The development of a validated instrument to evaluate bowel function after sphincter-preserving surgery for rectal cancer

What Are the Best Questionnaires To Capture Anorectal Function After Surgery in Rectal Cancer?

With enhanced surgical techniques and neoadjuvant therapy in rectal cancer, survivorship issues are at the forefront of clinical practice and research. More and more patients are living with altered bowel habits following rectal cancer surgery. Sound assessment of anorectal function after rectal cancer surgery is the foundation for the continuing effort to explore the adverse effects of such surgery on bowel function, as well as for working towards reducing these effects. The quality of the assessment is predominantly determined by the instrument administered. This article reviews various questionnaires for capturing anorectal function after surgery in rectal cancer, discussing their attributes and suitability for different evaluation contexts.

Outcomes in non-metastatic colorectal cancer

The measurement of outcomes in non-metastatic colon and rectal cancer patients is a multi-dimensional endeavor involving prediction tools, standard of care, and best treatment guidelines. Socioeconomic, demographic, and racial impacts on outcome must be carefully considered. Consideration must also be given to measures of cost, quality, and healthcare delivery in response to initiatives meant to optimize patient health while maintaining quality of life.

Outcomes of asymptomatic anastomotic leaks found on routine postoperative water-soluble enema following anterior resection for cancer

BACKGROUND

The incidence and consequence of an anastomotic leak associated with low anterior resection for cancer mandates covering stoma in most cases. A water-soluble enema is often performed to assess anastomotic integrity prior to stoma reversal. The functional outcome following reversal in patients with occult radiologically detected leaks is poorly defined. The goal of the present study was to determine the functional outcome in patients with a radiologically detected anastomotic leak who subsequently underwent stoma reversal.

METHODS

This case control study used patients with and without radiologically detected occult anastomotic leak having undergone reversal of covering stomata. The study group was matched with controls for age, gender, procedure, tumor stage, and adjuvant/neoadjuvant therapy. Validated fecal incontinence quality of life (FIQL), Cleveland Clinic Fecal Incontinence Score (CCFIS), and the Memorial Sloan-Kettering Cancer Center (MSKCC) Bowel Function Index (BFI) were used. Patient satisfaction, medication use, and ancillary procedures prior to closure were also recorded.

RESULTS

Thirteen patients with radiologically detected occult anastomotic leaks and 13 matched controls were identified from a prospectively maintained database. The FIQL, CCFIS, and MSKCC BFI scores were significantly reduced in those with occult leaks. The mean number of radiological and surgical interventions was significantly greater in the patients with occult leaks. Antidiarrheal and bulking agent use, as well as patient satisfaction, were the same for both groups. Only one patient in the occult leak group would not undergo stoma reversal again.

CONCLUSIONS

Reversal of a defunctioning ileostomy in the presence of an occult radiological leak can be associated with poorer functional outcomes, but patient satisfaction is undiminished.

Reliability and validity of a survey to measure bowel function and quality of life in long-term rectal cancer survivors

PURPOSE

Examination of reliability and validity of a specialized health-related quality of life questionnaire for rectal cancer (RC) survivors (≥5 years post-diagnosis).

METHODS

We mailed 1,063 Kaiser Permanente (KP) RC survivors (313 ostomy and 750 anastomosis) a questionnaire containing the Modified City of Hope Quality of Life-Ostomy (mCOH-QOL-O), SF-12v2, Duke-UNC Functional Social Support Questionnaire (FSSQ), and Memorial Sloan-Kettering Cancer Center Bowel Function Index (BFI). We adapted certain BFI items for use by subjects with intestinal ostomies. We evaluated reliability for all instruments with inter-item correlations and Cronbach's alpha. We assessed construct validity only for the BFI in the ostomy group, because such use has not been reported.

RESULTS

The overall response rate was 60.5 % (577 respondents/953 eligible). Compared with non-responders, participants were on average 2 years younger and more likely non-Hispanic white, resided in educationally non-deprived areas, and had KP membership through a group. The mCOH-QOL-O, SF-12, and FSSQ were found to be highly reliable for RC survivors. In the ostomy group, BFI Urgency/Soilage and Dietary subscales were found to be reliable, but Frequency was not. Factor analysis supported the construct of Urgency/Soilage and Dietary subscales in the ostomy group, although one item had a moderate correlation with all three factors. The BFI also demonstrated good concurrent validity with other instruments in the ostomy group.

CONCLUSIONS

With possible exception of the BFI Frequency subscale in populations with ostomies, components of our survey can be used for the entire population of RC survivors, no matter whether they received anastomosis or ostomy.

Measuring symptoms in gastrointestinal cancer: a systematic review of assessment instruments

PURPOSE

It is critical for gastrointestinal cancer researchers and clinicians to have access to comprehensive, sensitive and simple-to-use symptom measures that allow them to understand and quantify the subjective patient experience. Development and validation of such scales requires training in psychometrics and occasionally uses technical jargon that can be difficult to penetrate. This review evaluates existing measures of gastrointestinal cancer symptoms, provides tool descriptions, and uses predefined, objective quality criteria to rate psychometric quality and facilitate tool choices for researchers and clinicians.

METHODS

MEDLINE, EMBASE, CINAHL, and PsycINFO databases were systematically reviewed for scales assessing gastrointestinal cancer and gastrointestinal cancer site-specific symptoms. Evaluation criteria were the following: breadth of domain coverage (content validity), high internal consistency (α ≥  .80), sensitivity to change, and extent of validation.

RESULTS

In n = 36 validation studies, 26 gastrointestinal cancer symptom measures were identified. Of these, n = 13 tools met criteria for recommendation, and six in particular showed strong psychometric properties. The Functional Assessment of Cancer Therapy-Colorectal (FACT-C), European Organization for Research and Treatment of Cancer (EORTC) gastric cancer module (QLQ-STO22), FACT-Hepatobiliary (FACT-Hep), and EORTC oesophagus, oesophago-gastric junction and stomach module (QLQ OG-25) were identified as the most comprehensive and best validated scales for each of the major gastrointestinal cancer sites. The FACT-Colorectal Symptom Index (FCSI-9) and the National Comprehensive Cancer Network (NCCN) FACT-Hepatobiliary Symptom Index (FHSI-18) were specifically validated in patients with advanced colorectal and liver cancer and also demonstrated superior psychometric properties.

