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Int J Colorectal Dis (2015) 30:1563–1570 DOI 10.1007/s00384-015-2328-1

ORIGINAL ARTICLE

Persistent perineal morbidity is common following abdominoperineal excision for rectal cancer Dan Asplund 1

&

Mattias Prytz 1,2 & David Bock 1 & Eva Haglind 1 & Eva Angenete 1

Accepted: 26 July 2015 / Published online: 6 August 2015 # The Author(s) 2015. This article is published with open access at Springerlink.com

Abstract Purpose Short-term complications related to the perineal wound after abdominoperineal excision (APE) are a wellknown problem. Perineal morbidity in the longer term is an almost unexplored area. The aim of this cross-sectional study was to investigate the prevalence of perineal symptoms 3 years after APE for rectal cancer, to identify potential risk factors and to explore the relationship between perineal morbidity and global quality of life. Method All patients who underwent APE in Sweden between 2007 and 2009 (n=1373) were identified through the Swedish Colorectal Cancer Registry. Surviving patients were contacted 3 years after surgery and asked about participation. A total of 545 patients completed a detailed questionnaire. Clinical data was collected from the registry and surgical charts. Results Perineal symptoms occurred in 50 % of all patients 3 years after APE and more frequently in women (58 vs. 44 %; p=0.001). Delayed healing of the perineal wound (>4 weeks) occurred in 25 % of all patients and more frequently after extralevator APE (ELAPE) than after conventional APE (32 vs. 11 %, p4 weeks) healing

patients were asked to complete the questionnaire in the presence of a specialist nurse to detect any problems, misinterpretations, or concerns. Questions were revised accordingly, and the process continued until no uncertainties remained. During the development of the questionnaire, six Bcore^ perineal symptoms emerged and were included in this analysis: pain, sitting disability, paraesthesia, tension between the buttocks, sensation of tingling/stinging between the buttocks, and perineal cramps/sensation of urgency. The recall period was the past month. Response options were dichotomized as explained in the tables. Patients reporting at least one perineal symptom of severe intensity (response options quite a bit or very much, see Table 1) were defined by us to have a severe perineal morbidity. Also included in this analysis were questions on postoperative perineal wound healing and the EQ-5D visual analogue scale (VAS) question on global health-related quality of life [4, 16, 20].

factors for severe perineal morbidity (the experience of one or more symptom of severe intensity, see above), variables chosen as potential predictors were radiotherapy, sex, age, tumor height, and delayed perineal wound healing. Because of the observed strong association between surgical technique and perineal wound healing (Table 2), surgical technique was not included in the regression model. In the subgroup of patients who underwent ELAPE, perineal repair and excision of the coccyx were included as potential predictors as well. A loglinear binomial regression model [5] was used to estimate the relative risk (RR) and 95 % confidence intervals (95 % CIs). In case the binomial model did not converge, a log-linear Poisson regression with a robust error variance was used [27]. Additional statistical analyses involved chi-square test and Mann–Whitney U test for categorical and continuous variables, respectively. No correction for multiple testing was made, and results should therefore be regarded as interesting findings rather than as conclusive evidence.

Statistical analyses

Results All data were collected in a database, and statistical analyses were performed using SPSS 21.0 (IBM SPSS Inc. Armonk, NY, USA) and SAS v. 9 (SAS institute). In the analysis of risk

Out of the 1319 patients who were included in our previous analyses of oncological outcome [17, 18],

1373 cases of abdominoperineal excision for rectal cancer in Sweden 2007-2009 Surgical notes unavailable, n=54 Included in the analysis of oncological outcome (Prytz et al 2014 and 2015)

1319 paents Deceased, n=467 Introductory leer sent to 852 paents, followed by a phone call

Unable (mentally or physically) to parcipate, n = 91 Lost to follow-up, n=58

703 eligible paents No consent, n=107

Quesonnaire sent to 596 paents Quesonnaire not returned, n=51 545 paents returned a completed quesonnaire and were included in the analysis

