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The Long-term Gastrointestinal Functional Outcomes Following Curative Anterior Resection in Adults With Rectal Cancer: A Systematic Review and Meta-analysis

Scheer, Adena S. M.D.1; Boushey, Robin P. M.D.1; Liang, Shuyin B.Sc.2; Doucette, Steve M.Sc.3; O'Connor, Annette M. Ph.D.1; Moher, David Ph.D.3

Section Editor(s): Dunn, Kelli Bullard M.D., Editor

doi: 10.1097/DCR.0b013e3182214f11
Current Status

BACKGROUND: Significant variability and a lack of transparency exist in the reporting of anterior resection outcomes.

OBJECTIVES: This study aimed to qualitatively analyze the long-term functional outcomes and assessment tools used in evaluating patients with rectal cancer following anterior resection, to quantify the incidence of these outcomes, and to identify risk factors for long-term incontinence.

DATA SOURCES: MEDLINE, Embase, and CINAHL were searched using the terms rectal neoplasms, resection, and gastrointestinal function.

STUDY SELECTION: The studies included were in English and evaluated adults with rectal cancer, curative anterior resection, and a minimum 1-year follow-up. Patients with recurrent/metastatic disease were excluded. Of the 805 records identified, 48 articles were included.

INTERVENTION: The intervention performed was anterior resection.

MAIN OUTCOME MEASURES: The main outcome measure was incontinence (gas, liquid stool, and solid stool).

RESULTS: The histories of 3349 patients from 17 countries were summarized. Surgeries were conducted between 1978 to 2004 with a median follow-up of 24 months (interquartile range, 12, 57). Sixty-five percent of studies did not use a validated assessment tool. Reported outcomes and incidence rates were variable. The reported proportion of patients with incontinence ranged from 3.2% to 79.3%, with a pooled incidence of 35.2% (95% CI 27.9, 43.3). Risk factors for incontinence, identified by meta-regression, were preoperative radiation 0.009 and, in particular, short-course radiation (P = .006), and study quality (randomized controlled trial P = .004, observational P = .006).

LIMITATIONS: The meta-analysis was limited by the significant heterogeneity of the primary data.

CONCLUSIONS: Functional outcomes are inconsistently assessed and reported and require common definitions, and the more regular use of validated assessment tools, as well. Preoperative radiation and, in particular, short-course radiation may be a strong risk factor for incontinence; however, further studies are needed.

1 Department of General Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada

2 Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

3 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Funding/Support: The American Society of Colon and Rectal Surgeons resident research grant 2009.

Financial Disclosures: None reported.

Podium presentation at the meeting of The American Society of Colon and Rectal Surgeons Meeting, Minneapolis, MN, May 15 to 19, 2010, and at the Canadian Surgery Forum Quebec City, Quebec, Canada, September 2 to 5, 2010.

Correspondence: Adena S. Scheer, M.D., Department of General Surgery, The Ottawa Hospital, 501 Smyth Road Mailbox 202, Ottawa, Ontario, Canada K1H8L6. E-mail:

© The ASCRS 2011