CONCLUSIONS

Several comprehensive, well-validated scales exist to adequately assess gastrointestinal cancer site-specific symptoms. Specifically, gastrointestinal cancer submodules of the FACT quality of life questionnaire represent adequate tool choices in most instances and overall, were better validated than the respective EORTC tools. Further improvement of existing, highly rated measures is recommended.

Long-term outcome after laparoscopic bowel resections for deep infiltrating endometriosis: a single-center experience after 900 cases

Background. Laparoscopic bowel resections for endometriosis are safe and effective but only short-term follow-up has been evaluated. In the present study long-term outcome in terms of intestinal and urinary function, fertility, chronic pain, and recurrence was assessed. Materials and Methods. From January 2002 to December 2010 nine hundred patients underwent laparoscopic bowel resection for endometriosis, and on 774 (86%) a questionnaire was administered. Patients were divided into 3 groups on the strength of the operation date. Postoperative diarrhea, constipation, rectal bleeding, tenesmus, dyschezia, dysuria, dyspareunia, fertility, and recurrence of disease were assessed. Results. The median follow-up was 54 months (range 1–120). All the evaluated symptoms significantly improved over time, with P = 0.0001 for dyspareunia, constipation, and pelvic pain and P = 0.004 for diarrhea. Nonsignificant improvement was reported for dysuria and rectal bleeding (with P = 0.452 and P = 0.097, resp.). Conclusions. The present results confirm that bowel resections for endometriosis are correlated with an acceptable complication rate even at long-term follow-up and that symptoms significantly improve over time, except for rectal bleeding and dysuria, the latter associated with a neurological damage.

Patient-reported outcomes after neoadjuvant therapy for rectal cancer: a systematic review

Neoadjuvant therapy followed by total mesorectal excision is standard of care for locally advanced rectal cancer. However, this approach has been previously shown to be associated with high rate of morbidity and it may have a negative effect on patients' reported outcomes (PROs). In order to summarize findings on the effect of the neoadjuvant approach on PROs, we systematically reviewed articles published in the last five years. Thirty-five articles met the inclusion criteria. Ten articles compared the effect of surgery with and without neoadjuvant therapy, six articles compared different neoadjuvant therapies, ten articles reported on patients who were all treated with neoadjuvant therapy, and nine articles examined the effect of neoadjuvant therapy in the analyses. The results are summarized by function investigated and critically commented.

Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery

SUMMARY 

The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.

Correlation between fecal incontinence and quality of life after low anterior resection for rectal cancer

SUMMARY Aim: The purpose of this study was to investigate the correlation between fecal incontinence and quality of life after low anterior resection and long-term follow-up. Methods: For 72 patients with coloanal or low colorectal anastomosis, the quality of life was determined by the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires C-30 and CR-38. The Vaizey score was used for assessment of fecal incontinence. Results: The risk of fecal incontinence significantly increased with a lower level of anastomosis (p < 0.001). The QLQ CR-38 did not discern differences between patients. The OLQ C-30 only found significantly worse social and role function in patients with coloanal anastomosis. There was a weak correlation between fecal incontinence and quality of life only. Conclusion: Determination of quality of life by EORTC QLQ C-30 and CR-38 cannot replace measurement of functional outcome. Severity of fecal incontinence and quality of life should be determined separately for assessment of functional outcome after low anterior resection.

Development of an online library of patient-reported outcome measures in gastroenterology: the GI-PRO database

OBJECTIVES

Because gastrointestinal (GI) illnesses can cause physical, emotional, and social distress, patient-reported outcomes (PROs) are used to guide clinical decision making, conduct research, and seek drug approval. It is important to develop a mechanism for identifying, categorizing, and evaluating the over 100 GI PROs that exist. Here we describe a new, National Institutes of Health (NIH)-supported, online PRO clearinghouse-the GI-PRO database.

METHODS

Using a protocol developed by the NIH Patient-Reported Outcome Measurement Information System (PROMIS(®)), we performed a systematic review to identify English-language GI PROs. We abstracted PRO items and developed an online searchable item database. We categorized symptoms into content "bins" to evaluate a framework for GI symptom reporting. Finally, we assigned a score for the methodological quality of each PRO represented in the published literature (0-20 range; higher indicates better).

RESULTS

We reviewed 15,697 titles (κ>0.6 for title and abstract selection), from which we identified 126 PROs. Review of the PROs revealed eight GI symptom "bins": (i) abdominal pain, (ii) bloat/gas, (iii) diarrhea, (iv) constipation, (v) bowel incontinence/soilage, (vi) heartburn/reflux, (vii) swallowing, and (viii) nausea/vomiting. In addition to these symptoms, the PROs covered four psychosocial domains: (i) behaviors, (ii) cognitions, (iii) emotions, and (iv) psychosocial impact. The quality scores were generally low (mean 8.88 ± 4.19; 0 (min)-20 (max). In addition, 51% did not include patient input in developing the PRO, and 41% provided no information on score interpretation.

CONCLUSIONS

GI PROs cover a wide range of biopsychosocial symptoms. Although plentiful, GI PROs are limited by low methodological quality. Our online PRO library (www.researchcore.org/gipro/) can help in selecting PROs for clinical and research purposes.

Patient expectations of functional outcomes after rectal cancer surgery: a qualitative study

BACKGROUND

Rectal cancer patients' expectations of health and function may affect their disease- and treatment-related experience, but how patients form expectations of postsurgery function has received little study.

OBJECTIVE

We used a qualitative approach to explore patient expectations of outcomes related to bowel function after sphincter-preserving surgery for rectal cancer.

DESIGN

This was a cohort study of patients who were about to undergo sphincter-preserving surgery for rectal cancer.

SETTINGS

The study was conducted through individual telephone interviews with participants.

PATIENTS

Twenty-six patients (14 men and 12 women) with clinical TNM stage I to III disease were enrolled.