Fig. 2 Flowchart of patients

1566

Int J Colorectal Dis (2015) 30:1563–1570

852 were alive 3 years post-operatively and 703 patients were eligible for inclusion in this study (Fig. 2). A total of 596 patients agreed to receive the questionnaire by mail and 545 returned the questionnaire and were included in the analysis. Reasons for non-inclusion (n= 774) are presented in Fig. 2. Clinical characteristics of included patients, non-responders, and deceased patients are presented in Table 3. Non-responders were older and had more comorbidity as reflected by the preoperative ASA grade and received less neoadjuvant radiotherapy than responders to the questionnaire. Conventional APE

Table 3

was more common among non-responders, as were involved resection margins. The conventional APE and ELAPE groups differed regarding sex and tumor height, with more male patients and more distal tumors in the ELAPE group. The frequency of coccyx resection and method of perineal repair also differed between groups with very few resections and no use of flap or mesh in the conventional APE group. pT and pN stage and ASA grade were no different, and there were no significant differences regarding neoadjuvant radiotherapy and chemoradiotherapy (Table 4).

Clinical characteristics of patients operated by abdominoperineal excision in Sweden 2007–2009 Total cohort, n=1319

Number of patients Sex Age at operation BMI ASA classification

Radiation therapy

Chemoradiotherapy Tumor heighta pT stage

pN stage

Microscopic radicalityb Perineal dissection

Coccyx resection Perineal reconstruction

Female Male

Included in the analysis

Deceased at follow-up

545

467

307 142 (46.3 %) 165 (53.7 %) 69.3 26.8 61 (20.5 %) 165 (55.4 %)

%) %)

Non-responders

ASA 1 ASA 2

218 (40.0 327 (60.0 66.0 29.3 144 (27.0 314 (58.9

%) %)

170 (36.4 %) 297 (63.6 %) 71.9 27.3 69 (15.3 %) 235 52.2 %)

ASA 3 ASA 4 None Short (5×5 Gy)

73 (13.7 %) 2 (0.4 %) 64 (11.8 %) 355 (65.6 %)

137 (30.4 %) 9 (2.0 %) 123 (26.7 %) 222 (48.2 %)

72 (24.2 %) 0 64 (20.9 %) 181 (59.2 %)

Long (25×1,8/2 Gy) Yes No T0–T2 T3 T4

122 (22.6 %) 110 (20.2 %) 434 (79.8 %) 4,1 256 (47.9 %) 252 (47.1 %) 27 (5.0 %)

116 (25.2 %) 112 (24.0 %) 354 (76 %) 4,3 98 (21.2 %) 289 (62.4 %) 76 (16.4 %)

61 (19.9 %) 57 (18.6 %) 250 (81.4 %) 4,3 130 (42.9 %) 156 (51.5 %) 17 (5.6 %)

N0 N1 N2 Yes No/indeterminate Conventional APE ELAPE Indeterminate Yes No Suture Mesh

344 (63.9 %) 130 (24.2 %) 64 (11.9 %) 522 (96.0 %) 22 (4.0 %) 71 (13.0 %) 222 (40.7 %) 252 (46.2 %) 124 (27.7 %) 323 (72.3 %) 430 (79.6 %) 64 (11.9 %)

187 (41.1 %) 117 (25.7 %) 151 (33.2 %) 386 (83.0 %) 79 (17.0 %) 79 (16.9 %) 172 (36.8 %) 216 (46.3 %) 133 (35.6 %) 241 (64.4 %) 352 (76.4 %) 56 (12.1 %)

202 (68.2 %) 67 (22.6 %) 27 (9.1 %) 285 (92.8 %) 22 (7.2 %) 59 (19.2 %) 124 (40.45) 124 (40.4 %) 73 (28.4 %) 184 (71.6 %) 238 (78.3 %) 36 (11.8 %)

Flap

46 (8.5 %)

53 (11.5 %)

30 (9.9 %)

p value

0.076

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