Bowel function survey after segmental colorectal resections

Long-term Bowel Dysfunction and Decline in Quality of Life Following Surgery for Colon Cancer: Call for Personalized Screening and Treatment

BACKGROUND

Differences in long-term outcomes regarding types of colon resections are inconclusive, precluding patient counseling, effective screening, and personalized treatment.

OBJECTIVE

This study aimed to compare long-term bowel function and quality of life in patients who underwent right or left hemicolectomy or sigmoid colon resection.

DESIGN

This was a multicenter cross-sectional study.

SETTINGS

Seven Dutch hospitals participated in this study.

PATIENTS

This study included patients who underwent right or left hemicolectomy or sigmoid colon resection without construction of a permanent stoma between 2009 and 2015. Patients who were deceased, mentally impaired, or living abroad were excluded. Eligible patients were sent the validated Defecation and Fecal Continence and Short-Form 36 questionnaires.

MAIN OUTCOME MEASURES

Constipation, fecal incontinence (both Rome IV criteria), separate bowel symptoms, and generic quality of life were the main outcomes assessed.

RESULTS

This study included 673 patients who underwent right hemicolectomy, 167 who underwent left hemicolectomy, and 284 who underwent sigmoid colon resection. The median follow-up was 56 months. Sigmoid colon resection increased the likelihood of constipation compared to right and left hemicolectomy (OR, 2.92; 95% CI, 1.80-4.75; p < 0.001 and OR, 1.93; 95% CI, 1.12-3.35; p = 0.019). Liquid incontinence and fecal urgency increased after right hemicolectomy compared to sigmoid colon resection (OR, 2.15; 95% CI, 1.47-3.16; p < 0.001 and OR, 2.01; 95% CI, 1.47-2.74; p < 0.001). Scores on quality-of-life domains were found to be significantly lower after right hemicolectomy.

LIMITATIONS

Because of the cross-sectional design, longitudinal data are still lacking.

CONCLUSIONS

Different long-term bowel function problems occur after right or left hemicolectomy or sigmoid colon resection. The latter seems to be associated with more constipation than right or left hemicolectomy. Liquid incontinence and fecal urgency seem to be associated with right hemicolectomy, which may explain the decline in physical and mental generic quality of life of these patients. See Video Abstract at http://links.lww.com/DCR/C13 .

DISFUNCIN INTESTINAL A LARGO PLAZO Y DISMINUCIN DE LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE COLON SOLICITUD DE DETECCIN Y TRATAMIENTO PERSONALIZADOS

ANTECEDENTES:Las diferencias en los resultados a largo plazo con respecto a los tipos de resecciones de colon no son concluyentes, lo que impide el asesoramiento preoperatorio del paciente y la detección eficaz y el tratamiento personalizado de la disfunción intestinal postoperatoria durante el seguimiento.OBJETIVO:Comparar la función intestinal a largo plazo y la calidad de vida en pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide.DISEÑO:Estudio transversal multicéntrico.AJUSTES:Participaron siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide sin construcción de estoma permanente entre 2009 y 2015. Se excluyeron pacientes fallecidos, con discapacidad mental o residentes en el extranjero. A los pacientes elegibles se les enviaron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron el estreñimiento, la incontinencia fecal (ambos criterios de Roma IV), los síntomas intestinales separados y la calidad de vida genérica.RESULTADOS:Se incluyeron 673 pacientes con hemicolectomía derecha, 167 con hemicolectomía izquierda y 284 con resección de colon sigmoide. La mediana de seguimiento fue de 56 meses (RIC 41-80). La resección del colon sigmoide aumentó la probabilidad de estreñimiento en comparación con la hemicolectomía derecha e izquierda (OR, 2,92, IC 95%, 1,80-4,75, p < 0,001 y OR 1,93, IC 95%, 1,12-3,35, p = 0,019). La incontinencia de líquidos y la urgencia fecal aumentaron después de la hemicolectomía derecha en comparación con la resección del colon sigmoide (OR, 2,15, IC 95%, 1,47-3,16, p < 0,001 y OR 2,01, IC 95%, 1,47-2,74, p < 0,001). Las puntuaciones en los dominios de calidad de vida fueron significativamente más bajas después de la hemicolectomía derecha.LIMITACIONES:Debido al diseño transversal, aún faltan datos longitudinales.CONCLUSIONES:Se producen diferentes problemas de función intestinal a largo plazo después de la hemicolectomía derecha o izquierda, o la resección del colon sigmoide. Este último parece estar asociado con más estreñimiento que la hemicolectomía derecha o izquierda. La incontinencia de líquidos y la urgencia fecal parecen estar asociadas a la hemicolectomía derecha, lo que puede explicar el deterioro de la calidad de vida física y mental en general de estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/C13 . (Traducción-Dr. Yolanda Colorado ).

Functional Bowel Complaints and the Impact on Quality of Life After Colorectal Cancer Surgery in the Elderly

Background

The Low Anterior Resection Syndrome (LARS) is commonly reported after colorectal cancer surgery and significantly impairs quality of life. The prevalence and impact of LARS in the elderly after rectal cancer as well as colon cancer surgery is unclear. We aimed to describe the prevalence of LARS complaints and the impact on quality of life in the elderly after colorectal cancer surgery.

Materials and Methods

Patients were included from seven Dutch hospitals if they were at least one year after they underwent colorectal cancer surgery between 2008 and 2015. Functional bowel complaints were assessed by the LARS score. Quality of life was assessed by the EORTC QLQ-C30 and EORTC QLQ-CR29 questionnaires. Outcomes in patients ≥70 years were compared to a reference group of patients <70 years.

Results

In total 440 rectal cancer and 1183 colon cancer patients were eligible for analyses, of whom 133 (30.2%) rectal and 536 (45.3%) colon cancer patients were ≥70 years. Major LARS was reported by 40.6% of rectal cancer and 22.2% of colon cancer patients ≥70 years. In comparison, patients <70 years reported major LARS in 57.3% after rectal cancer surgery (p=0.001) and in 20.4% after colon cancer surgery (p=0.41). Age ≥70 years was independently associated with reduced rates of major LARS after rectal cancer surgery (OR 0.63, p=0.04). Patients with major LARS reported significantly impaired quality of life on almost all domains.

Conclusion

Elderly should not be withheld a restorative colorectal cancer resection based on age alone. However, a substantial part of the elderly colorectal cancer patients develops major LARS after surgery, which often severely impairs quality of life. Since elderly frequently consider quality of life and functional outcomes as one of the most important outcomes after treatment, major LARS and its impact on quality of life should be incorporated in the decision-making process.

Effects of Preoperative Radiotherapy on Long-Term Bowel Function in Patients With Rectal Cancer Treated With Anterior Resection: A Systematic Review and Meta-analysis

Background: Anterior resection is a common surgical approach used in rectal cancer surgery; however, this procedure is known to cause bowel injury and dysfunction. Neoadjuvant therapy is widely used in patients with locally advanced rectal cancer. In this study, we determined the effect of preoperative radiotherapy on long-term bowel function in patients who underwent anterior resection for treatment of rectal cancer. Methods: We performed a comprehensive literature search of the PubMed, Embase, Web of Science, and the Cochrane Library databases. A random-effects model was used in the meta-analysis by the Review Manager software, version 5.3. Results: This systematic review and meta-analysis included 12 studies, which used low anterior resection syndrome score with a total of 2349 patients. Based on them, we concluded that low anterior resection syndrome was significantly more common in the preoperative radiotherapy group (odds ratio 3.59, 95% confidence interval 2.68-4.81, P < .00001) and that major low anterior resection syndrome also occurred significantly more frequently in the preoperative radiotherapy group (odds ratio 3.28, 95% confidence interval 2.05-5.26, P < .00001). Subgroup analyses of long-course radiation, total mesorectal excision, and non-metastatic tumors were performed, and the results met the conclusions of the primary outcomes. Conclusions: Preoperative radiotherapy negatively affects long-term bowel function in patients who undergo anterior resection for rectal cancer.

