Advertisement

International Journal of Colorectal Disease

, Volume 22, Issue 11, pp 1311–1317 | Cite as

Effect of neoadjuvant chemoradiation on postoperative fecal continence and anal sphincter function in rectal cancer patients

  • Alexander P. Pietsch
  • Rainer Fietkau
  • Günther Klautke
  • Thomas Foitzik
  • Ernst Klar
Original Article

Abstract

Background and aims

Neoadjuvant chemoradiation (nCRT) followed by curative surgery has gained acceptance as the therapy of choice in locally advanced rectal cancer. This prospective study evaluates the effect of nCRT on postoperative anorectal function and continence.

Patients and methods

Group A consisted of 12 patients (59.8 ± 11.9 years, male:female = 8:4) who received nCRT (5-FU, CPT-11. 45 + 5.4 Gy boost) before surgery and Group B of 27 patients (61.9 ± 10.6 years, male:female = 16:11) who were treated by surgery alone. All patients received a questionnaire to evaluate stool continence and anorectal function before as well as after surgery. Anorectal function was further analyzed by perfusion manometry pre- and postoperatively.

Results

Preoperatively, none of the patients had signs or symptoms of fecal incontinence, and preoperative measurements showed values within normal limits. Postoperatively, fecal continence was impaired in both groups, but no significant difference was found between patients with or without nCRT. Anorectal manometry revealed an impairment of anorectal function after low anterior resection regardless of the treatment regime.

Conclusion

nCRT does not impair anorectal function and fecal continence. The deterioration of continence and anal sphincter function after sphincter preserving surgery is solely caused by the surgical procedure.

