Overlooked Long-Term Complications of Colorectal Surgery

Prediction of perioperative complications in colorectal cancer via artificial intelligence analysis of heart rate variability

BACKGROUND

Heart rate variability (HRV) represents efferent vagus nerve activity, which is suggested to be related to fundamental mechanisms of tumorigenesis and to be a predictor of prognosis in various cancers. Therefore, this study hypothesized that HRV monitoring could predict perioperative complication (PC) in colorectal cancer (CRC) patients.

AIM

To investigate the prognostic value of HRV in hospitalized CRC patients.

METHODS

The observational studies included 87 patients who underwent CRC surgical procedures under enhanced recovery after surgery programs in a first-class hospital. The HRV parameters were compared between the PC group and the non PC (NPC) group from preoperative day 1 to postoperative day (Pod) 3. In addition, inflammatory biomarkers and nutritional indicators were also analyzed.

RESULTS

The complication rate was 14.9%. HRV was markedly abnormal after surgery, especially in the PC group. The frequency-domain parameters (including pNN50) and time-domain parameters [including high-frequency (HF)] of HRV were significantly different between the two groups postoperatively. The pNN50 was significantly greater at Pod1 in the PC group than that in the NPC group and returned to baseline at Pod2, suggesting that patients with complications exhibited autonomic nerve dysfunction in the early postoperative period. In the PC group, HFs were also enhanced from Pod1 and were significantly higher than in the NPC group; inflammatory biomarkers were significantly elevated at Pod2 and Pod3; the levels of nutritional indicators were significantly lower at Pod1 and Pod2; and the white blood cell count was slightly elevated at Pod3.

CONCLUSION

HRV is independently associated with postoperative complications in patients with CRC. Abnormal HRV could predicted an increased risk of postoperative complications in CRC patients. Continuous HRV could be used to monitor complications in patients with CRC during the perioperative period.

Long-Term Complications of Proctectomy for Refractory Perianal Crohn's Disease: A Narrative Review

Despite a combination of medical and surgical treatments, many patients with perianal Crohn's disease (CD) continue to experience refractory disease, requiring proctectomy or proctocolectomy, with the creation of a permanent stoma. Although proctectomy is seen as an ultimate treatment aimed at effectively relieving debilitating symptoms and enhancing quality of life, many patients may still face long-term and chronic complications. This narrative review aims to provide an overview of the main complications that patients undergoing proctectomy for CD may experience throughout their lives. Relevant publications addressing complications of proctectomy for refractory perianal CD were searched in the Medline/PubMed, Embase, Cochrane, and LILACS databases. The main long-term complications that patients encounter are related to impaired perineal wound healing, stoma-related issues, sexual and urinary dysfunction, small bowel obstructions, and CD recurrence. These complications negatively affect the quality of life and frequently necessitate further treatment. Patients should receive preoperative counselling regarding the implications of these particular issues, and regular follow-up must be guaranteed to identify any problems early, allowing for prompt treatment.

Comparative pregnancy rate after colorectal resection versus other surgical procedures for deep infiltrating rectal endometriosis: a systematic review and meta-analysis

The debate around colorectal surgery for endometriosis has been ongoing, but to date no meta-analysis has investigated the impact of the different surgical approaches on the pregnancy rate. The aim of this meta-analysis study was to determine in women with deep infiltrating rectal endometriosis, how does colorectal resection surgery compare to other surgical techniques (e.g., rectal shaving, disc excision) in terms of pregnancy rates. We searched PubMed, Web of Science, Cochrane library and Clinical Trials for relevant studies published from inception to December 2024. We performed a systematic review and meta-analysis of all English language full-text articles addressing colorectal resection compared with other management of deep infiltrating rectal endometriosis and presenting pregnancy outcomes. We included a study when it (i) provided data on surgical management (shaving, disc excision, and/or colorectal resection) and (ii) detailed the pregnancy outcomes in each subgroup. Four authors independently performed the initial search to evaluate the eligibility criteria. Four authors extracted the data and a fifth author checked this extraction. Of the 113 full-text articles assessed for eligibility, we included 13 in the meta-analysis. These studies represented a total of 3,248 patients. Pregnancy information was available for 2,131 patients: 1073 colorectal resection, 502 shaving, 172 disc excisions, and 384 other practices (expectant management). Colorectal resection was associated with a lower pregnancy rate compared with the other techniques (N = 2,131, odds ratio [OR] = 0.64 [95% confidence interval 0.52-0.79], p < 0.001, I2 = 35%). There were similar results when comparing colorectal resection with rectal shaving (N = 952, OR = 0.51 [95% confidence interval 0.36-0.73], p < 0.001, I2 = 0%), but not when comparing colorectal resection with disc excision (N = 432, OR = 0.65 [95% confidence interval 0.37-1.13], p = 0.13). Conclusions Rectal resection for endometriosis is associated with a lower pregnancy rate compared with other type of surgery, such as shaving. Trial registration: PROSPERO registration number CRD42024512328.

Intraoperative nerve imaging with sodium fluorescein

Nerve damage during surgery is a common and serious complication, often leading to chronic pain, functional impairments, and diminished quality of life. However, existing methods for intraoperative nerve identification remain insufficient, especially for detecting small or hidden nerve branches. Here we present a new application of a clinically approved fluorescent agent, sodium fluorescein, to enhance nerve visualization during surgery. Utilizing both clinical and customized imaging systems, fluorescein remarkably improved nerve contrast, revealing structures undetectable with white light, including small branches embedded within tissues. With its established safety profile, low cost, and immediate clinical applicability, sodium fluorescein offers the potential to revolutionize surgical practice by minimizing nerve injuries and improving patient outcomes. Clinical Trial Registration: NCT06054178 .

Graphical abstract

Fertility Concerns Related to Surgery for Colorectal Cancer: An Under-Discussed Topic

As the incidence of colorectal cancer (CRC) increases among younger adults, the need for discussions regarding treatment-related infertility is growing. The negative impacts of gonadotoxic chemotherapy and pelvic radiation are well documented, but the role that surgical intervention for CRC plays in infertility is less clear. Additionally, treatment-related infertility counseling occurs infrequently. This review provides an overview of the connection between abdominal and pelvic surgery on male and female infertility and elucidates the role of surgeons in counseling to alleviate psychological distress in newly diagnosed patients. A review of the literature revealed that pelvic surgery leads to increased adhesion formation, which is known to be associated with female infertility. Furthermore, nerve damage from pelvic surgery has significant implications for ejaculatory issues in males and sexual dysfunction in both males and females, which ultimately impact pregnancy success. Patients have significant distress related to treatment-related infertility, and pre-treatment fertility counseling has been shown to alleviate some of this psychological burden. Nevertheless, many patients do not receive counseling, particularly in surgical clinics, despite surgeons often being the first providers to see newly diagnosed non-metastatic patients. Efforts should be made to enact protocols that ensure fertility conversations are being had with patients in surgical clinics and that patients are being referred to fertility specialists appropriately. This patient-centered approach will lessen the psychological burden placed on patients during a vulnerable time in their lives.