Complete Mesocolic Excision and D3 Lymphadenectomy versus Conventional Colectomy for Colon Cancer: A Systematic Review and Meta-Analysis

BACKGROUNDS

Previous systematic reviews suggest that the implementation of 'complete mesocolon excision' (CME) for colon tumors entails better specimen quality but with limited long-term outcomes. We performed a meta-analysis to compare the pathological, perioperative, and oncological results of CME with conventional surgery (CS) in primary colon cancer.

METHODS

Embase, MEDLINE and CENTRAL databases were searched using Medical Subject Headings for CME and D3 lymphadenectomy. The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

A total of 18,989 patients from 27 studies were included. Postoperative complications were higher in the CME group (relative risk [RR] 1.13, 95% confidence interval [CI] 1.04-1.22, I² = 0%), while no differences were observed in terms of anastomotic leak (I² = 0%) or perioperative mortality (I² = 49%). CME was associated with a higher number of lymph nodes harvested (I² = 95%), distance to high tie (I² = 65%), bowel length (I² = 0%), and mesentery area (I² = 95%). CME also had positive effects on 3- and 5-year overall survival (RR 1.09, 95% CI 1.04-1.15, I² = 88%; and RR 1.05, 95% CI 1.02-1.08, I² = 62%, respectively) and 3-year disease-free survival (RR 1.10, 95% CI 1.04-1.17, I² = 22%), as well as decreased local (RR 0.35, 95% CI 0.24-0.51, I² = 51%) and distant recurrences (RR 0.71, 95% CI 0.60-0.85, I² = 34%).

CONCLUSIONS

Limited evidence suggests that CME improves oncological outcomes with a higher postoperative adverse events rate but no increase in anastomotic leak rate or perioperative mortality, compared with CS.

Long-Term Functional Results of a Modified Caudal-to-Cranial Approach in Laparoscopic Segmental Left Colectomy for Diverticular Disease

A modified caudal-to-cranial approach to perform laparoscopic left colectomy for benign diseases has been recently designed to facilitate the low-tie mesenteric dissection. A chart review has been performed including all consecutive patients with uncomplicated diverticulitis who have been treated by segmental left colectomy with a caudal-to-cranial approach. A total of 34 patients were included in the study. 21 patients were male, mean age was 54.1 ± 11.3, and mean BMI was 26 ± 5.5. Patients with ASA Score I were 7, with ASA II were 9, and with ASA Score III were 5. Incontinence Score (IS) resulted in an average of 5 ± 2, 2 grade of incontinence and the CS score showed an average of 10 ± 3, 2 grade of constipation. Health status, evaluated by Short Form-36 questionnaire, was demonstrated in these patients' great physical function, role, general health, and social function. The anorectal manometry performed 6 months after surgery showed a normal value in terms of the anal resting pressure (47 ± 13 mmHg) and an increased volume to stimulate desire to defecate (197 ± 25 ml). The length of the anal sphincter was normal compared to the reference value (37 ± 5.4 mm). Although further studies are required to obtain definitive conclusions, our results are encouraging to propose low-tie segmental colectomy as the standard procedure for the treatment of uncomplicated diverticulitis, and our modified surgical approach could be considered useful to facilitate the surgical approach.

Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis

INTRODUCTION

As survival rates of colon cancer increase, knowledge about functional outcomes is becoming ever more important. The primary aim of this systematic review and meta-analysis was to quantify functional outcomes after surgery for colon cancer. Secondly, we aimed to determine the effect of time to follow-up and type of colectomy on postoperative functional outcomes.

MATERIALS AND METHODS

A systematic literature search was performed to identify studies reporting bowel function following surgery for colon cancer. Outcome parameters were bowel function scores and/or prevalence of bowel symptoms. Additionally, the effect of time to follow-up and type of resection was analyzed.

RESULTS

In total 26 studies were included, describing bowel function between 3 to 178 months following right hemicolectomy (n = 4207), left hemicolectomy/sigmoid colon resection (n = 4211), and subtotal/total colectomy (n = 161). In 16 studies (61.5%) a bowel function score was used. Pooled prevalence for liquid and solid stool incontinence was 24.1% and 6.9%, respectively. The most prevalent constipation-associated symptoms were incomplete evacuation and obstructive, difficult emptying (33.3% and 31.4%, respectively). Major Low Anterior Resection Syndrome was present in 21.1%. No differences between time to follow-up or type of colectomy were found.

CONCLUSION

Bowel function problems following surgery for colon cancer are common, show no improvement over time and do not depend on the type of colectomy. Apart from fecal incontinence, constipation-associated symptoms are also highly prevalent. Therefore, more attention should be paid to all possible aspects of bowel dysfunction following surgery for colon cancer and targeted treatment should commence promptly.

Does Bowel Function Change After Colectomy for Colon Malignancy?

BACKGROUND

Colon cancer patients often ask how surgery will affect bowel function. Current understanding is informed by conflicting data, making preoperative patient counseling difficult. We aimed to evaluate patient-reported bowel function changes after colectomy for colon malignancy.

MATERIAL AND METHODS

This was a retrospective analysis of a prospectively collected institutional database from July 2015 to June 2019. The included patients underwent colectomy for adenocarcinoma of the colon, and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation and postoperative followup. Preoperative and postoperative scores were compared using paired t-tests. Multivariable analysis was performed using domains demonstrating statistical significance on bivariate analysis, assessing the factors that were associated with symptomatic bowel function.

RESULTS

We identified 117 patients with a mean age of 64 ± 13 y. The median time between preoperative and postoperative questionnaire completion was 52 d (interquartile range 45-70). Bowel movement frequency increased significantly from a mean preoperative score of 9.72 to a mean postoperative score of 14.2 (P = 0.003). There were no significant differences in the remaining four domains of bowel function or global function. Multivariable analysis demonstrated higher likelihood of symptomatic postoperative frequency scores in male patients (OR 3.85, 95% CI 1.44-11.11, P = 0.007) and patients with symptomatic preoperative frequency (OR 5.56, 95% CI 1.62-19.02, P = 0.006).

CONCLUSIONS

Patient-reported bowel movement frequency worsens at postoperative follow-up after colectomy for colon cancer, while overall bowel function does not change. Men and patients with preoperative symptomatic frequency have an increased likelihood of reporting symptomatic postoperative frequency. These findings should guide more personalized and evidence-based preoperative patient counseling.

Patient-reported and physician-recorded bowel dysfunction following colorectal resection and radical cystectomy: a prospective, comparative study

AIM

Bowel dysfunction following anterior resection (AR) is termed low anterior resection syndrome. It is unclear whether such dysfunction occurs following other bowel/pelvic operations as well. This study aimed to characterize and compare bowel dysfunction following AR, right hemicolectomy (RH) and radical cystectomy (RC).

METHOD

A prospective study of consecutive patients undergoing AR, RH and RC (2002-2012) was performed at a tertiary referral centre in Sydney, Australia. Outcome measures included (i) patient-reported satisfaction with bowel function, self-described bowel function and self-reported change in bowel function; (ii) objective assessment of bowel function using validated criteria to identify symptoms and stratify patients into those with constipation and/or faecal incontinence (FI); and (iii) health-related quality of life (SF-36v2 Health Survey).

RESULTS

Of 743 eligible patients, 70% participated [AR, n = 338, mean age 69.6 years (SD 11.9), 59% men; RH, n = 150, 75.8 years (SD 10.5), 54% men; RC, n = 34, 71.1 years (SD 14.1), 71% men]. AR patients were three times more likely to report change in bowel function post-surgery and self-judged their bowel function as abnormal more frequently (64%) than RH patients (35%) and RC patients (35%) (P < 0.01). AR patients were four times more likely to meet criteria for concomitant constipation and FI. Patients with concomitant constipation and FI had lower physical and mental SF-36v2 scores (P < 0.001).

