Objective assessment of morbidity and quality of life after surgery for low rectal cancer. Early outcomes of 100 patients with laparoscopic resection for rectal neoplasm. Impact of functional results on quality of life after rectal cancer surgery. Quality of life in rectal cancer patients: a four-year prospective study. Quality of life after anterior resection versus abdominoperineal extirpation for rectal cancer. [Quality of life after rectal resection or extirpation. A comparison using different measurement parameters]. Laparoscopic vs open total mesorectal excision for rectal cancer: an evaluation of the mesorectum's macroscopic quality. Effect of sphincter-sacrificing surgery for rectal carcinoma on quality of life in Muslim patients. Quality of life after total mesorectal excision for rectal cancer. Laparoscopic abdominoperineal resection and anterior resection with curative intent for carcinoma of the rectum. Quality of life measures in Islamic rectal carcinoma patients receiving counselling. Laparoscopic rectal resection with anal sphincter preservation for rectal cancer: long-term outcome. Longitudinal assessment of quality of life in rectal cancer patients with or without stomas following primary resection. Quality of life of patients operated on for low rectal cancer: impact of the type of surgery and patients' characteristics. Comparison of quality of life in patients undergoing abdominoperineal extirpation or anterior resection for rectal cancer. Sphincter-sparing surgery after preoperative radiotherapy for low rectal cancers: feasibility, oncologic results and quality of life outcomes. Quality of life after surgery for rectal cancer with special reference to pelvic floor dysfunction. Requirement for bowel preparation in colorectal surgery. Prospective comparison of laparoscopic and conventional anterior resection. Laparoscopic ultralow anterior resection combined with per anum intersphincteric rectal dissection for lower rectal cancer. Diverting stoma after low anterior resection: more arguments in favor. Conventional approach x laparoscopic abdominoperineal resection for rectal cancer treatment after neoadjuvant chemoradiation: results of a prospective randomized trial. Comparison of defecatory function after colonic J-pouch anastomosis and straight anastomosis for stapled low anterior resection: results of a prospective randomized trial. Quality of life and functional outcome following anterior or abdominoperineal resection for rectal cancer. The efficacy and adverse effects of topical phenylephrine for anal incontinence after low anterior resection in patients with rectal cancer. Comparison of J-pouch and coloplasty pouch for low rectal cancers: a randomized, controlled trial investigating functional results and comparative anastomotic leak rates. Laparoscopic vs. open abdominoperineal resection for cancer. Laparoscopic abdominoperineal excision of the rectum. Amoxycillin and clavulanic acid versus cefotaxime and metronidazole as antibiotic prophylaxis in elective colorectal resectional surgery. Catheter management programs and postoperative urinary dysfunction. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. The role of the posterior cruciate ligament in total knee replacement. Sexual impairment and its effects on quality of life in patients with rectal cancer. Hand-assisted laparoscopic low anterior resection: initial experience with a new procedure.
OBJECTIVE: To determine whether an anterior resection for low rectal cancer is associated with less morbidity and a better quality of life than an abdominoperineal resection. PATIENTS AND METHODS: Fifty-three patients who had anterior resection for low rectal cancer were individually matched with 53 other patients, who had an abdominoperineal resection during the same period of time, for gender, age and socioeconomic status. There was no evidence of tumour recurrence in these patients. All patients answered three quality of life questionnaires at least one year after surgery: Short Form 36 version 2, EORTC QLQ-C30 and EORTC QLQ-CR38. Details on short-term and long-term complications were collected prospectively. RESULTS: There was no significant difference in both the short-term and the long-term complication rates between the two groups of patients. There was also no difference in the global quality of life score on the QLQ-C30. However, patients who had an anterior resection had a better perception of body image than those who had an abdominoperineal resection, as measured on the QLQ-CR38 questionnaire (P=0.009), but were more prone to suffer from constipation (P=0.001). CONCLUSIONS: The overall similarities in quality of life between the two groups is probably a reflection of better stoma care, although problems with body image still persist in stoma patients. Laparoscopic resection has been shown to be a feasible option in patients with colorectal diseases. However, there have been only a few studies on laparoscopic resection for rectal neoplasm. This report aimed to evaluate the early outcomes of patients treated by laparoscopic rectal resection for neoplasm.
                From May 2000 to April 2003, 100 patients underwent laparoscopic resection for rectal neoplasm with mesorectal excision. Data on the patients' demographics, operative details, and outcomes were collected prospectively. In those with successful laparoscopic resection, comparison was made between patients with predominantly intracorporeal surgery (ICS) and those with anterior resection performed with extracorporeal rectal transection and anastomosis following intracorporeal bowel mobilization and vessel ligation (IECS).
                Sixty-six men and 34 women (median age, 69 years; range, 40-85) were included. Operations included 91 anterior resections, eight abdominoperineal resections, and one Hartmann's procedure. Conversion was required in 15 patients and no conversion was needed in patients treated by laparoscopic abdominoperineal resection. One patient died 30 days after surgery because of liver failure. Postoperative complications occurred in 31 patients. Among them, three had anastomotic leakage and all of them could be treated conservatively. Reoperation was required in one patient with intestinal obstruction. Patients with conversion were found to have significantly more blood loss, longer time to resume diet, a longer hospital stay, and a higher morbidity rate when compared to those with successful laparoscopic surgery. Among those with successful laparoscopic procedures, no difference was observed between patients with ICS (n = 57) and those with IECS (n = 28), except that a shorter incision and less blood loss were found in patients in the former group.
