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10.1245/s10434-007-9402-z
Annals of Surgical Oncology 14:2056-2068 (2007)
© 2007 Society of Surgical Oncology
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Original Article

A Meta-Analysis of Quality of Life for Abdominoperineal Excision of Rectum versus Anterior Resection for Rectal Cancer

Julie A. Cornish, MBBCh, MRCS1, Henry S. Tilney, MBBS, MRCS1, Alexander G. Heriot, MD, FRCS2, Ian C. Lavery, MD3, Victor W. Fazio, MD3 and Paris P. Tekkis, MD, FRCS1,3

1 Department of Biosurgery and Surgical Technology, St Mary’s Hospital, Imperial College, 10th Floor QEQM Wing, Praed Street, London, W2 1NY, UK
2 Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
3 Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA

Correspondence: Address correspondence and reprint requests to: Paris P. Tekkis, MD, FRCS; E-mail: p.tekkis{at}imperial.ac.uk


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
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.

Key Words: Quality of life • Anterior resection • Abdominoperineal resection • Meta-analysis • Rectal cancer


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
For cancers in the lower third of the rectum that are amenable to radical resection, the choice for surgery often lies between anterior resection (AR) and abdominoperineal excision (APER). Many factors impact on the decision of which procedure to undertake which can be broadly classed as patient specific (i.e. gender, preoperative sphincter function), tumour specific (i.e. stage, potential distal resection margin) and surgeon preference. It is generally assumed that a restorative procedure (AR) with the potential to avoid a permanent stoma is preferable in terms of long-term quality of life (QoL) for patients.1 However, two recent reviews, including one by the Cochrane Collaboration,2,3 did not identify significant overall differences in QoL between the AR and APR groups, although heterogeneity between published studies at that time precluded formal meta-analysis.

While the indications for APER have narrowed in recent years following recognition that a shorter distal resection margin for rectal excision than was previously deemed necessary is adequate,4 there is still a proportion of patients in whom non-restorative resection will be required in order to achieve an adequate oncological clearance. Low rectal tumours situated between 2 cm and 5 cm from the dentate line are particularly challenging in terms of the decision-making process. The oncological superiority of APER has been called into question with higher rates of circumferential margin involvement and, hence, the potential for increased local recurrence demonstrated following APER when compared with the situation after AR.5 AR, however, is not without its complications, such as anastomotic dehiscence and the potential for poor functional outcomes,6 while negative preoperative perceptions of APER have been shown to be replaced by more favourable attitudes in the years following surgery7. The assumption that a permanent stoma is invariably associated with a poorer QoL is therefore open to challenge.

The present meta-analysis reviewed the available QoL evidence from comparative studies of AR versus APER in an attempt to identify differences between the procedures, either overall or in individual domains.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Selection
A literature search of the Medline, Embase, Pubmed and Cochrane Databases was conducted to identify studies published between 1966 and 2006 reporting comparisons of QoL between AR and APER. The following MeSH search headings were used: "quality of life" and "rectal cancer". The following terms were searched as text: "anterior resection", "abdominoperineal resection", "quality of life", "validated questionnaires", "low rectal cancer", "low anterior resection" (LAR) and "high anterior resection" (HAR). Articles were also identified by manual searching of the references of included studies and using the related articles function in PubMed (Fig. 1Go). No language restrictions were made. All of the abstracts, studies and citations scanned were reviewed. The latest date for this search was 14 October 2006.


Figure 1
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  		FIG. 1. Study selection process for meta-analysis.

 
Data Extraction
Data extraction was conducted independently by the two reviewers (J.C. and H.T.). The following information was extracted from each study: first author, year of publication, study population characteristics, study design (prospective, retrospective or other), inclusion and exclusion criteria, number of subjects in each group (APER, AR, LAR and HAR), quality of study, QoL tool used, definition of LAR and HAR, and tumour staging grade.

Inclusion Criteria
The following criteria were used to select studies for analysis: (a) studies comparing APER with AR; and (b) studies that used validated tools for QoL measurements.

Exclusion Criteria
The following criteria were used in order to exclude studies from the analysis: (a) studies in which the outcomes of comparison were not reported or when it was not possible to extract the data from the published results; (b) studies that did not use validated tools for measuring QoL outcomes; and (c) if more than one paper reported outcomes on the same patient group (then either the more recent or the one of higher quality was included).

