Factors determining the quality of life in patients undergoing radical surgery due to malignant tumors of the rectum

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Factors determining the quality of life in patients

undergoing radical surgery due to malignant tumors

of the rectum

Czynniki determinujące jakość życia u pacjentów poddanych

radykalnym zabiegom operacyjnym z powodu nowotworów

złośliwych odbytnicy

Tomasz Błaszkowski

^1ABDEF

, Józef Kładny

^1ADE

, Tariq Al-Amawi

^1BD

, Krystian Kaczmarek

^2C

,

Marcin Kwietniak

^1BD

, Piotr Wojtasik

^1BD

, Mirosław Halczak

^1BD

, Tomasz Michalak

^1BD

,

Maciej Zalewski

^1BD

, Karol Jezierski

^1ABD

, Mariusz Chmielak

^1AD

1Department of General and Oncological Surgery, Pomeranian Medical University in Szczecin, Poland; Head: prof. Józef Kładny MD PhD

2Department of Urology and Urological Oncology, Pomeranian Medical University in Szczecin, Poland;

Head: prof. Marcin Słojewski MD PhD

Article history: Received: 25.05.2020 Accepted: 19.03.2021 Published: 31.03.2021

ABSTRACT: Introduction: Rectal cancer is one of the most common malignancies in developed countries. However, despite the increasingly better preoperative diagnostics, adaptation of surgical techniques to the location and advancement of the tumor, the combination of surgical treatment with neoadjuvant therapy and adjuvant treatment, standardized control tests, Poland still has not obtained satisfactory results regarding long-term survival. In addition, the effects of therapy often differ significantly from those expected by patients and the doctors treating them.

Aim: To evaluate the effects of rectal cancer treatment among patients of the General and Oncological Surgery Clinic of the Pomeranian Medical University in Szczecin. The impact of numerous factors on postoperative quality of life was analyzed.

Material and methods: Between 2007–2015, 263 radical resection procedures were performed in patients with diagnosed rectal cancer. Retrospectively, based on medical records, a database was created covering a range of clinical data. Information about death dates of some patients was obtained at the Registry Office in Szczecin. A survey supplementing clinical data and standardized quality of life assessment forms (EORTC QLQ – C30 and CR29) were sent to 120 living patients. A telephone conversation was carried out with some patients who did not respond to the surveys. Finally, data from 90 people was collected, which represents 75% of the patients enrolled in the study. Patients’ quality of life was assessed using EORTC questionnaire evaluation guidelines.

Results: The patients’ quality of life worsened the most as a result of anorectal dysfunction. Incontinence of gases and stool, urgency and difficulty in defecation were demonstrated primarily in patients undergoing low rectal resection and irradiation.

Patients undergoing radiotherapy, as a result of persistent low anterior resection syndrome, were forced to partially or completely withdraw from professional activity and to limit the pursuit of their interests. Their contacts with family, friends and acquaintances have also deteriorated. The presence of the intestinal stoma significantly affected the deterioration of the reception of self-image of the body. However, no relation was found between the existence of the fistula and other aspects of the patients’ everyday life, including functioning in life and social roles.

Conclusions: Due to the acceptable postoperative quality of life of patients with fistula and numerous imperfections of sphincter preserving techniques, operations resulting in terminal ostomy should not be considered as an extremity, and in the case of tumors of the lower rectum with unaffected sphincters, they should be considered as alternative methods for low anterior resection.

KEYWORDS: colostomy, rectal cancer, quality of life, radiotherapy

STRESZCZENIE: Wprowadzenie: Rak odbytnicy jest jednym z najczęściej występujących nowotworów złośliwych w krajach wysoko rozwi- niętych. Jednak, pomimo coraz lepszej diagnostyki przedoperacyjnej, dostosowywania technik chirurgicznych do położenia i zaawansowania nowotworu, skojarzenia leczenia operacyjnego z terapią neoadjuwantową oraz leczeniem uzupełniającym, wystandaryzowanych badań kontrolnych, nadal nie uzyskano w Polsce satysfakcjonujących wyników dotyczących odległych przeżyć. Ponadto, efekty zastosowanej terapii niejednokrotnie znacznie odbiegają od tych oczekiwanych przez pacjentów oraz prowadzących ich lekarzy.

