Long-term anorectal function in rectal cancer patients treated with chemoradiotherapy and endorectal brachytherapy

AIM

The aim was to study anorectal function in long-term survivors after combined, curatively intended, chemoradiotherapy and endorectal brachytherapy for low rectal cancer.

METHODS

This was a case-control design. We compared anorectal function by anal manometry, anal functional lumen imaging probe (EndoFLIP) and rectal bag distension in rectal cancer patients (RCPs) and healthy, normal subjects (NSs). Symptoms were assessed by the low anterior resection syndrome (LARS) and Wexner faecal incontinence scores.

RESULTS

Thirteen RCPs (12 men, median age 68 years, range 52-92) after 60 Gy radiotherapy, 5 Gy endorectal brachytherapy and oral tegafur-uracil with complete clinical response (median time since treatment 2.8 years, range 2.2-5.6) were compared to 15 NSs (14 men, median age 64 years, range 47-75). RCPs had lower than normal anal resting pressure, 38.6 mmHg (range 8.8-67.7) versus 58.8 mmHg (25.7-105.2) (P < 0.003), and squeeze pressure, 117 mmHg (55.2-203) versus 188 mmHg (103-248) (P < 0.01). Squeeze-induced pressure increase recorded by EndoFLIP was also lower in RCPs (q > 7.56, P < 0.001) as was the anal canal resistance to increasing distension (q = 3.13, P < 0.05). No differences in median rectal volume at first sensation (72 [22-158] vs. 82 [36-190] ml, P = 0.4) or at urge to defaecate (107 [42-227] vs. 132 [59-334] ml, P = 0.2) were found. However, maximum tolerable rectal volume was lower in RCPs (145 [59-319] vs. 222 [106-447] ml, P < 0.02). The median (range) low anterior resection syndrome score was 27 (0-39) for RCPs and 7 (0-23) for NSs (P < 0.001), while the Wexner score was 0 (0-5) versus 0 (0-4) (P = 0.56).

CONCLUSION

Radiotherapy combined with endorectal brachytherapy for rectal cancer causes long-term anorectal symptoms, impaired anal sphincter function and reduced rectal capacity.

Cortical processing to anorectal stimuli after rectal resection with and without radiotherapy

BACKGROUND

Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers.

METHODS

Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing.

RESULTS

Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers.

CONCLUSIONS

Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.

Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury

STUDY DESIGN

Randomized, controlled clinical trial.

OBJECTIVES

Bladder and bowel management may cause serious autonomic dysreflexia (AD) in subjects with high spinal cord injury (SCI). We aimed at investigating autonomic responses to digital rectal evacuation (DE), transanal irrigation (TAI) with 500 ml and filling cystometry (FC) in SCI.

SETTING

Aarhus University Hospital, Denmark.

METHODS

Eight subjects with SCI (AIS A) at or above T6 (high SCI) and a previous history of AD were compared with three subjects with SCI (AIS A) between T10 and L2 (low SCI). In randomized order, DE, TAI and FC were performed. AD was defined as an acute rise in systolic blood pressure (sBP) of ⩾30 mm Hg above baseline. Blood levels of norepinephrine and epinephrine were determined before and shortly after the procedures.

RESULTS

During all three procedures, AD occurred in all patients with high SCI but not in those with low SCI. In high SCI subjects, DE increased median sBP from 127 (range: 86-154) to 188 (range: 140-206) mm Hg (P<0.02), TAI from 126 (range: 91-146) to 163 (range: 130-188) mm Hg (P<0.02) and FC from 125 (range: 106-149) to 200 (range: 179-220) mm Hg (P<0.01). The sBP increase was lower during TAI than during DE (P<0.05) or FC (P<0.02). In high SCI subjects, the blood levels of norepinephrine, but not those of epinephrine, increased significantly during all three stimuli (all P<0.05).

CONCLUSION

Bowel and bladder management caused AD in high SCI. The response is less severe during TAI than during FC or DE.

Abdominal Pain: A Comparison between Neurogenic Bowel Dysfunction and Chronic Idiopathic Constipation

Introduction. Most spinal-cord-injured patients have constipation. One-third develop chronic abdominal pain 10 years or more after injury. Nevertheless, very little is known about the nature of abdominal pain after spinal cord injury (SCI). It may be neuropathic or caused by constipation. Aim. To compare characteristics of abdominal pain in SCI with able-bodied with chronic idiopathic constipation (CIC). Subjects and Methods. 21 SCI and 15 CIC patients were referred for treatment of bowel symptoms. Constipation-related symptoms were assessed with the Cleveland Constipation Scoring System and the International Spinal Cord Injury Basic Bowel Function Data Set. Characteristics of abdominal pain were described using the Brief Danish Pain Questionnaire. Total gastrointestinal transit times (GITT) were measured by radiopaque markers. Results. Seventeen (81%) SCI and 14 (93%) CIC patients reported abdominal pain or discomfort within the last month (P = 0.38). Pain was considered more intense by CIC than by SCI patients (P < 0.05). Only minor differences were found in patient's qualitative description of abdominal pain or in the location of pain. In neither SCI nor CIC was pain associated with GITT. Conclusion. Most characteristics of abdominal pain among SCI patients resemble those of CIC. This indicates that constipation is a major cause of pain after SCI.