Measures of Outcomes of Interest
The tools identified as providing validated measures of QoL following rectal cancer excision were SF-36 and QLQ C30/CR38. The SF-36 and QLQ systems measure QoL within a range of domains, as well as providing an overall indication of QoL.

Short Form 36 Questionnaire
The SF-36 is a generic measure of health status developed in the USA and can be used to measure health outcomes of clinical interventions.8 It has been validated and tested for use in 13 countries.9 The scoring method for SF-36 uses an algorithm to transform dichotomous and continuous variables into a scale from zero to 100, with higher scores indicating best possible health.

QLQ C30 and QLQ CR38 Questionnaire
These systems were developed by the European Organisation for Research and Treatment of Cancer (EORTC) study group, to evaluate QoL of patients participating in clinical trials. The QLQ C30 contains core questions and the CR38 is specific for colorectal cancer. They have both been validated for use in clinical trials10 and score from zero to 100, with higher scores representing a better QoL for functional domains and lower scores indicating reduced problems in symptom domains.11

Statistical Analysis
The meta-analysis was performed in line with recommendations from the Cochrane Collaboration and the Quality of Reporting of Meta-analyses (QUORUM) guidelines.12,13 Statistical analyses of continuous variables, such as domain outcome for the QoL scores, were analysed using the weighted mean difference (WMD)14 and were reported with 95% confidence intervals (CI). The WMD summarises the differences between the two groups with respect to continuous variables, accounting for sample size. For studies that presented continuous data as means and range values, the standard deviations (SD) were calculated using statistical algorithms and checked using "bootstrap" re-sampling techniques. Thus, all continuous data were standardised for analysis. In the tabulation of results, squares indicate the point estimates of the effect of disease (WMD), with 95% confidence intervals indicated by horizontal bars. The diamond represents the summary estimate from pooled studies with 95% confidence intervals.

The quality of the non-randomised studies was assessed using Newcastle-Ottawa Scale (NOS).15 The quality of the studies was evaluated by examining patient selection methods, comparability of the study groups and assessment of outcome. Studies achieving eight or more stars were considered to be of higher quality. Heterogeneity was assessed using two methods. Firstly, graphical exploration with funnel plots was used to evaluate publication bias. Secondly, sensitivity analysis was undertaken. The results were presented for all rectal cancers and separately for those cancers within 8 cm of the anal verge. For each of these groups of data, there was further analysis of studies reporting on more than 100 patients, those of higher quality and those in which questionnaires were self administered. Analysis was conducted by Review Manager Version 4.2 (The Cochrane Collaboration, Software Update, Oxford, UK).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Eligible Studies
The literature search identified 24 studies that compared QOL between APER and AR. Of these, 12 were excluded because the outcomes of interest were not extractable or clearly reported,16–20 a non-validated questionnaire had been used21–25 or they had reported on duplicate patient samples from a centre26 (Fig. 1Go). One study reported on a validated questionnaire, the Nottingham health profile; however, it was the only study to use this tool and as such could not be meta-analysed.27 The 11 studies remaining, published between 2001 and 2006, matched the selection criteria and were therefore included in this meta-analysis.28–39

Analysis was performed on a total of 1,443 patients, which included 486 (33.7%) APER patients and 957 (66.3%) AR patients. The study characteristics are shown in Table 1Go. Of the 11 studies, 3 were prospective,31,36,39 and the remaining 8 were retrospective. In 3 studies, patients were matched for at least one variable,28,34,38 while the remainder reported no matching. The Short form 36 (SF-36), a tool for measuring QoL,28,33,34 was used in 3 studies. One study38 used the RAND 36 tool, which has been shown to be equivalent to the SF-36. In 8 studies,28,30–32,35–37,39 the European Organisation for research and treatment Cancer (EORTC) QLQ C30 tool was used, and 7 used the EORTC QLQ CR38 tool.28,30–32,35,37,39 One study by Camilleri-Brennan et al.28 used all three of the tools. Of the 4 SF-36 studies, the questionnaires were stated to have been self administered in 3; the exception being that of Jess et al.,33 who did not report the mode of administration. Of the 7 EORTC studies, the patients were seen to be allowed to self administer the questionnaire in 4, while clinician-led interviews were conducted in one37 and in two others no mention of the mode of administration was made.31,39