Cel: Celem niniejszej pracy jest ocena efektów leczenia nowotworów odbytnicy wśród pacjentów Kliniki Chirurgii Ogólnej i Onkologicznej Pomorskiego Uniwersytetu Medycznego w Szczecinie. Analizie poddany został wpływ licznych czynników na pooperacyjną jakość życia.

Materiał i metody: W latach 2007–2015 w ramach Kliniki Chirurgii Ogólnej i Onkologicznej Pomorskiego Uniwersytetu Medycznego w Szczecinie wykonano 263 radykalne zabiegi resekcyjne u pacjentów z rozpoznanym nowotworem złośliwym

Authors’ Contribution:

A – Study Design B – Data Collection C – Statistical Analysis D – Manuscript Preparation E – Literature Search F – Funds Collection

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of clinical advancement (downstaging). This had a great significance for the treatment of locally advanced tumors or tumors located near the sphincters, thus reducing the number of abdominoperineal amputations of the rectum [9].

Currently, the average 5-year survival rate of patients with rectal cancer in Poland is 47.7% [10]. Considering the significant exten- sion of patients’ lives, in the 21st century more and more attention has been paid to non-survival parameters which assess the effecti- veness of combined treatment in this group of patients. The resear- chers focused primarily on complications accompanying different treatment strategies and factors influencing their incidence, and in recent years also on postoperative quality of life.

MATERIAL AND METHODS

In the years 2007–2015, the Department of General and Oncological Surgery of the Pomeranian Medical University performed 263 radical resections in patients with diagnosed malignant neoplasm of the rectum – 41 high anterior resections, 129 low anterior resections, 50 abdominoperineal amputations, and 43 Hartmann resections.

Retrospectively, the history of diseases provided the basis for cre- ating a database which included personal data, concomitant diseases, results of laboratory, endoscopic and radiological tests, ope- rating protocols, data on neoadjuvant and adjuvant treatment, the course of the treatment process, with particular emphasis on adverse events, as well as histopathological expertises, which were standardized using the current TNM classification. Data on the applied pre- and postoperative radiotherapy regimens were obtained from the Department of Radiotherapy in Szczecin.

At the Registry Office, PESEL numbers were used to obtain information on the dates of death of some patients. On this basis, it was found that the 5-year survival rate of patients opera- ted on in 2007–2012 was 49.5%. In December 2017, a proprietary questionnaire supplementing clinical data and standardized quality of life assessment forms (EORTC QLQ–C30 and CR29) was sent by

ABBREVIATIONS

EORTC – European Organization for Research and Treatment of Cancer

LARS – Low Anterior Resection Syndrome TME – total mesorectal removal

INTRODUCTION

Colorectal cancer represents approximately 13% of all malignant neoplasms diagnosed each year in the European Union. It is the third most common cancer, after breast and prostate cancer, and the second-leading, after lung cancer, cause of cancer death. It is es- timated that every day, nearly 1,000 people are diagnosed with this disease in Europe [1]. Colorectal cancer most often forms at the end of the large intestine, i.e., in the rectum, where 27–58% adenocar- cinomas develop, depending on the classification of rectosigmoid junction cancer [2].

Even towards the end of the 1980s, rectal cancer was a neoplasm with a very poor prognosis. In Poland, only every fifth patient diagnosed with colorectal cancer survived for five years after being diagnosed [3]. In the 1990s, there was significant progress in the treatment of rectal cancer. The breakthrough was primarily the total mesorectal removal (TME) procedure introduced by Heald, which to this day remains the “gold standard” in the treatment of advanced neoplasms of the lower and middle rectum and in some cases, of the upper rectum. In this way the local recurrences was reduced from 20–40%

to 3–12%, while dramatically extending patient survival rate [4–6].

Another essential step was the combination of surgical treatment with periprocedural radiotherapy, which has been proven to have a beneficial effect on reducing local recurrences and on survival among patients treated with conventional surgical procedures [7]. In contrast, patients undergoing TME had reduced recurrences in the pelvis to merely 2%, but there was no effect of periprocedural irradiation on the lifespan of patients in this group [8]. On the other hand, in some cases the introduction of preoperative radiochemotherapy allowed to reduce tumor size (downsizing) or even return to the lower stages

odbytnicy. Retrospektywnie, na podstawie historii chorób, utworzono bazę danych obejmującą szereg danych klinicznych.

