Nonoperative management protocol for locally advanced rectal cancer.

AIM: The standard treatment for low rectal cancer is preoperative chemoradiotherapy followed by surgery with low anterior resection with diverting ileostomy or abdominoperineal resection, both of which have significant long-term effects on bowel and sexual function. Due to the high morbidity of surgery, there has been increasing interest in nonoperative management for low rectal cancer. The aim of this work is to conduct a pan-Canadian Phase II trial assessing the safety of nonoperative management for low rectal cancer. METHOD: Patients with Stage II or III low rectal cancer completing chemoradiotherapy according to standard of care at participating centres will be assessed for complete clinical response 8-14 weeks following completion of chemoradiotherapy. Subjects achieving a clinical complete response will undergo active surveillance including endoscopy, imaging and bloodwork at regular intervals for 24 months. The primary outcome will be the rate of local regrowth 2 years after chemoradiotherapy. Nonoperative management will be considered safe (i.e. as effective as surgery to achieve local control) if the rate of local regrowth is ≤30% and surgical salvage is possible for all local regrowths. Secondary outcomes will include disease-free and overall survival. CONCLUSION: The results will be highly clinically relevant, as it is expected that nonoperative management will be safe and lead to widespread adoption of nonoperative management in Canada. This change in practice has the potential to decrease the number of patients requiring surgery and the costs associated with surgery and long-term surgical morbidity.

Tolerating clear fluids diet on postoperative day 0 predicts early recovery of gastrointestinal function after laparoscopic colectomy.

INTRODUCTION: A high proportion of colorectal surgery patients within an enhanced recovery pathway (ERP) do not experience complications but remain hospitalized mainly waiting for gastrointestinal (GI) recovery. Accurate identification of these patients may allow discharge prior to the return of GI function. Therefore, the objective of this study is to determine if tolerating clear fluid (CF) on postoperative day (POD) 0 was associated with uncomplicated return of GI function after laparoscopic colorectal surgery. METHODS: Pooled data from three prospective studies from a single specialist colorectal referral center were analyzed (2013-2019). The present study included adult patients that underwent elective laparoscopic colectomy without stoma. Postoperative GI symptoms were collected daily in all three datasets. The main exposure variable, whether CF diet was tolerated on POD0, was defined as patients drinking at least 300 mL of CF without any nausea, anti-emetics, or vomiting (CF+ vs CF-). The main outcome measure was time to GI-3 (tolerating solid diet and passage of gas or stools). RESULTS: A total of 221 patients were included in this study, including 69% CF+ and 31% CF-. The groups were similar in age, gender, and comorbidities, but the CF- patients were more likely to have surgery for inflammatory bowel disease. CF+ patients had faster time to GI-3 (mean 1.6d (SD 0.7) vs. 2.3d (SD 1.5), p < 0.001). The CF+ group also experienced fewer complications (19% vs. 35%, p = 0.009), shorter mean LOS (mean 3.6d (SD 2.9) vs. 6.2d (SD 9.4), p = 0.002), and were more likely to be discharged by the target LOS (66% vs. 50%, p = 0.024). CONCLUSION: Toleration of CF on POD0 was associated with faster return of GI function, fewer complications, and shorter LOS. This may be used as a criteria for potential discharge prior to full return of GI function after laparoscopic colectomy within an ERP.

North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring.

BACKGROUND: Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up. METHODS: A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days. RESULTS: A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up. CONCLUSIONS: A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Quality indicator selection for the Canadian Partnership against Cancer rectal cancer project: A modified Delphi study.

