Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer

Abstract

Aims

The aims of the study were (1) to evaluate quality of life (QoL) and functional outcome in patients following anterior resection (AR) or abdominoperineal resection (APR) for rectal cancer, and (2) whether these outcomes were dependent on the level of anastomosis.

Methods

Patients who were without recurrent or metastatic disease were identified from the Norwegian Rectal Cancer Registry. QoL was assessed by the EORTC questionnaires QLQ-C30 and QLQ-CR38, and rectal function by a short questionnaire. Of 319 patients studied, 229 had undergone AR and 90 APR. The median age was 73 years, and the median time since surgery was 64 months.

Results

Mean QoL scores for body image and male sexual problems were better following AR than APR (P<0.01), also in patients with a low (≤3 cm) anastomosis. Patients who had undergone AR had higher mean scores for constipation (P<0.001) and more often used anti-diarrhoeal medication (P=0.005), than patients who had undergone APR. Patients with a low anastomosis (≤3 cm) had more incontinence for gas and solid stools (P<0.05), and had more incontinence (P=0.006) compared with patients with higher anastomosis, but there was no difference in QoL. Subgroup analysis showed that irradiated patients (n=34) had worse rectal function in terms of frequency, urgency, and incontinence (P<0.01).

Conclusions

Although rectal function was impaired in patients with low anastomosis, patients who had undergone AR had better QoL than patients who had undergone APR.

Introduction

Rectal cancer is a common disease; the incidence rates in Norway in 2001 were 15.7 (males) and 10.4 (females) per 100,000.¹ During the last two decades, the outcome following curative surgery has improved substantially, and 5-year survival after curatively intended resection is now 63%.² The prevalence of patients with diagnosed rectal cancer in Norway was 7169 in 2001, of which 49% were alive >5 years since diagnosis.¹ Thus, a large number of patients are long-term survivors following curative surgery for rectal cancer.

The introduction of stapling devices, the demonstration that short resection margins are adequate,³ and the introduction of total mesorectal excision (TME),⁴ have resulted in an increasing number of patients being treated with restorative surgery. The trend has been that increasingly lower anastomoses are performed.⁵

In patients with low rectal cancer, treatment options include anterior resection (AR) with anastomosis or abdominoperineal resection (APR) with a permanent stoma. While having a stoma may affect the patient's quality of life (QoL), low anastomoses may result in reduced anorectal function, which may also have an impact on QoL. Recent studies of smaller patient samples have not shown differences in QoL following AR compared with APR,⁶ but it has been suggested that QoL may be worse in patients undergoing low AR than in patients undergoing APR.7, 8 We sought to compare the QoL following AR or APR in a large, unselected patient sample.

TME has been the surgical procedure of choice for rectal cancer in Norway since 1993. All rectal cancer patients are registered in a national database, the Norwegian Rectal Cancer Registry.² Although the proportion of sphincter-saving procedures has increased, 35% of patients undergoing curative surgery still receive a permanent stoma.² There are no accurate means of pre-operatively identifying the patients who will have a poor functional outcome after AR or to predict the QoL after surgery.

The aims of the present study were to investigate QoL and functional outcome in patients following AR and APR. Furthermore, we sought to investigate whether the QoL and functional outcome differed in patients with low anastomosis compared with patients with high anastomosis, and at what anastomotic level deterioration in QoL and functional outcome became evident.