W Urzędzie Stanu Cywilnego uzyskano informację o datach zgonów części chorych. Do 120 żyjących osób wysłano ankietę uzupełniającą dane kliniczne oraz standaryzowane formularze oceny jakości życia (EORTC QLQ – C30 oraz CR29). Z częścią pacjentów, którzy nie odpowiedzieli na ankiety, przeprowadzono rozmowę telefoniczną. Ostatecznie zebrano dane od 90 osób, co stanowi 75% pacjentów włączonych do badania. Jakość życia pacjentów oszacowano, wykorzystując przewodniki oceny kwestionariuszy EORTC.

Wyniki: Jakość życia chorych w największym stopniu uległa pogorszeniu w wyniku dysfunkcji anorektalnej. Nietrzymanie gazów i stolca, parcia naglące oraz trudności z wypróżnieniami wykazano przede wszystkim u pacjentów poddanych niskiej resekcji odbytnicy oraz naświetlaniu. Osoby poddane radioterapii, na skutek przetrwałego zespołu niskiej resekcji odbytnicy, zmuszone były do częściowego lub całkowitego wycofania się z aktywności zawodowej oraz ograniczenia realizacji swoich zainteresowań. Pogorszeniu uległy również ich kontakty z rodziną, przyjaciółmi i znajomymi. Obecność stomii jelitowej w istotny sposób wpłynęła na pogorszenie odbioru obrazu własnego ciała. Nie stwierdzono jednak związku pomiędzy istnieniem przetoki a innymi aspektami codziennego życia pacjentów, łącznie z funkcjonowaniem w rolach życiowych i społecznych.

Wnioski: Z uwagi na akceptowalną pooperacyjną jakość życia pacjentów z przetoką oraz liczne niedoskonałości technik pro- wadzących do zaoszczędzenia aparatu zwieraczowego, operacje skutkujące wyłonieniem stomii nie powinny być traktowane jako ostateczność, a w przypadku guzów dolnej części odbytnicy z niezajętymi zwieraczami, należałoby rozważać je jako metody alternatywne do przedniej niskiej resekcji.

SŁOWA KLUCZOWE: jakość życia, kolostomia, radioterapia, rak odbytnicy

The main factors influencing the postoperative quality of life of patients who underwent surgery due to rectal cancer were identified in the paper.