AIM: It is well established that (i) magnetic resonance imaging, (ii) multidisciplinary cancer conference (MCCs), (iii) preoperative radiotherapy, (iv) total mesorectal excision surgery and (v) pathological assessment as described by Quirke are key processes necessary for high quality, rectal cancer care. The objective was to select a set of multidisciplinary quality indicators to measure the uptake of these clinical processes in clinical practice. METHOD: A multidisciplinary panel was convened and a modified two-phase Delphi method was used to select a set of quality indicators. Phase 1 included a literature review with written feedback from the panel. Phase 2 included an in-person workshop with anonymous voting. The selection criteria for the indicators were strength of evidence, ease of capture and usability. Indicators for which ≥90% of the panel members voted 'to keep' were selected as the final set of indicators. RESULTS: During phase 1, 68 potential indicators were generated from the literature and an additional four indicators were recommended by the panel. During phase 2, these 72 indicators were discussed; 48 indicators met the 90% inclusion threshold and included eight pathology, five radiology, 11 surgical, six radiation oncology and 18 MCC indicators. CONCLUSION: A modified Delphi method was used to select 48 multidisciplinary quality indicators to specifically measure the uptake of key processes necessary for high quality care of patients with rectal cancer. These quality indicators will be used in future work to identify and address gaps in care in the uptake of these clinical processes.

A mobile device application (app) to improve adherence to an enhanced recovery program for colorectal surgery: a randomized controlled trial.

BACKGROUND: Increased adherence with enhanced recovery pathways (ERP) is associated with improved outcomes. However, adherence to postoperative elements that rely on patient participation remains suboptimal. Mobile device apps may improve delivery of health education material and have the potential to foster behavior change and improve patient compliance. The objective of this study was to estimate the extent to which a novel mobile device app affects adherence to an ERP for colorectal surgery in comparison to standard written education. METHODS: This was a superiority, parallel-group, assessor-blind, sham-controlled randomized trial involving 97 patients undergoing colorectal resection. Participants were randomly assigned with a 1:1 ratio into one of two groups: (1) iPad including a novel mobile device app for postoperative education and self-assessment of recovery, or (2) iPad without the app. The primary outcome measure was mean adherence (%) to a bundle of five postoperative ERP elements requiring patient participation: mobilization, gastrointestinal motility stimulation, breathing exercises, and consumption of oral liquids and nutritional drinks. RESULTS: In the intervention group, app usage was high (94% completed surveys on POD0, 82% on POD1, 72% on POD2). Mean overall adherence to the bundle on the two first postoperative days was similar between groups: 59% (95% CI 52-66%) in the intervention group and 62% (95% CI 56-68%) in the control group [Adjusted mean difference 2.4% (95% CI - 5 to 10%) p = 0.53]. CONCLUSIONS: In this randomized trial, access to a mobile health application did not improve adherence to a well-established enhanced recovery pathway in colorectal surgery patients, when compared to standard written patient education. Future research should evaluate the impact of applications integrating novel behavioral change techniques, particularly in contexts where adherence is low.

Incisional Hernia After Midline Versus Transverse Specimen Extraction Incision: A Randomized Trial in Patients Undergoing Laparoscopic Colectomy.

OBJECTIVE: To compare the incidence of incisional hernia (IH) between midline and transverse specimen extraction site in patients undergoing laparoscopic colectomy. BACKGROUND: Midline specimen extraction incision is most commonly used in laparoscopic colectomy, but has high IH risk. IH may be lower for transverse incision. METHODS: A single-center superiority trial was conducted. Eligible patients undergoing laparoscopic colectomy were randomly assigned to midline or transverse specimen extraction. Primary outcome was IH incidence at 1 year. Power calculation required 76 patients per group to detect a reduction in IH from 20% to 5%. Secondary outcomes included perioperative outcomes, pain scores, health-related quality of life (SF-36), and cosmesis (Body Image Questionnaire). RESULTS: A total of 165 patients were randomly assigned to transverse (n = 79) or midline (n = 86) specimen extraction site, of which 141 completed 1-year follow-up (68 transverse, 73 midline). Patient, tumor, surgical data, and perioperative morbidity were similar. Pain scores were similar on each postoperative day. On intention-to-treat analysis, there was no difference in the incidence of IH at 1 year (transverse 2% vs midline 8%, P = 0.065) or after mean 30.3 month (standard deviation 9.4) follow-up (6% vs 14%, P = 0.121). On per-protocol analysis there were more IH after midline incision with longer follow-up (15% vs 2%, P = 0.013). On intention-to-treat analysis, SF-36 domains body pain and social functioning were improved after transverse incision. Cosmesis was higher after midline incision on per-protocol analysis, but without affecting body image. CONCLUSIONS: Per-protocol analysis of this trial demonstrates that a transverse specimen extraction site has a lower incidence of IH compared to midline with longer follow-up but has worse cosmesis.