Variation in nurses' compliance with an Early Warning Score protocol: A retrospective cohort study

Introduction

Early Warning Score (EWS) protocols are based on intermittent vital sign measurements, and aim to detect clinical deterioration in a timely manner. Despite its predictive value, its effectiveness remains suboptimal. An important limitation appears to be poor compliance with the EWS protocol and its variation between general wards. The current research does not yet provide an understanding of EWS compliance and variation in different nursing wards.

Aim

To explore the variation in nurses' compliance with the EWS protocol among patients with and without complications and between different nursing wards.

Methods

In a retrospective single-center cohort study, all patient files from three nursing wards of a tertiary teaching hospital in the Netherlands were reviewed over a 1-month period. Compliance was divided into three categories:1) calculation accuracy, 2) monitoring frequency end 3) clinical response.

Results

The cohort of 210 patients contained 5864 measurements, of which 4125 (70.6 %) included EWS. Significant differences in the measured vital signs within incomplete measurements were found among nursing wards. Compliance to monitoring frequency was higher within EWSs of 0-1 (78.4 %) than within EWSs of ≥2 (26.1 %). The proportion of correct follow-up was significantly higher in patients with complications, as was the correct clinical response to an EWS of ≥3 (84.8 % vs. 55.0; p = .011).

Conclusion

Our results suggest suboptimal compliance with the EWS protocol, with large variations between patients with and without complications and between different general care wards. Nurses tended to be more compliant with the EWS protocol for patients with complications.

Clinical application of eight-zone laparoscopic dissection strategy for rectal cancer: Experience and discussion

BACKGROUND

The incidence of rectal cancer is increasing worldwide, and surgery remains the primary treatment modality. With the advent of total mesorectal excision (TME) technique, the probability of tumor recurrence post-surgery has significantly decreased. Surgeons' focus has gradually shifted towards minimizing the impact of surgery on urinary and sexual functions. Among these concerns, the optimal dissection of the rectal lateral ligaments and preservation of the pelvic floor neurovascular bundle have become critical. To explore the optimal surgical technique for TME and establish a standardized surgical protocol to minimize the impact on urinary and sexual functions, we propose the eight-zone dissection strategy for pelvic floor anatomy.

AIM

To compare the differences in surgical specimen integrity and postoperative quality of life satisfaction between the traditional pelvic floor dissection strategy and the innovative eight-zone dissection strategy.

METHODS

We analyzed the perioperative data of patients who underwent laparoscopic radical resection of rectal cancer at Qilu Hospital of Shandong University between January 1, 2021 and December 1, 2023. This study included a total of 218 patients undergoing laparoscopic radical surgery for rectal cancer, among whom 109 patients underwent traditional pelvic floor dissection strategy, and 109 patients received the eight-zone dissection strategy.

RESULTS

There were no significant differences in general characteristics between the two groups. Patients in the eight-zone dissection group had higher postoperative specimen integrity (88.1% vs 78.0%, P = 0.047). At the 3-month follow-up, patients in the eight-zone surgery group had better scores in urinary issues (6.8 ± 3.3 vs 5.3 ± 2.5, P = 0.045) and male sexual desire (2.2 ± 0.6 vs 2.5 ± 0.5, P = 0.047) compared to the traditional surgery strategy group.

CONCLUSION

This study demonstrates that the eight-zone dissection strategy for laparoscopic lateral ligament dissection of rectal cancer is safe and effective. Compared with the traditional pelvic floor dissection strategy, this approach can reduce the risk of nerve injury and minimize the impact on urinary and sexual functions. Therefore, we recommend the clinical application of this strategy to better serve patients with rectal cancer.

The impact of plasma-rich platelet injection to perianal sphincters on incontinence and quality of life in patients with rectal cancer after low anterior or intersphincteric resection: a prospective cohort study

BACKGROUND

Incontinence is not rare after rectal cancer surgery. Platelet-rich plasma may promote tissue repair and generation but has never been tested for the treatment of anal incontinence. This study evaluated the impact of platelet-rich plasma injection on the severity of incontinence and quality of life after low rectal cancer surgery.

METHODS

This is a prospective cohort proof of concept study in a colorectal cancer institution. Patients had undergone low anterior or intersphincteric resection for low rectal cancer and had a Wexner score > 4. Ten milliliters of platelet-rich plasma were injected into the internal and external sphincters under endoanal ultrasound (EAUS) guidance. Primary outcome measure was > 2 point improvement in Wexner score (improved group). The patients were assessed with endo-anal ultrasound examination, manometry, the Wexner Questionnaire and SF-36 Health Surveys, and patients were asked whether they used pads and antidiarrheal medications before and 6 months after PRP injection.

RESULTS

Of 20 patients included in the study, 14 (70%) were men, and the average age was 56.8 (SD = 9.5) years. No statistically significant difference was found in Wexner scores before and after PRP injection (p = 0.66). Seven (35%) patients experienced a > 2 point improvement in Wexner score. Rectal manometry demonstrated improved squeezing pressure (p = 0.0096). Furthermore, physical functioning scoring (p = 0.023), role limitation (p = 0.016), emotional well-being (p = 0.0057) and social functioning (p = 0.043) domains on the SF-36 questionnaire improved. One (5%) and three (15%) patients stopped using pads and antidiarrheal medications.

CONCLUSION

Platelet-rich plasma injection does not restore Wexner scores, but more than one-third of patients may benefit from this application with an improvement of > 2 points in their scores. Platelet-rich plasma injection may improve squeezing pressure and certain life quality measures for incontinent patients after rectal cancer surgery.