MAIN OUTCOME MEASURES

The semistructured interview script contained open-ended questions on patient expectations of postoperative bowel function and its perceived impact on daily function and life. Two researchers analyzed the interview transcripts for emergent themes using a grounded theory approach.

RESULTS

Participant expectations of bowel function reflected 3 major themes: 1) information sources, 2) personal attitudes, and 3) expected outcomes. The expected outcomes theme contained references to specific symptoms and participants' descriptions of the certainty, importance, and imminence of expected outcomes. Despite multiple information sources and attempts at maintaining a positive personal attitude, participants expressed much uncertainty about their long-term bowel function. They were more focused on what they considered more important and imminent concerns about being cancer free and getting through surgery.

LIMITATIONS

This study was limited by context in terms of the timing of interviews (relative to the treatment course). The transferability to other contexts requires further study.

CONCLUSIONS

Patient expectations of long-term functional outcomes cannot be considered outside of the overall context of the cancer experience and the relative importance and imminence of cancer- and treatment-related events. Recognizing the complexities of the expectation formation process offers opportunities to develop strategies to enhance patient education and appropriately manage expectations, attend to immediate and long-term concerns, and support patients through the treatment and recovery process.

Early postoperative complications after stapled vs handsewn restorative proctocolectomy with ileal pouch-anal anastomosis in 148 patients with familial adenomatous polyposis coli: a matched-pair analysis

AIM

Restorative proctocolectomy with ileal pouch-anal anastomosis for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) has been modified from a transanal hand-suture after mucosectomy to a stapled ileal pouch-anal anastomosis (IPAA) without mucosectomy. Better functional results favour stapled anastomosis; however, stapled anastomosis results in higher rates of adenomas in persisting anorectal mucosa. The purpose of this study was to compare the two techniques of pouch-anal anastomosis with respect to early postoperative complications in a collective of FAP patients.

METHOD

The study was performed as a matched-pair analysis. Data were obtained from a prospectively collected database.

RESULTS

The overall rate of postoperative complications was higher after stapled IPAA (31% stapled vs 23% handsewn), with anastomotic stricture occurring in 24.3% (stapled) and 16.2% (handsewn) (P = 0.22). Any leakage or pelvic abscess formation after stapled anastomosis occurred within 30 days in almost all patients, whereas these were mainly diagnosed between 30 days and 6 months after handsewn IPAA. A laparoscopic approach was used in 56.7% of patients in the stapled group but in only two patients in the handsewn group. Intra-operative blood loss was significantly higher in the handsewn group (mean ± SD: 699 ± 511 ml vs 369 ± 343 ml; P < 0.0001), as was the volume of blood transfused (mean ± SD: 205 ± 365 ml vs 8 ± 49 ml; P < 0.0001). Function did not differ between the groups.

CONCLUSION

There was a nonstatistically significant tendency towards a higher rate of early postoperative complications after stapled IPAA. The timing of anastomotic leakage and abscess formation differed between the groups.

Anorectal and sexual functions after preoperative radiotherapy and full-thickness local excision of rectal cancer

AIMS

Local excision with preoperative radiotherapy may be considered as alternative management to abdominal surgery alone for small cT2-3N0 tumours. However, little is known about anorectal and sexual functions after local excision with preoperative radiotherapy. Evaluation of this issue was a secondary aim of our previously published prospective multicentre study.

METHODS

Functional evaluation was based on a questionnaire completed by 44 of 64 eligible disease-free patients treated with preoperative radiotherapy and local excision. Additionally, ex post, these results were confronted with those recorded retrospectively in the control group treated with anterior resection alone (N = 38).

RESULTS

In the preoperative radiotherapy and local excision group, the median number of bowel movements was two per day, incontinence of flatus occurred in 51% of patients, incontinence of loose stool in 46%, clustering of stools in 59%, and urgency in 49%; these symptoms occurred often or very often in 11%-21% of patients. Thirty-eight per cent of patients claimed that their quality of life was affected by anorectal dysfunction. Nineteen per cent of men and 20% of women claimed that the treatment negatively influenced their sexual life. The anorectal functions in the preoperative radiotherapy and local excision group were not much different from that observed in the anterior resection alone group.

CONCLUSIONS

Our study suggests that anorectal functions after preoperative radiotherapy and local excision may be worse than expected and not much different from that recorded after anterior resection alone. It is possible that radiotherapy compromises the functional effects achieved by local excision.

Men's experience with sexual dysfunction post-rectal cancer treatment: a qualitative study

In an effort to address reports from men that their sex life is worse after treatment for rectal cancer, this qualitative study was designed to better understand their experience with sexual dysfunction following rectal cancer treatment, thus providing information on the adaptation of a psycho-educational sexual health intervention for male rectal cancer survivors and simultaneously investigating barriers and promoters that would influence their participation in a psycho-educational sexual health intervention. Thirteen male rectal cancer survivors who were treated at Memorial Sloan-Kettering Cancer Center (MSKCC) for rectal cancer participated (median time post-treatment was 6.4 years). Six survivors participated in individual semi-structured phone interviews, and seven others took part in focus groups. We performed standard procedures of qualitative thematic text analysis, which involved independent review of interview and focus group transcripts by several analysts followed by consensus meetings to identify key themes. Participants reported bowel dysfunction (N = 13, or 100%) and erectile dysfunction (N = 12, or 92%) as chief complaints. The participants thought a psychoeducational sexual health intervention post-surgery would be helpful because it would provide educational information regarding the etiology of their problems and treatments to improve their sexual health (N = 8, or 62%). Most participants' primary concern immediately after treatment was surviving their disease; improving sexual functioning seemed to become more important over time. Barriers to potentially participating in a psycho-educational sexual health intervention included geographical distance from MSKCC (N = 3, or 3/13) and the risk of embarrassment when discussing sexual issues (N = 5, or 5/13). Men reported that a psycho-educational sexual health intervention would be helpful to improve their sexual functioning post-treatment. Discussion of bowel issues and logistical concerns gave information on the psycho-educational sexual health intervention.

