Abstract
Purposes
Sphincter-saving operation with coloanal anastomosis (CAA) has become an established option for very low rectal cancer, but few studies have compared its functional results and quality of life (QoL) with abdominoperineal resection (APR) showing controversial results.
Patients and methods
Patients treated for low rectal cancer with APR or CAA, disease-free after a median follow-up period of 26.5 (8–84) and 52.5 (12–156) months, respectively, were retrospectively reviewed. General and disease-specific changes in QoL and severity of disease were evaluated by Karnofsky scale, EORTC-C30, EORTC-CR38, SF-36, PGWBI, FIQL, PAC-QoL, ICIQ-SF, Stoma-QoL, AMS, Wexner's score and obstructed defecation syndrome (ODS) score.
Results
Twenty-six APR patients and 34 CAA patients entered the study. Karnofsky score did not show significant differences. The median Stoma-QoL was 58.2 (45–76.6), indicating a good stoma function in 95 % of patients. EORTC-C30, CR38, PGWBI and SF-36 questionnaires did not show significant differences between the two groups except for sexual function (better after CAA, p = 0.01). Eleven patients after APR and eight after CAA had urinary incontinence, and its severity did not differ significantly. Eighteen of 21 CAA patients complained of faecal incontinence [AMS, 80 (15–120); Wexner, 13 (2–19)] with an impact on their QoL [FIQL: lifestyle, 1.75 (0–4); coping/behaviour, 1.3 (0–3.5); depression, 2.1 (0–5.2); embarrassment, 2 (0–4.6)] and 11 complained of obstructed defecation [7.5 (3–16)] with significant consequences on QoL [PAC-QoL, 30.4 (19.2–80.3)].
Conclusions
QoL in patients with permanent stoma and in those after CAA did not differ significantly. APR patients had worse sexual function, while most CAA patients had faecal incontinence and sometime obstructed defecation, with important impact on their QoL.
Similar content being viewed by others
References
Law WL, Chu KW (2004) Anterior resection for rectal cancer with mesorectal excision: a prospective evaluation of 622 patients. Ann Surg 240:260–268. doi:10.1097/01.sla.0000133185.23514.32
Parks AG, Percy JP (1982) Resection and sutured colo-anal anastomosis for rectal carcinoma. Br J Surg 69:301–304. doi:10.1002/bjs.1800690602
Knight CD, Griffen FD (1980) An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 88:710–714
Di Betta E, D'Hoore A, Filez L, Penninckx F (2003) Sphincter saving rectum resection is the standard procedure for low rectal cancer. Int J Colorectal Dis 18:463–469. doi:10.1007/s00384-002-0474-8
Williams NS (1984) The rationale for preservation of the anal sphincter in patients with low rectal cancer. Br J Surg 71:575–581. doi:10.1002/bjs.1800710802
Williams NS, Price R, Johnston D (1980) The long term effect of sphincter preserving operations for rectal carcinoma on function of the anal sphincter in man. Br J Surg 67:203–208. doi:10.1002/bjs.1800670313
Hallböök O, Hass U, Wänström A, Sjödahl R (1997) Quality of life measurement after rectal excision for cancer: comparison between straight and colonic J-pouch anastomosis. Scand J Gastroenterol 32:490–493
Brown CJ, Fenech D, McLeod RS (2008) Reconstructive techniques after rectal resection for rectal cancer. Cochrane Database Syst Rev 16(2):CD006040. doi:10.1002/14651858.CD006040.pub2
Fisher SE, Daniels IR (2006) Quality of life and sexual function following surgery for rectal cancer. Colorectal Dis 8(Suppl 3):40–42. doi:10.1111/j.1463-1318.2006.01071.x
Hida J, Yasutomi M, Maruyama T, Tokoro T, Wakano T, Uchida T (1999) Enlargement of colonic pouch after proctectomy and coloanal anastomosis: potential cause for evacuation difficulty. Dis Colon Rectum 4:1181–1188. doi:10.1007/BF02238571