CONCLUSION

Bowel dysfunction occurred after RH and RC but rates were higher following AR. This suggests that low anterior resection syndrome occurs due to a direct impact of partial/complete loss of the rectum rather than just due to loss of bowel length and/or the consequence(s) of pelvic dissection.

Bowel function and quality of life after minimally invasive colectomy with D3 lymphadenectomy for right-sided colon adenocarcinoma

BACKGROUND

Changes in bowel function after right-sided colectomy are not well understood compared to those associated with left-sided colectomy or rectal resection. In particular, there are concerns about bowel function after right-sided colectomy with complete mesocolic excision, which has become popular in the West.

AIM

To evaluate the functional outcomes of patients who underwent right-sided colectomy with D3 lymphadenectomy for colon cancer.

METHODS

Functional data from patients who underwent minimally invasive right-sided colectomy for colon cancer from October 2017 to September 2018 were prospectively collected. Functional outcomes were evaluated preoperatively and at 3, 6, 12, and 18 mo postoperatively.

RESULTS

Prior to surgery, 57 patients answered the questionnaire, and 47 responded at three months, 52 at 6 mo, 52 at 12 mo, and 25 at 18 mo postoperatively. Most scales of quality of life and bowel function improved significantly over time. Urgency persisted to a high degree throughout the period without a significant change over time. The use of medications for defecation was about 10% over the entire period. Gas (P = 0.023) and fecal frequency (P < 0.001) increased, and bowel dysfunction group (P = 0.028) was more common among patients taking medication. At six months, resected bowel and colon lengths were significantly different as a risk factor between the dysfunction group and the no dysfunction group [odd ratio (OR): 1.095, P = 0.026; OR: 1.147, P = 0.031, respectively] in univariate analysis, but not in multivariate analysis.

CONCLUSION

Despite D3 lymphadenectomy, most bowel symptoms improved over time after right-sided colectomy using a minimally invasive approach, and continuous medication was needed in only approximately 10% of patients.

Ileocecal valve syndrome and vitamin b12 deficiency after surgery: a multicentric prospective study

Patients undergoing colon resection are often concerned about their functional outcomes after surgery. The primary aim of this prospective, multicentric study was to assess the intestinal activity and health-related quality-of-life (HRQL) after ileocecal valve removal. The secondary aim was to evaluate any vitamin B12 deficiency. The study included patients undergoing right colectomy, extended right colectomy and ileocecal resection for either neoplastic or benign disease. Selected items of GIQLI and EORTC QLQ-CR29 questionnaires were used to investigate intestinal activity and HRQL before and after surgery. Blood samples for vitamin B12 level were collected before and during the follow-up period. The empirical rule effect size (ERES) method was used to explain the clinical effect of statistical results. Linear mixed effect (LME) model for longitudinal data was applied to detect the most important parameters affecting the total score. A total of 158 patients were considered. Applying the ERES method, the analysis of both questionnaires showed clinically and statistically significant improvement of HRQL at the end of the follow-up period. Applying the LME model, worsening of HRQL was correlated with female gender and ileum length when using GIQLI questionnaire, and with female gender, open approach, and advanced cancer stage when using the EORTC QLQ-CR29 questionnaire. No significant deficiency in vitamin B12 levels was observed regardless of the length of surgical specimen. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory. In our series, no deterioration of HRQL and no vitamin B12 deficiency were found during the follow-up period. Nevertheless, warning patients about potential changes in bowel habits is mandatory.

Functional bowel complaints and quality of life after surgery for colon cancer: prevalence and predictive factors

AIM

Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS-like symptoms and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery.

METHOD

All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ-C30 and QLQ-CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories.

RESULTS

A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392-2.528) and a previous diverting stoma (OR 1.84, CI 1.14-2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains.

CONCLUSION

The results of this study highlight the presence of LARS-like symptoms after surgery for colonic cancer. Patients suffering from major LARS-like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients.

Fecal and urinary incontinence are major problems associated with rectal cancer

BACKGROUND

The goal of this retrospective cohort study was to analyze the incidence of urinary incontinence (UI) and fecal incontinence (FI) within 5 years of diagnosis in patients with rectal carcinoma (RC) and within 5 years of a randomly selected visit date in non-cancer controls followed in general practices in Germany.

METHODS

Patients who had received an initial RC diagnosis at one of 1262 general practices in Germany between January 2008 and December 2017 were included in this study (index date). Patients without cancer were matched (1:1) to RC patients by sex, age, index year, and practice. The main outcome of the study was the incidence of UI and FI within 5 years of RC diagnosis.

RESULTS

The study included 3249 individuals with RC and 3249 individuals without cancer (mean age 66.5 years, 57.3% males). Within 5 years of the index date, 8.6% of RC patients and 1.3% of patients without cancer received a FI diagnosis, and 16.7% of RC patients and 5.3% of patients without cancer received a UI diagnosis. Overall, RC was positively associated with both FI (hazard ratio (HR) 8.39, 95% CI 5.50-12.81) and UI (HR 3.59, 95% CI 2.91-4.44). These findings were corroborated in the different age subgroups.

CONCLUSION

In accordance with the literature, we confirmed that RC is significantly associated with fecal and urinary incontinence. However, it appears that the awareness of this fact needs to be improved among general practitioners since our data show lower percentages of fecal and urinary incontinence diagnoses compared with the percentages for specialized centers reported in the literature.

The risk of long-term bowel dysfunction after resection for sigmoid adenocarcinoma: a cross-sectional survey comparing complete mesocolic excision with conventional surgery

AIM

To investigate whether complete mesocolic excision (CME) might carry a higher risk of bowel dysfunction and subsequent reduction in quality of life compared with conventional resection.

METHOD

A cross-sectional questionnaire study based on data from a national survey regarding long-term bowel function and a population-based cohort study comparing CME (study group) with conventional resection (control group). A total of 622 patients undergoing elective resection for Stage I-III sigmoid adenocarcinoma at four university colorectal centres between June 2008 and December 2014 were eligible to receive the questionnaire in mid-November 2015. Primary outcomes were four or more bowel movements daily, nocturnal bowel movements, unproductive call to stool, obstructive sensation and impact of bowel function on quality of life (QOL).

RESULTS

One hundred and twenty-seven (69.0%) and 289 (66.0%) patients in the study and control groups, respectively, responded to the questionnaire after medians of 4.41 [interquartile range (IQR) 2.50, 5.83] and 4.57 (IQR 3.15, 5.82) years, respectively (P = 0.048). CME was not associated with: increased risk of four or more bowel movements daily [adjusted OR 1.14 (95% CI 0.59-2.14; P = 0.68)], nocturnal bowel movements [adjusted OR 1.31 (0.66-2.53; P = 0.43)], unproductive call to stool [adjusted OR 0.99 (0.54-1.77; P = 0.97)] or obstructive sensation [adjusted OR 1.01 (0.56-1.78; P = 0.96)]. While one in five patients in both groups had moderate to severe impact of bowel function on QOL, there was no association with CME.

CONCLUSION

For patients with sigmoid cancer, CME is associated with neither higher risk of bowel dysfunction nor impaired QOL.

Chronic diarrhoea following surgery for colon cancer-frequency, causes and treatment options

PURPOSE

The growing population of survivors after colon cancer warrants increased attention to the long-term outcome of surgical treatment. The change in bowel anatomy after resection disrupts normal gastrointestinal function and may cause symptoms. Thus, many patients surviving colon cancer have to cope with bowel dysfunction for the rest of their lives. We here aim to provide an overview of the literature on this topic.

METHODS

We review long-term functional outcomes of surgical treatment for colon cancer, the underlying pathology, and treatment options.