Review of bowel dysfunction of rectal cancer patients during the first five years after sphincter-preserving surgery: a population in need of nursing attention

PURPOSE

The aim of the review was to summarize the longitudinal changes in bowel dysfunction among patients with rectal cancer within the first five years following sphincter-preserving resection.

METHODS

A series of literature searches were conducted on six English-language electronic databases. Articles published after 1990 were searched. A total of 29 articles (reporting 27 studies) was found.

RESULTS

Bowel dysfunction, including an alteration in the frequency of bowel movements, incontinence, abnormal sensations, and difficulties with evacuation, is reported among patients with rectal cancer within the first five years after sphincter-preserving resection. These problems are most frequent and severe within the first year, especially within the first six months, and stabilize after one year. Some of the problems may last for years.

CONCLUSION

Supportive care for bowel dysfunction is needed, and should include the provision of information and psychological support delivered in multiple steps. Oncology nurses can play an important role in providing supportive care for rectal cancer patients with bowel dysfunction.

Coloanal anastomosis or abdominoperineal resection for very low rectal cancer: what will benefit, the surgeon's pride or the patient's quality of life?

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.

A review on functional results of sphincter-saving surgery for rectal cancer: the anterior resection syndrome

The aim of this review is to characterize the functional results and "anterior resection syndrome" (ARS) after sphincter-saving surgery for rectal cancer. The purpose of sphincter-saving operations is to save the anal sphincters by avoiding the need for rectal abdomino-perineal resection with a permanent stoma. A variety of alternative techniques have been proposed and, today, ultra-low anterior resections of the rectum are commonplace. Inevitably rectal resections modify anorectal physiology. The backdrop of the functional asset for ultralow anterior resections is related to a small neorectal capacity with high endo-neorectal pressures that act together on a weakened sphincteric mechanism. Sometimes a defecation disorder called ARS may be induced and the patient experiences an extremely low quality of life. Impaired bowel function is usually provoked either by colonic dysmotility, neorectal reservoir dysfunction, anal sphincter damage or by a combination of these factors. Surgical technique defects can contribute to these possible causes: anastomotic ischemia, short length of the descending colon and stretching of neorectal mesentery may play a role. Unfortunately, there is no therapeutic algorithm or gold standard treatment that may be used for ARS. Nevertheless, it is rational to use conservative therapy first and then resort to surgery. Drugs, rehabilitative treatment and sacral neuromodulation may be used; after failure of conservative methods, surgical treatment can be considered.

Patient-reported outcomes in gastroenterology: clinical and research applications

Patient-generated reports, also known as Patient-Reported Outcomes (PROs), capture the patients' illness experience in a structured format and may help bridge the gap between patients and providers. PROs measure any aspect of patient-reported health (e.g., physical, emotional or social symptoms) and can help to direct care and improve clinical outcomes. When clinicians systematically collect patient-reported data in the right place at the right time, PRO measurement can effectively aid in detection and management of conditions, improve satisfaction with care and enhance the patient-provider relationship. This review article summarizes the latest approaches to PRO measuring for clinical trials and clinical practice, with a focus on use of PROs in gastroenterology.

Polydextrose and soluble corn fiber increase five-day fecal wet weight in healthy men and women

Dietary fiber has well-established beneficial effects on laxation. Many fibers have been developed with positive sensory properties and 2 such fibers are polydextrose (PDX) and soluble corn fiber (SCF), which can be added to many commercially produced products. We conducted a randomized, double-blind, placebo-controlled, crossover study comparing the laxative effects of PDX and SCF at a dose of 20 g/d with a low fiber control (LFC) eaten daily as a muffin and cereal in 36 healthy men and women. Each treatment period was 10 d with a 2-wk washout period between. Participants collected fecal samples during the last 5 d of each treatment and completed food diaries and gastrointestinal tolerance questionnaires on d 1, 2, and 10 of each treatment period. Five-day fecal wet weight was higher after the PDX and SCF treatments than the LFC treatment (P ≤ 0.0007). The number of stools per day and daily fecal output also were significantly greater during the PDX treatment compared with the LFC treatment. The whole gut transit time did not differ among treatments. The PDX treatment resulted in a softer stool (P = 0.002) than the SCF and LFC treatments. Fecal pH was lowered by the PDX treatment (P = 0.02), whereas SCF tended to lower it compared with the LFC treatment (P = 0.07). When the participants consumed PDX and SCF, they reported significantly more flatulence and borborygmi compared with when they consumed the LFC. Consumption of PDX and SCF at a dose of 20 g/d results in a mild laxative effect with nominal gastrointestinal tolerance issues.

Long term effect of surgery and radiotherapy for colorectal cancer on defecatory function and quality of life

PURPOSE

Survival from rectal cancer has improved substantially. Understanding the consequences of treatment is important to optimise patient support and minimise impact on daily life. We aimed to define the long-term prevalence of pelvic dysfunction following curative rectal cancer surgery (+/- radiotherapy) within the context of overall quality of life.

METHODS

We evaluated bowel, urinary and sexual function and quality of life using three validated questionnaires in patients treated for rectal cancer. This group was compared to patients undergoing abdominal surgery without pelvic dissection for colon cancer during the same time period.

RESULTS

The response rate was 57% (381/667) with a median time interval of 4.4 years. A subset of rectal patients documented persistent problems with faecal leakage (16%); requiring to alter daily activities (18%); always needing to wear a protective pad (17%); rarely or never emptying their bowels fully (31%); difficulty controlling the passage of gas (32%) and requiring to modify diet (30%). Altered bowel function was found to impact on overall quality of life. Men reported increased erectile function difficulties. Pre-operative radiotherapy was associated with increased defecation problems as was low level of anastomosis (≤6 cm).

CONCLUSION

In keeping with emergent evidence, this study has quantified the extent of late adverse effects with a sub-set of rectal cancer patients reporting persistent bowel function problems. The implications are now to consider current follow-up services and to 'trial' new models of comprehensive assessment and interventions in patients who are 'at risk' of experiencing late adverse effects of treatment.