Predictors of adherence to enhanced recovery pathway elements after laparoscopic colorectal surgery.

INTRODUCTION: Enhanced recovery pathways (ERP) include a bundle of evidence-based preoperative, intraoperative, and postoperative interventions that together reduce morbidity and length of stay after colorectal surgery. Increased adherence with the bundle is associated with better postoperative outcomes, but adherence is lowest in the postoperative period. Identifying risk factors for lower adherence may help design quality improvement strategies. The aim of this study was to estimate the extent to which patient, procedural, and organizational factors predict adherence to postoperative ERP elements in laparoscopic colorectal surgery. METHODS: Patients in an institutional ERP registry undergoing elective laparoscopic colorectal surgery between 2012 and 2014 were analyzed. The ERP included 10 postoperative ERP elements classified into 2 groups: those requiring patient participation (PP, 5 elements, including nutritional intake and mobilization) and those provided by the clinical team (CT, 5 elements, including removal of catheters and type of analgesia). The impact of baseline and intraoperative factors on adherence was estimated using stepwise linear regression. RESULTS: A total of 223 patients were included (mean age 60, 48% male). Mean adherence was 79% to the PP bundle (range 65-93% for individual elements), and 82% for the CT bundle (range 68-98% for individual elements). The occurrence of nausea/vomiting in the first 24 h was associated with lower adherence to both bundles. In the PP bundle, patients who arrived at the ward after 6 p.m. had lower adherence. In the CT bundle, patients who had rectal resection had lower adherence while thoracic epidural was associated with higher adherence. CONCLUSIONS: With the exception of postoperative nausea and vomiting, predictors of adherence to ERP elements after colorectal surgery differed for elements requiring patient participation and those provided by the clinical team. Strategies to improve ERP adherence should target staff education and engagement of patients at risk for lower adherence.

Ensuring Early Mobilization Within an Enhanced Recovery Program for Colorectal Surgery: A Randomized Controlled Trial.

OBJECTIVE: To estimate the extent to which the addition of staff-directed facilitation of early mobilization to an Enhanced Recovery Program (ERP) impacts recovery after colorectal surgery, compared with usual care. SUMMARY BACKGROUND DATA: Early mobilization is considered an important component of ERPs but, despite guidelines recommendations, adherence remains quite low. The value of dedicating specific resources (eg, staff time) to increase early mobilization is unknown. METHODS: This randomized trial involved 99 colorectal surgery patients in an established ERP (median age 63, 57% male, 80% laparoscopic) randomized 1:1 to usual care (including preoperative education about early mobilization with postoperative daily targets) or facilitated mobilization [staff dedicated to assist transfers and walking from postoperative days (PODs) 0-3]. Primary outcome was the proportion of patients returning to preoperative functional walking capacity (6-min walk test) at 4 weeks after surgery. We also explored the association of the intervention with in-hospital mobilization, time to achieve discharge criteria, time to recover gastrointestinal function, 30-day comprehensive complication index, and patient-reported outcome measures. RESULTS: In the facilitated mobilization group, adherence to mobilization targets was greater on POD0 [OR 4.7 (95% CI 1.8-11.9)], POD1 [OR 6.5 (95% CI 2.3-18.3)], and POD2 [OR 3.7 (95% CI 1.2-11.3)]. Step count was at least 2-fold greater on POD1 [mean difference 843.3 steps (95% CI 219.5-1467.1)] and POD2 [mean difference 1099.4 steps (95% CI 282.7-1916.1)] There was no between-group difference in recovery of walking capacity at 4 weeks after surgery [OR 0.77 (95% CI 0.30-1.97)]. Other outcome measures were also not different between groups. CONCLUSIONS: In an ERP for colorectal surgery, staff-directed facilitation of early mobilization increased out-of-bed activities during hospital stay but did not improve outcomes. This study does not support the value of allocating additional resources to ensure early mobilization in ERPs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02131844.

Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery: A Randomized Controlled Trial.