Journey through the Decades: The Evolution in Treatment and Shared Decision Making for Locally Advanced Rectal Cancer

The management of locally advanced rectal cancer has undergone significant transformations over the decades and optimal treatment approaches continue to evolve. There have been numerous advances in surgery, chemotherapy, and radiation therapy from the first description of the abdominoperineal resection in 1908, timing of chemotherapy and radiation therapy in the late 20th and early 21st century, and most recently, the introduction of organ preservation or nonoperative management in 2004. Alongside these advancements, the concept of shared decision making in medicine has evolved, prompting a focus on patient-centered care. This evolution in practice has been fueled by a growing recognition of the importance of patient autonomy and the alignment of treatment options with patients' values and preferences. With the growing number of possible treatment options, variability in patient counseling exists, highlighting the need for a standardized approach to shared decision making in locally advanced rectal cancer. This narrative review will describe the evolution of treatment options of locally advanced rectal cancer as well as the concept of shared decision making and decision aids, and will introduce a decision aid for patients with locally advanced rectal cancer who have achieved a complete clinical response and are eligible for watch and wait.

Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus

The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.

Estimation of risk posed by malignant polyps amongst colorectal surgeons in Australia and New Zealand

PURPOSE

The estimation of the risk posed by malignant polyps for residual or lymphatic disease plays a central role. This study investigated colorectal surgeons' assessment of these risks associated with malignant polyps.

METHODS

A cross-sectional questionnaire was electronically administered to colorectal surgeons in Australia and New Zealand in October 2022. The questionnaire contained 17 questions on demographics, when surgeons consider colorectal resection appropriate, and the risk assessment for 5 hypothetical malignant polyps.

RESULTS

The mean risk of residual or lymphatic disease that would prompt surgeons to recommend colonic resection was 5%. However, this increased to a mean risk of 10% if the malignant polyp was located in the rectum, and the only resection option was abdominoperineal resection with end-colostomy. There was high concordance between the estimated risk of residual or lymphatic disease by colorectal surgeons and the Association of Coloproctology of Great Britain and Ireland (ACPGBI) guidelines for the 5 hypothetical malignant polyps, with the ACPGBI estimated risk lying within the 95% confidence interval for 4 of the 5 malignant polyps. Nonetheless, 96.6% of surgeons felt that an online risk calculator would improve clinical practice.

CONCLUSION

Colorectal surgeons in Australia and New Zealand accurately estimated the risk posed by malignant polyps. An online risk calculator may assist in better conveying risk to patients.

Readmission rates following major colorectal surgery

BACKGROUND

Readmissions following colorectal surgery (CRS) have negative clinical, psychological and financial implications. Identifying patients at risk of readmission remains challenging.

AIMS

To determine factors predictive of those likely to require readmission at 40-days following major CRS and to identify novel strategies capable of reducing readmissions.

METHODS

Consecutive patients were studied from a prospectively maintained database. All patients were operated on by a single surgeon in a high-volume centre. Where applicable, photography was recorded by patients and emailed directly to the institutional email of the consultant surgeon. Data was recorded and analysed using descriptive statistics.

RESULTS

515 patients were included over a 15-year period (2007-2022). The mean age at surgery was 64 years (18-93). The majority of patients were male (56.9%, n=293) and underwent cancer surgery (58.2%, n=299). Overall, 55 patients were readmitted within 40 days of major CRS (10.7%). Patients with pre-treatment diagnoses of heart failure (P=0.012), ischemic heart disease (P=0.002), renal impairment (P<0.001), atrial fibrillation (P=0.006), hypercholesterolemia (P=0.001), asthma (P=0.013) and hypertension (P=0.001) were more likely to require readmission. The majority of patients were readmitted for definitive management of surgical site issues (SSIs) (43.7% n=24). Other reasons included bowel obstruction (9.1%, n=5), pelvic sepsis (7.3%, n=4) and gastrointestinal upset (7.3%, n=4).

CONCLUSION

This series demonstrated that patients with cardiopulmonary comorbidities were more likely to be readmitted following major CRS and most readmissions are SSI related. Readmissions for SSIs can be reduced by patients sending photography to the treating surgeon which could reduce readmissions and A&E attendances.

The erectile and ejaculatory implications of the surgical management of rectal cancer

Colorectal cancer is a significant cause of cancer-related deaths worldwide. Although advances in surgical technology and technique have decreased mortality rates, surviving patients often experience sexual dysfunction as a common complication. The development of the lower anterior resection has greatly decreased the use of the radical abdominoperineal resection surgery, but even the less radical surgery can result in sexual dysfunction, including erectile and ejaculatory dysfunction. Improving the knowledge of the underlying causes of sexual dysfunction in this context and developing effective strategies for preventing and treating these adverse effects are essential to improving the quality of life for postoperative rectal cancer patients. This article aims to provide a comprehensive evaluation of erectile and ejaculatory dysfunction in postoperative rectal cancer patients, including their pathophysiology and time course and strategies for prevention and treatment.

Impact on defecatory, urinary and sexual function after high-tie sigmoidectomy: a post-hoc analysis of a multicenter randomized controlled trial comparing extended versus standard complete mesocolon excision

OBJECTIVE

To assess the effect of high inferior mesenteric artery tie on defecatory, urinary, and sexual function after surgery for sigmoid colon cancer. Performing a sigmoidectomy poses a notable risk of causing injury to the preaortic sympathetic nerves during the high ligation of the inferior mesenteric artery, as well as to the superior hypogastric plexus during dissection at the level of the sacral promontory. Postoperative defecatory and genitourinary dysfunction after sigmoid colon resection are often underestimated and underreported.

METHODS

This study is a secondary research of a multicenter, single-blind, randomized clinical trial. The trial involved patients with sigmoid cancer who underwent either extended complete mesocolic excision (e-CME) or standard CME (s-CME). Patients completed questionnaires to assess defecatory, urinary, and sexual function before, 1 month after surgery, and 1 year after surgery. Multivariate analysis was conducted to identify factors associated with functional dysfunction.

RESULTS

Seventy-nine patients completed functional assessments before and 1 year after surgery. One year after sigmoidectomy with a high tie of the inferior mesenteric artery, 15.2% of patients had minor low anterior resection syndrome (LARS) and 12.7% had major LARS; 22.2% of males and 29.4% of females had urinary dysfunction; and 43.8% of males and 27.3% of females had sexual dysfunction. After multivariate analysis, no significant associations were found between clinical and surgical factors and gastrointestinal or urinary dysfunction after 1 year of surgery. Age was identified as the only factor linked to sexual dysfunction in both sexes (women, β =  - 0.54, p = 0.002; men β =  - 0.38, p = 0.010). Regarding recovery outcomes, diabetes mellitus was identified as a contributing factor to suboptimal gastrointestinal recovery (p = 0.033) and urinary recovery in women (p = 0.039). Furthermore, the treatment arm was found to be significantly associated with the recovery of erectile function after 1 year of surgery (p = 0.046).