                Laparoscopic rectal resection with mesorectal dissection is feasible. The operating mortality and reoperation rates were low. Conversion was associated with an increased morbidity rate, leading to a longer hospital stay. Laparoscopically assisted anterior resection with rectal transection by a transverse stapler through the abdominal incision produced similar results when compared to a procedure that was predominantly intracorporeally performed. Quality of life is an important outcome measure that has to be considered when deciding treatment strategy for rectal cancer. The aim of this study was to find out the impact of surgery-related adverse effects on quality of life.
                The RAND-36 questionnaire and questionnaires assessing urinary, sexual, and bowel dysfunction were administered to 94 patients with no sign of recurrence a minimum of one year after curative surgery. Results were compared with age-matched and gender-matched general population.
                Eighty-two (87 percent) patients answered the questionnaires. Major bowel dysfunction was as common after high anterior resection as after low anterior resection. Urinary complaints occurred as often after anterior resection as after abdominoperineal resection, but sexual dysfunction was more common after abdominoperineal resection. Overall, the patients reported better general health perception but poorer social functioning than population controls. In particular, elderly patients reported a significantly better quality of life in many dimensions than their population controls. There was no significant difference in quality of life between treatment groups. Major bowel dysfunction after anterior resection impaired social functioning compared with that of patients without such symptoms. Urinary dysfunction impaired social functioning and impotence impaired physical and social functioning.
                Quality of life after rectal cancer surgery is not worse than that of the general population. The major adverse impact of bowel and urogenital dysfunction is on social functioning. These adverse effects need to be discussed with the patient and preoperative function needs to be taken into account when choosing between treatment options. Permanent colostomy is not always the factor that disrupts a person's quality of life most. To assess long-term quality of life in a population-based sample of rectal cancer patients.
                Quality of life in rectal cancer patients who suffer reduced bowel and sexual function is very important. Few studies, however, have long term follow-up data or sufficient sample sizes for reliable comparisons between operation groups.
                A 4-year prospective study of rectal cancer patients' quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-30 and CR38 questionnaires.
                A total of 329 patients returned questionnaires. Overall, anterior resection patients had better quality of life scores than abdominoperineal extirpation patients. High-anterior resection patients had significantly better scores than both low-anterior resection and abdominoperineal extirpation patients. Low-anterior resection patients, however, overall had a better quality of life than abdominoperineal extirpation patients, especially after 4 years. Abdominoperineal extirpation patients' quality of life scores did not improve over time. Stoma patients had significantly worse quality of life scores than nonstoma patients. Quality of life improved greatly for patients whose stoma was reversed.
                Anterior resection and nonstoma patients, despite suffering micturition and defecation problems, had better quality of life scores than abdominoperineal extirpation and stoma patients. Comparisons between abdominoperineal extirpation and anterior resection patients should consider the effect of temporary stomas. Improvements in quality of life scores over time may be explained by reversal of temporary stomas or physiologic adaptation. Abdominoperineal extirpation has been assumed to put patients at higher risk of disruption to quality of life than sphincter-preserving surgery in rectal cancer surgery. The aim of this study was to investigate quality of life in patients after anterior resection versus abdominoperineal extirpation for rectal cancer and to evaluate the psychometrics of the Danish version of a symptom-specific Fecal Incontinence Quality of Life Scale.
                Fourteen patients undergoing abdominoperineal extirpation and 26 undergoing anterior resection. The generic quality of life instrument SF-36 together with a new symptom-specific Fecal Incontinence Quality of Life Scale were used. Psychometric analysis of the symptom-specific scale was carried out.
                The only significant difference between the two groups was found in the total score of the symptom-specific scale in favour of anterior resection (P = 0.02). Psychometric evaluation of the symptom-specific fecal incontinence questionnaire proved it reliable and valid.
                The present study shows that a stoma influences quality of life only slightly, while a relatively high anterior resection does not. However, a few appropriate newer studies indicate that the cost of spinchter-preserving techniques in the form of incontinence disturbances may influence the quality of life seriously, which should be borne in mind when low anterior resection is intended. Further studies in this field are necessary and could benefit from use of the Fecal Incontinence Quality of Life Scale, including its total score. Two groups of 41 patients each who had undergone rectal resection or excision were questioned about the quality of their life an average of 4.3 or 3.8 years, respectively, after the operation. Three different measurements were obtained (Karnofsky, Grogono and Spitzer indexes). In addition, the patients provided a subjective estimate of the quality of their life. The quality of life was significantly better after resection than after excision, most clearly so according to the Grogono index, and this was also reflected in the patients' personal assessment. In males rectal excision frequently resulted in inferiority feelings, depression and disorders of sexual activity. Females found it easier to cope: they showed only minor differences in quality of life between resection and excision. Irrigation proved to be the best means of stoma care as far as quality of life was concerned. Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated.
                A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum.
                A three-grade scoring system showed no differences between the LTME and OTME groups.
                The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate. Living with a permanent colostomy significantly diminishes a patient's quality of life. However, little is known about its influence on worship patterns in Muslims. Therefore, the aim of this study was to assess the quality of life in Muslim patients after surgery for rectal carcinoma, especially with respect to religious worship.
                We studied 178 patients who had undergone curative surgery for colorectal carcinoma. The patients fell into three groups based on the type of surgery they underwent: abdominoperineal resection (n = 75), sphincter-saving resection (n = 51), and anterior resection including sigmoid colectomy (n = 52). Quality of life was measured with the Medical Outcomes Study Short Form 36 Health Survey and a questionnaire that asked participants about their work responsibilities, sexual life, and religious worship.