Local excision in early rectal cancer-outcome worse than expected: a population based study

BACKGROUND

Considering the morbidity and mortality after abdominal surgery for rectal cancer, our aim was to determine whether local excision in Stage I rectal cancer provides long-term survival equivalent to TME surgery, particularly in elderly patients.

METHODS

Data on 3694 consecutive patients with Stage I rectal cancer operated 1995-2006, were collected from the Swedish Rectal Cancer Register, a population-based, prospectively sampled data-base. Risk factors for death within 5 years after surgery, local recurrence rates, cumulative relative and overall survival rates were calculated for patients ≥ and <80 years-of-age. ASA grading related to surgical technique was analysed in a separate sample.

RESULTS

Local excision (LE) was associated with an increased mortality risk both ≥80 (HR 1.55) and <80 years-of-age (HR 1.45). After LE the 5-year local recurrence rate was 11.2% and the total and relative cumulative 5-year survival was 0.62 and 0.81 respectively. Hartmann's procedure (HA) showed an increased mortality risk only in younger patients (HR 2.15). The overall local recurrence rate was 7.2% with HA. Male gender (HR 1.70) and age (HR 1.06) were associated with a significantly increased mortality risk in all age groups. The ASA-grade was higher among patients operated with LE compared to Anterior Resection/Abdominoperineal resection.

CONCLUSION

Local excision has a poor outcome in the elderly. A negative selection bias towards old age and high co-morbidity could explain this. Hartmann's procedure has a high risk for mortality and local recurrence in younger patients.

Treatment options to improve anorectal function following rectal resection: a systematic review

AIM

Common problems after rectal resection are loose stools, faecal incontinence, increased frequency and evacuation difficulties, for which there are various therapeutic options. A systematic review was conducted to assess the outcome of treatment options aimed to improve anorectal function after rectal surgery.

METHOD

Publications including a therapeutic approach to improve anorectal function after rectal surgery were searched using the following databases: MEDLINE, PubMed, EMBASE, Pedro, CINAHL, Web of Science, PsychInfo and the Cochrane Library. The focus was on outcome parameters of symptomatic improvement of faecal incontinence, evaluation of defaecation and quality of life.

RESULTS

The degree of agreement on eligibility and methodological quality between reviewers calculated with kappa was 0.85. Fifteen studies were included. Treatment options included pelvic floor re-education (n=7), colonic irrigation (n=2) and sacral nerve stimulation (SNS) (n=6). Nine studies reported reduced incontinence scores and a decreased number of incontinent episodes. In 10 studies an improvement in resting and squeeze pressure was observed after treatment with pelvic floor re-education or SNS. Three studies reported improved quality of life after pelvic floor re-education. Significant improvement of the Fecal Incontinence Quality of Life Scale was found in three studies after SNS.

CONCLUSION

Conservative therapies such as pelvic floor re-education and colonic irrigation can improve anorectal function. SNS might be an effective solution in selected patients. However, methodologically qualitative studies are limited and randomized controlled trials are needed to draw evidence-based conclusions.

Nonoperative management of rectal cancer with complete clinical response after neoadjuvant therapy

INTRODUCTION

Nonoperative management (NOM) of rectal cancer after a complete clinical response (cCR) to neoadjuvant therapy is controversial. In this article, we retrospectively reviewed the outcomes of patients managed with selective NOM after a cCR to neoadjuvant treatment and compared these with patients who underwent standard rectal resection with a pathological complete response (pCR).

METHODS

Patients completing neoadjuvant chemoradiotherapy (CRT) for stage I to III rectal cancer between January 2006 and August 2010 were retrospectively reviewed. Median follow-up was calculated in months after completion of CRT.

RESULTS

Thirty-two patients (median follow-up 28 months) were treated by NOM after a cCR. Among 265 treated by CRT and rectal resection, 57 patients (22%) had a pCR and formed the control group (median follow-up 43 months). Factors associated with selective use of NOM included lower pretreatment stage, older age, and distal tumor location (P < 0.05). In the NOM group, 6 recurred locally (median 11 months, range 7-14), 3 of whom also had concurrent distant recurrence. All 6 local failures were controlled by salvage rectal resection with no further local recurrence of disease (median follow-up 17 months). In the rectal resection/pCR group, there were no local failures. The 2-year distant disease-free survival (88% vs 98%, P = 0.27) and overall survival (96% vs 100%, P = 0.56) were similar for NOM and rectal resection/pCR groups.

CONCLUSIONS

Rectal resection was successfully avoided in 81% of patients selected for NOM. When combined with salvage surgery, NOM appears to achieve similar local and distant disease control compared with patients with a pCR treated by rectal resection. Longer follow-up and prospective trials are warranted to evaluate this promising treatment option.

Long-term results and quality of life in patients treated with hemorrhoidectomy using two different techniques: Ligasure versus transanal hemorrhoidal dearterialization

BACKGROUND

Hemorrhoids are the most frequent anal pathology. We evaluated the results of 2 techniques at 1 year after surgery.

METHODS

The clinical charts and data of patients who underwent hemorrhoidectomy between January 2008 and June 2010 were considered and analyzed. Patients underwent surgery with 2 techniques: transanal hemorrhoidal dearterialization (THD) hemorrhoidectomy or LigaSure-vessel sealing system (Valleylab, Boulder, CO). Patients were chosen randomly to receive one technique or the other. The primary objectives were quality of life, quality of defecation, and regression of symptoms.

RESULTS

Forty-six patients treated with THD and 68 patients treated with Ligasure were enrolled in the study. No significant differences were observed in the rate of postoperative surgical complications or readmissions. Short- and medium-term (1-6 mo) results showed that THD patients had a higher rate of pain resolution compared with Ligasure patients (P < .05). Functionally, all patients treated with Ligasure showed more postoperative constipation despite administration of laxatives than patients treated with THD.

CONCLUSIONS

THD is an effective technique and is associated with the best short-term clinical and surgical outcomes if compared with Ligasure.

