HRQL after RPC in FAP Patients

The latest treatment of choice in FAP in the past two decades, has been RCP with IPAA, which preserves the sphincters as well as sexual and bladder function while nevertheless completely removing colorectal mucosa [19, 21].

However, increasing experience with long-term postoperative care of FAP patients has raised doubts as to whether - apart from its well-known elevated rate of complications [22, 23]

- IPAA really offers as much comfort as was initially thought. Indeed, ileorectal anastomosis (IRA) in the upper third of the rectum is again being discussed as an alternative procedure, and proposals have been made to base the choice between IPAA and IRA on an assessment of rectal cancer risk as defined by either the type of APC gene mutation, i.e. geno-type-phenotype correlation-based surgery or the number of rectal polyps found, or a combination of the two [24-27] and pouch polyposis may even occur [27, 28].

At the same time, increasing experience with the postoperative care of FAP patients has provided evidence that IPAA might not be as comfortable as originally assumed [28-32].

Many studies comparing functional results of FAP patients with IPAA with patients with IRA point out that results for patients with IPAA were poorer regarding the number of bowel movements per day, leakage, pad usage, perianal skin problems, food avoidance and inability to distinguish gas. Results of the HRQL surveys, however, demonstrate no difference between the IPAA and IRA groups. The Physical and Mental Summary Scales for IPAA and IRA groups are not significantly different, and none of the eight dimensions of the SF-36 Health Survey demonstrated statistical differences between IPAA and IRA groups. Therefore, better functional results are not equated with better HRQL.

Although patients with the IRA have better functional results than those with IPAA, the measured HRQL as determined by a validated generic HRQL instrument is the same for both groups. These results suggest that all patients with FAP might be optimally treated with an IPAA. More importantly, they evidence that HRQL should play a greater role in the evaluation of care and treatment in colon rectal surgery [33]

For the most part, studies focusing on quality of life [18,32,35] are difficult to interpret and compare, since different methods were used to measure function and quality of life. In summary, the main results of these studies show that both IRA and IPAA can be performed without postoperative mortality [21, 23,

32, 33]. However, subsequent complications are more common after IPAA [24, 26], with the lack of significance possibly due to the small number of patients, and IRA provides better overall continence function [24, 25, 28, 29, 33].

Nocturnal soiling and incontinence, in particular, as well as a significantly higher frequency of nighttime bowel movements, are responsible for this observation. Interestingly, IPAA does not inevitably lead to a lower quality of life compared with IRA. Ko et al. [17] observed no difference, while two reports judged IRA to be better, although statistical significance was lacking [28, 29, 34, 36].

Thus, the undoubtedly better function provided by IRA does not necessarily translate as improved quality of life, which is in good accord with other studies specifically investigating the relationship between continence function and quality of life [17,

Continence function, which is the main factor influencing patient comfort after rectal surgery, is also related to age and gender. Older and female patients are more likely to suffer from incontinence, especially after rectal surgery.

A major unresolved problem is the relationship between continence function and quality of life. It is still a moot point whether and to what extent, disordered continence inevitably leads to impaired quality of life.

Nor is the patient's ability to psychologically compensate for reduced function and, as it were, restore previous quality of life well understood. Many studies found no significant correlation between function and quality of life [17, 33]. In contrast, many others showed that continence function in otherwise healthy patients does affect quality of life [37].

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