BACKGROUND: Inadequate perioperative fluid therapy impairs gastrointestinal function. Studies primarily evaluating the impact of goal-directed fluid therapy on primary postoperative ileus are missing. The objective of this study was to determine whether goal-directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. METHODS: Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program. Patients were assigned randomly to receive intraoperative goal-directed fluid therapy (goal-directed fluid therapy group) or fluid therapy based on traditional principles (control group). Primary postoperative ileus was the primary outcome. RESULTS: One hundred twenty-eight patients were included and analyzed (goal-directed fluid therapy group: n = 64; control group: n = 64). The incidence of primary postoperative ileus was 22% in the goal-directed fluid therapy and 22% in the control group (relative risk, 1; 95% CI, 0.5 to 1.9; P = 1.00). Intraoperatively, patients in the goal-directed fluid therapy group received less intravenous fluids (mainly less crystalloids) but a greater volume of colloids. The increase of stroke volume and cardiac output was more pronounced and sustained in the goal-directed fluid therapy group. Length of hospital stay, 30-day postoperative morbidity, and mortality were not different. CONCLUSIONS: Intraoperative goal-directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program. Its previously demonstrated benefits might have been offset by advancements in perioperative care.

Incidence of incisional hernia in the specimen extraction site for laparoscopic colorectal surgery: systematic review and meta-analysis.

INTRODUCTION: The incidence of incisional hernia(IH) may be affected by the choice of specimen extraction incision. The objective of this study was to perform a systematic review and meta-analysis comparing the incidence of IH after midline and off-midline incisions in patients undergoing laparoscopic colorectal surgery. METHODS: A systematic search was performed according to PRISMA guidelines to identify all comparative studies from January 1991-August 2016 on the incidence of IH after midline and off-midline(transverse or Pfannenstiel) incisions in patients undergoing laparoscopic colorectal surgery. Case series and studies reporting the IH after stoma site extraction, SILS, or NOTES were excluded. The MINORS instrument was used for quality assessment for observational studies. Weighted estimates were calculated using a random-effects model. RESULTS: A total of 17 articles were identified and included for meta-analysis, 16 of which were observational studies and 1 was an RCT. The mean MINORS score for observational studies was 12.9 (SD 3.2, range 7-17). Sample sizes in the midline (mean 185, range 20-995) and off-midline(mean 184, range 20-903) groups were similar. Follow-up ranged from 17.3 to 42 months. The pooled incidence of IH was 10.6% (338/3177) in midline, 3.7% (48/1314) in transverse, and 0.9% (9/956) in Pfannenstiel incisions. IH was significantly higher in the midline compared to off-midline groups (weighted OR 4.1, 95% CI 2.0-8.3, I 2 = 79.7%, p for heterogeneity <0.001). Midline incisions were also at higher risk of IH versus transverse (weighted OR 3.0, 95% CI 1.4-6.7, I 2 = 72.7%, p for heterogeneity <0.001) and Pfannenstiel (weighted OR 8.6, 95% CI 3.0-24.6, I 2 = 43.5%, p for heterogeneity = 0.101) incisions. There was no publication bias according the funnel plot or statistically (Egger's p = 0.336). CONCLUSIONS: Midline incisions for specimen extraction in laparoscopic colorectal surgery are at significantly higher risk of IH compared to off-midline (transverse or Pfannenstiel) incisions, but these data are of poor quality and heterogeneous.

An innovative paradigm for surgical education programs in resource-limited settings.

The burden of surgical disease in low-income countries remains significant, in part owing to continued surgical workforce shortages. We describe a successful paradigm to expand Rwandan surgical capacity through the implementation of a surgical education partnership between the National University of Rwanda and the Centre for Global Surgery at the McGill University Health Centre. Key considerations for such a program are highlighted.

A survey of preoperative surgical nutrition practices, opinions, and barriers across Canada.