                The scores for all eight subscales of the Short Form 36 in the abdominoperineal resection group were significantly poorer than those in the sphincter-saving resection and anterior resection groups ( P< 0.001). In addition, social life and work responsibilities were significantly more affected in the abdominoperineal resection group than in the other two groups ( P< 0.001). A significantly ( P< 0.001) greater number of patients in the abdominoperineal resection group stopped praying daily (either alone or in a mosque) and fasting during Ramadan.
                Two aspects of religious worship (praying and fasting) were significantly impaired in the Muslim patients who had a stoma as a result of sphincter-sacrificing surgery. To improve quality of life in these patients, religious issues as they relate to the presence of a stoma should be discussed during preoperative counseling, the informed consent process, and counseling with local religious authorities. After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo-rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo-anal J-pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease-free survivors after APR, LRA and CPA.
                The charts of 301 consecutive patients who had undergone surgery for cancer in the middle or lower third of the rectum were analysed. Two hundred four patients were eligible for inclusion. The quality of life among these patients was assessed using one generic (EQ-5D) and two disease-specific questionnaires (EORTC QLQ-C30 and EORTC QLQ-CR38).
                The response rate was 82%. The median follow-up was 31 months. Overall, quality of life was good but CPA patients had better quality of life scores than APR and LRA patients. This difference was not only due to the better functional outcome but also to the lower incidence of disturbed micturition and sexual problems in the CPA group.
                The quality of life after colo-anal J-pouch anastomosis is better than after abdominoperineal resection (APR) and low colo-rectal anastomosis (LRA). The quality of life after APR is similar to that after LRA. Within a 5-year period, 380 rectal carcinoma patients undergoing laparoscopic abdominoperineal excision or laparoscopic anterior resection were recruited to a multicenter study by 23 institutions in Germany and Austria. This study was initiated by the Laparoscopic Colorectal Surgery Study Group.
                One hundred forty-nine patients (39.2%) underwent abdominoperineal resection (APR), and 231 patients (60.8%) were treated by anterior resection (AR). The mean operating time was 208 min, and the conversion rate was 6.1%. Intraoperative complications, mostly vascular or bowel injuries, were observed in 22 patients (5.8%). Overall, a total of 257 postoperative complications and problems occurred in 143 patients, resulting in a morbidity rate of 37.6%. In the AR group, the anastomotic leakage rate increased as the distance of the tumor from the anal verge decreased. The perioperative mortality rate was low (6/1.6%). Most of the patients received a high transsection of the inferior mesenteric artery with radical lymph node dissection (342/90.0%); the mean number of recovered lymph nodes was 13.0, with considerable variation among the individual institutions. Intraoperative tumor cell spillage was reported in 12 patients (3.2%). Sufficient follow-up findings are available for 288 (77%) patients. To date, 19 patients have sustained a local recurrence (6.6%), and 30 (10.4%) have developed distant metastases. Within the (admittedly limited) mean follow-up of 24.8 months, the overall survival rate is 86.6%, the disease-free survival (freedom from both local recurrence and distant metastases) rate is 62.4% for APR, with the corresponding rates for AR being 71.7 and 54.8%, respectively, as established by the Kaplan-Meier function. These data show no alarmingly high recurrence rates at this time.
                In principle, laparoscopic anterior resection with curative intent generates considerably more reservations than laparoscopic abdominoperineal resection, which is technically much easier to perform. This prospective study was conducted to compare changes in the health-related quality of life (HRQoL) and religious practices of patients who underwent surgery for rectal cancer.
                We prospectively followed 93 Muslim patients after surgery for colorectal carcinoma: abdominoperineal excision (APE, n = 50), sphincter-saving resection (LAR, n = 22) or anterior resection including sigmoid colectomy (AR, n = 1). The HRQoL was measured pre- and postoperatively at 15-18 months with the Medical Outcomes Study Short Form 36 Health Survey (SF-36) and a modified version of the American Society of Colorectal Surgeons (ASCRS) Fecal Incontinence questionnaire. Life standards, including religious practice, were measured using the Ankara University Life Standard Questionnaire.
                No difference was detected in any SF-36 Health Survey HRQoL domain among the groups, although there were differences within groups before and after surgery. The ASCRS Fecal Incontinence questionnaire scales of lifestyle, coping/behaviour and depression/self-perception were similar in the APE and AR groups and were significantly worse than in the AR group (P ≤ 0.004). The embarrassment scale was worse in the APE than in the LAR and AR groups (P < 0.001). Religious worship (praying alone, praying in mosques, fasting during Ramadan and purifying alms) was not significantly different among the groups.
                HRQoL measured by the SF-36 questionnaire and religious practices were not significantly different after APE compared with AR. Ostomy support and pre- and postoperative health-related and religious counselling may have had beneficial effects.
                © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland. Total mesorectal excision (TME) is the surgical gold standard treatment for middle and low third rectal carcinoma. Laparoscopy has gradually become accepted for the treatment of colorectal malignancy after a long period of questions regarding its safety. The purposes of this study were to examine prospectively our experience with laparoscopic TME and high rectal resections, to evaluate the surgical outcomes and oncologic adequacy, and to discuss the role of this procedure in the treatment of rectal cancer.
                Between December 1992 and December 2004, all patients who underwent elective laparoscopic sphincter preserving rectal resection for rectal cancer were enrolled prospectively in this study. Data collection included preoperative, operative, postoperative and oncologic results with long-term follow-up.