Effect of preoperative radio(chemo)therapy on long-term functional outcome in rectal cancer patients: a systematic review and meta-analysis

BACKGROUND

Preoperative radio(chemo)therapy (pR(C)T) significantly reduces the local recurrence risk and is therefore recommended in stage II/III rectal cancer. However, this multimodal treatment approach may be associated with late adverse effects. To determine the impact of pR(C)T on long-term anorectal, sexual, and urinary function, we performed a systematic review and meta-analysis.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched for studies reporting on long-term functional outcome after rectal cancer resection with pR(C)T. Only studies that reported anorectal, sexual, and/or urinary function after rectal cancer resection in TME-technique with pR(C)T were eligible for inclusion.

RESULTS

Twenty-five studies, including 6,548 patients, were identified. Methodological quality of the eligible studies was low. The majority of studies reported higher rates of anorectal (14/18 studies) and male sexual dysfunction (9/10 studies) after pR(C)T. Few studies examined female sexual dysfunction (n = 4). Meta-analysis revealed that stool incontinence occurred more often in irradiated patients (risk ratio (RR) = 1.67; 95 % confidence interval (CI), 1.36, 2.05; p < 0.0001) and manometric results were significantly worse after pR(C)T (mean resting pressures (weighted mean difference (WMD) = 15.04; 95 % CI, 0.77, 29.31; p = 0.04) and maximum squeeze pressures (WMD = 30.39; 95 % CI, 21.48, 39.3; p < 0.0001)). Meta-analysis of erectile dysfunction revealed no statistical significance (RR = 1.41; 95 % CI, 0.74, 2.72; p = 0.3). Six of eight studies and meta-analysis demonstrated no negative effect of pR(C)T on urinary function (RR = 1.05; 95 % CI, 0.67, 1.65; p = 0.82).

CONCLUSIONS

Although quality of studies on long-term functional outcome is limited, current evidence demonstrates that pR(C)T negatively affects anorectal function after TME.

Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer

OBJECTIVE

The aim of this study was to develop and validate a scoring system for bowel dysfunction after low anterior resection (LAR) for rectal cancer, on the basis of symptoms and impact on quality of life (QoL).

BACKGROUND

LAR for rectal cancer often results in severe bowel dysfunction (LAR syndrome [LARS]) with incontinence, urgency, and frequent bowel movements. Several studies have investigated functional outcome, but the terminology is inconsistent hereby complicating comparison of results.

METHODS

Questionnaires regarding bowel function was sent to all 1143 LAR patients eligible for inclusion identified in the national Colorectal Cancer Database. Associations between items and QoL were computed by binomial regression analyses. The important items were selected and regression analysis was performed to find the adjusted risk ratios. Individual score values were designated items to form the LARS score, which was divided into "no LARS," "minor LARS," and "major LARS." Validity was tested by receiver operating characteristic (ROC) curve and Spearman's rank correlation and discriminant validity was tested by Student t tests.

RESULTS

A total of 961 patients returned completed questionnaires. The 5 most important items were "incontinence for flatus," "incontinence for liquid stools," "frequency," "clustering," and "urgency." The range (0-42) was divided into 0 to 20 (no LARS), 21 to 29 (minor LARS), and 30 to 42 (major LARS). The score showed good correlation and a high sensitivity (72.54%) and specificity (82.52%) for major LARS. Discriminant validity showed significant differences between groups with and without radiotherapy (P < 0.0001), tumor height more or less than 5 cm (P < 0.0001), and total mesorectal excision/partial mesorectal excision (P = 0.0163).

CONCLUSIONS

We have constructed a valid and reliable LARS score correlated to QoL--a simple tool for quick clinical evaluation of the severity of LARS.

Sigmoidectomy syndrome? Patients' perspectives on the functional outcomes following surgery for diverticulitis

BACKGROUND

Bowel function following surgery for diverticulitis has not previously been systematically described.

OBJECTIVE

This study aimed to document the frequency, severity, and predictors of suboptimal bowel function in patients who have undergone sigmoid colectomy for diverticulitis.

DESIGN

This study is a retrospective analysis.

SETTING

This study was conducted at a large, academic medical center.

PATIENTS

Three hundred twenty-five patients who underwent laparoscopic or open sigmoid colectomy with restoration of intestinal continuity for diverticulitis were included in the study population. Of these, 249 patients (76.6%) returned a 70-question survey incorporating the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, and the Memorial Bowel Function Instrument.

MAIN OUTCOME MEASURES

Survey responders and nonresponders were compared with the use of χ and t tests. Responders with suboptimal bowel function (fecal incontinence, urgency and/or incomplete emptying) were then compared with those with good outcomes by the use of logistic regression analysis to determine the predictors of poor function.

RESULTS

Of the responders, 24.8% reported clinically relevant fecal incontinence (Fecal Incontinence Severity Index ≥ 24), 19.6% reported fecal urgency (Memorial Bowel Function Instrument Urgency Subscale ≥ 4), and 20.8% reported incomplete emptying (Memorial Bowel Function Instrument Emptying Subscale ≥ 4). On logistic regression analysis, fecal incontinence was predicted by female sex (OR = 2.3, p = 0.008) and the presence of a preoperative abscess (OR = 1.4, p < 0.05). Fecal urgency was associated with female sex (OR = 1.3, p < 0.05) and a diverting ileostomy (OR = 2.1, p < 0.001). Incomplete emptying was associated with female sex (OR = 1.4, p < 0.05) and postoperative sepsis (OR = 1.9, p < 0.05).

LIMITATIONS

This study was limited by the fact that we did not use a nondiverticulitis control group and we had limited preoperative data on the history of bowel impairment symptoms.

CONCLUSION

One-fifth of patients reported fecal urgency, fecal incontinence, or incomplete emptying after surgery for diverticulitis. Despite the limitations of our study, these results are concerning and should be investigated further prospectively.

Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer

PURPOSE

Neoadjuvant chemoradiotherapy for rectal cancer can result in complete disappearance of tumor and involved nodes. In patients without residual tumor on imaging and endoscopy (clinical complete response [cCR]) a wait-and-see-policy (omission of surgery with follow-up) might be considered instead of surgery. The purpose of this prospective cohort study was to evaluate feasibility and safety of a wait-and-see policy with strict selection criteria and follow-up.