Joo JS, Latulippe JF, Alabaz O, Weiss EG, Nogueras JJ, Wexner SD (1998) Long-term functional evaluation of straight coloanal anastomosis and colonic J-pouch: is the functional superiority of colonic J-pouch sustained? Dis Colon Rectum 41:740–746. doi:10.1007/BF02236262
Canda AE, Terzi C, Gorken IB, Oztop I, Sokmen S, Fuzun M (2010) Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients. Int J Colorectal Dis 25:197–204. doi:10.1007/s00384-009-0807-y
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC et al (1993) The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 3(85):365–376. doi:10.1093/jnci/85.5.365
Sprangers MA, te Velde A, Aaronson NK (1999) The construction and testing of the EORTC colorectal cancer-specific quality of life questionnaire module (QLQ-CR38). European Organization for Research and Treatment of Cancer Study Group on Quality of Life. Eur J Cancer 35:238–247
Karnofsky DA, Burchenal JH (1949) The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM (ed) Evaluation of chemotherapeutic agents. Columbia University Press, New York, p 196
Dupuy HJ (1984) The psychological general well-being (PGWB) index. In: Wenger NK, Mattson ME, Furberg CD, Elinson J (eds) Assessment of quality of life in clinical trials of cardiovascular therapies, Chap. 9. Le Jacq Publishing, New York, pp 170–183
Aaronson NK, Acquadro C, Alonso J, Apolone G, Bucquet D, Bullinger M, Bungay K, Fukuhara S, Gandek B, Keller S et al (1992) International Quality of Life Assessment (IQOLA) Project. Qual Life Res 1:349–351. doi:10.1007/BF00434949
Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P (2004) ICIQ: a brief and robust measure for evaluating the symptom and impact of urinary incontinence. Neurourol Urodyn 23:322–330. doi:10.1002/nau.20041
Prieto L, Thorsen H, Juul K (2005) Development and validation of a quality of life questionnaire for patients with colostomy or ileostomy. Health Qual Life Outcomes 3:62. doi:10.1186/1477-7525-3-62
Temple LK, Bacik J, Savatta SG, Gottesman L, Paty PB, Weiser MR, Guillem JG, Minsky BD, Kalman M, Thaler HT, Schrag D, Wong WD (2005) The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer. Dis Colon Rectum 48:1353–1365. doi:10.1007/s10350-004-0942-z
Jorge JMN, Wexner SD (1993) Etiology and management of faecal incontinence. Dis Colon Rectum 36:77–97. doi:10.1007/BF02050307
American Medical Systems (1996) Fecal incontinence scoring system. American Medical Systems, Minnetonka
Rockwood TH, Church JM, Fleshman JW, Kane RL, Mavrantonis C, Thorson AG, Wexner SD, Bliss D, Lowry AC (2000) Faecal incontinence quality of life scale: quality of life instrument for patients with faecal incontinence. Dis Colon Rectum 43:9–16. doi:10.1007/BF02237236
Altomare DF, Spazzafumo L, Rinaldi M, Dodi G, Ghiselli R, Piloni V (2008) Set-up and statistical validation of a new scoring system for obstructed defaecation syndrome. Colorectal Dis 10:84–88. doi:10.1111/j.1463-1318.2007.01262.x
Marquis P, De La Loge C, Dubois D, McDermott A, Chassany O (2005) Development and validation of the patients assessment of constipation quality of life questionnaire. Scand J Gastroenterol 40:540–551. doi:10.1080/00365520510012208
Abercrombie JE, Williams NS (1995) Total anorectal reconstruction. Br J Surg 82:438–442. doi:10.1002/bjs.1800820404
Gervaz P, Rotholz N, Wexner SD, You SY, Saigusa N, Kaplan E, Secic M, Weiss EG, Nogueras JJ, Belin B (2001) Colonic J-pouch function in rectal cancer patients: impact of adjuvant chemoradiotherapy. Dis Colon Rectum 44:1667–1675. doi:10.1007/BF02234388
Moriya Y (2006) Function preservation in rectal cancer surgery. Int J Clin Oncol 11:339–343. doi:10.1007/s10147-006-0608-z
Kollmorgen CF, Meagher AP, Wolff BG, Pemberton JH, Martenson JA, Illstrup DM (1994) The long-term effect of adjuvant postoperative chemoradiotherapy for rectal carcinoma on bowel function. Ann Surg 220:676–682