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QUALITY OF LIFE BASED ON THE QLQ-C30 QUESTIONNAIRE

High anterior resection (n = 26) Low anterior resection (n = 47) Δ p

Global health status 64.0 57.8 6.2 0.3968

FUNCTIONAL SCALES

Physical fitness 76.3 76.3 0 0.9904

Role functioning 82.0 76.3 5.7 0.2094

Patient emotions 71.2 76.7 5.5 0.3349

Cognitive functioning 82.2 73.8 8.4 0.1051

Social functioning 78.9 70.6 8.3 0.5189

SYMPTOM SCALES

Fatigue 30.6 30.3 0.3 0.8785

Nausea and vomiting 1.2 4.9 3.7 0.1416

Pain 17.7 20.0 2.3 0.8405

Dyspnea 10.2 8.5 1.7 0.7434

Insomnia 25.6 40.4 14.8 0.0490

Loss of appetite 14.1 7.8 6.9 0.6507

Constipation 26.8 30.4 3.6 0.4329

Diarrhea 5.1 20.5 15.4 0.0054

Financial problems 33.2 31.9 1.3 0.8383

QUALITY OF LIFE BASED ON THE QLQ-CR29 QUESTIONNAIRE

High anterior resection (n = 26) Low anterior resection (n = 47) Δ p

Body image 84.1 72.5 11.6 0.2136

Anxiety 55.3 54.0 1.3 0.9534

Body weight 70.5 78.6 8.1 0.4700

Sex drive (M) 42.7 (n = 7) 28.0 (n = 26) 14.7 -

Sex drive (F) 9.2 (n = 18) 9.9 (n = 20) 0.7 -

SYMPTOM SCALES

Urinary frequency 29.9 37.1 7.2 0.2715

Defecation frequency 11.3 27.8 16.5 0.0050

Presence of blood or mucus in the stool 1.2 6.1 4.9 0.1415

Urinary incontinence 15.3 17.7 2.4 0.9827

Symptoms of dysuria 1.3 6.3 5.0 0.1358

Abdominal pain 19.1 24.0 4.9 0.5356

Perineal pain 5.1 13.4 8.3 0.0875

Abdominal bloating 20.3 30.4 10.1 0.1196

Dry mouth 24.3 26.1 1.8 0.7754

Hair loss 19.2 14.8 4.4 0.5535

Taste disorders 12.8 8.5 4.3 0.9451

Gas incontinence 14.0 36.1 22.1 0.0031

Fecal incontinence 5.1 26.2 21.1 0.0009

Skin irritation around the perineum/stoma 7.6 20.5 12.9 0.0141

Feeling of embarrassment 11.5 34.7 23.2 0.0032

Problems with stoma care 33.0 (n = 1) 22.2 (n = 6) 10.8 -

Impotence (M) 45.9 (n = 8) 49.3 (n = 25) 3.4 -

Pain/discomfort during sexual intercourse 10.2 (n = 13) 20.0 (n = 15) 9.8 -

Tab. I. Postoperative quality of life of EORTC questionnaire respondents depending on the type of surgery.

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mail to 120 living patients. Within two months, we received respon- ses from 75 patients (62.5%). We also received 5 blank questionnaires in return due to the possible change of the patient’s address. Patients who did not complete the questionnaires and did not change their contact number since the day of qualifying for treatment were in- terviewed by phone. In this way, we obtained data from another 15 patients, as well as the final number of respondents amounting to 90 people, which accounts for 75% of all respondents. It was also found that 3 patients died during the study, i.e., after December 1, 2017.

Patient questionnaires QLQ–C30 and QLQ–CR29 were developed according to a guide drawn up by the EORTC [11]. For all functional scales, symptomatic scales, individual symptoms, as well as for the “Global health status” assessed in QLQ–C30, the Score was calculated.

The higher the score for Global Health Status, the higher the quality of life, and on functional scales, the better the level of functioning.

However, a higher score achieved in symptomatic scales and in individual symptoms is associated with a greater severity of an unde- sirable symptom, so the patient’s quality of life is worse in this case.

Statistical significance of the results was determined in accordance with the evaluation criteria of the EORTC questionnaires propo- sed by King and Person [12, 13]. The difference in scores assigned to a specified parameter (on a scale from 0 to 100) greater than or equ- al to 20 was considered to be particularly significant. Values from 10 to 20 were defined as significant, while results between 0 and 9 as insignificant.

The obtained scores were additionally compared using the non-pa- rametric Mann-Whitney U test.

Among the many analyzed parameters, statistically significant results were obtained for the type of surgery performed, the use of radiotherapy and the presence of a colostomy.

RESULTS

Analysis of the effect of the height of colorectal anastomosis on postoperative quality of life demonstrated significantly worse (Δ > 20) results concerning gas and fecal incontinence, as well as the accompanying feeling of embarrassment in patients undergoing low anterior resection. A score of between 10 and 20 was found on seven other scales (diarrhea, defecation rate, perineal itching, abdominal distension, insomnia, body dissatisfaction, and reduced sexual drive in men). In all these parameters, patients with low anastomosis performed worse compared to patients whose intestine was con- nected farther from the anal sphincters.

Comparison of the quality of life between patients treated with and without radiotherapy demonstrated a worse quality of life in almost every analyzed parameter in irradiated patients. These patients more frequently (Δ > 20) reported body dissatisfaction (Δ = 21.7) and most of all, they suffered from gas incontinence (Δ = 23.9) and fecal incontinence (Δ = 20.6), which was often the cause of embarrassing situations (Δ = 28.5).

Comparison of the quality of life between patients who had a re- stored continuity of the gastrointestinal tract during the study with

those with an exteriorized colostomy, demonstrated a slightly better quality of life (Δ < 10) in patients without a fistula in terms of most parameters assessed. However, people without a fistula made significantly more (Δ > 20) complaints of chronic constipation. Mo- reover, patients with an exteriorized colostomy assessed their body image as much worse (Δ = 22), and the fistula was often the cause of embarrassing situations (Δ = 15.2).

DISCUSSION

Combined therapy for rectal cancer often has a great impact on the everyday functioning of patients, leaving an imprint on them also after the end of oncological treatment.

This includes, but is not limited to, gas and fecal incontinence, sexual dysfunction or inconvenience resulting from the presence of a fistula.

It is often impossible to assess these usually irreversible changes based on physical, laboratory and radiological examinations. It is based on the subjective perceptions of patients, which to some extent can be reflected by standardized questionnaires such as those developed by the European Organization for Research and Treatment of Cancer (EORTC) [14, 15], which are also used in this analysis.