PATIENTS AND METHODS

Patients with a cCR after chemoradiotherapy were prospectively selected for the wait-and-see policy with magnetic resonance imaging (MRI) and endoscopy plus biopsies. Follow-up was performed 3 to 6 monthly and consisted of MRI, endoscopy, and computed tomography scans. A control group of patients with a pathologic complete response (pCR) after surgery was identified from a prospective cohort study. Functional outcome was measured with the Memorial Sloan-Kettering Cancer Center (MSKCC) bowel function questionnaire and Wexner incontinence score. Long-term outcome was estimated by using Kaplan-Meier curves.

RESULTS

Twenty-one patients with cCR were included in the wait-and-see policy group. Mean follow-up was 25 ± 19 months. One patient developed a local recurrence and had surgery as salvage treatment. The other 20 patients are alive without disease. The control group consisted of 20 patients with a pCR after surgery who had a mean follow-up of 35 ± 23 months. For these patients with a pCR, cumulative probabilities of 2-year disease-free survival and overall survival were 93% and 91%, respectively.

CONCLUSION

A wait-and-see policy with strict selection criteria, up-to-date imaging techniques, and follow-up is feasible and results in promising outcome at least as good as that of patients with a pCR after surgery. The proposed selection criteria and follow-up could form the basis for future randomized studies.

Function after intersphincteric resection for low rectal cancer and its influence on quality of life

AIM

The aim of the study was to investigate function and quality of life after different types of intersphincteric resection (ISR).

METHOD

Between January 2006 and February 2008, 45 patients (34 men and 11 women) with distal third rectal cancer underwent curative ISR. Function was evaluated using the Memorial Sloan Kettering Cancer Center bowel function questionnaire and Wexner score, anal manometry and measurements of rectal capacity were also performed. Quality of life was assessed using the Serbian version of the European Organisation for Research and Treatment of Cancer, quality of life questionnaire (EORTC QLQ-C30) and the translated version of the fecal incontinence quality of life scale (FIQL).

RESULTS

There were no postoperative deaths. Partial ISR was performed in 22 (48.9%) patients, subtotal ISR was performed in 19 (42.2%) patients and total ISR was performed in four (8.9%) patients. Anastomotic leakage occurred in nine (20%) patients. Five (11.1%) of 45 patients had major (complete) incontinence and a further six (13.3%) patients had continuing frequent faecal leakage 12 months after ileostomy reversal. There was no significant difference in quality of life between the groups in the EORTC QLQ-C30 scale, but this was significantly altered by internal anal sphincter resection in two of the FIQL scales (coping/behaviour and depression/self-perception).

CONCLUSION

Although ISR does not affect quality of life in general, the extent of internal anal sphincter resection has a negative impact on symptom-specific quality of life owing to faecal incontinence.

Complications among colorectal cancer survivors: SF-6D preference-weighted quality of life scores

BACKGROUND

Societal preference-weighted health-related quality of life (HRQOL) scores enable comparing multidimensional health states across diseases and treatments for research and policy.

OBJECTIVE

To assess the effects of living with a permanent intestinal stoma, compared with a major bowel resection, among colorectal cancer (CRC) survivors.

RESEARCH DESIGN

Cross-sectional multivariate linear regression analysis to explain preference-weighted HRQOL scores.

SUBJECTS

In all, 640 CRC survivors (≥ 5 years) from 3 group model health maintenance organizations; ostomates and nonostomates with colorectal resections for CRC were matched on gender, age (± 5 years), time since diagnosis, and tumor site (rectum vs. colon).

MEASURES

SF-6D scoring system was applied to Medical Outcomes Study Short Form-36 version 2 (SF-36v2); City of Hope Quality of Life-Ostomy; and Charlson-Deyo comorbidity index.

METHODS

Survey of CRC survivors linked to respondents' clinical data extracted from health maintenance organization files.

RESULTS

Response rate was 52%. Ostomates and nonostomates had similar sociodemographic characteristics. Mean SF-6D score was 0.69 for ostomates, compared with 0.73 for nonostomates (P < 0.001), but other factors explained this difference. Complications of initial cancer surgery, and previous year comorbidity burden, and hospital use were negatively associated with SF-6D scores, whereas household income was positively associated.

CONCLUSIONS

CRC survivors' SF-6D scores were not associated with living with a permanent ostomy after other factors were taken into account. Surgical complications, comorbidities, and metastatic disease lowered the preference-weighted HRQOL of CRC survivors with and without ostomies. Further research to understand and reduce late complications from CRC surgeries as well as associated depression is warranted.

Patient-reported outcomes after neoadjuvant chemoradiotherapy for rectal cancer: a multicenter prospective observational study

OBJECTIVE

To prospectively describe patient-reported outcomes (PROs) after preoperative chemoradiotherapy (pCRT) for rectal cancer.

BACKGROUND

Little evidence is available on PROs after pCRT for rectal cancer.

PATIENTS AND METHODS

Patients with rectal cancer, candidates to receive pCRT, were enrolled in a multicenter prospective observational trial. Health-related quality of life was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and its colorectal cancer module (QLQ-CR38), and fecal incontinence and bowel function were evaluated using the fecal incontinence score questionnaire and a set of ad hoc questions. Questionnaires were filled out before CRT (t₀), 2 to 3 weeks after completion of CRT (t₁), and at 6 (t₂) and 12 months (t₃) after surgery. Primary analysis of selected scales included: global quality of life, physical functioning, social functioning, fatigue, body image, future prospective, and gender-related sexual problems.

RESULTS

Of 149 eligible patients, questionnaires were completed in 100%, 95%, 88% and 77% of cases at t0, t₁, t₂, and t₃, respectively. At t₃, 78% of patients reported stool fractionation and 72% sensation of incomplete defecation. Only 14% of patients had optimal continence. Physical/social functioning, fatigue, and body image showed a decrease just after pCRT and returned to baseline levels at 1 year after treatment. Global quality of life was stable over time. Male sexual problems were greatly impaired throughout the study period (P < 0.001) with major clinically meaningful changes between baseline and 1 year after treatment.

