ANTERIOR RESECTION - DO THE PATIENTS PERCEIVE ANY CLINICAL BENEFIT

Purpose: Functional results following anterior resection of the rectum have been sparsely reported. Results concerning stool frequency and c ontinence 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 st udy serially before and 1 year after low anterior resection for carcin oma the changes in clinical function; and (2) to study if these change s could be attributable to the characteristics of the population, comp aring the results with sex-matched and age-matched controls. Material and Methods: Sample size was previously established according the prev alence of continence disorders found in two previous studies carried o ut in our country, 36% for anterior resection, and 6% among general po pulation in our community. Thirty-eight consecutive patients (mean age 63.9 years, range 41-77 years) with a diagnosis of rectal carcinoma w ere 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 a ge with patients who were questioned 1 year after the anterior resecti on 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 as sistant before and 1 year after operation or 1 year after closure of t he temporary defunctioning loop ileostomy. Patients were questioned ab out bowel frequency over 24 h, urgency, tenesmus, erratic defecatory p atterns, discrimination of bowel content and continence. Results: Clin ical function of patients before and after operation. Compared with pr e-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). Frequen cy of erratic defecatory patterns (44%), urgency (40%) and obstructed defecation (20%) did not differ between the preoperative and postopera tive 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%, resp ectively, after the operation. Before the operation 32% of patients re ported fecal leaks while in the postoperative period 52% patients comp lained 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 h ad 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 discrimina tion 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 whe n compared with a control population of the same age and sex. A distin ct anterior resection syndrome exists consisting of increased bowel fr equency, erratic defecatory patterns, urgency, tenesmus, obstructed de fecation, and minor fecal leakage. Furthermore, these disturbances in defecatory function did not differ significantly from symptoms produce d by the rectal carcinoma, and patients experienced no major benefit f rom surgery from a functional point of view.