For decades, colorectal surgeons were convinced that patients with an exteriorized stoma after rectal amputation had a much poorer quality of life compared to patients after anterior resection with a maintained gastrointestinal tract continuity [16]. This undoub- tedly brought about a significant development of techniques that now allow for performing ultra-low resections with sphincter preservation. Accordingly, it was quite surprising to find the result of the analysis of 35 studies, which assessed the quality of life of 5,127 patients after abdominoperineal amputation, Hartmann procedure and anterior resection of the rectum published in 2005 by Pachler and Wille-Jorgensen [17]. As many as 14 studies demonstrated that patients who underwent procedures resulting in the creation of a stoma were not burdened with a lower postoperative quality of life compared to patients who underwent sphincter saving procedures.

Other studies uncovered certain differences, but not always in favor of low rectal resections. It is likely that this was due to a weak functional effect of sphincters, often preserved at all cost. Williamson [18] used anal manometric tests to demonstrate that as many as 90%

of people after rectal resection have anorectal dysfunction of varying severity. Patients may experience varying symptoms that hinder their daily functioning, ranging from difficulty in defecation, more frequent bowel movements, to fecal and gas incontinence. These disturbances of the bowel function, which occur after proctecto- my with sphincter saving, and adversely affect the quality of life of patients, are referred to in the literature as Low Anterior Resection Syndrome (LARS) [19]. Until recently, they were considered to be of a temporary nature and usually disappear within a year of surgery [20]. However, published long-term studies show that end-seg- ment disturbances persist for many years and in a large proportion of patients. Harris [21] examined the quality of life in 46 patients 60–108 months after surgery and showed the presence of fecal incontinence in 43%, fecal urgency in 39% and difficult or incomplete evacuation in 39% of respondents.

This study assesses the quality of life after 33–129 months from admission to the Department of Oncological Surgery in Szczecin.

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Without radiotherapy (n = 55) Periprocedural radiotherapy (n = 35) Δ p

Physical fitness 78.5 72.8 5.7 0.2955

Role functioning 84.3 70.5 13.8 0.0040

Social functioning 80.6 62.9 17.7 0.0143

SYMPTOM SCALES

Fatigue 27.3 38.2 10.9 0.0421

Nausea and vomiting 2.7 4.7 2 0.5648

Pain 15.3 21.2 5.9 0.6877

Dyspnea 7.9 8.5 0.6 0.8744

Insomnia 32.7 44.7 12.0 0.1024

Loss of appetite 10.9 12.4 1.5 0.8597

Constipation 29.6 19.0 10.6 0.0880

Diarrhea 9.6 26.6 17.0 0.0026

Without radiotherapy (n = 55) Periprocedural radiotherapy (n = 35) Δ p

Body image 82.1 60.4 21.7 0.0021

Anxiety 60.7 46.8 13.9 0.0286

Body weight 77.0 76.9 0.1 0.9737

Sex drive (M) 25.9 (n = 23) 27.1 (n = 22) 1.2 -

Sex drive (F) 6.6 (n = 30) 11.1 (n = 12) 4.5 -

SYMPTOM SCALES

Urinary frequency 34.6 39.4 4.8 0.3992

Abdominal pain 17.5 27.5 10.0 0.1845

Perineal pain 9.0 14.2 5.2 0.1996

Abdominal bloating 24.7 26.6 1.9 0.9423

Dry mouth 22.9 28.5 5.6 0.3756

Hair loss 15.7 11.4 4.3 0.3740

Gas incontinence 19.9 43.8 23.9 0.0003

Fecal incontinence 11.5 32.1 20.6 0.0035

Skin irritation around the perineum/stoma 12.1 23.4 11.3 0.0061

Problems with stoma care 14.7 (n = 9) 17.7 (n = 15) 3 -

Impotence (M) 44.9 (n = 23) 50.0 (n = 22) 5.1 -

Pain/discomfort during sexual intercourse (F) 11.0 (n = 21) 23.3 (n = 10) 12.3 -

Tab. II. Postoperative quality of life of EORTC questionnaire in respondents who underwent radiotherapy or were treated only with surgery.