CONCLUSIONS

A high tie of the inferior mesenteric artery during sigmoidectomy is associated with a high incidence of defecatory and genitourinary dysfunction. Age was identified as a significant factor associated with sexual dysfunction 1 year after sigmoid colon resection in both sexes.

TRIAL REGISTRATION

Clinical trials NCT03083951 HIGHLIGHTS: • One year after high-tie sigmoidectomy, 27.9% of patients had LARS; 22.2% of the men and 29.4% of the women had urinary dysfunction; and 43.8% of the men and 27.3% of the women had sexual dysfunction. • e-CME is associated with a high rate of urinary dysfunction in men 1 year after surgery. However, after multivariate analysis, no association was found between e-CME and urinary dysfunction in men. • Age was correlated with the recovery of sexual function in both sexes 1 year after surgery. Furthermore, diabetes mellitus was identified as the factor associated with poorer recovery of urinary function in females.

Patient-Reported Outcomes in Colorectal Surgery

Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment. Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening. This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.

"Transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM): a new endoscopic treatment for suspicious deep submucosal invasion T1 rectal carcinoma

BACKGROUND

Endoscopic techniques allow resections of deep submucosal invasion rectal carcinoma, but mostly are facing issues such as costs, follow-up care or size limit. Our aim was to design a new endoscopic technique, which retains the advantages over surgical resections while eliminating the disadvantages mentioned above.

PATIENTS AND METHODS

We propose a technique for the resection of the superficial rectal tumours, with highly suspicious deep submucosal invasion. It combines steps of endoscopic submucosal dissection, muscular resection and edge-to-edge suture of the muscular layers, finally performing the equivalent of a "transanal endoscopic microsurgery" with a flexible colonoscope (F-TEM).

RESULTS

A 60-year-old patient was referred to our unit, following the discovery of a 15 mm distal rectum adenocarcinoma. The computed tomography and the endoscopic ultrasound examination revealed a T1 tumour, without secondary lesions. Considering that the initial endoscopic evaluation highlighted a depressed central part of the lesion, with several avascular zones, an F-TEM was performed, without severe complication. The histopathological examination revealed negative resection margins, without risk factors for lymph node metastasis, no adjuvant therapy being proposed.

CONCLUSION

F-TEM allows endoscopic resection of highly suspicious deep submucosal invasion T1 rectal carcinoma and it proves to be a feasible alternative to surgical resection or other endoscopic treatments as endoscopic submucosal dissection or intermuscular dissection.

Erectile Dysfunction in Pelvic Cancer Survivors and Current Management Options

Pelvic malignancies, including prostate, rectal, and bladder cancers, are among the most frequent malignancies found in the male population. These issues are most effectively and commonly treated with radiotherapy and/or surgery. However, these treatments can cause collateral damage, resulting in significant impacts on quality of life, with erectile dysfunction being one of the most frequent postoperative complications. Currently, there are several treatment options for erectile dysfunction, including oral phosphodiesterase type 5 inhibitors, vacuum erection devices, intracorporeal injections, and penile prosthesis. The latter has shown to be an effective and safe technique, with results comparable to those obtained by patients without pelvic surgery or radiotherapy. The results of early penile rehabilitation programs are promising and they have been incorporated into a greater proportion of treatment plans more recently, with varying degrees of success. In this narrative review, we summarize the literature on erectile dysfunction after pelvic cancer treatments and its management.

Outcomes for men undergoing rectal prolapse surgery - a systematic review

AIM

Rectal prolapse is considered rare in men but the prevalence can be high in certain populations. It is unclear which surgical approach offers lower recurrence rates and better functional outcomes in men. The aim of this work was to determine the recurrence rates, complications and functional outcomes after prolapse surgery in men.

METHOD

The MEDLINE, EMBASE and Scopus databases were systematically searched to identify studies on outcomes following surgical management of full-thickness rectal prolapse in men (over 18 years of age) published between 1951 and September 2022. Outcomes of interest included recurrence rate after surgery, bowel function, urinary function, sexual function and postoperative complications.

RESULTS

Twenty-eight studies involving 1751 men were included. Two papers focused exclusively on men. Twelve studies employed a mixture of abdominal approaches, ten employed perineal approaches and six compared both. The recurrence rate varied across studies, ranging from 0% to 34%. Sexual and urinary function were poorly reported, but the incidence of dysfunction appears low.

CONCLUSION

The outcomes of rectal prolapse surgery in men are poorly studied with small sample sizes and variable outcomes reported. There is insufficient evidence to recommend a specific repair approach based on the recurrence rate and functional outcomes. Further studies are required to identify the optimal surgical approach for rectal prolapse in men.

Advances in physical diagnosis and treatment of male erectile dysfunction

Erectile dysfunction (ED) is the most common male sexual dysfunction by far and the prevalence is increasing year after year. As technology advances, a wide range of physical diagnosis tools and therapeutic approaches have been developed for ED. At present, typical diagnostic devices include erection basic parameter measuring instrument, erection hardness quantitative analysis system, hemodynamic testing equipment, nocturnal erection measuring instrument, nerve conduction testing equipment, etc. At present, the most commonly used treatment for ED is pharmacological therapy represented by phosphodiesterase five inhibitors (PDE5i). As a first-line drug in clinical, PDE5i has outstanding clinical effects, but there are still some problems that deserve the attention of researchers, such as cost issues and some side effects, like visual disturbances, indigestion, myalgia, and back pain, as well as some non-response rates. Some patients have to consider alternative treatments. Moreover, the efficacy in some angiogenic EDs (diabetes and cardiovascular disease) has not met expectations, so there is still a need to continuously develop new methods that can improve hemodynamics. While drug have now been shown to be effective in treating ED, they only control symptoms and do not restore function in most cases. The increasing prevalence of ED also makes us more motivated to find safer, more effective, and simpler treatments. The exploration of relevant mechanisms can also serve as a springboard for the development of more clinically meaningful physiotherapy approaches. Therefore, people are currently devoted to studying the effects of physical therapy and physical therapy combined with drug therapy on ED. We reviewed the diagnosis of ED and related physical therapy methods, and explored the pathogenesis of ED. In our opinion, these treatment methods could help many ED patients recover fully or partially from ED within the next few decades.

