Assessment of long-term bowel dysfunction after restorative proctectomy for neoplastic disease: A population-based cohort study

Published:November 27, 2021DOI:



      The purpose of this study was to describe postoperative bowel dysfunction after restorative proctectomy, and to identify factors associated with its development.


      Patients who underwent restorative proctectomy for rectal cancer between April 1998 and November 2018 were identified from the Hospital Episode Statistics database and linked to the Clinical Practice Research Datalink for postoperative follow-up. Bowel dysfunction was defined according to relevant symptom-based read codes and medication prescription–product codes. A Cox proportional hazards model was performed to identify factors associated with postoperative bowel dysfunction, adjusting for relevant covariates.


      In total, 2,197 patients were included. The median age was 70.0 (interquartile range: 62.0–77.0) years old, and the majority (59.2%) of patients were male. After a median follow-up of 51.6 (24.0–90.0) months, bowel dysfunction was identified in 620 (28.2%) patients. Risk factors for postoperative bowel dysfunction included extremes of age (<40 years old: adjusted hazards ratio 2.35, 95% confidence interval 1.18–4.65; 70–79 years old: adjusted hazards ratio 1.25, 95% confidence interval 1.03–1.52), radiotherapy (adjusted hazards ratio 1.94, 95% confidence interval 1.56–2.42), distal tumors (adjusted hazards ratio 1.62, 95% confidence interval 1.34–1.94), history of diverting ostomy (adjusted hazards ratio 1.58, 95% confidence interval 1.33–1.89), and anastomotic leak (adjusted hazards ratio 1.48, 95% confidence interval 1.06–2.05). A minimally invasive surgical approach was protective for postoperative bowel dysfunction (adjusted hazards ratio 0.68, 95% confidence interval 0.53–0.86).


