Arroyo A. Frangi F. Candela Polo R. Calpena Rico Department of Surgery, University General Hospital of Elche, Alicante, Spain

Anastomotic leakage after surgery for rectal cancer: a risk factor for local recurrence, distant metastasis and reduced cancer‐specific survival?

The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer-specific survival was analysed. Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5-year follow-up were analysed with multivariate methods. After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour-node-metastasis stages I-III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5-year cancer-specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5-year overall or 5-year cancer-specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy (P = 0.055) and rectal washout (P = 0.046) reduced the LR rate, but did not influence survival. Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow-up on the basis of the occurrence of AL after AR might not be justified.

Anastomotic leakage after curative anterior resection for rectal cancer: short and long‐term outcome

The influence of symptomatic anastomotic leakage (AL) after anterior resection (AR) for rectal cancer on short and long-term mortality and local and distant recurrence was analysed. All patients with a first diagnosis of rectal carcinoma were prospectively registered in a national database. This comprised 1494 Danish citizens who had had a curative AR between May 2001 and December 2004. Data on survival and recurrence were obtained from the National Patient Register. Multivariate analyses were performed. Anastomotic leakage increased the 30-day mortality [odds ratio (OR) 4.01 (95% CI 2.24-7.17)]. Of other possible risk factors, only age had a significant interaction with leakage, as the risk of death within 30 days of AR decreased with increasing age. Long-term survival decreased significantly after AL [hazard ratio (HR) of 1.63, CI 1.21-2.19]. A total of 97 (6.7%) and 258 (18.0%) patients had local and distant recurrence respectively in the follow-up period. The risk of local and distant recurrence after AL was not different with HR of 1.50 (CI 0.84-2.69) and 1.13 (CI 0.76-1.69) respectively. No other factors influenced the risk of recurrence due to AL. Anastomotic leakage after AR for rectal cancer increases the 30-day and long-term mortality, but AL did not increase the risk of local and distant recurrence.

A meta-analysis comparing side to end with colonic J-pouch formation after anterior resection for rectal cancer

A meta-analysis of published literature comparing J-pouch with side to end anastomosis after anterior resection (AR) for rectal cancer. Electronic databases were searched from January 1980 to March 2009. A systematic review was performed to obtain a summative outcome. Four randomized controlled trials involving 273 patients were analysed. One hundred and thirty-eight patients were in the J-pouch and 135 in the side to end anastomosis (STEA) group. No significant difference in surgically related outcomes was established (hospital stay, operative time, estimated blood loss, overall morbidity and mortality). Resting pressures at 24 months post-operatively were lower in J-pouch group compared with STEA and approached statistical significance [random effects model: SMD = -1.23, 95% CI (-2.47, -0.01), z = -1.94, P = 0.053]. No statistical difference was found in volumetric parameters (Volume at which the patient first experiences a sensation to defaecate and maximal tolerable volume). No statistical difference except urgency at 6 months [P < 0.05] was elicited in functional outcomes (use of enemas, bowel medications, pads, incomplete defaecation and stool frequency) between J-pouch and STEA groups. J-pouch or STEA are acceptable and safe options after AR for rectal cancer. Either approach may be considered according to surgeon choice. A randomized controlled trial including a larger number of patients is required to strengthen the evidence.

A Meta-Analysis of Quality of Life for Abdominoperineal Excision of Rectum versus Anterior Resection for Rectal Cancer