Malnutrition is prevalent among surgical candidates and associated with adverse outcomes. Despite being potentially modifiable, malnutrition risk screening is not a standard preoperative practice. We conducted a cross-sectional survey to understand healthcare professionals' (HCPs) opinions and barriers regarding screening and treatment of malnutrition. HCPs working with adult surgical patients in Canada were invited to complete an online survey. Barriers to preoperative malnutrition screening were assessed using the Capability Opportunity Motivation-Behaviour model. Quantitative data were analyzed using descriptive statistics and qualitative data were analyzed using summative content analysis. Of the 225 HCPs surveyed (n = 111 dietitians, n = 72 physicians, n = 42 allied HCPs), 96%-100% agreed that preoperative malnutrition is a modifiable risk factor associated with worse surgical outcomes and is a treatment priority. Yet, 65% (n = 142/220; dietitians: 88% vs. physicians: 40%) reported screening for malnutrition, which mostly occured in the postoperative period (n = 117) by dietitians (n = 94). Just 42% (48/113) of non-dietitian respondents referred positively screened patients to a dietitian for further assessment and treatment. The most prevalent barriers for malnutrition screening were related to opportunity, including availability of resources (57%, n = 121/212), time (40%, n = 84/212) and support from others (38%, n = 80/212). In conclusion, there is a gap between opinion and practice among surgical HCPs pertaining to malnutrition. Although HCPs agreed malnutrition is a surgical priority, the opportunity to screen for nutrition risk was a great barrier.

How well do we measure the impact of bowel dysfunction on health-related quality of life after rectal cancer surgery?

BACKGROUND: Rectal cancer surgery risks causing bowel dysfunction, which has an important impact on health-related quality of life. The validity of generic tools used to measure health-related quality of life after bowel dysfunction is unclear. This study aimed to determine the content validity of health-related quality-of-life measurement tools in rectal cancer. METHODS: This was a qualitative single-center study in which adult patients who underwent rectal cancer surgery with sphincter preservation from July 2017 to October 2020 were recruited. Patients were excluded if they developed local metastasis, required a permanent stoma, or had surgery <1 year since recruitment. Telephone-based semi-structured interviews were conducted. Bowel dysfunction was measured using the Low Anterior Resection Syndrome score. Content analysis was achieved using the International Classification of Functioning framework. RESULTS: Recurrent bowel dysfunction-related concepts included "Mental functions," "Defecation functions," "Emotional functions," "Recreation and leisure," "Intimate relationships," and "Remunerative employment." A mean of 7.5 recurrent bowel dysfunction-related concepts were identified within the health-related quality of life instruments analyzed. The European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire-C30 (n = 11) and the 36-Item Short Form Health Survey (n = 9) covered the greatest number of recurrent bowel dysfunction-related concepts. Concepts such as "Mental functions," "Urination functions," "Sexual functions," "Driving," and "Mobility" were not covered by any instrument. CONCLUSION: The content of traditional health-related quality-of-life instruments is missing important areas that represent the impact of bowel dysfunction after rectal cancer surgery on health-related quality of life. These findings could help improve patient-centered care in rectal cancer surgery.

Decision-making preferences and regret in rectal cancer patients undergoing restorative proctectomy: A prospective cohort study.

BACKGROUND: How patients make treatment choices in rectal cancer is poorly understood and may affect long-term regret and satisfaction. The objective of this study is to characterize decision-making preferences and their effect on decisional regret in patients undergoing restorative proctectomy for rectal cancer. METHODS: A prospective cohort study was conducted in a single academic specialist rectal cancer center from October 2018 to June 2022. Adult patients who underwent restorative proctectomy at least one year prior were recruited. Health literacy was assessed using the BRIEF instrument. Decision-making preferences regarding cancer treatment were assessed using the Control Preferences Scale. Decisional regret regarding their choice of restorative proctectomy was assessed using the Decision Regret Score. Bowel dysfunction was measured using the low anterior resection syndrome score. RESULTS: Overall, 123 patients were included. Health literacy was categorized as adequate in 63%, marginal in 25%, and limited in 12%. Patients with adequate health literacy were more likely to prefer a collaborative decision-making role compared with those with low health literacy (86% vs 65%, P = .016). Patients with incongruence between preferred and actual decision-making roles were more likely to report high regret (56% vs 25%, P = .003). Patients with major low anterior resection syndrome were also more likely to experience high regret compared with patients with no/minor low anterior resection syndrome (44% vs 25%, P = .036). CONCLUSION: A significant proportion of patients with rectal cancer undergoing restorative proctectomy do not have a decision-making role that is congruent with their preferences, and these patients experience a high degree of regret.

Impact of an enhanced recovery program on short-term outcomes after scheduled laparoscopic colon resection.

