QoL and Stoma

Progress in neoadjuvant therapy and the use of mechanical staplers have led to a dramatic reduction in the number of abdominoperineal extirpations (APE) during the last 20 years. So far, whenever feasible, the golden standard in the treatment of rectal cancer is a sphincter-saving procedure such as AR. In many of the works in the literature, a definitive stoma is generally associated with a reduced QoL [37-40], with an increase in social isolation [41] and deterioration of body image.

In 2001, Grumann et al. [42] published a prospective study to evaluate QoL in patients undergoing APE or AR. For the first time, surprisingly, the Authors concluded that patients undergoing APE do not have a poorer QoL than patients undergoing AR. Also, after low AR, patients have a poorer QoL than after undergoing APE. Jess et al. [43] demonstrated that stoma influences QoL only slightly, while faecal incontinence after low AR can seriously affect QoL.

These data were partially confirmed by a recent Cochrane review [44]. Among 25 potential studies, Pachler included only eight of these (with 620 patients enrolled). It was claimed that it is not possible to come to the conclusion that QoL measures for stoma patients were poorer than for non-stoma patients.

The 4-year prospective study by Engel et al. [45] drew a completely different picture. Patients after APE had a lower overall QoL than after AR. Also, over time the scores improved only in AR and not in APE patients.

Moreover, Engel et al. took into account the problem of temporary stoma. The results of this study suggested that a stoma, even if temporary, affects QoL and the reversal of it can be one of the explanations of improvement in QoL scores in patients undergoing AR.

In our experience, we test anal sphincter function before planning surgery, especially in old patients or in patients with previous anal surgery. As reported in the literature [46], we do think that faecal incontinence can influence QoL more than the presence of a stoma. Correct instructions about how to manage the stoma and how to perform colonic irrigation can reduce the problems connected to the presence of a stoma. As demonstrated by Hamashima [47], long-term QoL could be recognised according to the characteristics of rectal cancer patients, independent of the presence of a stoma.

Also, we think that a temporary stoma, especially in patients undergoing low AR with colonic J-pouch, can be useful. In our unit, these patients follow some training sessions (sometimes using pouch filling) in order to develop confidence in new perceptions and to increase sphincter tone in response to pouch distension. The stoma is usually reversed 60 days after surgery.

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