                A total of 218 patients were operated on during the study period: 142 patients underwent laparoscopic TME and 76 patients underwent anterior resection. Of the TME patients, 122 patients were operated using the double-stapling technique, and 20 patients underwent colo-anal anastomosis with hand-sewn sutures. Mean operative time was 138 min (range, 107-205), and mean blood loss was 120 ml (range, 30-350). Conversion to open surgery occurred in 26 cases (12%). Mortality rate during the first 30 days was 1%. Anastomotic leaks were observed in 10.5% of the patients. Of these, 61.9% needed reoperation and diverting stoma, and the rest were treated conservatively. Three patients had postoperative bleeding requiring relaparoscopy. Other minor complications (infection and urinary retention) occurred in 9.1% of patients. Mean ambulation time and mean hospital stay were 1.6 days (range, 1-5) and 6.4 days (range, 3-28) , respectively. Patients were followed for a mean period of 57 months. No port site metastases were observed during follow-up. The recurrence rate was 6.8 %. Overall survival rate was 67% after 5 years and 53.5% after 10 years.
                Laparoscopic anterior resection and TME with anal sphincter preservation for rectal cancer is feasible and safe. The short- and long-term outcomes reported in this series are comparable with those of conventional surgery. The purpose of this study was to assess the longitudinal impact of stoma formation on the health-related quality of life of rectal cancer patients treated with adjuvant chemotherapy.
                Health-related quality of life data was prospectively collected in a randomized trial designed to compare 24 weeks of bolus 5-fluorouracil/leucovorin with 12 weeks of continuous 5-fluorouracil in patients with resected Dukes B and C colorectal cancer. Health-related quality of life data was collected at baseline, during adjuvant treatment, and at one and three years after completion of chemotherapy.
                Between 1993 and 2003, 186 rectal cancer patients were enrolled. One hundred thirty-nine patients had anterior resection, of whom 46 had a temporary defunctioning colostomy. Forty-seven patients had abdominoperineal resection with formation of a permanent colostomy. There was no significant difference in global health-related quality of life between patients with and patients without a stoma at any time point. However, during adjuvant treatment, role (P = 0.04) and social (P = 0.005) functioning were significantly worse in stoma patients than in nonstoma patients. Moreover, the impairment in social functioning persisted at one (P = 0.03) and three years (P = 0.04) after adjuvant chemotherapy.
                Our results demonstrate important adverse effects of either temporary or permanent stoma formation on subsequent health-related quality of life in patients with rectal cancer. This study was designed to compare the impact of a permanent colostomy and sociodemographic characteristics on the quality of life of patients operated on for low rectal cancer.
                A cross-sectional study was performed by use of the European Organization for Research and Treatment of Cancer QLQ-C30 and CR-38 questionnaires. Patients came to the hospital to fill out the self-administered questionnaire or were sent the questionnaire by mail, followed by a live or telephone interview. All patients had undergone one of four operations: low anterior resection with colorectal or coloanal anastomosis (non-stoma group), or abdominoperineal resection with pseudocontinent perineal colostomy (nonstoma group) or left lower quadrant colostomy (stoma group).
                A total of 132 patients were included for analysis and there were no missing data. For the majority of quality of life scores (26/29), there was no significant difference between stoma and nonstoma patients. However, stoma patients complained of diminished body image (P = 0.0022), and this was especially true for married (P = 0.0073) and less educated (P = 0.0014) patients at subgroup analysis. Stoma patients experienced greater financial worries (P = 0.0029), whereas nonstoma patients had greater gastrointestinal concerns (P = 0.0098).
                Although most quality of life scores between stoma and nonstoma patients were similar, significant differences regarding body image, finance, and gastrointestinal symptoms, especially for married and less educated patients, were noticed. These factors should be taken into account, along with oncologic criteria, to better tailor treatments to patients. To evaluate the quality of life (QoL) in patients undergoing anterior resection (AR) or abdominoperineal extirpation (APE) for rectal cancer in a sample of patients recruited from a field trial.
                Abdominoperineal resection has been reported to put patients at higher risk of disruption to QoL than sphincter-preserving surgery.
                Fifty patients treated with AR and 23 patients treated with APE were prospectively followed up. All patients were treated in curative attempt and were disease-free throughout the study. QoL was assessed before surgery and 6 to 9 and 12 to 15 months after surgery.
                Multivariate analysis of variance and subsequent post hoc comparisons revealed a main effect for time (role function, emotional function, body image, future perspective, and micturition-related problems) and group in favor of APE (sleeping problems, constipation, diarrhea), and a time-by-group interaction (role function). No significant results were obtained for the remaining scores, but patients undergoing APE consistently had more favorable QoL scores than those undergoing AR. Multivariate analysis and post hoc comparisons revealed a particularly poor QoL for patients undergoing low AR. They had a significantly lower total QoL, role function, social function, body image, and future perspective, and more gastrointestinal and defecation-related symptoms than patients undergoing high AR.