INTRODUCTION: Both enhanced recovery programs (ERP) and laparoscopy can reduce complications and length of stay (LOS) in colon surgery. We investigated whether ERP further improved the short-term outcomes of scheduled laparoscopic colectomies. METHODS: We performed an audit of all patients undergoing scheduled laparoscopic colon resection between January 2003 and August 2010 in our institution. An ERP including accelerated introduction of oral nutrition, mobilization, pain control, and catheter management was introduced in 2005. Demographic data, intra and postoperative details and 30-day ER visit and readmission rate were collected. We compared LOS and short-term outcomes for patients on the program with those receiving traditional postoperative care using Chi-square and regression models. Data are presented as median [25th, 75th percentile]. Statistical significance was defined as p < 0.05. RESULTS: 136 (46%) of 297 eligible patients were enrolled in the ERP. At baseline, the two groups had similar demographic characteristics, but patients in the ERP were more likely to have their operation by a colorectal surgeon (p = 0.01). Patients in the ERP ate solids earlier (p < 0.001) and had earlier removal of their urinary catheter (p < 0.001). LOS was 4 [3, 6] days for both groups (p < 0.01), with more patients in the ERP discharged by POD 3 (p < 0.001). After adjusting for other variables, ERP enrolment remained an independent predictor of LOS (p < 0.01), along with age (p < 0.01) and in-hospital complications (p < 0.001). Complication rates were similar between the two groups. Patients in the ERP had significantly fewer ER visits (p = 0.02), but there were no differences in readmission rates. CONCLUSION: In patients undergoing scheduled laparoscopic colectomy in a university-based clinical teaching unit, ERP can further reduce length of stay and postoperative ER visits without increasing readmission rates.

Does the Low Anterior Resection Syndrome Score Accurately Represent the Impact of Bowel Dysfunction on Health-Related Quality of Life?

BACKGROUND: Bowel dysfunction after rectal cancer surgery is common, but its effect on health-related quality of life (HRQOL) is complex. Objective measures of bowel function may not be a good representation on the actual impact on HRQOL. Therefore, the objective of this study is to determine whether there are differences between patient-reported bowel-related impairment versus a standardized measure of bowel dysfunction on HRQOL. METHODS: A prospective database starting in September 2018 of adult patients who had undergone sphincter preserving rectal cancer surgery up to October 2021 was queried. Patients were excluded if they had local recurrence, metastasis, persistent stoma, or had less than 1-year follow-up. Patients were administered the study instruments at their standard surveillance visit: patient-reported bowel-related quality of life(BQOL) impairment, HRQOL using the Short Form-36 (SF-36), and bowel dysfunction using the low anterior resection syndrome(LARS) score. RESULTS: Overall, 136 patients were included. There were 43% with no LARS, 22% with minor LARS, and 35% with major LARS. For the BQOL, 26% of subjects reported no impairment, 57% minor impairment, and 17% major impairment. There was a high proportion of discordance between BQOL and LARS, with 23% minor or major LARS in patients with no BQOL impairment, and 32% with no or minor LARS with major BQOL impairment. The BQOL was associated with more changes in SF-36 scores compared to the LARS score. CONCLUSIONS: The patient-reported BQOL is likely to be a more relevant outcome of interest to patients than the objective LARS score. This has important implications for shared decision-making for rectal cancer treatments.

Predictors of pre- and post-treatment bowel dysfunction severity in patients with rectal cancer.

