Anterior resection: do the patients perceive any clinical benefit?
OBJECTIVE
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.


METHODS
Sample size was previously established according the prevalence of continence disorders fund 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.
Ortiz
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Colorectal Unit, Virgen del Camino Hospital, Universidad Publica De Navarra, Pamplona, Spain.
Armendariz
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P
D000328:Adult; D000368:Aged; D000714:Anastomosis, Surgical / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000503:physiopathology*; D012007:Rectum / Q000503:physiopathology / Q000601:surgery*; D012016:Reference Values; D012494:Sampling Studies; D016896:Treatment Outcome