Teleky B, Jech B, Karner-Hanusch J, Kuehrer I, Götzinger P, Herbst F, Jakesz R (2006) Straight and colonic J-pouch reconstruction after low anterior resection. Acta Chir Iugosl 53:109–112. doi:10.2298/ACI0602109T
Montesani C, Pronio A, Santella S, Boschetto A, Aguzzi D, Pirozzi R, D'Amato A, Vestri A (2004) Rectal cancer surgery with sphincter preservation: functional results related to the level of anastomosis. Clinical and instrumental study. Hepatogastroenterology 51:718–721
Otto S, Kroesen AJ, Hotz HG, Buhr HJ, Kruschewski M (2008) Effect of anastomosis level on continence performance and quality of life after colonic J-pouch reconstruction. Dig Dis Sci 53:14–20. doi:10.1007/s10620-007-9815-3
Ho YH, Seow-Choen F, Tan M (2001) Colonic J-pouch function at six months versus straight coloanal anastomosis at two years: randomized controlled trial. World J Surg 25:876–881. doi:10.1007/s00268-001-0044-1
Ho YH (2006) Techniques for restoring bowel continuity and function after rectal cancer surgery. World J Gastroenterol 12:6252–6260
Pachler J, Wille-Jørgensen P (2005) Quality of life after rectal resection for cancer, with or without permanent colostomy. Cochrane Database Syst Rev 18(2):CD004323. doi:10.1002/14651858.CD004323.pub2
Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Hölzel D (2003) Quality of life in rectal cancer patients: a four year prospective study. Ann Surg 238:203–213. doi:10.1097/01.sla.0000080823.38569.b0
Fucini C, Gattai R, Urena C, Bandettini L, Elbetti C (2008) Quality of life among five-year survivors after treatment for very low rectal cancer with or without a permanent abdominal stoma. Ann Surg Oncol 15:1099–1106. doi:10.1245/s10434-007-9748-2
Gosselink MP, Busschbach JJ, Dijkhuis CM, Stassen LP, Hop WC, Schouten WR (2006) Quality of life after total mesorectal excision for rectal cancer. Colorectal Dis 8:15–22
Kasparek MS, Hassan I, Cima RR, Larson DR, Gullerud RE, Wolff BG (2011) Quality of life after coloanal anastomosis and abdominoperineal resection for distal rectal cancers: sphincter preservation vs quality of life. Colorectal Dis 13:872–877
How P, Stelzner S, Branagan G, Bundy K, Chandrakumaran K, Heald RJ, Moran B (2012) Comparative quality of life in patients following abdominoperineal excision and low anterior resection for low rectal cancer. Dis Colon Rectum 55:400–406. doi:10.1097/DCR.0b013e3182444fd1
Grumann MM, Noack EM, Hoffmann IA, Schlag PM (2001) Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg 233:149–156
Jess P, Christiansen J, Bech P (2002) Quality of life after anterior resection versus abdominoperineal extirpation for rectal cancer. Scand J Gastroenterol 37:1201–1204. doi:10.1080/003655202760373425
Campos-Lobato LF, Alves-Ferreira PC, Lavery IC, Kiran RP (2011) Abdominoperineal resection does not decrease quality of life in patients with low rectal cancer. Clinics (Sao Paulo) 66:1035–1040. doi:10.1590/S1807-59322011000600019
Camilleri-Brennan J, Steele RJ (2002) Objective assessment of morbidity and quality of life after surgery for low rectal cancer. Colorectal Dis 4:61–66
Mulsow J, Winter DC (2011) Sphincter preservation for distal rectal cancer—a goal worth achieving at all costs? World J Gastroenterol 17:855–861. doi:10.3748/wjg.v17.i7.855
Author information
Authors and Affiliations
Corresponding author
Additional information
This paper was presented in part at the 4th National Meeting of the Italian Society of Colorectal Surgery Genua 2012
Rights and permissions
About this article
Cite this article
Digennaro, R., Tondo, M., Cuccia, F. et al. Coloanal anastomosis or abdominoperineal resection for very low rectal cancer: what will benefit, the surgeon's pride or the patient's quality of life?. Int J Colorectal Dis 28, 949–957 (2013). https://doi.org/10.1007/s00384-012-1629-x
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00384-012-1629-x