Coloanal Anastomosis

The furthest extent of restorative proctectomy involves a colon to anal anastomosis in the deep pelvis. While the anastomosis can be challenging, it can allow the patient to avoid a permanent ostomy. Patient and surgeon preparation can improve patient outcomes. This article will describe the options, technical challenges, and anecdotal tips for coloanal anastomosis.

Diffuse reflection spectroscopy at the fingertip: design and performance of a compact side-firing probe for tissue discrimination during colorectal cancer surgery

Optical technologies are widely used for tissue sensing purposes. However, maneuvering conventional probe designs with flat-tipped fibers in narrow spaces can be challenging, for instance during pelvic colorectal cancer surgery. In this study, a compact side-firing fiber probe was developed for tissue discrimination during colorectal cancer surgery using diffuse reflectance spectroscopy. The optical behavior was compared to flat-tipped fibers using both Monte Carlo simulations and experimental phantom measurements. The tissue classification performance was examined using freshly excised colorectal cancer specimens. Using the developed probe and classification algorithm, an accuracy of 0.92 was achieved for discriminating tumor tissue from healthy tissue.

A population-based study of the management of rectal malignant polyps and the use of trans-anal surgery

INTRODUCTION

Rectal malignant polyps can be managed by use of trans-anal resections (TAR). Traditional techniques of resection have been replaced by use of platforms such as trans-anal minimally invasive surgery (TAMIS) or trans-anal endoscopic microsurgery (TEM). This study reviewed the management of rectal malignant polyps, in particular focussing on when clinicians used TAR.

METHODS

A population wide cohort study of all malignant rectal polyps diagnosed in Queensland, Australia from 2011 to 2018 was undertaken. Patient and pathological factors were compared across the management strategies of polypectomy, TAR and rectal resection.

RESULTS

Overall 430 patients were diagnosed with a malignant rectal polyp during the study period, with 103 undergoing a TAR. There was increasing use of TAR across the study period as a management strategy (P < 0.001). Polypectomy alone was more likely to be the management strategy over TAR or rectal resection if there were clear margins (P < 0.001). The distance to the closest polypectomy margin was also significantly higher in the polypectomy group with mean clearance 2.09 mm in polypectomy group versus 0.86 mm in TAR group and 0.99 mm in resection group (P < 0.001). Rectal resection was more likely to be the management strategy over TAR if there was LVI (P < 0.001), depth of invasion was deeper (P < 0.001) and there was tumour budding (P = 0.001).

CONCLUSION

TAR is an effective management strategy for rectal polyps and is utilized particularly in rectal malignant polyps when there are close or involved margins. Future guideline development should consider incorporation of TAR given the advances in techniques afforded by TAMIS or TEM platforms.

Low Anterior Resection Syndrome: What Have We Learned Assessing a Large Population?

Our goal was to assess the rate of symptoms commonly included in LARS score in a large general population. The study was based on a population-based design. We disseminated LARS scores through community online platforms and general practitioners throughout Lithuania. We received 8183 responses to the questionnaire. There were 142 (1.74%) participants who were excluded for lack of information. There were 6100 (75.9%) females and 1941 (24.1%) males. After adjusting for sex and age, male participants had a significant average score of 18.4 (SD ± 10.35) and female 20.3 (SD ± 9.74) p < 0.001. There were 36.4% of participants who had minor LARS symptoms, and 14.2% who had major LARS symptoms. Overall, major LARS-related symptoms were significantly related to previous operations: 863 participants in the operated group (71.7%), and 340 in the non-operated group (28.3%; p0.001). In 51−75-year-old patients, major LARS was significantly more prevalent with 22.7% (p < 0.001) and increasing with age, with a higher incidence of females after the age of 75. After excluding colorectal and perineal procedures, the results of multivariate logistic regression analysis indicated the use of neurological drugs and gynaecological operations were independent risk factors for major LARS−odd ratio of 1.6 (p = 0.018, SI 1.2−2.1) and 1.28 (p = 0.018, SI 1.07−1.53), respectively. The symptoms included in the LARS score are common in the general population, and there is a variety of factors that influence this, including previous surgeries, age, sex, comorbidities, and medication. These factors should be considered when interpreting the LARS score following low anterior resection and when considering treatment options preoperatively.

Improvement Effect of Bifidobacterium animalis subsp. lactis MH-02 in Patients Receiving Resection of Colorectal Polyps: A Randomized, Double-Blind, Placebo-Controlled Trial

Background

Postoperative symptoms, bowel dysfunction and recurrence are common problems after resection of colorectal polyps. We aimed to evaluate the efficacy of Bifidobacterium in the postoperative patients.

Methods

In this single-center, randomized, double-blind, placebo-controlled trial, adults (≥ 18 years) undergoing endoscopic resection of colorectal polyps were treated with probiotics (Bifidobacterium animalis subsp. lactis MH-02, 2 × 10⁹ colony-forming units per packet) or placebo once daily for 7 days. The primary clinical endpoint was a reduction in the mean total postoperative symptoms score within 7 days postoperatively. Secondary clinical endpoints were the single symptom scores, time to recovery of bowel function, and changes in the intestinal microbiota. This study is registered with the number ChiCTR2100046687.

Results

A total of 100 individuals were included (48 in probiotic group and 52 in placebo group). No difference was seen in the mean scores between the two groups (0.29 vs. 0.43, P = 0.246). Colorectal polyps size (P = 0.008) and preoperative symptoms (P = 0.032) were influential factors for the primary endpoint. Besides, MH-02 alleviated difficult defecation (P = 0.045), and reduced the time to recovery of bowel function (P = 0.032). High-throughput analysis showed that MH-02 can help restore the diversity of intestinal microbiota, and increased the relative abundance of Bifidobacterium, Roseburia, Gemmiger, Blautia and Ruminococcus, while reduced the relative abundance of Clostridium at genus level (P < 0.05).

Conclusion

In this prospective trial, MH-02 showed efficacy in patients with resection of colorectal polyps, particularly in the recovery of bowel function, and the changes in the intestinal microbiota may provide evidence for further exploration of the therapeutic mechanisms.

Comparison of postoperative laparoscopic and open total mesorectal excision on lower urinary tract function in men with rectal cancer

OBJECTIVES

This study investigated male voiding dysfunction (VD) or lower urinary tract function in rectal cancer (RC) patients after laparoscopic or open total mesorectal excision with pelvic autonomic nerve preservation (PANP).