RESULTS

Common symptoms include constipation, urge for defecation and diarrhoea. Causes of diarrhoea after colon cancer surgery are sparsely studied, but they probably include bile acid malabsorption, small intestinal bacterial overgrowth and disruption of the ileal brake. Specific diagnosis should be made to allow individual treatment based on the underlying pathology. Studies on treatment of functional problems after surgery for colon cancer are extremely few, but some lessons can be drawn from the treatment of other patient groups having undergone colon surgery.

CONCLUSION

Diarrhoea is likely a common long-term complication after colon cancer surgery. Attention to this complication and a specific diagnosis will aid the targeted treatment of patients suffering from this complication.

Effectiveness of Pelvic Floor Rehabilitation for Bowel Dysfunction After Intersphincteric Resection for Lower Rectal Cancer

BACKGROUND

The aim of this study was to evaluate the effectiveness of pelvic floor rehabilitation (PFR) for patients with bowel dysfunction after intersphincteric resection (ISR) and to compare the treatment response to that of patients after low anterior resection (LAR).

METHODS

Thirty patients with postoperative bowel dysfunction for more than 6 months were enrolled and treated with PFR for 6 months.

RESULTS

In the ISR group, significant improvements in the number of bowel movements and the use of antidiarrheal medications were observed, but no significant improvement was observed in the Wexner score (WS) and the fecal incontinence severity index (FISI). Meanwhile, in the LAR group, WS and FISI were better post-treatment than pre-treatment (WS: 10.7-5.7; p = 0.01, FISI: 28-11; p = 0.01). In the assessment of fecal incontinence quality of life (FIQL), only the Coping/Behavior category was improved in the ISR group (1.56 before, 2.16 after PFR; p = 0.01), while all four categories were improved significantly in the LAR group. The anorectal manometric examination showed no significant increase in sphincter pressure and the tolerable volume in patients after ISR.

CONCLUSIONS

PFR improved several clinical symptoms of patients after ISR. Compared with patients after LAR, patients after ISR showed an insufficient response to PFR in improving fecal incontinence. Considering the result of the generalized assessment of the quality of life scale, PFR may offer a therapeutic effect for several symptoms of patients after ISR.

Acceptability and benefit of rectal irrigation in patients with Low Anterior Resection Syndrome: a qualitative study

AIM

Low Anterior Resection Syndrome (LARS) following rectal cancer surgery impairs the patient's quality of life (QoL). Rectal Irrigation has been demonstrated to be effective for anterior resection syndrome but many surgeons do not suggest it as a treatment. This feasibility study aimed to explore treatment acceptability and the benefit of rectal irrigation in patients who developed LARS following an anterior resection for rectal cancer.

METHODS

This was a qualitative study, involving semi-structured interviews. Twenty-one patients diagnosed with LARS following anterior resection for rectal cancer in a single tertiary centre were offered rectal irrigation as a treatment option. Qualitative interviews (n=17) were conducted at baseline to explore patient reported impact of LARS on QoL, treatment acceptability and factors influencing the decision to accept/decline treatment. Follow up interviews were carried out at six months for the treatment group only (n=12), to assess its practicality and impact on QoL.

RESULTS

Qualitative interview findings suggest rectal irrigation is an acceptable method of treatment for LARS. Participants who perceived their symptoms to be more severe or poorly controlled were most likely to consider rectal irrigation as a treatment option. The patients who completed treatment reported improvements in their QoL, the ability to control the time of defaecation being the key benefit CONCLUSION: Clinicians should consider offering rectal irrigation as a treatment option to patients presenting with bowel dysfunction following anterior resection as it can improve symptoms. Patients who perceive that their symptoms are severe are more likely to consider treatment. This article is protected by copyright. All rights reserved.

Risk Factors in Acquired Faecal Incontinence

Acquired faecal incontinence arising in the non-elderly population is a common and often devastating condition. We conducted a retrospective cohort analysis in 629 patients (475 female) referred to a tertiary centre, to determine the relative importance of individual risk factors in the development of faecal incontinence, as demonstrated by abnormal results on physiological testing. Potential risk factors were identified in all but 6% of patients (7 female, 32 male). In women, the principal risk factor was childbirth (91%), and in most cases at least one vaginal delivery had met with complications such as perineal injury or the need for forceps delivery. Of the males, half had undergone anal surgery and this was the only identified risk factor in 59%. In many instances, assignment of cause was hampered by a long interval between the supposed precipitating event and the development of symptoms. Abnormalities of anorectal physiology were identified in 76% of males and 96% of females (in whom they were more commonly multiple). These findings add to evidence that occult damage to the continence mechanism, especially through vaginal delivery and anal surgery, can result in subsequent faecal incontinence, sometimes after an interval of many years.

Ileocaecal valve syndrome after surgery in adult patients: myth or reality?

AIM

The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires.

METHOD

In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data.

RESULTS

We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant.

CONCLUSION

We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings.

A prospective case control study of functional outcomes and related quality of life after colectomy for neoplasia

AIM

Our aim was to assess bowel function and its effect on overall quality of life (QOL) when compared to healthy controls after colectomy.

METHODS

Patients undergoing resection of colorectal neoplasia were recruited pre-operatively and followed up at 6 and 12 months, to assess 'early' bowel function. Patients who underwent surgery 2 to 4 years previously were recruited for assessment of 'intermediate' bowel function. Healthy relatives were recruited as controls. The Memorial Sloan-Kettering Cancer Centre and EQ-5D questionnaires were used to assess bowel function and QOL, respectively. Statistical assessment included regression analyses, parametric and non-parametric tests. The association between QOL and Memorial Sloan-Kettering Cancer Centre (MSKCC) scores was evaluated using Spearman's rank correlation.

RESULTS

Ninety-one patients were recruited for assessment of 'early' and 85 for 'intermediate' bowel function. There were 85 controls. Patients had a significantly higher number of bowel movements at each follow-up (p < 0.001). At 12 months after surgery, patients reported difficulty with gas-stool discrimination. The 'intermediate' group were found to have lower scores for flatus control (<0.001) and total frequency score (p 0.03), indicating worse function. Patients with higher total MSKCC scores, no symptoms of urgency and those able to control flatus reported better QOL (p 0.006, 0.007 and 0.005, respectively) at 6 and 12 months. Gas-stool differentiation and complete evacuation correlated with better QOL in the 'intermediate' bowel function group (p 0.02 and 0.02, respectively).

CONCLUSION

Colonic resection adversely affects elements of bowel function up to 4 years after surgery. Good colonic function, represented by higher MSKCC scores, correlates with better QOL.

Long-term functional outcome of colonic resections: how much does faecal impairment influence quality of life?

AIM

Older data suggest that colonic resection has a negative impact on continence and quality of life. The aim of this study was to evaluate the functional outcome of colonic resections for colonic cancer and diverticulitis and its influence on quality of life.

METHODS

Patients who underwent colonic resection between 2005 and 2013 were identified from a prospective database. A survey with two questionnaires [Faecal Incontinence Quality of Life (FIQL) scale, Short Form 12 (SF-12)] and additional questions concerning bowel function was sent to all patients.

RESULTS

Colonic resection was performed in 362 patients in the study period; 297 patients returned the questionnaires (response rate 82.0%). Faecal urgency or incontinence more than once a month was present in 15% of patients and 25% of patients reported that bowel symptoms limited their quality of life. The mean total FIQL score for all patients was 3.58. The SF-12 score was comparable to a reference population without prior colonic resection. Patients after right-sided resections had liquid stool more often than others (45.3% vs 38.7%, P = 0.011). No differences in bowel function and quality of life were detected between resections for colonic cancer and diverticulitis.

CONCLUSION

Most patients experience no limitation in bowel function after segmental colectomy. Those with limitations in bowel function still seem to cope well, as the quality of life is not severely affected. Nevertheless, most patients with lower functional scores also had lower quality of life scores. Whether surgery is a relevant factor has to be questioned, as the prevalence of faecal incontinence in a comparable population without prior surgery is almost identical.