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  		TABLE 1. Characteristics of included studies comparing QoL following abdominoperineal excision of rectum (APER) versus anterior resection (AR). r = retrospective study, P = prospective cohort study
 
Analysis of the mean age of the patient groups for AR and APER revealed no significant difference between the procedures (WMD 0.13; 95% CI –3.03, 3.28; P = 0.94). Male patients accounted for 49% of those undergoing AR and 60% of those undergoing APER. Four of the studies assessed patients more than 1 year after surgery28,32,34,38, one study at 12 months36 and one study at 12–15 months31. The mean time of follow-up was 43.9 months for APER and 46.1 months for AR.

Meta-Analysis of Abdominoperineal Excision of Rectum Versus Anterior Resection
General Health Score
Seven studies gave a general (or global) health score for QLQ C30 and four for SF-36. There was no difference in general QoL scores between APER and AR using either tool. The general QoL score expresses the patient’s personal health evaluation10,40 and is not a cumulative total of other domain scores.

Individual Domains
Patients undergoing APER scored better in emotional (WMD 3.84; 95% CI 1.88, 5.80; P < 0.001) and cognitive function (WMD 3.58; 95% CI 1.51, 5.65; P < 0.001) using the QLQ C30 tool.

Using the SF-36 tool, better physical function scores were achieved for AR patients (WMD –11.63; 95% CI –14.6, –8.65, P < 0.001); however, the QLQC30 did not show a significant difference (WMD – 1.95; 95% CI –6.96, 3.06; P = 0.46).

A significant improvement was demonstrated in role function in AR patients using the SF-36 tool (WMD –13.9; 95% CI –23.6, –4.01; P < 0.006); this was not seen in the QLQ30 group (WMD –1.88; 95% CI –5.53, 1.77; P = 0.31).

The SF-36 assessment revealed a significantly lower bodily pain score for AR (WMD –9.83; 95% CI –16.7, –2.97; P = 0.005); however, the pain scores in the QLQ C30 group did not show a difference between APER and AR patients (WMD 1.35; 95% CI –1.22, 3.91; P = 0.30).

To confirm that no bias had been introduced by merging RAND 36 with SF-36 data, the studies were reanalysed without including the RAND 36 data,38 and no alteration in the results was shown. The domains of physical function, role function and bodily pain remained significantly better for AR patients.

AR patients had a significantly better score in the vitality domain than the APER group (WMD –10.38; 95% CI –17.2, –3.63; P = 0.003). There was no equivalent in the QLQ C30 domains. There was a fatigue score reported in the QLQ C30 group, but this was not shown to be significantly different between APER and AR patients (WMD –6.95; 95% CI – 20.31, 6.40; P = 0.31).

The QLQ CR38 tool focused on different aspects of QoL than the other QOL tools and has shown a significant difference in three domains: sexual function, male sexual problems and future perspective (Fig. 2Go). Analysis of five studies showed that measures of sexual function (WMD –2.73; 95% CI –4.93, –0.64, P = 0.01) and male sexual problems (WMD 12.45; 95% CI 1.78, 23.812; P = 0.02) were improved following AR than after APER. APER demonstrated higher scores for future perspective than AR patients (WMD 4.24; 95% CI 1.53, 6.96; P = 0.002) using the QLQ CR38 tool.


Figure 2
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  		FIG. 2. Forrest plot of CR38 outcomes of sexual function and future perspective for abdominoperineal excision of rectum (APER) versus anterior resection (AR).

 
Meta-analysis of Low Anterior Resection versus APER
General Health Score
Five studies using QLQ C30 and three using SF –36 reported on QoL measurements for low APER versus AR for rectal cancer. As with overall analysis there was no significant difference in general health scores between APER and AR for patients with tumours in the lower half of the rectum.

Individual Domains
For low AR, there was significantly better physical function than for APER, in both the QLQ C30 (WMD –4.67; 95%CI –9.10, –0.23; P = 0.04) and the SF-36 (WMD –11.60; 95% CI –15.3, –7.86; P < 0.001) groups.

Analysis of three studies revealed higher scores for AR for role function (WMD –12.93; 95% CI –21.3, 4.47; P = 0.003) and vitality (WMD –8.67; 95% CI –13.9, –3.48; P = 0.001), assessed using SF-36, than for APER. Degree of bodily pain was not shown to be significantly different between LAR and APER using SF36, but it was less in patients undergoing AR.