Keywords

Neoadjuvant chemoradiation Rectal cancer Fecal incontinence Manometry 

References

  1. 1.
    Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1(8496):1479–1482CrossRefPubMedGoogle Scholar
  2. 2.
    Lewis WG, Holdsworth PJ, Kuzu A, Finan PJ, Johnston D (1992) Anterior resection syndrome: the physiological basis of patients’ symptoms. Gut 33:A6CrossRefGoogle Scholar
  3. 3.
    Lewis WG, Martin IG, Williamson ME, Stephenson BM, Holdsworth PJ, Finan PJ, Johnston D (1995) Why do some patients experience poor functional results after anterior resection of the rectum for carcinoma? Dis Colon Rectum 38:259–263CrossRefPubMedGoogle Scholar
  4. 4.
    Paty PB, Enker WE, Cohen AM, Minsky BD, Friedlander-Klar H (1994) Long-term functional results of coloanal anastomosis for rectal cancer. Am J Surg 67:90–94CrossRefGoogle Scholar
  5. 5.
    Kapiteijn E, Marijnen CA, Nagtegaal ID, Putter H, Steup WH, Wiggers T, Rutten HJ, Pahlman L, Glimelius B, van Krieken JH, Leer JW, van de Velde CJ (2001) Dutch colorectal cancer group. Preoperative radiotherapy combined with total mesorectal excision for resectable rectal cancer. N Engl J Med 345:638–646CrossRefPubMedGoogle Scholar
  6. 6.
    Sauer R, Fietkau R, Wittekind C, Rodel C, Martus P, Hohenberger W, Tschmelitsch J, Sabitzer H, Karstens JH, Becker H, Hess C, Raab R (2003) German rectal cancer group. Adjuvant vs neoadjuvant radiochemotherapy for locally advanced rectal cancer: the German trial CAO/ARO/AIO-94. Colorectal Dis 5:406–415CrossRefPubMedGoogle Scholar
  7. 7.
    Swedish Rectal Cancer Trial (1997) Preoperative radiotherapy improves survival in resectable rectal carcinoma: report from a nation-wide Swedish trial. N Engl J Med 336:980–987CrossRefGoogle Scholar
  8. 8.
    Broens P, Van Limbergen E, Penninckx F, Kerremans R (1998) Clinical and manometric effects of combined external beam irradiation and brachytherapy for anal cancer. Int J Colorectal Dis 13:68–72CrossRefPubMedGoogle Scholar
  9. 9.
    Iwamoto T, Nakahara S, Mibu R, Hotokezaka M, Nakano H, Tanaka M (1997) Effect of radiotherapy on anorectal function in patients with cervical cancer. Dis Colon Rectum 40:693–697CrossRefPubMedGoogle Scholar
  10. 10.
    Putta S, Andreyev HJ (2005) Faecal incontinence: a late side-effect of pelvic radiotherapy. Clin Oncol (R Coll Radiol) 17:469–477CrossRefGoogle Scholar
  11. 11.
    Varma JS, Smith AN, Busuttil A (1985) Correlation of clinical and manometric abnormalities of rectal function following chronic radiation injury. Br J Surg 72:875–878CrossRefPubMedGoogle Scholar
  12. 12.
    Varma JS, Smith AN, Busuttil A (1986) Function of the anal sphincters after chronic radiation injury. Gut 27:528–533CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Vordermark D, Sailer M, Flentje M, Thiede A, Kolbl O (1999) Curative-intent radiation therapy in anal carcinoma quality of life and sphincter function. Radiother Oncol 52:239–243CrossRefPubMedGoogle Scholar
  14. 14.
    Yeoh EK, Sun WM, Russo A, Ibanez L, Horowitz M (1996) A retrospective study of the effects of pelvic irradiation for gynaecological cancer on anorectal function. Int J Radiat Oncol Biol Phys 35:1003–1010CrossRefPubMedGoogle Scholar
  15. 15.
    Yeoh EE, Holloway RH, Fraser RJ, Botten RJ, Di Matteo AC, Moore JW, Schoeman MN, Bartholomeusz FD (2004) Anorectal dysfunction increases with time following radiation therapy for carcinoma of the prostate. Am J Gastroenterol 99:361–369CrossRefPubMedGoogle Scholar
  16. 16.
    Ammann K, Kirchmayr W, Klaus A, Muhlmann G, Kafka R, Oberwalder M, De Vries A, Ofner D, Weiss H (2003) Impact of neoadjuvant chemoradiation on anal sphincter function in patients with carcinoma of the midrectum and low rectum. Arch Surg 138:257–261CrossRefPubMedGoogle Scholar
  17. 17.
    Birnbaum EH, Myerson RJ, Fry RD, Kodner IJ, Fleshman JW (1994) Chronic effects of pelvic radiation therapy on anorectal function. Dis Colon Rectum 37:909–915CrossRefPubMedGoogle Scholar
  18. 18.
    Dahlberg M, Glimelius B, Graf W, Påhlman L (1998) Preoperative irradiation affects functional results after surgery for rectal cancer: results from a randomized study. Dis Colon Rectum 41:543–551CrossRefPubMedGoogle Scholar
  19. 19.
    Dehni N, McNamara DA, Schlegel RD, Guiguet M, Tiret E, Parc R (2002) Clinical effects of preoperative radiation therapy on anorectal function after proctectomy and colonic J-pouch-anal anastomosis. Dis Colon Rectum 45:1635–1640CrossRefPubMedGoogle Scholar
  20. 20.
    Gervaz P, Rotholtz N, Wexner SD, You SY, Saigusa N, Kaplan E, Secic M, Weiss EG, Nogueras JJ, Belin B (2001) Colonic J-pouch function in rectal cancer patients: impact of adjuvant chemoradiotherapy. Dis Colon Rectum 44:1667–1675CrossRefPubMedGoogle Scholar
  21. 21.
    Nathanson DR, Espat NJ, Nash GM, D’Alessio M, Thaler H, Minsky BD, Enker W, Wong D, Guillem J, Cohen A, Paty PB (2003) Evaluation of preoperative and postoperative radiotherapy on longterm functional results of straight coloanal anastomosis. Dis Colon Rectum 46:888–894CrossRefPubMedGoogle Scholar
  22. 22.
    Peeters KC, van de Velde CJ, Leer JW, Martijn H, Junggeburt JM, Kranenbarg EK, Steup WH, Wiggers T, Rutten HJ, Marijnen CA (2005) Late side effects of short-course preoperative radiotherapy combined with total mesorectal excision for rectal cancer: increased bowel dysfunction in irradiated patients—a Dutch colorectal cancer group study. J Clin Oncol 23:6199–6206CrossRefPubMedGoogle Scholar