METHODS

One hundred and eighty-seven male RC patients admitted between January 2016 and May 2019 were enrolled in this study, 112 of whom underwent laparoscopic total mesorectal excision (LTME) and 75 underwent open total mesorectal excision (OTME). The International Prostatic Symptom Score (IPSS) was compared between the two groups.

RESULTS

The postoperative IPSS in patients with RC was elevated on day 7 and gradually decreased during the first month after surgery. Compared with the OTME group, the IPSS scores decreased less in the LTME group at week 1, and months 1 and 3 postoperatively (6.82 ± 2.13 vs 10.15 ± 3.86, 5.70 ± 2.45 vs 7.21 ± 2.0, and 5.01 ± 2.09 vs 5.75 ± 2.55, respectively; P < 0.05). The VD rate was significantly lower in the LTME group than the OTME group at 1, 2, and 3 weeks postoperatively (21.4% vs 26.8%,13.4% vs 25.3%, and 9.8% vs18.6%, respectively; P < 0.05); however, there was no major difference in the incidence of VD 6 months postoperatively between the two groups (P > 0.05). VD was more frequent in the OTME group than the LTME group 6 months postoperatively, but the difference was not statistically significant (odds ratio = 1.857, 95% CI, 0.964-3.645, P = 0.064).

CONCLUSIONS

LTME may be superior to OTME with respect to PANP of lower urinary tract function in males with RC.

Patient and pathological predictors of management strategy for malignant polyps following polypectomy: a systematic review and meta-analysis

PURPOSE

Malignant polyps present a treatment dilemma for clinicians and patients. This meta-analysis sought to identify the factors that predicted the management strategy for patients diagnosed with a malignant polyp.

METHODS

A literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Collaboration prognostic studies guidelines. Reports from 1985 onwards were included, data on patient and pathological factors were extracted and random effects meta-analysis models were used.

RESULTS

Fifteen studies were included. Seven studies evaluated lymphovascular invasion (LVI). The odds of surgery were significantly higher in malignant polyps with LVI (OR 2.20, 95% CI 1.36-3.55). Ten studies revealed the odds of surgery were significantly higher with positive polypectomy margins (OR 8.09, 95% CI 4.88-13.40). Tumour differentiation was compared in eight studies. There were significantly lower odds of surgery in malignant polyps with well/moderate differentiation compared with poor differentiation (OR 0.31, 95% CI 0.21-0.46). There were non-significant trends favouring surgical resection in younger patients, males and Haggitt 4/Kikuchi Sm3 lesions. There was considerable heterogeneity in the meta-analyses for the variables age, gender, polyp morphology and Haggitt/Kikuchi level (I² > 75%).

CONCLUSION

This meta-analysis has demonstrated that LVI, positive polypectomy resection margins, and poor tumour differentiation significantly predict malignant polypectomy patients who underwent subsequent surgery. Age and gender were important factors predicting management, but not consistently across studies, whilst polyp morphology and Haggitt/Kikuchi levels did not significantly predict the management strategy. Further research may assist in understanding the management preferences.

The Role of Traditional Acupuncture in Low Anterior Resection Syndrome Treatment: A Pilot Study

BACKGROUND

There is limited evidence on the efficacy of acupuncture in bowel dysfunction treatment.

OBJECTIVE

The aim of this pilot study was to investigate the potential value of acupuncture in the treatment of low anterior resection syndrome.

DESIGN

This was an open-design pilot study.

SETTINGS

This was a single-center study.

PATIENTS

Nine (5 female) patients with major low anterior resection syndrome were included.

INTERVENTIONS

All patients underwent acupuncture by a trained specialist once a week for 10 weeks.

MAIN OUTCOME MEASURES

Bowel function was assessed by using the low anterior resection syndrome score and the Memorial Sloan-Kettering Cancer Center bowel function instrument before the procedure, just after finishing the course of acupuncture, and 6 months after the treatment.

RESULTS

The average age was 56.44 (50-65; SD ±5.4). Median age was 56 years. At the end of the procedure, all patients reported significant improvement in low anterior resection syndrome symptoms: the average low anterior resection syndrome score before acupuncture was 39 (±2.7), after acupuncture it was 30.3 (±10.6), and 6 months after acupuncture it was 7.22 (±10.244; p < 0.000). The average Memorial Sloan-Kettering Cancer Center bowel function instrument score before acupuncture was 55.33 (±11.55), after the procedure it was 60 (±14.97), and 6 months later it was 70.22 (±12.2; p < 0.000).

LIMITATIONS

The small sample size and the fact that this is a single-center nonblinded study are limitations of this work.

CONCLUSIONS

Acupuncture may be effective in low anterior resection syndrome treatment and needs further evaluation. The procedure is safe and feasible. See Video Abstract at http://links.lww.com/DCR/B700.

REGISTRATION

ClinicalTrials.gov: NCT03916549.

EL PAPEL DE LA ACUPUNTURA TRADICIONAL EN EL TRATAMIENTO DEL SNDROME DE RESECCIN ANTERIOR BAJA UN ESTUDIO PILOTO

ANTECEDENTES:Existe evidencia limitada sobre la eficacia de la acupuntura para el tratamiento de la disfunción intestinal.OBJETIVO:El objetivo de este estudio piloto fue investigar el valor potencial de la acupuntura en el tratamiento del síndrome de resección anterior baja.DISEÑO:Este fue un estudio piloto de diseño abiertoAJUSTES:Este fue un estudio en un solo centroPACIENTES:Fueron incluidos nueve pacientes con síndrome de resección anterior baja (muy sintomáticos), cinco de ellos eran mujeresINTERVENCIONES:Todos los pacientes fueron tratados con acupuntura, una vez a la semana durante diez semanas por un especialista capacitado.PRINCIPALES MEDIDAS DE RESULTADO:La función intestinal fue evaluada, antes del procedimiento, justo al finalizar el ciclo de acupuntura y a los seis meses, utilizando la puntuación (score) para el síndrome de resección anterior baja y el instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center.RESULTADOS:La edad media fue 56,44 (50 - 65) (DE ± 5,4). Edad mediana 56 años. Al final del procedimiento, todos los pacientes manifestaron una mejoría significativa de los síntomas del síndrome de resección anterior baja: La puntuación promedio del síndrome de resección anterior baja antes de la acupuntura fue 39 (± 2,7), después de - 30,3 (± 10,6) y 6 meses después de 7,22 (± 10,244) (p <0,000). El puntaje promedio del instrumento de función intestinal del Memorial Sloan-Kettering Cancer Center antes de la acupuntura fue 55.33 (± 11.55), después del procedimiento 60 (± 14.97) y 6 meses después 70.22 (± 12.2) (p <0,000).LIMITACIONES:Tamaño de muestra pequeño, estudio no cegado en un solo centro.CONCLUSIONES:La acupuntura puede ser eficaz en el tratamiento del síndrome de resección anterior baja, pero es necesario continuar evaluando su utilidad. El procedimiento es seguro y factible. Consulte Video Resumen en http://links.lww.com/DCR/B700.