Similarly to the overall analysis, cognitive and emotional domain scores were better following APER than low AR when assessed using QLQ C30 (WMD 3.57; 95% CI 1.41, 5.73; P = 0.001 and WMD 3.51; 95% CI 1.40, 5.62; P = 0.001 respectively). Future perspectives remained significantly better for APER patients than LAR (WMD 4.40; 95% CI 0.37, 8.44: P = 0.03) using the CR38 tool. Assessment of the mental health and emotional role domains of the SF-36 tool showed there to be no significant difference in scores between APER and low AR patients.

Sexual function assessed by QLQ CR38 was better following low AR than APER (WMD –2.36; 95% CI –4.74, –0.03; P = 0.05). There was no significant difference in social function following low AR versus APER when assessed by either SF-36 or QLQ C30. Individual domain scores for pain, fatigue, insomnia, diarrhoea, constipation or dyspnoea in QLQ C30 were similar between APER and low AR.

Sensitivity Analysis
General Health Score
In studies with over 100 patients, the general health score was not significantly different following APER or AR when assessed using QLQ C30, but a lack of sufficient studies reporting outcomes on larger numbers of patients precluded similar analysis of SF-36 data.

Individual Domains
Cognitive and emotional function remained better for APER than for AR patients using the QLQ C30 questionnaire. Role function, however, was better following AR. The domains of sexual function and male sexual problems revealed better outcomes for patients undergoing AR when scored using the QLQ CR38 tool. Future perspective scores, however, were superior for APER patients.

High Quality Studies (≥8 stars)
General Health Score
The general health score in high quality studies, within QLQ C30, were similar between APER and AR patients.

Individual Domains
High quality studies using QLQ C30 showed physical function to be significantly better for AR patients, an effect not shown on overall analysis or in other subgroups. Cognitive and emotional function remained consistently better for APER patients, as did the role function of AR patients. The domain score for insomnia was significantly higher for APER patients, suggesting a poorer QoL for this symptom that was not identified in other subgroups.

QLQ CR38 reported significantly better scores in tests of sexual function and male sexual problems following AR than APER, but future perspective remained higher for APER patients.

Self-administered Questionnaire Studies
General Health Score
General health scores using SF-36 and QLQ C30 questionnaires were not significantly different between AR and APER patients for the studies that allowed patients to self administer the questionnaire.

Individual Domains
QLQ C30 identified significant differences between APER and AR patients in three domains: role, cognitive and emotional function. Cognitive and emotional function were shown to be significantly better following APER than after AR. Role function scores were higher for AR patients (P = 0.003). Male sexual problems and sexual function (QLQ CR38) remained significantly better for AR. For self-administered SF-36 questionnaires, four individual domains revealed significantly higher scores for AR patients: physical function, role function, bodily pain and vitality.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The results of the present meta-analysis suggest that, contrary to commonly held preconceptions, there are no differences in general health perception following rectal cancer excision by APER or AR, both overall and for studies considering only tumours within 8 cm of the anal verge, when assessed by means of validated questionnaires. These findings are consistent among sensitivity analyses of larger studies, those of higher quality and those in which the questionnaires were self administered. Individual domains from the QoL tools assessed highlighted how, in general, patients undergoing APER had improved psychological and emotional scores, with superior ‘future perspective’ than those undergoing AR, while those outcomes focusing on physical symptoms and pain tended to be more positive following AR. While individual studies have suggested that body image was impaired in patients receiving permanent stomas,41 in this study no significant difference in this dimension of the QLQ-CR38 was revealed, either overall or on sensitivity analysis.