                Patients undergoing APE do not have a poorer QoL than patients undergoing AR. Patients undergoing low AR have a lower QoL than those undergoing APE. Attention should be paid to QoL concerns expressed by patients undergoing low AR. The present study assesses the choice of surgical procedure, oncologic results and quality of life (QOL) outcomes in a retrospective cohort of 53 patients with low-lying rectal cancers (within 6 cm of the anal verge) treated surgically following preoperative radiotherapy (RT, median dose 45Gy) with or without concomitant 5-fluorouracil. QOL was assessed in 23 patients by using two questionnaires developed by the QOL Study Group of the European Organization for Research and Treatment of Cancer: EORTC QLQ-C30 and EORTC QLQ-CR38. After a median interval of 29 days from completion of RT, abdominoperineal resection (APR) was performed in 29 patients (55%), low anterior resection in 23 patients (20 with coloanal anastomosis) and transrectal excision in one patient. The 3-year actuarial overall survival and locoregional control rates were 71.4% and 77.5% respectively, with no differences observed between patients operated by APR or restorative procedures. For all scales of EORTC QLQ-C30 and EORTC QLQ-CR38, no significant differences in median scores were observed between the two surgical groups. Although patients having had APR tended to report a lower body image score (P = 0.12) and more sexual dysfunction in male patients, all APR patients tended to report better physical function, future perspective and global QOL. In conclusion, sphincter-sparing surgery after preoperative RT seems to be feasible, in routine practice, in a significant proportion of low rectal cancers without compromising the oncologic results. However, prospective studies are mandatory to confirm this finding and to clarify the putative QOL advantages of sphincter-conserving approaches. Conventional outcomes such as survival, tumour recurrence and complication rates after surgery for rectal cancer have been rigorously assessed, but the importance of maintaining quality of life (QOL) after surgery for rectal cancer has received less attention. The aim of the current study was to analyse QOL and the occurrence of pelvic dysfunction after the surgical treatment of rectal cancer.
                Between May 2005 and May 2008, 150 patients with rectal cancer underwent abdominoperineal resection (APR) or anterior resection (AR). Seventy-four answered two preoperative questionnaires. At a follow up of 1 year, 65 were alive without sign of recurrence and answered the same questionnaires: (a) validated RAND 36-item health survey QOL questionnaire; and (b) self-administered disease-related questionnaire with special reference to anorectal and urogenital function.
                The postoperative general QOL was similar after surgery, and mental functioning was better (P < 0.001). Problems with physical functions were associated with anal dysfunction after AR (P < 0.001) and problems with social functioning were associated with urinary dysfunction (P = 0.038). At 1 year after surgery, urinary incontinence was worse (P = 0.026) after all operations, and the incidence of dysuria was higher after APR than AR (P = 0.001). Male sexual function also worsened (P = 0.060). Anorectal dysfunction caused more inconvenience among patients who underwent AR (P = 0.028). Preoperative radiation was associated with postoperative ejaculation problems (P = 0.028) and anal incontinence (P = 0.012).
                Factors affecting QOL and pelvic floor function should be taken into account when making treatment decisions in rectal cancer.
                © 2011 The Authors. Colorectal Disease © 2011 The Association of Coloproctology of Great Britain and Ireland. To determine whether mechanical bowel preparation influences the incidence of anastomotic dehiscence following colorectal surgery, 186 patients undergoing elective left colonic or rectal resection were randomized before surgery to bowel preparation (n = 89) or no bowel preparation (n = 97). Surgical technique was standardized and no patient had a defunctioning colostomy. Seventeen patients were excluded (seven with preparation, ten without). Indications for surgery in the remaining 169 patients were carcinoma (133 patients), diverticular disease (26), inflammatory bowel disease (six) and miscellaneous conditions (four). Operations performed were left colonic resection or reversal of Hartmann's procedure (26 with preparation, 28 without) and anterior resection (56 versus 59). The overall morbidity rate (18 per cent) was similar in the two groups. All seven clinical anastomotic leaks occurred after low anterior resection, in three of the 39 patients who had undergone bowel preparation and four of the 36 who had not (P > 0.9). Two deaths occurred, both of patients who had received bowel preparation, one being secondary to anastomotic leakage. Bowel preparation does not influence outcome after elective colorectal surgery. A prospective comparison of laparoscopically assisted (n = 11) and conventional (n = 14) anterior resection in patients with sigmoid colon or upper rectal cancer was carried out. Patients were not randomized; age and the presence of metastases determined the type of surgery. Laparoscopic assistance was used to mobilize the tumour and minimize the abdominal incision. This was achieved in all patients and six of the 11 required only a muscle-splitting incision. The mean(s.d.) operating time was longer for laparoscopic than conventional surgery (205(31) versus 123(26) min, P = 0.01). The mean(s.d.) time to reintroduction of normal diet (2.5(0.2) versus 3.6(0.3) days, P = 0.01), postoperative analgesia requirement (2.6(0.4) versus 7.4(2.1) doses of pethidine, P = 0.01) and length of hospital stay (12.3(3) versus 14.3(6) days, P = 0.08) were less in the laparoscopic group. Histopathological examination of the resection specimens showed similar results for the two procedures. Major complications were few and occurred in a similar proportion of patients treated laparoscopically or conventionally. Laparoscopically assisted anterior resection is technically feasible, adequate tumour excision can be achieved and recovery after operation is enhanced. Rectal resection with total mesorectal excision is perhaps the most technically challenging of laparoscopic procedures, and the purpose of this study was to show that laparoscopic ultralow anterior resection is feasible for lower rectal cancer. Seven patients with lower rectal cancer were treated in this way with a satisfactory outcome in each case, and on the basis of this limited study, we suggest that extension of laparoscopy to the treatment of very low rectal lesions may be of advantage. The necessity of a protective stoma in patients undergoing low anterior resection with total mesorectal excision for primary rectal cancer is discussed controversially. We conducted a randomized, controlled, pilot-study to evaluate the need for diverting ileostomy in patients undergoing low anterior resection [NCT00457327].
