Abstract
Background
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.
Methods
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.
Results
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.
Conclusion
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.
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Di Betta E, D’Hoore A, Filez L, Penninckx F. Sphincter saving rectum resection is the standard procedure for low rectal cancer. Int J Colorectal Dis 2003; 18:463–469
Pachler J, Wille-Jorgensen P. Quality of life after rectal resection for cancer, with or without permanent colostomy. Cochrane Database Syst Rev 2004:CD004323
Savatta SG, Temple LKF. Quality of life in patients treated for curable rectal cancer. Semin Rectal Surg 2005; 16:170–180
Tiret E, Poupardin B, McNamara D, Dehni N, Parc R. Ultralow anterior resection with intersphincteric dissection–what is the limit of safe sphincter preservation? Colorectal Dis 2003; 5:454–457
Tekkis PP, Heriot AG, Smith J, Thompson MR, Finan P, Stamatakis JD. Comparison of circumferential margin involvement between restorative and nonrestorative resections for rectal cancer. Colorectal Dis 2005; 7:369–374
Chambers WM, Mortensen NJ. Postoperative leakage and abscess formation after colorectal surgery. Best Pract Res Clin Gastroenterol 2004; 18:865–880
Zolciak A, Bujko K, Kepka L, Oledzki J, Rutkowski A, Nowacki MP. Abdominoperineal resection or anterior resection for rectal cancer: patient preferences before and after treatment. Colorectal Dis 2006; 8:575–580
Bowling A, Bond M, Jenkinson C, Lamping DL. Short Form 36 (SF-36) Health Survey questionnaire: which normative data should be used? Comparisons between the norms provided by the Omnibus Survey in Britain, the Health Survey for England and the Oxford Healthy Life Survey. J Public Health Med 1999; 21:255–270
Gandek B. Translating functional health and well being: International Quality of Life Assessment (IQOLA) project studies of the SF-36 Health Survey. J Clin Epidemiol 1998; 51:891–1214
Aaronson NK, Ahmedzai S, Bergman B, Bullinger M, Cull A, Duez NJ, Filiberti A, Flechtner H, Fleishman SB, de Haes JC, et al. 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 1993; 85:365–376
Sprangers MA, te Velde A, Aaronson NK. 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 1999; 35:238–247
Clarke M, Horton R. Bringing it all together: Lancet-Cochrane collaborate on systematic reviews. Lancet 2001; 357:1278
Stroup DF, Berlin JA, Morton SC, Williamson GD, Rennie D et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology. JAMA 2000; 283:2008–2012
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7:177–188
Athannsiou T KP, Crossman MC, Amrani M, Pepper JR et al. Off pump myocardial revascularisation is associated with less incidence of stroke in elderly patients. Ann Thorac Surg 2004; 77:745–753
Allal AS, Gervaz P, Gertsch P, Bernier J, Roth AD, Morel P, Bieri S. Assessment of quality of life in patients with rectal cancer treated by preoperative radiotherapy: a longitudinal prospective study. Int J Radiat Oncol Biol Phys 2005; 61:1129–1135
Hamashima C. Long-term quality of life of postoperative rectal cancer patients. J Gastroenterol Hepatol 2002; 17:571–576
Harisi R, Bodoky G, Borsodi M, Flautner L, Weltner J. Rectal cancer therapy: decision making on basis of quality of life? Zentralbl Chir 2004; 129:139–148
Schmidt C, Loehnert M. The influence of surgery on perceived quality of life in patients with colorectal cancer. Qual Life Res 2002; 11:679
Whynes DK, Neilson AR, Robinson MH, Hardcastle JD. Colorectal cancer screening and quality of life. Qual Life Res 1994; 3:191–198
Williams NS, Johnston D. The quality of life after rectal excision for low rectal cancer. Br J Surg 1983; 70:460–462
MacDonald LD, Anderson HR. The health of rectal cancer patients in the community. Eur J Surg Oncol 1985; 11:235–241
Frigell A, Ottander M, Stenbeck H, Pahlman L. Quality of life of patients treated with abdominoperineal resection or anterior resection for rectal carcinoma. Ann Chir Gynaecol 1990; 79:26–30
La Monica G, Audisio RA, Tamburini M, Filiberti A, Ventafridda V. Incidence of sexual dysfunction in male patients treated surgically for rectal malignancy. Dis Colon Rectum 1985; 28:937–940
Grundmann R, Said S, Krinke S. [Quality of life after rectal resection or extirpation. A comparison using different measurement parameters]. Dtsch Med Wochenschr 1989; 114:453–457
Hoppe De Mamani S, Schlag PM. [Quality of life after rectal surgery]. Chirurg 2004; 75:26–31
Renner K, Rosen HR, Novi G, Holbling N, Schiessel R. Quality of life after surgery for rectal cancer: do we still need a permanent colostomy? Dis Colon Rectum 1999; 42:1160–1167
Camilleri-Brennan J, Steele RJ. Objective assessment of morbidity and quality of life after surgery for low rectal cancer. Colorectal Dis 2002; 4:61–66