Practice of traditional Chinese medicine for psycho-behavioral intervention improves quality of life in cancer patients: A systematic review and meta-analysis

Background

Cancer patients suffer from diverse symptoms, including depression, anxiety, pain, and fatigue and lower quality of life (QoL) during disease progression. This study aimed to evaluate the benefits of Traditional Chinese Medicine psycho-behavioral interventions (TCM PBIs) on improving QoL by meta-analysis.

Methods

Electronic literature databases (PubMed, CNKI, VIP, and Wanfang) were searched for randomized, controlled trials conducted in China. The primary intervention was TCM PBIs. The main outcome was health-related QoL (HR QoL) post-treatment. We applied standard meta analytic techniques to analyze data from papers that reached acceptable criteria.

Results

The six TCM PBIs analyzed were acupuncture, Chinese massage, Traditional Chinese Medicine five elements musical intervention (TCM FEMI), Traditional Chinese Medicine dietary supplement (TCM DS), Qigong and Tai Chi. Although both TCM PBIs and non-TCM PBIs reduced functional impairments in cancer patients and led to pain relief, depression remission, reduced time to flatulence following surgery and sleep improvement, TCM PBIs showed more beneficial effects as assessed by reducing both fatigue and gastrointestinal distress. In particular, acupuncture relieved fatigue, reduced diarrhea and decreased time to flatulence after surgery in cancer patients, while therapeutic Chinese massage reduced time to flatulence and time to peristaltic sound.

Conclusion

These findings demonstrate the efficacy of TCM PBIs in improving QoL in cancer patients and establish that TCM PBIs represent beneficial adjunctive therapies for cancer patients.

Bowel function and quality of life after superior mesenteric nerve plexus transection in right colectomy with D3 extended mesenterectomy

BACKGROUND

The aim of this study was to ascertain the impact of injury to the superior mesenteric nerve plexus caused by right colectomy with D3 extended mesenterectomy as performed in the prospective multicenter trial: "Safe Radical D3 Right Hemicolectomy for Cancer through Preoperative Biphasic Multi-detector Computed Tomography" in which all soft tissue surrounding the superior mesenteric vessels from the level of the middle colic artery to that of the ileocolic artery was removed.

METHODS

Bowel function and gastrointestinal quality of life in two consecutive cohorts that underwent right colectomy with and without D3 extended mesenterectomy were compared. Main outcome measures were the Diarrhea Assessment Scale (DAS) and Gastrointestinal Quality of Life Index (GIQLI). The data were collected prospectively through telephone interviews.

RESULTS

Forty-nine patients per group, comparable for age, sex, length of bowel resected but with significantly shorter follow-up time in the experimental group, were included. There was no difference in total DAS scores, subscores or additional questions except for higher bowel frequency scores in the D3 group (p = 0.02). Comparison of total GIQLI scores and subscales showed no difference between groups. Regression analysis with correction for confounding factors showed 0.48 lower bowel frequency scores in the D2 group (p = 0.022). Within the D3 group presence of jejunal arteries cranial to the D3 dissection area showed 1.78 lower DAS scores and 0.7 lower bowel frequency scores.

CONCLUSIONS

Small bowel denervation after right colectomy with D3 extended mesenterectomy leads to increased bowel frequency but does not impact gastrointestinal quality of life. Individual anatomical variants can affect postoperative bowel function differently despite standardized surgery.

Therapeutic Evaluation of Biofeedback Therapy in the Treatment of Anterior Resection Syndrome After Sphincter-Saving Surgery for Rectal Cancer

BACKGROUND

Anterior resection syndrome (ARS) is common after sphincter-saving surgery for rectal cancer. It includes changes in the frequency and urgency of bowel movements and fecal incontinence. The therapeutic efficacy of biofeedback on ARS is unclear. We sought to evaluate the effectiveness of biofeedback therapy in patients with ARS after anterior resection for rectal cancer and to investigate the associated factors for therapeutic success.

PATIENTS AND METHODS

The study was designed as a retrospective review of the data from 61 patients with ARS collected from a prospectively maintained institutional cancer database. Therapeutic efficacy was evaluated using anorectal manometry, the number of bowel movements daily, and fecal incontinence scoring systems (Vaizey and/or Wexner scores). Changes of > 15% in the Vaizey and/or Wexner scores were considered to indicate effectiveness. Stepwise logistic regression models were performed to evaluate whether the associated factors influenced therapeutic efficacy.

RESULTS

The parameters of anorectal manometry in patients with rectal cancer were significantly lower than those in control group (P < .01). After biofeedback therapy, significant improvements were observed in the incontinence scale scores (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P < .001; maximum squeeze pressure, P = .001; and rectal capacity, P = .015). In contrast, no significant difference in the rectal initial sensation threshold was observed (P = .089). Patients with fecal incontinence as the primary symptom experienced significant improvements in all variables (P < .01), except for the rectal initial sensation threshold (P = .125). Age at surgery, current smoking status, diabetes, treatment cycles, laparoscopic surgery, interval from surgery to biofeedback therapy, and the use of radiation therapy were closely associated with therapeutic success. On multivariate analysis, current smoking status (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.01-0.87), number of biofeedback therapy cycles (OR, 0.01; 95% CI, 0.00-0.06), and laparoscopic surgery (OR, 11.53; 95% CI, 1.17-113.61) were factors contributing to biofeedback therapeutic success.

CONCLUSION

Biofeedback therapy can improve the anal function of patients after restorative resection for rectal cancer.

Effects of 12 weeks of probiotic supplementation on quality of life in colorectal cancer survivors: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Probiotics may help resolve bowel symptoms and improve quality of life. We investigated the effects of 12 weeks of probiotics administration in colorectal cancer patients.

METHODS

We conducted a double-blind, randomized, placebo-controlled trial. The participants took probiotics (Lacidofil) or placebo twice a day for 12 weeks. The cancer-related quality of life (FACT), patient's health-9 (PHQ-9), and bowel symptom questionnaires were completed by each participant.

RESULTS

We obtained data for 32 participants in the placebo group and 28 participants in the probiotics group. The mean ages of total participants were 56.18 ± .86 years and 58.3% were male. Administration of probiotics significantly decreased the proportion of patients suffering from irritable bowel symptoms (0 week vs. 12 week; 67.9% vs. 45.7%, p=0.03), improved colorectal cancer-related FACT (baseline vs. 12 weeks: 19.79 ± 4.66 vs. 21.18 ± 3.67, p=0.04) and fatigue-related FACT (baseline vs. 12 weeks: 43.00 (36.50-45.50) vs. 44.50 (38.50-49.00), p=0.02) and PHQ-9 scores (0 weeks vs. 12 weeks; 3.00 (0-8.00) vs. 1.00 (0-3.00), p=0.01). We found significant differences in changes of the proportion of patients with bowel symptoms (p<0.05), functional well-being scores (p=0.04) and cancer-related FACT scores (p=0.04) between the two groups.

CONCLUSION

Probiotics improved bowel symptoms and quality of life in colorectal cancer survivors.

What Are the Best Questionnaires To Capture Anorectal Function After Surgery in Rectal Cancer?

With enhanced surgical techniques and neoadjuvant therapy in rectal cancer, survivorship issues are at the forefront of clinical practice and research. More and more patients are living with altered bowel habits following rectal cancer surgery. Sound assessment of anorectal function after rectal cancer surgery is the foundation for the continuing effort to explore the adverse effects of such surgery on bowel function, as well as for working towards reducing these effects. The quality of the assessment is predominantly determined by the instrument administered. This article reviews various questionnaires for capturing anorectal function after surgery in rectal cancer, discussing their attributes and suitability for different evaluation contexts.

Increased primary health care use in the first year after colorectal cancer diagnosis

OBJECTIVE

The view that the general practitioner (GP) should be more involved during the curative treatment of cancer is gaining support. This study aimed to assess the current role of the GP during treatment of patients with colorectal cancer (CRC).

DESIGN

Historical prospective study, using primary care data from two cohorts.