      Bowel dysfunction was common after restorative proctectomy, and several patient, disease, and treatment-level factors were associated with its development.
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        • Arnold M.
        • Rutherford M.J.
        • Bardot A.
        • et al.
        Progress in cancer survival, mortality, and incidence in seven high-income countries 1995–2014 (ICBP SURVMARK-2): a population-based study.
        Lancet Oncol. 2019; 20: 1493-1505
        • Araghi M.
        • Soerjomataram I.
        • Bardot A.
        • et al.
        Changes in colorectal cancer incidence in seven high-income countries: a population-based study.
        Lancet Gastroenterol Hepatol. 2019; 4: 511-518
        • Siegel R.L.
        • Torre L.A.
        • Soerjomataram I.
        • et al.
        Global patterns and trends in colorectal cancer incidence in young adults.
        Gut. 2019; : 682179-682185
        • Bryant C.L.
        • Lunniss P.J.
        • Knowles C.H.
        • Thaha M.A.
        • Chan C.L.H.
        Anterior resection syndrome.
        Lancet Oncol. 2012; 13: e403-e408
        • Keane C.
        • Wells C.
        • O’Grady G.
        • Bissett I.P.
        Defining low anterior resection syndrome: a systematic review of the literature.
        Colorectal Dis. 2017; 19: 713-722
        • Chapman S.J.
        • Bolton W.S.
        • Corrigan N.
        • Young N.
        • Jayne D.G.
        A cross-sectional review of reporting variation in postoperative bowel dysfunction after rectal cancer surgery.
        Dis Colon Rectum. 2017; 60: 240-247
        • Emmertsen K.J.
        • Laurberg S.
        Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer.
        Ann Surg. 2012; 255: 922-928
        • Keane C.
        • Fearnhead N.S.
        • Bordeianou L.G.
        • Christensen P.
        • Espin Basany E.
        • Laurberg S.
        • LARS International Collaborative Group
        International consensus definition for low anterior resection syndrome.
        Dis Colon Rectum. 2020; 63: 274-284
        • de Geus S.W.L.
        • Sachs T.E.
        • Tseng J.F.
        Big data vs. clinical trials in HPB surgery.
        J Gastrointest Surg. 2020; 24: 1127-1137
        • Herrett E.
        • Gallagher A.M.
        • Bhaskaran K.
        • Forbes H.
        • Mathur R.
        • van Staa T.
        Data resource profile: clinical practice research datalink (CPRD).
        Int J Epidemiol. 2015; : 44827-44836
        • Nachiappan S.
        • Askari A.
        • Mamidanna R.
        • et al.
        The impact of adjuvant chemotherapy timing on overall survival following colorectal cancer resection.
        Eur J Surg Oncol. 2015; 41: 1636-1644
        • Arhi C.S.
        • Burns E.M.
        • Bouras G.
        • Aylin P.
        • Ziprin P.
        • Darzi A.
        Complications after discharge and delays in adjuvant chemotherapy following colonic resection: a cohort study of linked primary and secondary care data.
        Colorectal Dis. 2019; 21: 307-314
        • Kang C.Y.
        • Halabi W.J.
        • Chaudhury O.O.
        • et al.
        Risk factors for anastomotic leakage after anterior resection for rectal cancer.
        JAMA Surg. 2013; 148: 65-71
        • Wei D.
        • Johnston S.
        • Goldstein L.
        • Nagle D.
        Minimally invasive colectomy is associated with reduced risk of anastomotic leak and other major postoperative complications and reduced hospital resource utilization as compared with open surgery: a retrospective population-based study of comparative effectiveness and trends of surgical approach.
        Surg Endosc. 2020; 34: 610-621
        • Bordeianou L.G.
        • Anger J.T.
        • Boutros M.
        • et al.
        Measuring pelvic floor disorder symptoms using patient-reported instruments: proceedings of the consensus meeting of the pelvic floor consortium of the American Society of Colon and Rectal Surgeons, the International Continence Society, the American Urogynecologic Society, and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction.
        Dis Colon Rectum. 2020; 63: 6-23
        • Rosen R.C.
        • Cappelleri J.C.
        • Smith M.D.
        • Lipsky J.
        • Pena B.M.
        Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction.
        Int J Impot Res. 1999; 11: 319-326
        • Isidori A.M.
        • Pozza C.
        • Esposito K.
        • et al.
        Development and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction.
        J Sex Med. 2010; 7: 1139-1146
        • Barry M.J.
        • Fowler Jr., F.J.
        • O’Leary M.P.
        • et al.
        The American Urological Association symptom index for benign prostatic hyperplasia: the measurement committee of the American Urological Association.
        J Urol. 1992; 148: 1549-1557
        • Abrams P.
        • Avery K.
        • Gardener N.
        • Donovan J.
        • ICIQ Advisory Board
        The international consultation on incontinence modular questionnaire:
        J Urol. 2006; 175: 1063-1066
        • Juul T.
        • Elfeki H.
        • Christensen P.
        • Laurberg S.
        • Emmertsen K.J.
        • Bager P.
        Normative data for the low anterior resection syndrome score (LARS score).
        Ann Surg. 2019; 269: 1124-1128
        • van Heinsbergen M.
        • Van der Heijden J.A.G.
        • Stassen L.P.
        • et al.
        The low anterior resection syndrome in a reference population: prevalence and predictive factors in the Netherlands.
        Colorectal Dis. 2020; 22: 46-52
        • Simianu V.V.
        • Fichera A.
        • Bastawrous A.L.
        • et al.
        Number of diverticulitis episodes before resection and factors associated with earlier interventions.
        JAMA Surg. 2016; 151: 604-610
        • Croese A.D.
        • Lonie J.M.
        • Trollope A.F.
        • Vangaveti V.N.
        • Ho Y.H.
        A meta-analysis of the prevalence of low anterior resection syndrome and systematic review of risk factors.
        Int J Surg. 2018; 56: 234-241
        • Martellucci J.
        Low anterior resection syndrome: a treatment algorithm.
        Dis Colon Rectum. 2016; 59: 79-82
        • Battersby N.J.
        • Bouliotis G.
        • Emmertsen K.J.
        • et al.
        Development and external validation of a nomogram and online tool to predict bowel dysfunction following restorative rectal cancer resection: the POLARS score.
        Gut. 2018; 67: 688-696
        • Hain E.
        • Manceau G.
        • Maggiori L.
        • Mongin C.
        • Prost À la Denise J.
        • Panis Y.
        Bowel dysfunction after anastomotic leakage in laparoscopic sphincter-saving operative intervention for rectal cancer: a case-matched study in 46 patients using the low anterior resection score.
        Surgery. 2017; 161: 1028-1039
        • Sturiale A.
        • Martellucci J.
        • Zurli L.
        • et al.
        Long-term functional follow-up after anterior resection for cancer.
        Int J Colorectal Dis. 2016; 32: 83-88
        • Bregendahl S.
        • Emmertsen K.J.
        • Lous J.
        • Laurberg S.
        Bowel dysfunction after low anterior resection with and without neoadjuvant therapy for rectal cancer: a population-based cross-sectional study.
        Colorectal Dis. 2013; 15: 1130-1139
        • Ho V.P.
        • Lee Y.
        • Stein S.L.
        • Temple L.K.
        Sexual function after treatment for rectal cancer: a review.
        Dis Colon Rectum. 2011; 54: 113-125
        • Lange M.M.
        • van de Velde C.J.
        Urinary and sexual dysfunction after rectal cancer treatment.
        Nat Rev Urol. 2011; 8: 51-57
        • Bregendahl S.
        • Emmertsen K.J.
        • Lindegaard J.C.
        • Laurberg S.
        Urinary and sexual dysfunction in women after resection with and without preoperative radiotherapy for rectal cancer: a population-based cross-sectional study.
        Colorectal Dis. 2015; 17: 26-37
        • Eid Y.
        • Bouvier V.
        • Menahem B.
        • et al.
        Digestive and genitourinary sequelae in rectal cancer survivors and their impact on health-related quality of life: outcome of a high-resolution population-based study.
        Surgery. 2019; 166: 327-335

      Linked Article

      • Big data exposes the tip of the LARS iceberg
        SurgeryVol. 172Issue 3
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          Multidisciplinary treatment algorithms for rectal cancer are often complex and may take many months to complete. Total neoadjuvant treatment for locally advanced rectal cancer, for example, typically includes systemic induction chemotherapy followed by short-course radiotherapy or long-course chemotherapy, and then surgical resection several weeks later. With a subsequent postoperative recovery, the patient may spend the better part of a year in treatment. If a temporary diverting stoma is required, there may be a further delay to restoration of bowel continuity.
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