Avoiding a permanent stoma following rectal cancer excision is believed to improve quality of life (QoL), but evidence from comparative studies is contradictory. The aim of this study was to compare QoL following abdominoperineal excision of rectum (APER) with that after anterior resection (AR) in patients with rectal cancer. A literature search was performed to identify studies published between 1966 and 2006 comparing values of QoL following APER and AR. Random-effect meta-analysis was used to combine the data. Sensitivity analyses were performed for larger studies, those of higher quality and those using self-administered QoL questionnaires. The outcomes for 1,443 patients from 11 studies, of whom 486 (33%) underwent APER, were included. QoL assessments were made at periods of up to 2 years following surgery. There was no significant difference in global health scores between APER and AR. Vitality (WMD -9.82; 95% CI -27.01, -2.04, P = 0.01) and sexual function (WMD -2.73; 95% CI -4.93, -0.64, P = 0.01) were improved in the AR patients. Patients with low AR had improved physical function scores in comparison with APER patients (WMD -4.67; 95% CI -9.10, -0.23; P = 0.004). Cognitive (WMD 3.57; 95% CI 1.41, 5.73; P < 0.001) and emotional function scores (WMD 3.51; 95% CI 1.40, 5.62; P < 0.001) were higher for APER patients. Overall, when comparing APER with AR, we identified no differences in general QoL following the procedures. Individualisation of care for rectal cancer patients is essential, but a policy of avoidance of APER cannot currently be justified on the grounds of QoL alone.

Abdominoperineal resection or anterior resection for rectal cancer: patient preferences before and after treatment

Literature data do not provide any evidence as to whether oncological outcome and quality of life after anterior resection (AR) are superior to those observed after abdominoperineal resection (APR) for low-lying rectal cancer. In view of this, patient preferences should play an important role in the process of decision making. The aim of this study was to investigate these preferences. A series of consecutive patients with rectal cancer (60 prior to surgery, 65 after APR and 124 after AR) who attended our outpatient clinic were asked to express their preference as to the type of surgery. The second part of the study was performed 4 years later; 30 patients evaluated before surgery, free of disease, were again asked to express their preference as to the type of treatment. Patient preferences as to performing APR, AR or as to leaving the decision to the surgeon were as follows: (i) the group prior to surgery - 5%, 30% and 65%, respectively, (ii) group after APR - 46%, 22% and 32%, respectively, and (iii) group after AR - 4%, 69% and 28%, respectively. Patients after AR pointed to the type of surgery that they had undergone more frequently than patients after APR (69%vs 46%, respectively, P < 0.001). Sixty per cent of patients evaluated twice had altered their initial preferences, usually choosing the type of surgery that they had undergone. Our results suggest that the sequelae of AR are generally perceived as more acceptable than those of APR. Nevertheless, approximately half of the patients after APR prefer the type of surgery that they have undergone, which suggests the positive reappraisal of APR, once experienced.

Biofeedback therapy for excessive stool frequency and incontinence following anterior resection or total colectomy.

Excessive stool frequency and incontinence after anterior resection (AR) or total colectomy (TC) can be refractory to expectancy and antidiarrheal agents. We prospectively assessed efficacy of anorectal biofeedback therapy (BF) in this clinical situation. Thirteen patients (10 men and 3 women; mean age, 62.1 (standard error of the mean (SEM), 4.6) years) had more than six bowel movements per day and/or episodes of incontinence, which did not abate after antidiarrheal agents were given for at least six (mean, 27.9 (SEM, 6.3)) months after surgery. All underwent four sessions of outpatient BF. Assessment was by continence questionnaire and anorectal physiology tests, which were administered before and after BF. In seven AR patients, daily stool frequency was decreased (8.7 (SEM, 2.1) before and 4.6 (SEM, 1.2) after, P < 0.05), and daily incontinence episodes were reduced (2.7 (SEM, 0.9) before and 0.4 (SEM, 0.2) after, P < 0.05) after BF. Six TC patients also had decreased daily stool frequency (6.2 (SEM, 2.1) before, 3.3 (SEM, 1.6) after; P < 0.05) and incontinence episodes (2.4 (SEM, 0.9) before, 0.5 (SEM, 1) after; P < 0.05) after BF. There were no significant changes in anorectal physiology parameters after BF. At a mean follow-up of 10.6 (SEM, 2.5) months after BF, there were no regressions or complications. BF is a safe and effective option for refractory excessive stool frequency and/or incontinence following AR or TC.