CLINICS 2011;66(6):1035-1040 were not significantly different between LAR and APR patients (Table 2). Postoperative complications Table 3 outlines the 30 d postoperative complications. Except for urinary retention, which was more common among patients undergoing APR, all other complications rates were not significantly different between the two surgical groups. Overall QOL Table 4 demonstrates the SF-36 physical (pSF-36) and mental (mSF-36) components scores. Physical component In the unadjusted analysis, patients undergoing APR had a trend to a lower pSF-36 score at baseline and 36 mo after surgery than those undergoing LAR. However, these differences could not be observed when the analysis was adjusted for age at surgery, BMI, pathologic stage, use of radiation therapy, and 30 days postoperative complications. Mental component The mean baseline mSF-36 score was significantly lower in patients undergoing APR (43.56 ¡ 10.05) than in those undergoing LAR (48.54 ¡ 9.73), p = 0.003. However, this difference could not be observed at the 6-, 12-, and 36-mo postoperative follow-up intervals. Changes in overall QOL The changes in the pSF-36 were not significantly different between the two groups during the entire follow-up period. Patients undergoing APR positively changed the mean mSF- 36 score in every follow-up period, whereas LAR patients actually decreased their mean mSF-36 score during the follow-up period. (Table 5). DISCUSSION This study was designed to compare the overall QOL of patients with low rectal cancer undergoing APR vs. LAR. Our results demonstrate that patients undergoing APR have lower mSF-36 and pSF-36 scores at baseline when compared with patients who undergo LAR. However, in the post- operative period, patients undergoing APR tend to have improvement in SF-36 scores, such that at 6 mo after surgery the overall QOL difference between LAR and APR is no longer statistically significant. This difference further Table 2 - Radiation therapy and pathologic stage. APR 68 (44%) LAR 85 (56%) p Value Variables Preoperative radiation Postoperative radiation Pathologic complete response Pathologic stage I II III IV 41 (60) 5 (7) 2 (3) 20 (29) 18 (26) 24 (35) 4 (6) 67 (79) 1 (1) 15 (18) 30 (35) 15 (18) 21 (24) 4 (5) 0.02 0.06 0.02 0.5 Nominal variables expressed as absolute numbers with percentage in parenthesis. APR: Abdominoperineal resection, LAR: Low anterior resection. Quality of life after rectal cancer surgery de Campos-Lobato LF et al. Table 3 - Postoperative complications. APR 68 (44%) LAR 85 (56%) p Value Variables Urinary infection Urinary retention Wound infection Wound dehiscence Abd/Pelvic Abscess Perineal infection Anastomotic leak Reoperation Readmission 1 (2) 8 (12) 2 (3) 2 (3) 4 (6) 9 (13) 2 (3) 9 (13) 3 (4) 2 (2) 3 (4) 1 (1) 5 (6) 7 (8) 5 (6) 4 (5) 0.63 0.02 1 0.59 1 0.46 0.07 1037 Nominal variables expressed as absolute numbers with percentage in parenthesis. APR: Abdominoperineal resection, LAR: Low anterior resection, Abd: Abdominal, N/A: Not applicable. decreases and essentially disappears at the 36-mo post- operative period. The QOL differences between patients undergoing APR and LAR have been studied in the past;18 however, many of these studies did not use validated tools to assess QOL,19-21 included patients without a baseline QOL assessment,22-24 did not adjust the analysis for confounding factors such as age, gender, and tumor staging,19,22 or also included patients with upper-third rectal cancers.22,25 A 2005 Cochrane review26 regarding the QOL of rectal cancer patients undergoing LAR and APR evaluated a sample of 1,412 from 25 studies. The authors concluded that the studies reviewed did not confirm any conclusions about the QOL of patients undergoing APR being inferior or superior to that of patients who underwent LAR and opined that better designed studies with larger samples are required. The main drawbacks cited by the review were the absence of baseline QOL assessment, inclusion of mid- and upper- third rectal cancers, short follow-up and missing data, and finally no data regarding patient social class. In an attempt to overcome these limitations of the previous studies, we included only low rectal cancer patients who had the overall QOL assessed prior to surgery. Moreover, we evaluated the overall QOL using the SF-36, a tested and validated measure of health status that was developed in the United States and that is currently validated for use in 13 countries.27,28 Finally, we also adjusted the overall QOL to decrease the effect of potentially confounding factors, thus effectively placing more emphasis on the treatment paradigm, that is, APR or LAR. The fact that patients who underwent APR have a similar long-term QOL to those who underwent LAR is an apparent contradiction to traditional beliefs.14 An APR is without a doubt a much greater mutilation than an LAR and also has a potentially major impact on body image.29 However, LAR has been associated with side effects that can drastically decrease overall postoperative QOL, including fecal incon- tinence, urgency and outlet dysfunction, as well as those complications typical of any anastomosis, such as strictures, and leaks.30-33 The realization that a permanent ostomy is inevitable in an attempt to defeat their cancer is likely responsible for the lower QOL at baseline for the APR patients, because this