Iatrogenic effects of radical cancer surgery on male fertility

Iatrogenic causes of male infertility can include medications, chemotherapy, radiation, and surgery. In this review, we discuss commonly performed urologic cancer surgeries and nonurologic surgeries that harbor a high risk of iatrogenic infertility. These include radical prostatectomy, radical cystectomy, retroperitoneal lymph node dissection, pelvic colon surgery, and anterior spine surgery. In addition, we review the anatomy and surgical strategies that help to reduce the risks of infertility. With an increase in life expectancy and improvements in fertility preservation, it is important to properly counsel patients about the risks of infertility and provide options for fertility preservation before surgery.

Overtreatment in nonmalignant lesions detected in a colorectal cancer screening program: a retrospective cohort study

Background

Although colorectal cancer (CRC) screening programs reduce CRC incidence and mortality, they are associated with risks in healthy subjects. However, the risk of overtreatment and overdiagnosis has not been determined yet. The aim of this study was to report the surgery rates in patients with nonmalignant lesions detected within the first round of a fecal immunochemical test (FIT) based CRC screening program and the factors associated with it.

Methods

We included in this analysis all patients with nonmalignant lesions detected between May 2013 and June 2019 in the Galician (Spain) CRC screening program. We calculated surgery rate according to demographic variables, the risk classification according to the colonoscopy findings (European guidelines for quality assurance), the endoscopist’s adenoma detection rate (ADR) classified into quartiles and the hospital’s complexity level. We determined which variables were independently associated with surgery rate and expressed the association as Odds Ratio and its 95% confidence interval (CI).

Results

We included 15,707 patients in the analysis with high (19.9%), intermediate (26.9%) low risk (23.3%) adenomas and normal colonoscopy (29.9%) detected in the analyzed period. Colorectal surgery was performed in 162 patients (1.03, 95% CI 0.87–1.19), due to colonoscopy complications (0.02, 95% CI 0.00–0.05) and resection of colorectal benign lesions (1.00, 95% CI 0.85–1.16). Median hospital stay was 6 days with 17.3% patients developing minor complications, 7.4% major complications and one death. After discharge, complications developed in 18.4% patients. In benign lesions, an endoscopic resection was performed in 25.4% and a residual premalignant lesion was detected in 89.9%. The variables independently associated with surgery in the multivariable analysis were age (≥60 years = 1.57, 95% CI 1.11–2.23), sex (female = 2.10, 95% CI 1.52–2.91), the European guidelines classification (high risk = 67.94, 95% CI 24.87–185.59; intermediate risk = 5.63, 95% CI 1.89–16.80; low risk = 1.43; 95% CI 0.36–5.75), the endoscopist’s ADR (Q4 = 0.44, 95% CI 0.28–0.68; Q3 = 0.44, 95% CI 0.27–0.71; Q2 = 0.71, 95% CI 0.44–1.14) and the hospital (tertiary = 0.54, 95% CI 0.38–0.79).

Conclusions

In a CRC screening program, the surgery rate and the associated complications in patients with nonmalignant lesions are low, and related to age, sex, endoscopic findings, endoscopist’s ADR and the hospital’s complexity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08606-w.

PDE-5i Management of Erectile Dysfunction After Rectal Surgery: A Systematic Review Focusing on Treatment Efficacy

Erectile dysfunction (ED) is one of the main functional complications of surgical resections of the rectum due to rectal cancers or inflammatory bowel disease (IBD). The present systematic review aimed at revising ED management strategies applied after rectal resections and their efficacy in terms of improvement of the International Index of Erectile Function (IIEF) score. A literature search was conducted on Medline, EMBASE, Scopus, and Cochrane databases by two independent reviewers following the PRISMA guidelines. Randomized and nonrandomized controlled trials (RCTs, NRCTs), case-control studies, and case series evaluating medical or surgical therapies for ED diagnosed after rectal surgery for both benign and malignant pathologies were eligible for inclusion.

Out of 1028 articles initially identified, only five met the inclusion criteria: two RCTs comparing oral phosphodiesterase type-5 inhibitor (PDE-5i) versus placebo; one NRCT comparing PDE-5i versus PDE-5i + vacuum erection devices (VEDs) versus control; and two before-after studies on PDE-5i. A total of 253 (82.7%) rectal cancer patients and 53 (17.3%) IBD patients were included. Based on two RCTs, PDE-5i significantly improved IIEF compared to placebo at 3 months (SMD = 1.07; 95% CI [0.65, 1.48]; p < .00001; I² = 39%). Improved IIEF was also reported with PDE-5i + VED at 12 months. There is a paucity of articles in the literature that specifically assess efficacy of ED treatments after rectal surgery. Many alternative treatment strategies to PDE-5is remain to be investigated. Future studies should implement standardized preoperative, postoperative, and follow-up sexual function assessment in patients undergoing rectal resections.

pT1 Colorectal Cancer Detected in a Colorectal Cancer Mass Screening Program: Treatment and Factors Associated with Residual and Extraluminal Disease

Simple Summary

Our study has evaluated the burden of pT1 CRC (confined to submucosa) detected during the first round of a CRC screening program, the surgery related complications and the factors related to four relevant outcomes: initial endoscopic resection, surgery rescue and residual disease after endoscopic resection and, finally, extraluminal disease after surgical resection. 38% of the CRC were detected in this stage.74.9% were initially resected endoscopically and 43.8% did not require surgery. There were inhospital surgical complications in 30.7%, mainly mild with no death and complications after discharge in 16.3% of the patients Residual disease was detected in 12 (4.3%) after endoscopic resection and extraluminal disease in 18 (8.6%) patients after surgery. We have determined several variables independently associated with the four outcome variables evaluated.

