Long-term anorectal dysfunction after postoperative radiotherapy for rectal cancer

PURPOSE: Adjuvant radiotherapy in the treatment of rectal cancer has been shown to increase long-term morbidity causing severe anorectal dysfunction with physiologic changes whose interaction remains poorly understood. This study examines long-term anorectal morbidity from adjuvant postoperative radiotherapy. METHODS: In a prospective study, patients with Dukes B or C rectal carcinoma were randomized to postoperative radiotherapy or no adjuvant treatment after anterior resection. The long-term effect of radiotherapy on anorectal function in a subset of surviving patients was assessed from a questionnaire on subjective symptoms and from physiology laboratory evaluation and flexible sigmoidoscopy. RESULTS: Twelve of 15 patients (80 percent) treated with radiotherapy had increased bowel frequency compared with 3 of the 13 patients (23 percent) who did not have radiation therapy (P = 0.003). The former group had loose or liquid stool more often (60 vs. 23 percent, P = 0.05), had fecal incontinence more often (60 vs. 8 percent, P = 0.004), and wore pad more often (47 vs. 0 percent, P = 0.004). They also experienced fecal urgency and were unable to differentiate stool from gas more often. Endoscopy revealed a pale and atrophied mucosa and telangiectasias in the irradiated patients. Anorectal physiology showed a reduced rectal capacity (146 vs. 215 ml, P = 0.03) and maximum squeeze pressure (59 vs. 93 cm H2O, P = 0.003) in the radiotherapy group. Impedance planimetry demonstrated a reduced rectal distensibility in these patients (P < 0.0001). CONCLUSIONS: Adjuvant postoperative radiotherapy after anterior resection causes severe long-term anorectal dysfunction, which is mainly the result of a weakened, less sensitive anal sphincter and an undistensible rectum with reduced capacity.