Engel J, Kerr J, Schlesinger-Raab A, Eckel R, Sauer H, Holzel D. Quality of life in rectal cancer patients: a four-year prospective study. Ann Surg 2003; 238:203–213
Gosselink MP, Busschbach JJ, Dijkhuis CM, Stassen LP, Hop WC, Schouten WR. Quality of life after total mesorectal excision for rectal cancer. Colorectal Dis 2005; 8:15–22
Grumann MM, Noack EM, Hoffmann IA, Schlag PM. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Ann Surg 2001; 233:149–156
Guren MG, Eriksen MT, Wiig JN, Carlsen E, Nesbakken A, Sigurdsson HK, Wibe A, Tveit KM. Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer. Eur J Surg Oncol 2005; 31:735–742
Jess P, Christiansen J, Bech P. Quality of life after anterior resection versus abdominoperineal extirpation for rectal cancer. Scand J Gastroenterol 2002; 37:1201–1204
Kuzu MA, Topcu O, Ucar K, Ulukent S, Unal E, Erverdi N, Elhan A, Demirci S. Effect of sphincter-sacrificing surgery for rectal carcinoma on quality of life in Muslim patients. Dis Colon Rectum 2002; 45:1359–1366
Rauch P, Miny J, Conroy T, Neyton L, Guillemin F. Quality of life among disease-free survivors of rectal cancer. J Clin Oncol 2004; 22:354–360
Schmidt CE, Bestmann B, Kuchler T, Longo WE, Kremer B. Prospective evaluation of quality of life of patients receiving either abdominoperineal resection or sphincter-preserving procedure for rectal cancer. Ann Surg Oncol 2005; 12:117–123
Sideris L, Zenasni F, Vernerey D, Dauchy S, Lasser P, Pignon JP, Elias D, Di Palma M, Pocard M. Quality of life of patients operated on for low rectal cancer: impact of the type of surgery and patients’ characteristics. Dis Colon Rectum 2005; 48:2180–2191
Vironen JH, Kairaluoma M, Aalto AM, Kellokumpu IH. Impact of functional results on quality of life after rectal cancer surgery. Dis Colon Rectum 2006; 49:568–578
Allal AS, Bieri S, Pelloni A, et al. Sphinctor-sparing surgery after preoperative radiotherapy for low rectal cancers: feasibility, oncological results and quality of life outcomes. Br J Cancer 2000; 82:1131–1137
Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992; 30:473–483
Camilleri-Brennan J, Steele RJ. Objective assessment of quality of life following panproctocolectomy and ileostomy for ulcerative colitis. Ann R Coll Surg Engl 2001; 83:321–324
Matzel KE, Bittorf B, Gunther K, Stadelmaier U, Hohenberger W. Rectal resection with low anastomosis: functional outcome. Colorectal Dis 2003; 5:458–464
Lee SJ, Park YS. Serial evaluation of anorectal function following low anterior resection of the rectum. Int J Colorectal Dis 1998; 13:241–246
Kakodkar R, Gupta S, Nundy S. Low anterior resection with total mesorectal excision for rectal cancer: functional assessment and factors affecting outcome. Colorectal Dis 2006; 8:650–656
Dehni N, Tiret E, Singland JD, Cunningham C, Schlegel RD, Guiguet M, Parc R. Long-term functional outcome after low anterior resection: comparison of low colorectal anastomosis and colonic J-pouch-anal anastomosis. Dis Colon Rectum 1998; 41:817–822; discussion 822–823
Lyons RA, Lucas M, Wareham K, Price D, Williams J, Hutchings HA. SF-36 scores vary by method of administration: implications for study design. J Public Health Med 1999; 21:41–45
Heald RJ, Smedh RK, Kald A, Sexton R, Moran BJ. Abdominoperineal excision of the rectum-an endangered operation. Norman Nigro Lectureship. Dis Colon Rectum 1997; 40:747–751
Paty PB, Enker WE, Cohen AM, Lauwers GY. Treatment of rectal cancer by low anterior resection with coloanal anastomosis. Ann Surg 1994; 219:365–373
Watanabe M, Teramoto T, Hasegawa H, Kitajima M. Laparoscopic ultralow anterior resection combined with per annum intersphincteric rectal dissection for lower rectal cancer. Dis Colon Rectum 2000; 43:S94–97
McNamara DA, Parc R. Methods and results of sphincter-preserving surgery for rectal cancer. Cancer Control 2003; 10:212–218
Heriot AG, Tekkis PP, Constantinides V, Paraskevas P, Nicholls RJ, Darzi A, Fazio VW. Meta-analysis of colonic reservoirs versus straight coloanal anastomosis after anterior resection. Br J Surg 2006; 93:19–32
Park JJ, Del Pino A, Orsay CP, Nelson RL, Pearl RK, Cintron JR, Abcarian H. Stoma complications: the Cook County Hospital experience. Dis Colon Rectum 1999; 42:1575–1580
Nugent KP, Daniels P, Stewart B, Patankar R, Johnson CD. Quality of life in stoma patients. Dis Colon Rectum 1999; 42:1569–1574
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Cornish, J.A., Tilney, H.S., Heriot, A.G. et al. A Meta-Analysis of Quality of Life for Abdominoperineal Excision of Rectum versus Anterior Resection for Rectal Cancer. Ann Surg Oncol 14, 2056–2068 (2007). https://doi.org/10.1245/s10434-007-9402-z
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DOI: https://doi.org/10.1245/s10434-007-9402-z