                Forty patients after elective sphincter-saving low anterior resection were eligible for intraoperative randomization. The primary objective of this trial was to demonstrate similar risks after the resection with both techniques. A priori stopping rules were defined for early termination of the trial.
                Between July 4, 2006 and March 12, 2007, a total of 41 patients were screened and 34 patients were randomized. Eighteen patients were randomized to the stoma group and 16 patients to the nonstoma group The symptomatic anastomotic leakage rate was significantly higher in the nonstoma group (37.5 percent) than in the stoma group (5.5 percent, P = 0.02). In all six cases in the nonstoma group, reoperations were necessary. The study was stopped after 34 patients were included. A meta-analysis of the available data confirmed the value of a protective ostomy for patients undergoing low anterior resection.
                The data demonstrate a high risk for patients undergoing low anterior resection without diverting ileostomy. The aims of this study were to evaluate the safety and efficacy of laparoscopic abdominoperineal resection compared to conventional approach for surgical treatment of patients with distal rectal cancer presenting with incomplete response after chemoradiation.
                Twenty eight patients with distal rectal adenocarcinoma were randomized to undergo surgical treatment by laparoscopic abdominoperineal resection or conventional approach and evaluated prospectively. Thirteen underwent laparoscopic abdominoperineal resection and 15 conventional approach.
                There was no significant difference (p<0,05) between the two studied groups regarding: gender, age, body mass index, patients with previous abdominal surgeries, intra and post operative complications, need for blood transfusion, hospital stay after surgery, length of resected segment and pathological staging. Mean operation time was 228 minutes for the laparoscopic abdominoperineal resection versus 284 minutes for the conventional approach (p=0.04). Mean anesthesia duration was shorter (p=0.03) for laparoscopic abdominoperineal resection when compared to conventional approach : 304 and 362 minutes, respectively. There was no need for conversion to open approach in this series. After a mean follow-up of 47.2 months and with the exclusion of two patients in the conventional abdominoperineal resection who presented with unsuspected synchronic metastasis during surgery, local recurrence was observed in two patients in the conventional group and in none in the laparoscopic group.
                We conclude that laparoscopic abdominoperineal resection is feasible, similar to conventional approach concerning surgery duration, intra operative morbidity, blood requirements and post operative morbidity. Larger number of cases and an extended follow-up are required to adequate evaluation of oncological results for patients undergoing laparoscopic abdominoperineal resection after chemoradiation for radical treatment of distal rectal cancer. Although defecatory function after low anterior resection for rectal cancer is reported to be better following colonic J-pouch than straight anastomosis, few prospective randomized trials comparing the two forms of anastomosis have been reported. We performed a prospective randomized trial comparing straight anastomosis with colonic J-pouch anastomosis both clinically and physiologically in patients undergoing stapled low colorectal anastomosis.
                A total of 42 consecutive patients were intraoperatively randomized to undergo either straight anastomosis or colonic J-pouch anastomosis. Clinical defecatory function was evaluated by a questionnaire answered preoperatively, then 6 and 12 months postoperatively. Anorectal physiological assessment was also carried out before surgery, then 12 months postoperatively.
                The clinical defecatory function assessed 6 months and 12 months after surgery did not differ between the two groups. However, while the length of high-pressure zone was significantly shortened, and (neo)rectal capacity was significantly reduced postoperatively in the straight group, none of these physiological parameters were significantly altered in the pouch group.
                Although the aim of colonic J-pouch to preserve reservoir function was physiologically achieved, the improvement in clinical defecatory function was not significant. Thus, further prospective studies are needed to confirm the functional superiority of colonic J-pouch anastomosis for stapled low colorectal anastomosis after low anterior resection. 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.
                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.
                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 (< or = 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 (< or = 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).
                Although rectal function was impaired in patients with low anastomosis, patients who had undergone AR had better QoL than patients who had undergone APR. Anal incontinence is experienced by some patients with rectal cancer who received low anterior resection. This study was to examine the efficacy and adverse effects of the alpha-1 adrenergic agonist phenylephrine, which causes contraction of the internal anal sphincter and raises the resting pressure in these patients.
                Thirty-five patients with anal incontinence were treated with 30% phenylephrine or a placebo randomly allocated in a double-blind study. The efficacy of the drug was assessed by changes in the following standardized questionnaire scores: the fecal incontinence severity index (FISI), fecal incontinence quality of life (FIQL) scales, and a global efficacy question. Anal sphincter function was evaluated using anorectal manometry.
                Phenylephrine did not improve either the FISI score or any of the four FIQL scores. Five of 17 (29%) patients reported subjective improvement after phenylephrine compared with 4 of 12 (33%) using the placebo. The maximum resting anal pressure did not differ between baseline and after 4 weeks application of phenylephrine (30.0 to 27.3 mmHg). In the phenylephrine group, allergic dermatitis was developed in five patients and headache in two.
                In the patients with anal incontinence after low anterior resection for rectal cancer, phenylephrine gel did not seem to be helpful in relieving symptoms with some adverse effects. To assess the efficacy of a novel coloplasty colonic pouch design in optimizing bowel function after ultralow anterior resection.
                A colonic J-pouch may reduce excessive stool frequency and incontinence after anterior resection, but at the risk of evacuation problems. Experimental surgery on pigs has suggested that a coloplasty pouch (CP) may be a useful alternative. Although CP has recently been shown to be feasible in patients, there is no randomized controlled trial comparing bowel function with the J-pouch.