SETTING

Registration Network Groningen (RNG) consisting of 18 GPs in three group practices with a dynamic population of about 30,000 patients.

SUBJECTS

Patients who underwent curative treatment for CRC (n = 124) and matched primary care patients without CRC (reference population; n = 358).

MAIN OUTCOME MEASURES

Primary healthcare use in the period 1998-2009.

FINDINGS

Patients with CRC had higher primary healthcare use in the year after diagnosis compared with the reference population. After correction for age, gender, and consultation behaviour, CRC patients had 54% (range 23-92%) more face-to-face contacts, 68% (range 36-108%) more drug prescriptions, and 35% (range -4-90%) more referrals compared with reference patients. Patients consulted their GP more often for reasons related to anaemia, abdominal pain, constipation, skin problems, and urinary infections. GPs also prescribed more acid reflux drugs, laxatives, anti-anaemic preparations, analgesics, and psycholeptics for CRC patients.

CONCLUSIONS

The GP plays a significant role in the year after CRC diagnosis. This role may be associated with treatment-related side effects and psychological problems. Formal guidelines on the involvement of the GP during CRC treatment might ensure more effective allocation and communication of care between primary and secondary healthcare services.

Bowel dysfunction after rectal cancer treatment: a study comparing the specialist's versus patient's perspective

OBJECTIVES

To investigate how bowel dysfunction after sphincter-preserving rectal cancer treatment, known as low anterior resection syndrome (LARS), is perceived by rectal cancer specialists, in relation to the patient's experience.

DESIGN

Questionnaire study.

SETTING

International.

PARTICIPANTS

58 rectal cancer specialists (45 colorectal surgeons and 13 radiation oncologists).

RESEARCH PROCEDURE

The Low Anterior Resection Syndrome Score (LARS score) is a five-item instrument for evaluation of LARS, which was developed from and validated on 961 patients. The 58 specialists individually completed two LARS score-based exercises. In Exercise 1, they were asked to select, from a list of bowel dysfunction issues, five items that they considered to disturb patients the most. In Exercise 2, they were given a list of scores to assign to the LARS score items, according to the impact on quality of life (QOL).

OUTCOME MEASURES

In Exercise 1, the frequency of selection of each issue, particularly the five items included in the LARS score, was compared with the frequency of being selected at random. In Exercise 2, the answers were compared with the original patient-derived scores.

RESULTS

Four of the five LARS score issues had the highest frequencies of selection (urgency, clustering, incontinence for liquid stool and frequency of bowel movements), which were also higher than random. However, the remaining LARS score issue (incontinence for flatus) showed a lower frequency than random. Scores assigned by the specialists were significantly different from the patient-derived scores (p<0.01). The specialists grossly overestimated the impact of incontinence for liquid stool and frequent bowel movements on QOL, while they markedly underestimated the impact of clustering and urgency. The results did not differ between surgeons and oncologists.

CONCLUSIONS

Rectal cancer specialists do not have a thorough understanding of which bowel dysfunction symptoms truly matter to the patient, nor how these symptoms affect QOL.

Post-colectomy assessment of gastrointestinal function: a prospective study on colorectal cancer patients

BACKGROUND

Anatomical changes after intestinal resection and the effects of adjuvant treatment for colorectal cancer may lead to gastrointestinal disturbances. The aim of our study was to assess gastrointestinal function using validated health-related quality of life (HRQoL) questionnaires that are able to reliably quantify patients' symptoms.

METHODS

Two hundred and eighty-nine colorectal cancer patients underwent HRQoL assessment preoperatively and at 3,6 and 12 months postoperatively. They were evaluated with the Gastrointestinal Quality of Life Index (GIQLI) ["global" and "symptoms" scales and questions 3 ("bloating"), 4 ("excessive gas"), 6 ("gurgling noises"), 7 ("frequent bowel movements (BMs)"), 30 ("urgent BMs"), 31 ("diarrhea"), 32 ("constipation"), 36 ("uncontrolled stools")] and the European Organization for Research and Treatment of Cancer (EORTC) modules QLQ-C30 (symptom scales: "constipation" and "diarrhea") and QLQ-CR29 (symptom scales: "defecation problems," "incontinence," and "bloating").

RESULTS

GIQLI "global" and "symptom" indices and the majority of single-item scores and the EORTC QLQ-C30 "constipation" and "diarrhea" subscales showed significant postoperative improvement (p < 0.05). Females and younger age (<70 years) patients appeared to have worse postoperative gastrointestinal function. Rectal cancer patients had more "urgent BMs," "uncontrolled stools" and worse "global" and "symptom" scores at 3 months and more "diarrhea" at 3 and 6 months than colon cancer patients (p < 0.03). Right colectomy patients had less "excessive passage of gas," "constipation," and "uncontrolled stools" than left colectomy patients (3 months, p < 0.01). Anterior resection patients faced more gastrointestinal difficulties, especially in the first 6 months after surgery. Adverse effects related to stage and adjuvant treatment were predominant only at baseline (p < 0.05). GIQLI "diarrhea" and "constipation" scores were correlated with the respective EORTC QLQ-C30 domains (p = 0.0001).

CONCLUSIONS

Overall, gastrointestinal function is improved after colorectal cancer surgery. However, women and younger patients are at higher risk of postoperative gastrointestinal dysfunction.

Assessment of patient-reported measures of bowel function before and after pelvic radiotherapy: an ancillary study of the North Central Cancer Treatment Group study N00CA

PURPOSE

The Bowel Function Questionnaire (BFQ) has been used in clinical trials to assess symptoms during and after pelvic radiotherapy (RT). This study evaluated the importance of symptoms in the BFQ from a patient perspective.

METHODS

Patients reported presence or absence of symptoms and rated importance of symptoms at baseline, 4 weeks after completion of pelvic RT, and 12 and 24 months after RT. The BFQ measured overall quality of life (QOL) and symptoms of nocturnal bowel movements, incontinence, clustering, need for protective clothing, inability to differentiate stool from gas, liquid bowel movements, urgency, cramping, and bleeding. Bowel movement frequency also was recorded. A content validity questionnaire (CVQ) was used to rate symptoms as "not very important," "moderately unimportant," "neutral," "moderately important," or "very important."

RESULTS

Most of the 125 participating patients rated all symptoms as moderately or very important. Generally, patients gave similar ratings for symptom importance at all study points, and ratings were independent of whether the patient experienced the symptom. Measures of greatest importance (moderately or very important) at baseline were ability to control bowel movements (94 %), not having to wear protective clothing (90 %), and not having rectal bleeding (94 %). With the exception of need for protective clothing, the presence of a symptom at 4 weeks was associated with significantly worse QOL (P < .01 for all).

CONCLUSIONS

The BFQ has excellent content validity. Patients rated most symptoms as moderately or very important, indicating the BFQ is an appropriate tool for symptom assessment during and after pelvic RT.

Preservation of the inferior mesenteric artery via laparoscopic sigmoid colectomy performed for diverticular disease: real benefit or technical challenge: a randomized controlled clinical trial

BACKGROUND

Defecatory disorders are very common complications after left hemicolectomy and anterior rectal resection. These disorders seem related primarily to colonic denervation after the resection. To evaluate the real benefits of inferior mesenteric artery (IMA) preservation via laparoscopic left hemicolectomy performed for diverticular disease in terms of reduced colonic denervation and improved postoperative intestinal functions, a randomized, single-blinded (patients) controlled clinical trial was conducted.

METHODS

From January 2004 to January 2010, patients with symptomatic diverticular disease and a surgical indication were enrolled in the study and randomly assigned to two treatment groups. The first group underwent laparoscopic left hemicolectomy, which preserved the IMA by sectioning the sigmoid arteries one by one near the colonic wall, In the second group, the IMA was sectioned immediately below the origin of left colic artery. Defecation disorders were assessed by anorectal manometry and by three questionnaires to evaluate constipation, incontinence, and quality of life 6 months after the intervention.