CONCLUSIONS

These findings add to the body of evidence available regarding pCRT and help clinicians to make more informed treatment decisions.

The psychological context of quality of life: a psychometric analysis of a novel idiographic measure of bladder cancer patients' personal goals and concerns prior to surgery

BACKGROUND

Over the past two decades, there has been an increasing focus on quality of life outcomes in urological diseases. Patient-reported outcomes research has relied on structured assessments that constrain interpretation of the impact of disease and treatments. In this study, we present content analysis and psychometric evaluation of the Quality of Life Appraisal Profile. Our evaluation of this measure is a prelude to a prospective comparison of quality of life outcomes of reconstructive procedures after cystectomy.

METHODS

Fifty patients with bladder cancer were interviewed prior to surgery using the Quality of Life Appraisal Profile. Patients also completed the EORTC QLQ-C30 and demographics. Analysis included content coding of personal goal statements generated by the Appraisal Profile, examination of the relationship of goal attainment to content, and association of goal-based measures with QLQ-C30 scales.

RESULTS

Patients reported an average of 10 personal goals, reflecting motivational themes of achievement, problem solving, avoidance of problems, maintaining desired circumstances, letting go of roles and responsibilities, acceptance of undesirable situations, and attaining milestones. 503 goal statements were coded using 40 different content categories. Progress toward goal attainment was positively correlated with relationships and activities goals, but negatively correlated with health concerns. Associations among goal measures provided evidence for construct validity. Goal content also differed according to age, gender, employment, and marital status, lending further support for construct validity. QLQ-C30 functioning and symptom scales were correlated with goal content, but not with progress toward goal attainment, suggesting that patients may calibrate progress ratings relative to their specific goals. Alternately, progress may reflect a unique aspect of quality of life untapped by more standard scales.

CONCLUSIONS

The Brief Quality of Life Appraisal Profile was associated with measures of motivation, goal content and progress, as well as relationships with demographic and standard quality of life measures. This measure identifies novel concerns and issues in treating patients with bladder cancer, necessary for a more comprehensive evaluations of their health-related quality of life.

Functional outcome following restorative rectal cancer surgery

The trend towards preoperative adjuvant and neoadjuvant therapies in selected patients with rectal cancer has led to increases in sphincter preservation with a limited understanding of the factors governing unsatisfactory functional outcomes. Data would suggest the need for a more selective use of standard radiotherapeutic fields in low- to intermediate-risk cases where there appears to be limited survival or locoregional recurrence benefit and where there is under-reported toxicity. This article discusses the complex factors which impact on functional outcome following open rectal cancer surgery particularly when it is accompanied by adjuvant therapy.

A predictive model for local recurrence after transanal endoscopic microsurgery for rectal cancer

BACKGROUND

The outcome of local excision of early rectal cancer using transanal endoscopic microsurgery (TEM) lacks consensus. Screening has substantially increased the early diagnosis of tumours. Patients need local treatments that are oncologically equivalent to radical surgery but safer and functionally superior.

METHODS

A national database, collated prospectively from 21 regional centres, detailed TEM treatment in 487 subjects with rectal cancer. Data were used to construct a predictive model of local recurrence after TEM using semiparametric survival analyses. The model was internally validated using measures of calibration and discrimination.

RESULTS

Postoperative morbidity and mortality were 14.9 and 1.4 per cent respectively. The Cox regression model predicted local recurrence with a concordance index of 0.76 using age, depth of tumour invasion, tumour diameter, presence of lymphovascular invasion, poor differentiation and conversion to radical surgery after histopathological examination of the TEM specimen.

CONCLUSION

Patient selection for TEM is frequently governed by fitness for radical surgery rather than suitable tumour biology. TEM can produce long-term outcomes similar to those published for radical total mesorectal excision surgery if applied to a select group of biologically favourable tumours. Conversion to radical surgery based on adverse TEM histopathology appears safe for p T1 and p T2 lesions.

Sphincter preservation in low rectal cancer is facilitated by preoperative chemoradiation and intersphincteric dissection

OBJECTIVE

The aim of this study was to evaluate oncologic outcome in patients with locally advanced distal rectal cancer treated with preoperative chemoradiation followed by low anterior resection (LAR)/stapled coloanal anastomosis, LAR/intersphincteric dissection/hand-sewn coloanal anastomosis, or abdominoperineal resection (APR).

SUMMARY BACKGROUND DATA

Distal rectal cancer presents a surgical challenge, and the goals of treatment often include tumor eradication without sacrifice of the anal sphincters. The technique of intersphincteric resection removes the internal anal sphincter to gain additional distal rectal margin in hopes of avoiding a permanent stoma.

METHODS

We analyzed 148 patients with stage II and III rectal cancers (endorectal ultrasound staged uT3-4 and/or uN1) located < or =6 cm from the anal verge, treated by preoperative chemoradiation and total mesorectal excision from 1998 to 2004. Eighty-five patients (57%) had sphincter-preserving resection (41, LAR/stapled coloanal anastomosis; 44, LAR/intersphincteric resection/hand-sewn coloanal anastomosis); 63 patients had APR.

RESULTS

Patients undergoing APR were older, with more poorly differentiated tumors evidencing less response to chemoradiation and more likely to require extended resection. Complete resection with negative histologic margins was achieved in 92%; circumferential margins were positive in 2 (5%) of 44 in the intersphincteric resection group and 8 (13%) of 63 in the APR group. Distal margins were positive in 2 (5%) of 44 in the intersphincteric resection group. With median follow-up of 47 months, there were a total of 7 local recurrences (5%): 1, 0, and 6 in the stapled anastomosis, intersphincteric resection, and APR groups, respectively. Estimated 5-year recurrence-free survival for the stapled anastomosis, intersphincteric resection, and APR groups were 85%, 83%, and 47% respectively (P = 0.001).

CONCLUSIONS

In low rectal cancer, sphincter preservation is facilitated by a significant response to preoperative chemoradiation and intersphincteric resection, without compromise of margins or outcome. In those who have a less favorable response, abdominoperineal resection is more likely to be required and is associated with poorer outcome.