BACKGROUND: Treatment of rectal cancer is frequently associated with low anterior resection syndrome. However, data concerning the contribution rectal tumors have on pretreatment bowel-dysfunction is scarce. We sought to evaluate the impact of the untreated rectal cancer on bowel-dysfunction and the relationship of pretreatment and post-treatment function. METHODS: A prospective database of adults with rectal cancer at a single university-affiliated colorectal referral center from August 2018 to March 2022 was queried. Bowel-dysfunction was measured using the low anterior resection syndrome score questionnaire (categorized as no, minor, or major low anterior resection syndrome) which was provided to patients at their primary visit, and after treatment. Patients were included if they underwent rectal cancer treatment and had pre- and post-treatment low anterior resection syndrome measurements. Observed low anterior resection syndrome scores were compared to normative low anterior resection syndrome data for age and sex-specific distributions from published data. Multiple multinomial regression compared pre- and post-treatment low anterior resection syndrome scores. RESULTS: Overall, 121 patients were included with mean age 62.0 years (standard deviation 12.3), 74% male, and mean tumor height 8.7 cm (standard deviation 5.72). The proportion of pretreatment observed low anterior resection syndrome were 48% no low anterior resection syndrome, 28% minor, and 24% major. Male and older patients were more likely to have worse than predicted low anterior resection syndrome categories (P < .05). On average, low anterior resection syndrome category did not change after treatment (P = .618) and pretreatment low anterior resection syndrome category was a significant independent predictor of post-treatment category (P = .037). CONCLUSION: Pretreatment bowel-dysfunction in rectal cancer patients is common and significantly worse than predicted for older and male patients. Importantly, pretreatment bowel-dysfunction predicted postoperative function. These results may better inform the shared decision-making process.

Trajectory of gastrointestinal function after laparoscopic colorectal surgery within an enhanced recovery pathway.

BACKGROUND: Early identification of colorectal surgery patients predicted to have uneventful gastrointestinal recovery may allow for early discharge. Our objective was to identify trajectories of gastrointestinal recovery within a colorectal surgery enhanced recovery pathway. METHODS: Data from 2 prospective studies enrolling adult patients undergoing elective laparoscopic colorectal resection at a specialist colorectal referral center were analyzed (2013-2019). All patients were managed according to a mature enhanced recovery pathway with a 3-day target length of stay. Postoperative gastrointestinal symptoms were collected daily and expressed using the validated I-FEED score. Latent-class growth curve (trajectory) analysis was used to identify different I-FEED trajectories over the first 3 postoperative days. RESULTS: A total of 192 patients were analyzed. Trajectory analysis identified 3 distinct trajectories: trajectory 1 had no gastrointestinal symptoms (41%); trajectory 2 had mild early symptoms with improvement over time (48%); and trajectory 3 had gastrointestinal symptoms that significantly worsened between postoperative days 1 and 2 (11%). I-FEED score ≤1 on postoperative day 1 predicted trajectory 1. Trajectory 1 had the best clinical outcomes, whereas trajectory 3 had the worst. CONCLUSION: I-FEED trajectory over postoperative days 1-3 was associated with clinical outcomes and may be used to predict gastrointestinal recovery. Findings from this study may inform clinical decision making regarding early hospital discharge within colorectal enhanced recovery pathways.

Patients' preferences for sphincter preservation versus abdominoperineal resection for low rectal cancer.

BACKGROUND: Surgery for low rectal cancer can be associated with severe bowel dysfunction and impaired quality of life. It is important to determine how patients value the trade-off between anorectal dysfunction versus abdominoperineal resection. Therefore, the objective was to determine patients' preferences for treatment for low rectal cancer. METHODS: Ambulatory patients without colorectal cancer at a single high-volume academic colorectal referral center from September 2019 to March 2020 were included. Patients with prior stoma or malignancy were excluded. Participants were presented with a hypothetic scenario describing a low rectal cancer. A threshold task identified preferences for functional and oncologic outcomes for sphincter preservation versus abdominoperineal resection. RESULTS: A total of 123 patients were recruited. Patients preferred abdominoperineal resection over sphincter preservation if there were more than a mean of 6.7 (standard deviation 4.0) daily bowel movements, 1.9 (standard deviation 2.6) daily episodes of stool incontinence, and 6.5 (standard deviation 3.2) gas incontinence. Abdominoperineal resection was preferred over sphincter preservation in 38% if daily activities were altered owing to fecal urgency. Patients were willing to accept a 10% (interquartile range, 5-25) absolute increase in risk of margin involvement with sphincter preservation to avoid abdominoperineal resection. Abdominoperineal resection was the preferred option overall for 18% of patients. CONCLUSION: An important proportion of patients would prefer abdominoperineal resection over sphincter preservation owing to the impairments in anorectal function associated with sphincter preservation. The decision to perform sphincter preservation or abdominoperineal resection should consider how the patients' value functional outcomes with a low anastomosis.