196 Chapter 9 after proctectomy 29. Westerduin et al. identified five domains of the EORTC QLQ-30 as well as two functional and five emotional domains of the -CR29 which were significantly better beyond one year postoperatively in patient with AL compared to the patients without AL 28. Hain et al. reported additional impaired -CR29 outcomes (more blood and mucus in stool, and frequent bowel movements and urination per day) in patients with symptomatic AL compared to the combined groups of patients with no or asymptomatic AL 23. Di Re et al. also demonstrated lower mean EQ-VAS scores among patients with AL vs non-AL patients in a matched cohort, at one year after surgery (range up to 5 years), although the difference did not reach statistical significance 21. At 18 and 24 months postoperatively, van Kooten et al. found no differences in RSCL scores between AL and non-AL patients 30. Arron et al. found no difference in overall HRQoL scores between AL and non-AL patients at two years relative to baseline EORTC QLQ-C30 scores 22. Similar results were described when SF-36 scores were compared more than two years after surgery between patients with AL (median of 4 years postoperatively) and without AL (median of 6.4 years postoperatively) 25. Riss et al. described no significant difference in mental and physical QoL scores measured by the SF-12 questionnaire at a median follow-up time of 106.8 months after rectal surgery (range of 32.5–170.4 months) comparing AL to AL patients from a matched cohort 27. Two additional studies evaluated longer-term impact of AL on QoL 20, 31. Lim et al. assessed the EORTC QLQ-C30 in patients without AL, with subclinical leaks, and with clinical leaks with and without ileostomy closure (overall median follow-up time of 26 months; IQR 19-37 months) 20. They found worse scores in patients with clinical leaks in whom ileostomy reversal was not possible. Miura et al. did not find significant differences in overall modified FIQL scores when comparing AL and non-AL patients at a median time of 63 months after low rectal cancer surgery 31. Van Kooten et al. conducted a supplementary analysis on EORTC QLQ-C30 and -CR29 outcomes 14 years post-surgery, with no statistically significant differences between AL and non-AL patients 30. Other outcomes related to QoL Some additional outcomes that might influence QoL are summarized in Supplementary S6. Neo-adjuvant treatments were described by nine studies 20-24, 26-29, which showed to be significantly different between AL and non-AL patients in one study for chemoradiation therapy and in another study for radiotherapy only 24, 28. Diverting stoma rates between AL and non-AL patients were compared in six studies 21, 22, 24, 27-29, of which two found significant differences (more diverting in AL group) 27, 29. Stoma status during follow-up was clearly described by two studies 22, 24, which all showed significant differences between AL and non-AL patients within the first year after surgery. Two additional studies described permanent stoma rates related
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