Anorectal function after long-term transanal colonic irrigation

AIM

The increased use of transanal colonic irrigation (TAI) warrants study of its effects on anorectal function after long term use.

METHOD

Anorectal physiology tests were performed in 12 patients with chronic idiopathic constipation (CC) and 10 with idiopathic faecal incontinence (FI) [median 55 years (range 21-70)] before and after a median 68 (range 32-113) months use of TAI.

RESULTS

In CC median, urge rectal volume increased from 121 (70-264) to 268 ml (69-484) (P = 0.05) whereas rectal compliance, volume at first sensation, maximum tolerable rectal volume, anal sensory level, median anal resting and squeeze pressures were unaltered. In FI median, urge volume increased from 125 (range 50-221) to 158 ml (range 97-287) (P = 0.033) and maximum tolerable volume increased from 156 (80-321) to 253 ml (162-332) (P = 0.047). Median anal resting pressure decreased from 48 (29-100) to 32 cmH(2) O (12-79) (P = 0.011) and anal squeeze pressure decreased from 69 (30-107) to 38 cmH(2) O (30-70) (P = 0.017). Rectal compliance, volume at first sensation and anal sensory level were unaltered.

CONCLUSIONS

As rectal compliance was unaltered, it is likely that the increased rectal tolerable volume is explained by patients adapting to irrigation rather than by changes in the property of the mechanical rectal wall. As anal sphincter function was deteriorated only in FI, we suggest that this is because of the natural history of FI rather than any effect of long term TAI.

Long-term outcome and safety of transanal colonic irrigation for neurogenic bowel dysfunction

STUDY DESIGN

Long-term follow-up study.

OBJECTIVES

Short-term results find transanal colonic irrigation (TAI) favourable in the treatment of neurogenic bowel dysfunction (NBD). Therefore, long-term results need to be described.

SETTING

Department of Surgery P, Aarhus University Hospital, Denmark.

METHODS

Between 1994 and 2007, 211 (115 female) patients with NBD (age: 7-81 years (median 49)) were introduced to TAI. One hundred and seventy-three patients had spinal cord injury and 38 had other neurological disorders. Data were obtained from hospital records and a mailed questionnaire. Treatment was considered successful in patients still using TAI, patients who had used TAI until they died and patients whose symptoms had resolved while using TAI.

RESULTS

Successful outcome was achieved in 98 (46%) patients after a mean follow-up of 19 months (range 1-114 months). A Kaplan-Meier plot showed a dropout of 20% in the first 3 months. After 3 years, the rate of success was 35% and remained almost unchanged afterwards. A regression analysis showed male gender (odds ratio (OR) 2.1), mixed symptoms (OR 2.9) and prolonged colorectal transit time (OR 2.4) to be significantly associated with successful outcome. One non-lethal bowel perforation occurred in approximately 50,000 irrigations (0.002%), whereas minor side effects were observed in 48%.

CONCLUSION

After a mean follow-up of 19 months, 46% was successfully treated. The rate of success was 35% after 3 years and remained almost unchanged afterwards. TAI is safe and can be introduced to most patients suffering from NBD.

The pattern of colorectal dysfunction changes with time since spinal cord injury

BACKGROUND

Cross-sectional studies suggest that colorectal dysfunction after spinal cord injuries (SCI) worsens as time goes by. However, follow-up studies are needed to prove this.

STUDY DESIGN

Prospective study.

OBJECTIVE

To describe long-term colorectal function in SCI patients.

SETTING

Members of the Danish Spinal Cord Injuries Association.

METHODS

In 1996, 424 members of the Danish Paraplegic Association answered a detailed questionnaire describing their colorectal function. In 2006, those who continued as members (n=284) received an identical questionnaire. Data for patients responding both in 1996 and in 2006 (n=159) were compared.

RESULTS

In 1996, 25% of the respondents reported that colorectal dysfunction had some or a major impact on their quality of life. At follow-up 10 years later, it was 38% (P<0.005). In 1996 11% defecated less than every second day and 16% spent more than 30 min at each defecation; in 2006, it was 19% (P<0.01) and 25% (P<0.00001), respectively. Digital anorectal stimulation or evacuation was performed at least once every week by 48% in 1996 and by 56% in 2006 (P<0.0001). Fecal incontinence was reported at least once a month by 22% in 1996 and by 17% in 2006 (P<0.001).

CONCLUSION

While the frequency and severity of constipation-related symptoms increase with time since SCI, there is a decrease in the frequency of fecal incontinence.