                After anterior resection for cancer, patients were allocated to either J-pouch or CP-anal anastomoses. Continence scoring, anorectal manometry, and endoanal ultrasound assessments were made before surgery. All complications were recorded, and these preoperative assessments were repeated at 4 months. The assessments were repeated again at 1 year, and a quality of life questionnaire was added.
                Eighty-eight patients were recruited from October 1998 to April 2000. Both groups were well matched for age, gender, staging, adjuvant therapy, and mean follow-up. There were no differences in the intraoperative time and hospital stay. CP resulted in more anastomotic leaks. At 4 months, J-pouch patients had 10.3% less stool fragmentation but poorer stool deferment and more nocturnal leakage. However, there were no differences in the bowel function, continence score, and quality of life at 1 year. There were no differences in the anorectal manometry and endoanal ultrasound findings.
                Coloplasty pouches resulted in more anastomotic leaks and minimal differences in bowel function. At present, the J-pouch remains the benchmark for routine clinical practice, and due care (including defunctioning stoma) should be exercised in situations requiring CP. The aim of this study was to compare the safety and efficacy of laparoscopic abdominoperineal resection and open abdominoperineal resection for cancer.
                Records of 194 patients who underwent laparoscopic abdominoperineal resection (42 patients) or open abdominoperineal resection (152 patients) at three institutions between 1991 and 1997 were reviewed. Follow-up was through office charts, American College of Surgeons cancer registry, or telephone contact. Tumors included (laparoscopic abdominoperineal resection and open abdominoperineal resection, respectively) adenocarcinoma (86 and 92 percent), squamous (12 and 7 percent), and gastrointestinal stromal (2 and 1.4 percent) types; Stages I (17 and 26 percent), II (24 and 33 percent), III (43 and 32 percent), and IV (14 and 9 percent); and those with invasion of pelvic structures (14 and 16 percent).
                Laparoscopic abdominoperineal resection was converted to open abdominoperineal resection in 21 percent because of vessel injury (33 percent), poor exposure (22 percent), adhesions (22 percent), inguinal hernia (11 percent), or radiation fibrosis (11 percent). Perineal infections occurred more often in the laparoscopic abdominoperineal resection group (24 vs. 8 percent; P=0.02). Late stoma complications were similar. Mean hospital stay was shorter after laparoscopic abdominoperineal resection (7 vs. 12 days). Radial margins were positive in 12 percent of laparoscopic abdominoperineal resection and 12.5 percent of open abdominoperineal resection specimens. Tumor recurrence was similar for both local (19 and 14 percent) and distant (38 and 26 percent) recurrence. Survival rates were similar by Kaplan-Meier curves, with median follow-up of 19 and 24 months, respectively (P=0.22; log rank).
                Laparoscopic abdominoperineal resection can be performed safely and results in a shorter hospital stay. A randomized, prospective trial is needed to determine the long-term outcome of cancer treatment. In laparoscopic abdominoperineal resection of the rectum (LAP-AP) an abdominal incision is completely avoided as the tumor is delivered through the perineal incision. It is our belief that the view provided in the pelvis by laparoscopy is significantly better than at laparotomy and allows excellent anatomical definition and meticulous dissection. In this study we compared the adequacy of excision of the first 12 patients undergoing LAP-AP to the last 16 patients undergoing open abdominoperineal resection (OP-AP). In all patients the procedure was carried with curative intent for adenocarcinoma and the Dukes staging and Jass score's were similar in both groups. [table: see text] The data demonstrate similar nodal harvest in both groups as well as extent of radial excision. However, two patients in the open group had microscopic radial margin involvement despite being microscopically clear at surgery. We conclude that although long-term follow-up is required to address the issue of local cancer recurrence, laparoscopic rectal dissection appears as good as open surgery and may allow a more precise assessment of excision margins. In a prospective randomised controlled trial, amoxycillin plus clavulanic acid was compared to a combination of cefotaxime and metronidazole as prophylactic antibiotics in 164 patients who underwent elective colorectal resectional surgery. Wound infection occurred in 15 patients (9.1%) and deep surgical infection in 4 (2.4%). Seven cases of wound infection and 2 cases of deep infection occurred in the amoxycillin plus clavulanic acid arm, while 8 cases of wound infection and 2 cases of deep infection occurred in the cefotaxime plus metronidazole arm. Eighty-eight percent of infections occurred in patients who had low anterior resection or abdominoperineal resection of the rectum. Both the amoxycillin plus clavulanic acid and the combination of cefotaxime and metronidazole offer the same degree of protection against post-operative infection. The use of amoxycillin plus clavulanic acid as antibiotic prophylaxis is recommended because of its easier use and cheaper cost. This study was designed to compare the effectiveness of two approaches to urinary catheter management in controlling postoperative urinary dysfunction in 110 patients following abdominoperineal resection or low anterior bowel resection. Patients, stratified by sex and surgical procedure, were randomly assigned to either straight gravity drainage or a 6-day progressive catheter clamping program. The bladder training program following abdominoperineal resection reduced significantly the urinary dysfunction rate in women but not in men. Marked differences in dysfunction rates were related to type of surgery, gender, and surgeon. Etiology of postoperative voiding dysfunction in various groups is discussed. The Laparoscopic approach has been applied to colorectal surgery for many years; however, there are only a few reports on laparoscopic low and ultralow anterior resection with construction of coloanal anastomosis. This study compares open versus laparoscopic low and ultralow anterior resections, assesses the feasibility and efficacy of the laparoscopic approach of total mesorectal excision (TME) with anal sphincter preservation (ASP), and analyzes the short-term results of patients with low rectal cancer.