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Without stoma (n = 67) With stoma (n = 23) Δ p

Physical fitness 77.2 73.6 3.6 0.1708

Role functioning 79.4 77.6 1.8 0.3481

Social functioning 75.1 69.6 5.5 0.3235

SYMPTOM SCALES

Fatigue 29.0 38.9 9.9 0.0751

Nausea and vomiting 3.0 5.0 2.0 0.2437

Pain 19.0 13.6 5.4 0.4325

Dyspnea 8.4 7.2 1.2 0.7962

Insomnia 34.3 46.3 12.0 0.1331

Loss of appetite 9.4 17.3 7.9 0.1055

Constipation 30.7 10.0 20.7 0.0030

Diarrhea 14.4 21.7 7.3 0.0979

Without stoma (n = 67) With stoma (n = 23) Δ p

Body image 79.3 57.3 22.0 0.0006

Anxiety 53.4 60.9 7.5 0.3352

Body weight 74.5 84.1 9.6 0.1465

Sex drive (M) 32.1 (n = 30) 15.4 (n = 15) 16.7 -

Sex drive (F) 6.8 (n = 34) 12.5 (n = 8) 5.7 -

SYMPTOM SCALES

Urinary frequency 33.9 44.0 10.1 0.1316

Abdominal pain 21.3 21.6 0.3 0.5829

Perineal pain 9.9 14.4 4.5 0.3342

Abdominal bloating 25.7 24.6 1.1 0.8122

Dry mouth 24.3 27.5 3.2 0.6839

Hair loss 14.4 13.0 1.4 0.6538

Gas incontinence 28.3 31.8 3.5 0.4050

Fecal incontinence 17.9 24.1 6.2 0.2325

Skin irritation around the perineum/stoma 14.3 22.7 8.4 0.1587

Problems with stoma care X 17.3 - -

Impotence (M) 50 (n = 30) 42.3 (n = 15) 7.7 -

Pain/discomfort during sexual intercourse (F) 16.6 (n = 26) 6.6 (n = 5) 10.0 -

Tab. III. Postoperative quality of life of EORTC questionnaire respondents depending on the presence or absence of a colostomy.

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Of the 73 patients who underwent colorectal anastomosis, involun- tary bowel movements are still present in 27 (37%), gas incontinence in 39 (53%), fecal urgency in 24 (33%), and evacuation difficulty in 44 respondents (60%). Analysis of 10 parameters showed a particularly significant influence of two factors on the probability of anorectal disorders – the height of the intestinal anastomosis and the use of radiotherapy. When comparing patients’ quality of life after low anterior resection with patients whose anastomosis was made more than five centimeters from the anal edge, the first group performed significantly worse in terms of gas and fecal incontinence, as well as the accompanying feeling of embarrassment. For these symptoms, the difference in the score, calculated on the basis of the comple- ted EORTC QLQ–CR29, was over 20 (Δ > 20 at p < 0.005), which means a particularly significant impact on the daily functioning of patients. A score between 10 and 20 (Δ 10–20) was also obtained for diarrhea, frequency of defecation and anal itching, in each case indicating worse functioning of people after low resection. The relationship between the height of anastomosis and the probability of anorectal dysfunction was also analyzed by Rasmussen [22]. Guided by clinical data and manometric tests of 43 patients after anterior rectal resection, Rasmussen showed a clear correlation between the distance of anastomosis from the edge of anus and the severity of fecal incontinence, and between the volume of the preserved rectal fragment and the frequency of defecation.

In this study, the parameter with the most adverse effect on the functioning of the distal gastrointestinal tract turned out to be the combination of surgery and radiotherapy. Analysis of EORTC questionnaires showed that to this day, patients exposed to radiation suffer from gas incontinence (Δ = 23.9; p = 0.0003) and stool incontinence (Δ = 20.6; p = 0.0035), which is often the cause of embarrassing situations (Δ = 28.5; p = 0.0001). These persons significantly more often report a higher than before treatment frequency of defecation in the QLQ–CR29 questionnaire (Δ = 16.5; p = 0.0114) and diarrhea (Δ = 17.0; p = 0.026) in QLQ–C30. It was also demonstrated that patients undergoing radiotherapy, probably due to extensive disorders of anorectal function, were forced to withdraw partially or completely from professional activity and to limit the pursuit of their interests (Δ = 13.8; p = 0.040). Their contacts with family, friends and acquaintances have also deteriorated (Δ = 17.7; p = 0.0143). It should be noted that such a strong correlation was not observed when analyzing the consequences of low colorectal anastomosis.