RESULTS

A total of 107 patients were included in the study. The 54 patients with preserved IMA showed a statistically lower incidence of defecation disorders such as fragmented evacuations, alternating bowel function, constipation, and minor incontinence, as well as less lifestyle alteration than the 53 patients with the IMA sectioned just below the left colic artery.

CONCLUSIONS

This study confirmed that preservation of the IMA should be recommended to reduce the incidence of defecatory disorders after left hemicolectomy for benign disease.

Colorectal cancer patients with liver metastases and severe hyperbilirubinemia: A consecutive series that explores the benefits and risks of chemotherapy

Background:

Do colorectal cancer patients with hyperbilirubinemia and liver metastases benefit from chemotherapy?

Methods/Results:

This study entailed a review of 3,019 consecutive patients with colorectal cancer. Within this cohort, 20 met the study’s a priori selection criteria, which included a new diagnosis of colorectal cancer, no prior therapy, and a total bilirubin of ≥3.0 mg/dL. All 20 patients had liver metastases, and as a whole the group had a median serum bilirubin of 6.4 mg/dL (range 3.1, 28 mg/dL). Six patients received chemotherapy with an oxaliplatin-containing regimen, and four subsequently sustained a drop in their bilirubin. In one instance, a drop from 27.2 to 2.5 mg/dL occurred. These six patients lived a median of 71 days (range 23+, 283 days), but one treatment-related death occurred. In contrast, patients who received only supportive care lived a median of 28 days.

Conclusion:

Chemotherapy appears to provide modest benefit to newly diagnosed colorectal cancer patients with severe hyperbilirubinemia.

Effectiveness of biofeedback therapy in the treatment of anterior resection syndrome after rectal cancer surgery

BACKGROUND

Although anterior resection syndrome commonly occurs after anal sphincter-saving surgery, no standard treatment option is currently available.

OBJECTIVE

The aim of the present study was to evaluate the clinical effectiveness of biofeedback in patients with anterior resection syndrome after sphincter-saving surgery for rectal cancer.

DESIGN

This study was a retrospective review of data collected during the course of treatment.

SETTINGS

Patients were treated at a teaching hospital (Asan Medical Center) in Seoul, Korea, from January 2003 through December 2008.

PATIENTS

Patients who received biofeedback therapy for anterior resection syndrome after rectal cancer surgery were included.

MAIN OUTCOME MEASURES

The Cleveland Clinic Florida fecal incontinence score, number of bowel movements per day, a visual analog scale for assessing patient satisfaction, and anorectal manometry were used to assess outcome of biofeedback treatment.

RESULTS

: After biofeedback therapy, significant improvements were observed in fecal incontinence score (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P = .010; maximum squeeze pressure, P = .006; rectal capacity, P = .003). Compared with patients who started biofeedback treatment less than 18 months after surgery, those who started biofeedback at 18 months or longer after surgery showed greater improvements in fecal incontinence score (P = .032). Only patients with fecal incontinence as the primary symptom showed significant improvements in all variables, including fecal incontinence score, P < .001; defecation frequency, P < .001; and anorectal manometry (maximum resting pressure, P = .027; maximum squeeze pressure, P = .021; rectal capacity, P = .004). Patients who received radiation therapy in addition to surgery reported a significantly higher satisfaction score than those receiving surgery alone (P = .041).

LIMITATIONS

This is a nonrandomized retrospective study. Anorectal manometry was not regularly performed in all patients.

CONCLUSIONS

Biofeedback therapy produced significant clinical benefits for patients with severe fecal incontinence and may be an effective treatment for patients with anterior resection syndrome after surgery for rectal cancer.

Sentinel node biopsy for the individualization of surgical strategy for cure of early-stage colon cancer

INTRODUCTION

The requirement for nodal analysis currently confounds the oncological propriety of focused purely endoscopic resection for early-stage colon cancer and complicates the evolution of innovative alternatives such as natural orifice transluminal endoscopic surgery (NOTES) and its hybrids. Adjunctive sentinel node biopsy (SNB) deserves consideration as a means of addressing this shortfall.

METHODS

Data from two prospectively maintained databases established for multicentric studies of SNB in colon cancer that employed similar methodologies were pooled to establish technique potency selectively in T1/T2 disease (both overall and under optimized conditions) and to project potential clinical impact.

RESULTS

Of 891 patients with T1-4, M0 intraperitoneal colon cancer, 225 had T1/T2 disease. Sentinel nodes were either not found or were falsely negative in 18 patients with T1/T2 cancers (8%) as compared with 17% (112/646) in those with T3/T4 disease (P = 0.001). Negative predictive value (NPV) in the former exceeded 95%, while sensitivity [including immunohistochemistry (IHC)] was 81%. In the 193 patients with T1/T2 disease recruited from those centers contributing >22 patients, sensitivity was 89% and NPV 97%. Thus, in this cohort, SNB could have correctly prompted localized resection (obviating en bloc mesenteric dissection) in 75% (144) of patients, including 59 with T1 lesions potentially amenable to intraluminal resection alone as their definitive treatment. Forty-four patients (23.4%) would still have conventional resection, leaving three patients (1.6% overall) understaged (11% false-negative rate).

CONCLUSION

These findings support the further investigation of SNB as oncological augment for localized resective techniques. Specific prospective study should pursue this goal.

Donor-site morbidity after free ileocolon flap transfer for esophageal and voice reconstruction

BACKGROUND

Radical excision of advanced hypopharyngeal and laryngeal tumors usually compromises both swallowing and speech. Among the available reconstruction methods, the free ileocolon flap allows rehabilitation of both functions in one stage. The donor-site morbidity of this flap has not been addressed in head and neck cancer patients.

METHODS

A retrospective study was conducted in 34 patients between April of 2003 and December of 2007 to investigate donor-site morbidity in patients undergoing reconstruction with free ileocolon flaps. Complications such as diarrhea, upper gastrointestinal tract distress, bowel leak, abscess, or hernia formation were evaluated. Significant association of diarrhea and upper gastrointestinal distress, previous abdominal operations, systemic diseases, primary versus secondary reconstruction, flap length, and postoperative chemotherapy were subsequently evaluated. Differences were considered significant for values of p <or= 0.05.

RESULTS

There were no perioperative or postoperative deaths. Nineteen patients (56 percent) experienced temporary diarrhea. In all but two patients, diarrhea discontinued by 4 months. Chemotherapy was significantly associated with diarrhea (p < 0.01). Colchicine, terbinafine, and heroin withdrawal episodically caused diarrhea but statistical conclusions could not be drawn. Six patients (18 percent) suffered from upper gastrointestinal tract problems (gastroduodenal ulcer, erosive gastritis, and minor bleeding), probably because of insufficient gastric protection.

CONCLUSIONS

The free ileocolon flap proved to be a reliable method when simultaneous restoration of swallowing and speech was required, with donor-site morbidity comparable to that of the other intestinal flaps.

Could lymphatic mapping and sentinel node biopsy provide oncological providence for local resectional techniques for colon cancer? A review of the literature

BACKGROUND

Endoscopic resectional techniques for colon cancer are undermined by their inability to determine lymph node status. This limits their application to only those lesions at the most minimal risk of lymphatic dissemination whereas their technical capacity could allow intraluminal or even transluminal address of larger lesions. Sentinel node biopsy may theoretically address this breach although the variability of its reported results for this disease is worrisome.

METHODS

Medline, EMBASE and Cochrane databases were interrogated back to 1999 to identify all publications concerning lymphatic mapping for colon cancer with reference cross-checking for completeness. All reports were examined from the perspective of in vivo technique accuracy selectively in early stage disease (i.e. lesions potentially within the technical capacity of endoscopic resection).