Abstract

The aim of this study is to describe the treatment of pT1 colorectal cancer (CRC) in a mass screening program, the surgery-related complications and the factors associated with residual disease after endoscopic resection and extraluminal disease after surgery. We included in this retrospective analysis all the pT1 CRC detected in the Galician CRC screening program between May 2013 and June 2019. We determined which variables were independently associated with the outcomes of the study through a multivariable logistic regression analysis. We included 370–354 pT1 N0(X), 16 pT1N1- out of the 971 CRC detected; 277 (74.9%) were resected endoscopically and 162 (43.8%) were not referred to surgery. There were surgical complications in 30.7% and 16.3% of the patients during hospitalization and after discharge. Residual disease was detected in 12 (4.3%) after endoscopic resection and extraluminal disease in 18 (8.6%) patients after surgery. The variables independently associated with initial endoscopic resection were a pedunculated morphology (OR 33.1, 95% CI 4.3–254), a diameter ≥ 20 mm (OR 3.94, 95% CI 1.39–11.18) and a Site–Morphology–Size–Access score < 9 (OR 428, 95% CI 42–4263). The variables related with surgery rescue were a piecemeal resection (OR 4.48, 95% CI 1.48–13.6), an infiltrated/nonevaluable resection border (OR 7.44, 95% CI 2.12–26.0), a non-well-differentiated histology (OR 4.76, 95% CI 1.07–20.0), vascular infiltration (OR 8.24, 95% CI 2.72–25.0) and a Haggitt 4 infiltration of the submucosa (OR 5.68, 95% CI 2.62–12.3). Residual disease after endoscopic resection was associated with an infiltrated/nonevaluable resection border (OR 34.9, 95% CI 4.08–298), a non-well-differentiated histology (OR 6.67, 95% CI 1.05–50.0), and the vascular infiltration of the submucosa (OR 7.61, 95% CI 1.55–37.4). The variables related with extraluminal disease after surgical resection were no endoscopic resection (OR 4.34, 95% CI 1.26–14.28), a non-well-differentiated histology (OR 4.35, 95% CI 1.39–14.29) and the lymphatic infiltration of the submucosa (OR 4.8, 95% CI 1.32–17.8). In a CRC screening program, although most of pT1 CRC are candidates for endoscopic treatment, surgery is a safe procedure. We have defined some easy to evaluate variables that can be used in the decision-making process.

"Prophylactic" transanal irrigation (TAI) to prevent symptoms of low anterior resection syndrome (LARS) after rectal resection: results at 12-month follow-up of a controlled randomized multicenter trial

BACKGROUND

Low anterior resection syndrome (LARS) is associated with a severe negative impact on patients' quality of life (QOL). In a recent prospective randomized controlled trial (RCT) by our group, early ("prophylactic") use of transanal irrigation (TAI) following rectal resection for rectal cancer was shown to improve symptoms associated with LARS significantly compared with a group under supportive therapy (ST) within 1 and 3 months following closure of the protective ileostomy. The aim of the present study was to evaluate the outcome after 12 months when patients had the option to choose between the two therapeutic options and/or modify the regimen of TAI (volume and time).

METHODS

In the RCT, 18 patients had been allocated to start with TAI following ileostomy closure, while 19 patients remained on ST only. Once the 3-month follow-up had been completed patients could choose between TAI or ST, respectively, and were invited for follow-up after 12 months. The maximum number of bowel movements during the day and the Wexner and LARS score as well as physical (PC) and mental (MC) component of the SF-36 questionnaire were evaluated. Furthermore, in patients who had changed their treatment arm, reasons for this decision were reported.

RESULTS

Six patients were lost to follow-up (all in the ST group). One patient from the ST group started with TAI due to problems associated with LARS, bringing the total number of TAI patients to 19. Nine patients from the previous TAI arm changed to ST due to the long duration of the emptying process (n: 8) or pain during TAI (n: 1), respectively. After 12 months, the median volume of water used for irrigation was 600 ml (range 200-1000 ml). The ten patients who continued with TAI patients showed a lower number of defecation episodes per daytime (TAI median 3; 1-6, ST median 5; 2-10, p: 0.018) and per night (TAI median 0; 0-1, ST median 1; 0-5, p: 0.004) compared to the ST group. Although the LARS score was lower in patients who used TAI after 12 months (TAI median 18; 9-32, ST median 30; 3-39), this failed to reach the level of significance (p: 0.063). Evaluation of the Wexner score and the 36-item Short Form Health Survey as well as comparison of patients who remained on TAI (n: 9) versus those who had stopped TAI after 3 months (n: 9) failed to find any statistically significant difference between TAI and ST.

CONCLUSIONS

This follow-up study revealed that a considerable number of patients decided to stop TAI within 12 months. However, the number of bowel movements during the day were still lower when TAI was used than when patients had ST only.

CATEGORY

Randomized trial.

REGISTRATION NUMBER

DRKS00011752, https://apps.who.int/trialsearch/ .

Importance of patient reported and clinical outcomes for patients with locally advanced rectal cancer and their treating physicians. Do clinicians know what patients want?

INTRODUCTION

Several factors are included in decision making for treatment of patients with locally advanced rectal cancer, including a trade-off between risks and gains of both clinical and functional outcomes. However, it is largely unknown which outcomes are most important to patients and whether this differs between patients and clinicians.

METHODS

Both clinicians and patients treated for locally advanced rectal cancer were invited to fill out an online questionnaire, including a choice-based conjoint experiment. Participants were presented 14 comparisons of two hypothetical case presentations, characterized by different treatments and outcomes of care (6 attributes) and were asked to select the case with the best outcome at that moment. Hierarchical Bayes Estimation was used to calculate the relative importance (RI) of each of the six attributes.

RESULTS

In total, 94 patients and 128 clinicians completed the questionnaire. For patients, avoiding surgery with permanent stoma was most important (RI 24.4, 95%CI 21.88-26.87) and a 2-year difference in disease-free survival was least important (RI 5.6, 95%CI 4.9-6.2). Clinicians assigned highest importance to avoiding severe and daily worries about cancer recurrence (RI 30.7, 95%CI 29.1-32.4), while this was ranked 4th by patients (RI 17.9, 95%CI 16.5-19.4, p < 0.001).

CONCLUSION

When confronted with different outcomes within one case description, patients find the duration of disease free survival the least important. In addition, considerable differences were found between the importance assigned by patients and clinicians to clinical and functional outcomes, most notably in avoiding surgery with permanent stoma and worries about recurrence.