Quality of life after rectal cancer surgery de Campos-Lobato LF et al. maintained, colorectal cancer database was queried for patients with low rectal cancer who underwent curative intent APR or LAR between January 1, 1995, and January 1, 2009. Low rectal cancer was defined as cancer where the tumor was located no more than 5 cm from the anal verge, as detected by rigid proctoscopy. Only patients with documented preoperative overall QOL assessment were included. APR and LAR patients were compared with respect to demographics, preoperative morbidity, treatment character- istics, tumor stage, and overall QOL. Overall QOL was assessed through the validated short-form 36 questionnaire (SF-36), given up to 30 days prior to surgery, then at 6-, 12-, and 36-mo intervals postoperatively. SF-36, a widely used QOL questionnaire, includes 36 items selected from a larger pool of items originally used in the RAND Coorporation’s Medical Outcomes Study.17 Using multi-item scales of 35 items, it assesses eight health concepts as follows: 1. Physical functioning (10 items) 2. Role limitations caused by physical health problems (3 items) 3. Role limitations caused by emotional problems (3 items) 4. Social functioning (2 items) 5. Emotional well-being (5 items) 6. Energy/fatigue (4 items) 7. Pain (2 items) 8. General health perceptions (5 items) A final item assesses the patient’s perception of changes in health status over the last 12 mo. In order to ensure the honesty and accuracy of patient answers, patients were given the opportunity to fill out the preoperative questionnaire privately in the clinic or to take the questionnaires home with them, to complete and return by mail before the date of their surgery. The follow-up questionnaires were mailed to the patients’ homes, for them to complete at their convenience. Statistical analysis Categorical variables were expressed as numbers and percentages and compared with Pearson x2 and Fischer’s exact tests. Parametirc data were expressed as mean and standard deviation with the Student t-test for comparison. Nonparametric data were depicted as medians and inter- quartile ranges and compared with the Wilcoxon rank sum test. The overall QOL of APR versus LAR patients was compared with an analysis of covariance, adjusting for age at surgery, body mass index (BMI), chemoradiation use, and 30 days postoperative complications. RESULTS Pretreatment characteristics The database query returned 606 patients. Preoperative QOL assessment responses were available for 153 patients, and only these patients were hence included in this study. Sixty eight (44 percent) patients underwent APR and 85 (56 percent) patients underwent LAR. Five of the 85 LAR operations were intersphinteric resections. The median age was 57 y (interquartile range 49-67), and 49 (32 percent) patients were female. The proportion of patients with 1036 Continuous variables expressed as medians and interquartile ranges. Nominal variables expressed as absolute numbers with percentages in parenthesis. APR: Abdominoperienal resection, LAR: Low anterior resection, BMI: Body mass index, ASA: American Society of Anesthesiologists classification, DAV: Distance from anal verge. CLINICS 2011;66(6):1035-1040 American Society of Anesthesiologists (ASA) classification 3 or 4 was significantly higher in the APR group (45 patients, 65 percent) than in the LAR group (36 patients, 43 percent), p = 0.04. The median age of patients undergoing APR (63 y, interquartile range 54-74) was also significantly higher than those undergoing LAR (55 y, interquartile range 45-61), p , 0.001. Other demographics and preoperative morbidity were not significantly different between the two groups. As expected, the median tumor distance from anal verge was significantly shorter in APR (3 cm, interquartile range 2-4) than in LAR patients (4 cm, interquartile range 3-5), p , 0.01. All patients undergoing LAR also underwent a diverting stoma creation. Only 6 out of 85 LAR patients still had a diverting loop ileostomy at 6 mo after the index procedure, and 3 out of these received adjuvant chemother- apy. There were 8 patients (19 percent) with a pretreatment stage (c-stage) I, 22 patients (52 percent) with a c-stage II, 7 patients (17 percent) with a c-stage III, and 5 patients (12 percent) with a c-stage IV. C-stage dispersion was not significantly different between the two groups (Table 1). Radiotherapy and pathologic stage A total of 114 patients (74 percent) underwent radiation treatment, with 108 patients (95 percent) undergoing radiation before surgery. The proportion of patients receiv- ing preoperative radiation treatment was significantly higher in the LAR group (67 patients, 79 percent) than in the APR group (41 patients, 60 percent), p = 0.02. However, the use of postoperative radiation was higher in patients undergoing APR (5 patients, 7 percent) than in those undergoing LAR (1 patient, 1 percent); this was, however, not statistically significant (p = 0.06). A total of 17 patients (13 percent) had pathologic complete response: 2 patients (5 percent) in the APR group and 15 patients (4 percent) in the LAR group, p = 0.02. Twelve (8 percent) patients were pathologic stage (p-stage) I, 33 patients (22 percent) p-stage II, 45 patients (29 percent) p-stage III, and 8 patients (5 percent) p-stage IV. Excluding patients with pathologic complete response, the p-stages Table 1 - Pretreatment characteristics. APR 68 (44%) LAR 85 (56%) Variables Age (years) Gender (Female) BMI kg/m2 ASA 1 2 3 4 DAV (cm) Clinical stage I II III IV 63 (54-74) 26 (38) 28 (24-32) 1 (1) 23 (34) 42 (62) 2 (3) 3 (2-4) 13 (19) 39 (57) 7 (10) 9 (14) 55 (45-61) 23 (27) 26 (23-30) 1 (1) 48 (56) 35 (41) 1 (2) 4 (3-5) 16 (19) 41 (48) 20 (24) 8 (9) p Value ,0.001 0.14 0.11 0.04 ,0.001 0.17