The Impact of Anastomotic Leakage on Long-term Function after Anterior Resection for Rectal Cancer

BACKGROUND: It is still not clear whether anastomotic leakage after anterior resection for rectal cancer affects long-term functional outcome. OBJECTIVE: This study aimed to evaluate how anastomotic leakage following anterior resection for rectal cancer influences defecatory, urinary, and sexual function. DESIGN: In this retrospective population-based cohort study, patients were identified through the Swedish Colorectal Cancer Registry, which was also used for information on the exposure variable anastomotic leakage and covariates. SETTINGS: A nationwide register was used for including patients. PATIENTS: All patients undergoing anterior resection for rectal cancer in Sweden from April 2011 to June 2013 were included. MAIN OUTCOME MEASURES: Outcome was any defecatory, sexual, or urinary dysfunction, assessed 2 years after surgery by a postal questionnaire. The association between anastomotic leakage and function was assessed in multivariable logistic and linear regression models, with adjustment for confounding. RESULTS: Response rate was 82%, resulting in 1180 included patients. Anastomotic leakage occurred in 7.5%. A permanent stoma was more common among patients with leakage (44% vs 9%; p < 0.001). Patients with leakage had an increased risk of aid use for fecal incontinence (OR, 2.27; 95% CI, 1.20-4.30) and reduced sexual activity (90% vs 82%; p = 0.003), whereas the risk of urinary incontinence was decreased (OR, 0.53; 95% CI, 0.31-0.90). A sensitivity analysis assuming that a permanent stoma was created because of anorectal dysfunction strengthened the negative impact of leakage on defecatory dysfunction. LIMITATIONS: Limitations include the use of a questionnaire that had not been previously validated, underreporting of anastomotic leakage in the register, and small patient numbers in the analysis of sexual symptoms. CONCLUSIONS: Anastomotic leakage was found to statistically significantly increase the risk of aid use due to fecal incontinence and reduced sexual activity, although the impact on defecatory dysfunction might be underestimated, because permanent stomas are sometimes fashioned because of anorectal dysfunction. Further research is warranted, especially regarding urogenital function.