                We analyzed our experience via a prospective, randomized control trail. From June 2001 to September 2002, 171 patients with low rectal cancer underwent TME with ASP, 82 by the laparoscopic procedure and 89 by the open technique. The lowest margin of tumors was below peritoneal reflection and 1.5-8 cm above the dentate line (1.5-4.9 cm in 104 cases and 5-8 cm in 67 cases). The grouping was randomized.
                Results of operation, postoperative recovery, and short-term oncological follow-up were compared between 82 laparoscopic procedures and 89 controls who underwent open surgery during the same period. In the laparoscopic group, 30 patients in whom low anterior resection was performed had the anastomosis below peritoneal reflection and more than 2 cm above the dentate line, 27 patients in whom ultralow anterior resection was performed had anastomotic height within 2 cm of the dentate line, and 25 patients in whom coloanal anastomosis was performed had the anastomosis at or below the dentate line. In the open group, the numbers were 35, 27, and 27, respectively. There was no statistical difference in operation time, administration of parenteral analgesics, start of food intake, and mortality rate between the two groups. However, blood loss was less, bowel function recovered earlier, and hospitalization time was shorter in the laparoscopic group.
                Totally laparoscopic TME with ASP is feasible, and it is a minimally invasive technique with the benefits of much less blood loss during operation, earlier return of bowel function, and shorter hospitalization. We randomised 129 knees which were to be replaced using a standard posterior-cruciate-ligament (PCL)-retaining cemented total knee replacement into two groups. In one the PCL was retained in the normal way and in the other it was resected. They were well matched, with a predominance of women, and a mean age of 67 years. There was no statistically significant difference in the Hospital for Special Surgery scores at a mean of 57 months (56 to 60) between the two groups although 21 patients (24 knees) were lost to follow-up. Relief from pain, correction of deformity, range of movement, stability and strength were comparable in both. Radiological assessment showed femoral rollback in approximately 20% of knees with a slightly higher incidence in the PCL-resected group. There was no significant loosening detected in either group at review at two years. At five years, one knee in the PCL-retained group had been revised because of infection and one patient in each group was awaiting revision for loosening. Our findings have shown no significant difference in the five-year results for a PCL-retaining total knee replacement if the PCL is excised or preserved. This suggests two important points. First, the PCL is not functional in most patients with a total knee replacement even when retained. Secondly, patients with an excised PCL show a good result with a PCL-retaining implant, thereby questioning the need for a posterior stabilised design in such a situation. The effects of rectal surgery on patients' postoperative quality of life (QOL) and sexual function has been little studied to date. The present study aims to address this issue.
                519 patients who had undergone surgery for rectal cancer from January 1997 to January 2003 were included in the study. The EORTC-QLQ-C-30 questionnaire and an additional, tumor-specific module were administered prospectively multiple times over a 2-year period: before surgery, on discharge from the hospital, and at 3, 6, 12, and 24 months after surgery. Comparisons were made between men and women, different age groups, and different surgical procedures: abdominoperineal resection (APR) versus anterior resection (AR).
                There were significant differences between men and women on scales of function and symptoms. Women had worse scores for physical function and overall quality of life and higher values for fatigue. Sexual life was impaired in both men and women, but the impairment was significantly more severe in men, and men felt more distressed by it than women did. Physical function and overall quality of life were better in patients aged 69 and younger, while patients aged 70 and older suffered from fatigue. Younger patients had a more severe impairment of sexuality, which, over the time period of the study, led to severe emotional symptoms. Sexuality was more severely impaired in patients who had undergone APR than in those who had undergone AR.
                These findings show that the quality of life is changed by surgery for rectal cancer and is influenced by the patient's sex and age, as well as by the particular surgical approach used. Laparoscopic low anterior resection for rectal cancer has never gained wide acceptance among general surgeons, mainly due to the technical difficulties encountered during pelvic dissection. It has therefore been stated that these patients should undergo open rather than laparoscopic surgery. Hand-assisted laparoscopic surgery (HALS) is a new technique that has the potential to overcome many of the existing limitations of pure laparoscopy. In the treatment of rectal cancer, HALS could reproduce an operative setting similar to that of the open approach.
                To assess the technical feasibility of hand-assisted laparoscopic low anterior resection for rectal cancer and evaluate potential benefits and drawbacks of this new procedure, a pilot study was conducted at a university hospital on 16 consecutive patients during a 12-month period. Only patients with extraperitoneal rectal cancer were included in this series. Patients' clinical data, operative time, conversion rate, complications, and early outcome measures were prospectively examined.
                There were 9 men and 7 women. The average +/- SD operation time was 238 +/- 38 min. Conversion to open surgery was never required. Ten of 16 patients were off pain medication on the third postoperative day. Eight were able to walk the day after surgery. Three minor postoperative complications were recorded. Mean postoperative stay for patients without complications was 5.6 +/- 1.4 days.
                From a technical standpoint, the reported hand-assisted procedure makes pelvic dissection during laparoscopic low anterior resection almost equivalent to the laparotomic operation. The incision for hand access that is needed with this technique does not seem to compromise the quick recovery of patients undergoing purely laparoscopic procedures.
The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision/Hartmann's operation. The included studies challenges the assumption that anterior resection patients fare better.Larger, better designed and executed prospective studies are needed to answer this question.