  23. 23.
    Welsh FK, McFall M, Mitchell G, Miles WF, Woods WG (2003) Pre-operative short-course radiotherapy is associated with faecal incontinence after anterior resection. Colorectal Dis 5:563–568CrossRefPubMedGoogle Scholar
  24. 24.
    Pollack J, Holm T, Cedermark B, Holmstrom B, Mellgren A (2006) Long-term effect of preoperative radiation therapy on anorectal function. Dis Colon Rectum 49:345–52CrossRefPubMedGoogle Scholar
  25. 25.
    Saito N, Ono M, Sugito M, Ito M, Morihiro M, Kosugi C, Sato K, Kotaka M, Nomura S, Arai M, Kobatake T (2004) Early results of intersphincteric resection for patients with very low rectal cancer: an active approach to avoid a permanent colostomy. Dis Colon Rectum 47:459–466CrossRefPubMedGoogle Scholar
  26. 26.
    van Duijvendijk P, Slors JF, Taat CW, van Tets WF, van Tienhoven G, Obertop H, Boeckxstaens GE (2002) Prospective evaluation of anorectal function after total mesorectal excision for rectal carcinoma with or without preoperative radiotherapy. Am J Gastroenterol 97:2282–2289CrossRefPubMedGoogle Scholar
  27. 27.
    Riepl M, Pietsch A, Klautke G, Fehr R, Fietkau R (2000) Endoskopische prätherapeutische Clipmarkierung von Tumoren im Gastrointestinaltrakt. Eine Methode zur exakteren Definition von Zielvolumina. Strahlenther Onkol 176:517–523CrossRefPubMedGoogle Scholar
  28. 28.
    Jorge JM, Wexner SD (1993) Etiology and management of fecal incontinence. Dis Colon Rectum 36:77–97CrossRefPubMedGoogle Scholar
  29. 29.
    Frykholm GJ, Sintorn K, Montelius A et al (1996) Acute lumbosacral plexopathy during and after preoperative radiotherapy of rectal adenocarcinoma. Radiother Oncol 38:121–130CrossRefPubMedGoogle Scholar
  30. 30.
    Gervaz P, Hennig R, Buechler M, Soravia C, Brigstock DR, Morel P, Egger JF, Friess H (2003) Long-term expression of fibrogenic cytokines in radiation-induced damage to the internal anal sphincter. Swiss Surg 9:193–197CrossRefPubMedGoogle Scholar
  31. 31.
    da Silva GM, Berho M, Wexner SD, Efron J, Weiss EG, Nogueras JJ, Vernava AM III, Connor JT, Gervaz P (2003) Histologic analysis of the irradiated anal sphincter. Dis Colon Rectum 46:1492–1497CrossRefPubMedGoogle Scholar
  32. 32.
    Lim JF, Tjandra JJ, Hiscock R, Chao MW, Gibbs P (2006) Preoperative chemoradiation for rectal cancer causes prolonged pudendal nerve terminal motor latency. Dis Colon Rectum 49:12–19CrossRefPubMedGoogle Scholar
  33. 33.
    Reis ED, Vine AJ, Heimann T (2002) Radiation damage to the rectum and anus: pathophysiology, clinical features and surgical implications. Colorectal Dis 4:2–12CrossRefPubMedGoogle Scholar
  34. 34.
    Kollmorgen CF, Meagher AP, Wolff BG, Pemberton JH, Martenson JA, Ilstrup DM (1994) The long-term effect of adjuvant postoperative chemoradiotherapy for rectal carcinoma on bowel function. Ann Surg 220:676–682CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Lewis WG, Williamson ME, Kuzu A, Stephenson BM, Holdsworth PJ, Finan PJ, Ash D, Johnston D (1995) Potential disadvantages of post-operative adjuvant radiotherapy after anterior resection for rectal cancer: a pilot study of sphincter function, rectal capacity and clinical outcome. Int J Colorectal Dis 10:133–137CrossRefPubMedGoogle Scholar
  36. 36.
    Lundby L, Krogh K, Jensen VJ, Gandrup P, Qvist N, Overgaard J, Laurberg S (2005) Long-term anorectal dysfunction after postoperative radiotherapy for rectal cancer. Dis Colon Rectum 48:1343–1349CrossRefPubMedGoogle Scholar
  37. 37.
    Kienle P, Abend F, Dueck M, Abel U, Treiber M, Riedl S (2006) Influence of intraoperative and postoperative radiotherapy on functional outcome in patients undergoing standard and deep anterior resection for rectal cancer. Dis Colon Rectum 49:557–567CrossRefPubMedGoogle Scholar
  38. 38.
    Shibata D, Ghillem JG, Lanouette N, Paty P, Minsky B, Harrison L, Wong WD, Cohen A (2000) Functional and quality-of-life outcomes in patients with rectal cancer after combined modality therapy, intraoperative radiation therapy, and sphincter preservation. Dis Colon Rectum 43:752–758CrossRefPubMedGoogle Scholar
  39. 39.
    Allgayer H, Dietrich CF, Rohde W, Koch GF, Tuschhoff T (2005) Prospective comparison of short-and long-term effects of pelvic floor exercise/biofeedback training in patients with fecal incontinence after surgery plus irradiation versus surgery alone for colorectal cancer: clinical, functional and endoscopic/endosonographic findings. Scand J Gastroenterol 40:1168–1175CrossRefPubMedGoogle Scholar
  40. 40.
    Abbasakoor F, Vaizey CJ, Boulos PB (2006) Improving the morbidity of anorectal injury from pelvic radiotherapy. Colorectal Dis 8:2–10CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Alexander P. Pietsch
    • 1
    • 3
  • Rainer Fietkau
    • 2
  • Günther Klautke
    • 2
  • Thomas Foitzik
    • 1
  • Ernst Klar
    • 1
  1. 1.Department of SurgeryUniversity of RostockRostockGermany
  2. 2.Department of Radiation OncologyUniversity of RostockRostockGermany
  3. 3.Department of General, Thoracic, Vascular, and Transplantation SurgeryUniversity of RostockRostockGermany

Personalised recommendations