RESULTS

Fifty-two studies detailing the experiences of 3390 patients were identified. Considerable variation in patient characteristics as well as in surgical and histological quality assurances were however evident among the studies identified. In addition, considerable contamination of the studies by inclusion of rectal cancer without subgroup separation was frequent. Indeed such is the heterogeneity of the publications to date, formal meta-analysis to pool patient cohorts in order to definitively ascertain technique accuracy in those with T1 and/or T2 cancer is not possible. Although lymphatic mapping in early stage neoplasia alone has rarely been specifically studied, those studies that included examination of false negative rates identified high T3/4 patient proportions and larger tumor size as being important confounders. Under selected circumstances however the technique seems to perform sufficiently reliably to allow it prompt consideration of its use to tailor operative extent.

CONCLUSION

The specific question of whether sentinel node biopsy can augment the oncological propriety for endoscopic resective techniques (including Natural Orifice Transluminal Endoscopic Surgery [NOTES]) cannot be definitively answered at present. Study heterogeneity may account for the variability evident in the results from different centers. Enhanced capacity (perhaps to the level necessary to consider selective avoidance of en bloc mesenteric resection) by its confinement to only early stage disease is plausible although not proven. Specific study of the technique in early stage tumors is clearly essential before proffering this approach.

Lymphatic mapping and sentinel node biopsy in the colonic mesentery by Natural Orifice Transluminal Endoscopic Surgery (NOTES)

INTRODUCTION

Although intraluminal and transluminal techniques can achieve localized resection of early-stage alimentary tumours, they do not designate the status of the filtering mesenteric lymph nodes. Natural orifice transluminal endoscopic surgery (NOTES) may however effect sentinel node biopsy from within the peritoneum.

METHODS

A transgastric NOTES technique was utilized in six pigs. A conventional double-channel gastroscope created both the 12mm anterior gastrotomy and the pneumoperitoneum and enabled peritoneoscopy. The sigmoid colon was fully exposed by an intracolonic magnet under extracorporeal control. Colonoscopy facilitated submucosal injection of methylene blue dye (3 ml) at the apex of the sigmoid loop under direct transgastric vision. The mesocolon was searched for blue-stained lymph channels and nodes, the latter being resected and retrieved by the intraperitoneal endoscope. At procedure end, three pigs underwent immediate laparotomy for scrutiny of the operation site while three were survived for forensic laparotomy on postoperative day 14.

RESULTS

Each procedure was a technical success. Gastrotomy, pneumoperitoneum, peritoneoscopy and sigmoid exposure were promptly achieved (mean 9.2 min). Post-injection, blue lymphatics identifying specific nodes were immediately appreciable and these could be dissected cleanly and retrieved intact per oram. Mean lymphadenectomy time was 19 (range 12-32) min. All survival animals thrived during convalescence. At laparotomy, there was neither mesentery penetration, bowel ischemia nor mesenteric hematoma/hemorrhage in any pig and no residual blue stained nodes in those sacrificed early.

CONCLUSION

Sentinel node biopsy can be performed without abdominal wall transgression. Thus potentially the oncological proprietary of local resectional techniques may be augmented while preserving their ideals and dividends.

What’s wrong with sentinel node mapping in colon cancer?

Despite near-universal embrace of the concept and clinical relevance of lymphatic mapping for sentinel node identification and analysis for cancers of the breast and integument, the same technique has struggled to a find a role in gastrointestinal cancers in general and, perhaps, in colon cancer in particular. Despite many studies demonstrating its feasibility in malignancies of the large bowel, concern is continually aroused by the variable and often unacceptably low sensitivity rates. Additionally, many confess uncertainty as to what benefit it could ever confer to patients even if it were proven sufficiently accurate given that standard surgical resection incorporates mesenteric resection anyway. However, the huge impact sentinel node mapping has had on clinical practice in certain cancers means that each of these aspects merit careful reconsideration, from very first principles.

Techniques for restoring bowel continuity and function after rectal cancer surgery

A very low local recurrence rate of 3%-6% (associated with improved 5 year survival) is possible when proper oncological surgery is performed of mid and distal rectal adenocarcinoma. Restoration of bowel continuity is possible in most cases, without compromise of cancer clearance. Re-anastomosis can be performed with stapled, transabdominal hand-sewn or coloanal pull-through techniques. However after a direct (straight) anastomosis of the colon to the distal rectum/anus, up to 33% of patients have 3 or more bowel movements/d; some can be troubled with up to 14 stools a day. Construction of a 6-cm colonic J-pouch is likely to cause some reversed peristalsis which improves postoperative bowel frequency without causing neo-rectum evacuation problems. Colonic J-pouch-anal anastomosis patients have a median of 3 bowel movements a day compared with a median of 6 a day for straight anastomoses, at 1 year after surgery. In the longer term, bowel adaptation may enable the function after a straight anastomosis to approximate that of a colonic J-pouch-anal anastomosis. This probably depends in the former, upon whether the more rigid sigmoid colon or more distensible descending colon is used. An additional advantage of the colonic J-pouch-anal anastomosis is the lower risk of anastomotic complications. A more vascularized side-to-end (colonic J-pouch-anal) anastomosis is likely to heal better than an end-to-end (straight) anastomosis. Where the pelvis is too narrow for a bulky colonic J-pouch anal anastomosis, a coloplasty-anal-anastomosis is an option. The latter results in postoperative bowel function comparable with the colonic J-pouch. However, the risk of anastomotic complications is higher possibly related to its end-to-end anastomotic configuration. Laparoscopic techniques for accomplishing all the above are being proven to be effective. Restorative surgery for rectal cancer can be safely and effectively performed with methods to improve bowel function very acceptably; the future advances are likely in laparoscopy.

Fecal incontinence in females older than aged 40 years: who is at risk?

PURPOSE

This study was designed to estimate the prevalence of, and identify risk factors associated with, fecal incontinence in racially diverse females older than aged 40 years.

METHODS

The Reproductive Risks for Incontinence Study at Kaiser is a population-based study of 2,109 randomly selected middle-aged and older females (average age, 56 years). Fecal incontinence, determined by self-report, was categorized by frequency. Females reported the level of bother of fecal incontinence and their general quality of life. Potential risk factors were assessed by self-report, interview, physical examination, and record review. Multivariate logistic regression analysis was used to determine the independent association between selected risk factors and the primary outcome of any reported fecal incontinence in the past year.

RESULTS

Fecal incontinence in the past year was reported by 24 percent of females (3.4 percent monthly, 1.9 percent weekly, and 0.2 percent daily). Greater frequency of fecal incontinence was associated with decreased quality of life (Medical Outcome Short Form-36 Mental Component Scale score, P = 0.01), and increased bother (P < 0.001) with 45 percent of females with fecal incontinence in the past year and 100 percent of females with daily fecal incontinence reporting moderate or great bother. In multivariate analysis, the prevalence of fecal incontinence in the past year increased significantly [odds ratio per 5 kg/m2 (95 percent confidence interval)] with obesity [1.2 (1.1-1.3)], chronic obstructive pulmonary disease [1.9 (1.3-2.9)], irritable bowel syndrome [2.4 (1.7-3.4)], urinary incontinence [2.1 (1.7-2.6)], and colectomy [1.9 (1.1-3.1)]. Latina females were less likely to report fecal incontinence than white females [0.6 (0.4-0.9)].

CONCLUSIONS

Fecal incontinence, a common problem for females, is associated with substantial adverse affects on quality of life. Several of the identified risk factors are preventable or modifiable, and may direct future research in fecal incontinence therapy.

Bowel function after urinary diversion

Removal of bowel segments for the purposes of urinary diversion may have a significant effect on bowel function. The remaining bowel may not be able to fulfill its normal role, resulting in not only malabsorption syndromes, but also dysfunctional defecation. Provided, however, care is taken in selecting patients and the bowel segments for such procedures and follow-up is vigilant, complications should be minimal. There appears to be a significant risk of developing symptoms of increased bowel frequency following urinary diversion and reconstruction. Patients need to be counselled regarding this prior to surgery, however, further data needs to be collected to accurately quantify the risk and the effect it has on quality of life.