Anterior resection: do the patients perceive any clinical benefit?

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Abstract
Purpose: Functional results following anterior resection of the rectum have been sparsely reported. Results concerning stool frequency and continence vary widely. These variations may represent several areas of bias, but one of the main concerns is study design. Many studies are focused on physiological results and even when a control population is included in the study design, it is not used to compare the clinical functional outcome. The aims of this prospective study were: (1) to study serially before and 1 year after low anterior resection for carcinoma the changes in clinical function; and (2) to study if these changes could be attributable to the characteristics of the population, comparing the results with sex-matched and age-matched controls. Material and Methods: Sample size was previously established according the prevalence of continence disorders found in two previous studies carried out in our country, 36% for anterior resection, and 6% among general population in our community. Thirty-eight consecutive patients (mean age 63.9 years, range 41 – 77 years) with a diagnosis of rectal carcinoma were invited to participate in the study. The lower margin of the tumor was located between 4 and 15 cm from the anal margin (median of level tumor 6.0 cm). A control group of 25 volunteers matched for sex and age with patients who were questioned 1 year after the anterior resection were also studied. Median level of anastomosis was 6.2±2.7 cm (range 2 – 11) above the anal margin. In six patients with an anastomosis less than 4 cm from the anal margin, a loop ileostomy was constructed and closed 3 months later. Patients were interviewed by a research assistant before and 1 year after operation or 1 year after closure of the temporary defunctioning loop ileostomy. Patients were questioned about bowel frequency over 24 h, urgency, tenesmus, erratic defecatory patterns, discrimination of bowel content and continence. Results: Clinical function of patients before and after operation. Compared with pre-operative, bowel frequency of 3.9/day (range 0.3 – 14) did not differ significantly 1 year after operation at 2.3/day (range 0.5 – 6). Frequency of erratic defecatory patterns (44%), urgency (40%) and obstructed defecation (20%) did not differ between the preoperative and postoperative period. Forty-eight percent of patients suffered tenesmus and 20% were unable to discriminate between flatus and feces before operation, whereas these troublesome symptoms were present in 24% and 16%, respectively, after the operation. Before the operation 32% of patients reported fecal leaks while in the postoperative period 52% patients complained of this alteration. Clinical function of patients compared with controls. Patients had a mean stool frequency per day of 2.3 (range 0.5 – 6) and controls 1.3 (range 0.3 – 5). Forty-four percent of patients had erratic defecatory patterns, 24% suffered tenesmus and 40% urgency, whereas these troublesome symptoms were present in 12% in the control population. Moreover, obstructed defecation was present in 20% and 4%, respectively. All controls and 84% of patients maintained discrimination of flatus, liquid and solid feces. Fifty-two percent of patients and 8% of controls suffered from altered continence. Conclusions: One year after low anterior resection patients had poor bowel function when compared with a control population of the same age and sex. A distinct anterior resection syndrome exists consisting of increased bowel frequency, erratic defecatory patterns, urgency, tenesmus, obstructed defecation, and minor fecal leakage. Furthermore, these disturbances in defecatory function did not differ significantly from symptoms produced by the rectal carcinoma, and patients experienced no major benefit from surgery from a functional point of view. But: Les publications ayant trait aux résultats fonctionnels après résection antérieure du rectum sont rares; les résultats ayant trait à la fréquence des selles et à la continence présentent une grande disparité. Ces variations peuvent résulter de plusieurs biais dont l'un concerne en particulier la méthodologie de l'étude. De nombreuses études se concentrent sur les résultats physiologiques et même lorsqu'elles incluent un groupe-contrôle, ce dernier n'est pas utilisé dans le but de comparer les résultats fonctionnels. Le but de cette étude prospective était d'étudier, de manière séquentielle avant et une année après une résection antérieure basse pour cancer les changements fonctionnels cliniques, et, deuxiémement, d'étudier si ces changements pouvaient être attribués aux caractéristiques de la population en comparant les résultats avec des groupes-contrôles comparables quant au sexe et à l'âge. Matériel et méthodes: La taille du groupe avait étéétablie à l'avance en fonction de la prévalence des troubles de la continence relevés dans deux études préalables réalisées dans notre pays qui démontraient 36% de troubles après résection antérieure et 6% dans la population générale. Trente-huit patients consécutifs (âgés de 41 à 77 ans avec un âge moyen de 63,9 ans) chez lesquels le diagnostic de cancer du rectum avait été posé ont été invités à...

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