The present meta-analysis facilitated the aggregation of data from a variety of sources, all using standardised QoL assessment tools, the results of which provided greater statistical power to detect significant differences, with subsequent sensitivity analysis demonstrating the robustness of the pooled analysis. The heterogeneity of the studies was analysed and the results can be seen in Tables 2Go–5GoGoGo and in the funnel plot in Fig. 3Go. There was significant heterogeneity in some of the outcomes in the overall analysis (Tables 2Go and 3Go); however, with sensitivity analysis, this heterogeneity was only present for male sexual problems and male sexual enjoyment in the high quality studies and studies involving more than 100 patients. Subgroup analysis of the studies that had involved self-administered questionnaires did not show any significant heterogeneity. It was not possible to specifically analyse patients in terms of their contingence or age as this could not be extracted. The results supported the tentative conclusions of a previous Cochrane review2 in which meta-analysis was not undertaken due to inadequate number of comparative studies using similar assessment questionnaires. Reported results using two major systems (the ‘Short-Form 36’ and ‘European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires’ C30 and CR38) were included, allowing for an overall assessment that accounted for factors such as body image and physical functioning. It is tempting to account for the similar results for general QoL shown by both tools when comparing APER and AR, as a balancing of negative psychological attitudes towards a stoma by the potentially poor functional outcomes associated with an ultra-low colorectal anastomosis. The real reasons, however, appear to be more complex.38 Emotional and cognitive scores from the QLQ C30 were consistently shown to be better for APER patients, while physical function was shown to be better for AR patients using both tools. The improved emotional scores for APER patients may represent the finality of the treatment, as a patient no longer needs to be concerned about invasive examinations of the lower end or worry about future complications once healed adequately.


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  		TABLE 2. Quality of life outcomes measured using EORTC QLQ C30, CR38 and SF-36 tools for abdominoperineal excision of rectum (APER) versus anterior resection (AR). Statistically significant results are shown in bold. WMD = weighted mean difference, HG = heterogeneity, CI = confidence interval. WMD values that are positive favour APER unless indicated by an asterisk for the symptom domains in CR38 and C30 tools
 

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  		TABLE 3. Quality of life outcomes measured using EORTC QLQ C30, CR38 and SF-36 for anterior resection versus abdominoperineal excision of rectum for cancers less than 8 cm from anal verge. Statistically significant results are shown in bold. WMD = weighted mean difference, HG = heterogeneity, CI = confidence interval. WMD values that are positive favour APER unless indicated by an asterisk for the symptom domains in CR38 and C30 tools
 

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  		TABLE 4. Sensitivity analysis for quality of life outcomes using subgroups of studies with more than 100 patients, high quality studies and studies with self-administered questionnaires. Quality of life measured using SF-36, EORTC QLQ C30 and CR38 for abdominoperineal excision of rectum versus anterior resection. Statistically significant results are shown in bold. WMD = weighted mean difference, HG = heterogeneity, CI = confidence interval. WMDs that are positive favour APER unless indicated by an asterisk for the symptom domains in CR38 and C30 tools
 

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  		TABLE 5. Sensitivity analysis for quality of life outcomes using subgroups of studies with more than 100 patients, high quality studies and studies with self-administered questionnaires. Quality of life measured using SF-36, EORTC QLQ C30 and CR38 for abdominoperineal excision of rectum versus anterior resection for cancers less than 8 cm from anal verge. Statistically significant results are shown in bold. WMD = weighted mean difference, HG = heterogeneity, CI = confidence interval. WMDs that are positive favour APER unless indicated by an asterisk for the symptom domains in CR38 and C30 tools
 

Figure 3
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  		FIG. 3. Funnel plot of abdominoperineal excision of rectum (APER) versus anterior resection (AR; all studies) using the C30 emotional variable scores. This is a scatter plot of the incidence estimated from individual studies plotted on the horizontal axis (OR), against the standard error of the estimate shown on the vertical axis (SE [logOR])

 
Overall, and in larger and higher quality studies, the ‘future perspective’ of APER patients was demonstrated to be significantly better than those following AR. The term future perspective refers to the patients’ understanding of the "stage of the disease".11 This may represent a perceived finality about the APER, with patients having undergone a definitive, irreversible procedure, the functional results of which might be considered more predictable. For AR patients, the functional outcomes are substantially more variable, being affected by factors such as pre-operative sphincter function and anastomotic complications.42 The presence of early/late complications would have an impact on the functional and emotional outcomes; however, the data was not available to extract. Of the 11 studies, 7 excluded patients experiencing recurrence at the time of assessment31,33–38 and 7 included patients who had undergone curative surgery only.31–33,35–38 No further data extraction with regard to recurrence is possible from the papers.