The results are consistent with numerous literature reports. Rando- mized clinical trials have shown that anorectal dysfunctions occur almost twice as often among patients undergoing radiation therapy, compared with those whose treatment was based only on surgery [23–26]. In a 2015 multicenter study assessing the quality of life among Danish patients, an average of 14 years after treatment, Chen demonstrated the persistence of advanced symptoms of Low Anterior Resection Syndrome (LARS) in 46% of living people. Pre- operative radiation therapy using 25 Gy was a factor that significantly influenced its incidence. LARS was found in 35% of respondents treated with surgery alone with the TME technique and in as many as 56% of respondents subjected to irradiation followed by surgery [27]. On the other hand, Pietrzak and Bujko [28] used the analysis of data obtained from 111 patients who underwent 5-day radiotherapy before surgery and 110 patients who underwent neoadjuvant radiochemotherapy to find various types of defecation disorders in as many as two thirds of the respondents. At the same time, they did not show any major differences in the quality of life between the

two groups, in which surgical treatment was preceded by different irradiation schedules.

Assessment of the quality of life after over three years from the day of surgery allows to identify on an objective basis the impact of a fistula on the daily functioning of patients. By this time, most patients are used to the existence and daily management of a stoma. The authors’ analysis showed that, although people with a fistula have a much poorer perception of their own body image (Δ = 22.0; p = 0.0006), and more frequently experience embarrassing situations (Δ = 150.2;

p = 0.0284), their overall quality of life is only slightly different from that reported by people without a stoma. It is worth noting that when these groups of people were compared, no significant difference (Δ > 10) was found for general health, nor for any of the functional scales included in the QLQ–C30 questionnaire. This means that the mere presence of a fistula does not have an adverse effect on functioning in life roles as well as contacts with family or friends, as it was previously shown for patients with significant anorectal dysfunction after radiotherapy. The results are supported by numerous reports from recent years [29–33]. De Campos [33] explains the similar quality of life of patients after low rectal resection and abdominoperineal amputation, primarily by the fact of the feeling of disappointment experienced by a large number of patients in whom the sphincter apparatus was preserved. These patients may have unrealistic preoperative expectations, often sustained by their attending physicians.

On the other hand, the final effect of treatment, more frequent complications and often significant anorectal dysfunction result in great frustration due to the need to continue living with numerous inco- nveniences. In turn, patients who were originally scheduled to have a stoma tend to have lower expectations. However, after surgery, they learn that functioning with a fistula is possible without major limita- tions. It therefore appears that procedures involving the selection of a lifelong colostomy should not be merely a last resort, when other forms of treatment become impossible due to infiltration or a short distance of the tumor from the sphincters. Each patient qualified for treatment due to low rectal cancer should be thoroughly briefed on the numerous shortcomings of combination therapy, including the possibility of dangerous complications and frequent irreversible anorectal dysfunction, which may significantly impede the further functioning of patients in everyday life.

CONCLUSIONS

1. The patients’ quality of life deteriorated to the greatest extent as a result of anorectal dysfunction;

2. Gas and fecal incontinence, fecal urgency and difficult passage of stools have been demonstrated primarily in patients undergoing low rectal resection and radiation;

3. As a result of persistent low anterior resection syndrome, people undergoing radiotherapy were forced to withdraw partially or fully from professional activity and to limit the pursuit of their interests. Their contacts with family, friends and acquaintances have also deteriorated;

4. The presence of an intestinal stoma had a major impact on the deterioration of body image. That said, no relationship was found between a fistula and other aspects of the patients’ daily lives, including functioning in life and social roles.

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Word count: 4263 Page count: 9 Tables: 3 Figures: – References: 33 10.5604/01.3001.0014.8131 Table of content: https://ppch.pl/issue/13784

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The authors declare that they have no competing interests.

The content of the journal „Polish Journal of Surgery” is circulated on the basis of the Open Access which means free and limitless access to scientific data.

This material is available under the Creative Commons – Attribution-NonCommercial 4.0 International (CC BY-NC 4.0).

The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcodeode Tomasz Błaszkowski MD PhD; Department of General and Oncological Surgery, Pomeranian Medical University in Szczecin; Unii Lubelskiej street 1, 71-252 Szczecin, Poland; Phone: +48 91 425 0400; E-mail: tblaszko123@gmail.com Blaszkowski T., Kladny J., Al-Amawi T., Kaczmarek K., Kwietniak M., Wojtasik P., Halczak M., Michalak T., Zalewski M., Jezierski K., Chmielak M.: Factors determining the quality of life in patients undergoing radical surgery due to malignant tumors of the rectum; Pol Przegl Chir 2021; 93(3): 1-9

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