Where stated, most QoL assessments in the included studies were undertaken up to 1 year following surgery. It is possible, therefore, that further improvement in bowel function over time may lead to more favourable QoL assessment for AR patients with more extended follow-up. While some authors have reported that functional recovery following AR is largely complete by 6 months,43 others have suggested that at 1 year following low AR, stool frequency is still significantly higher than that preoperatively (3.3 versus 2.0 per 24 h) and that the so-called ‘anterior resection syndrome’ lasts at least 1 year.44 Few studies of longer-term follow-up after low AR are available. In one study45 comparing long-term outcomes following straight and colonic pouch reconstructions at a mean follow-up of 5 years, it was outlined how continued improvement in the long-term was possible due to recovery of sphincter function, increase in neorectal volume and return of the anorectal reflexes. Comparisons of QoL between AR and APER following prolonged follow-up are therefore needed to assess whether functional adaptation leads to a long-term improvement.

The method of administration of the questionnaires is important due to the potential for embarrassment answering the often personal questions, including those concerning sexual function, in the presence of an investigator. Previous studies have suggested a significantly lower score in seven out of eight variables using self-administered SF-36, with the largest differences in role (emotional) (14.74; 95% CI 7.76, 21.7) and social function (7.21; 95% CI 3.19. 11.23).46 It is interesting to note, therefore, that in the context of the present study, there were very few differences in absolute terms between the results obtained from overall analysis and those from purely self-administered studies.

Although differences in the methods of formulation of the two systems of QoL assessment make comparisons between individual domains difficult, it can be seen that there were inconsistencies highlighted between them for similar outcomes. While in QLQ C30, APER patients scored significantly higher on the ‘emotional’ scale, there was no difference in the ‘role (emotional)’ section of the SF 36 tool. Similarly, while on overall analysis there were highly significant lower overall scores for physical and role function for APER patients when assessed with SF-36, when the QLQ C30 instrument was used, although there was a similar negative impact for APER patients, this failed to achieve statistical significance.

The decision of which operation to perform would depend on a number of variables, including the likely oncological outcome, the life expectancy of the individual patient and their attitude towards a permanent stoma. There is evidence to suggest that oncological outcomes such as circumferential resection margins and rates of local recurrence are less favourable following APER than AR.5,47 Such results may reflect technical factors that render APER a more complex procedure or differences in anatomy and tumour biology that may negatively impact on lower rectal tumours, which are more likely to be treated with sphincter-sacrificing surgery. In some cases, however, the height of the lesion will necessitate APER, as even ultra-low AR with intersphincteric dissection will be inadequate to permit a safe oncological excision.48,49 A lack of randomised studies of AR versus APER for tumours of matched distance from the anal verge means that inferences often need to be drawn obliquely from studies of individual procedures. This issue has been partially addressed in the present study by reanalysing data from those studies in which only tumours in the lower half of the rectum (< 8 cm from the anal verge) were included. These pooled results also mask the individual functional outcomes for some patients, such as those with poor sphincter function in whom the formation of a coloanal anastomosis, even with the use of a transverse coloplasty or colonic j-pouch, will be unacceptable.50,51 It is clear that individualisation of therapy is required.

The overall findings of the present study, highlighting no overall difference in QoL between those patients with and without permanent stomas, challenge the conclusions that may be drawn from other reports which have highlighted rates of stoma-related complications of up to 34%,52 with deterioration in overall lifestyle and sexual activity in 80% and 43%, respectively.53 Meta-analysis of individual domains from the QoL instruments suggested improved cognitive, emotional and future perspective scores for those undergoing APER.

In conclusion, the results of the present meta-analysis show that the argument for restorative resections for rectal cancer cannot hinge solely on the issue of a perception of superior QoL outcomes for patients. It is clear that the preconception of many surgeons and patients is that QoL will be better if a permanent stoma is avoided. Our analysis has shown this not to be the case. To the contrary, overall, patients undergoing APER experience postoperatively a global QoL—incorporating the physical and psychological effects of treatment with or without a permanent stoma—that appears to be equivalent to that after AR. Overall measures of QoL, measured using a variety of validated tools, are not significantly different between APER and AR patients, but further comparative studies with longer periods of follow-up are needed. Individual domains do highlight significant differences between the two surgical approaches which may help to inform the decision making process for preoperative patients, but individualisation of care incorporating QoL outcomes and functional, oncological and technical considerations is essential for rectal cancer patients.

Received for publication December 15, 2006. Accepted for publication February 12, 2007.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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