Impact of a defunctioning ileostomy and time to stoma closure on bowel function after low anterior resection for rectal cancer: a systematic review and meta-analysis.

BACKGROUND: Impaired bowel function after low anterior resection (LAR) for rectal cancer is a frequent problem with a major impact on quality of life. The aim of this study was to assess the impact of a defunctioning ileostomy, and time to ileostomy closure on bowel function after LAR for rectal cancer. METHODS: We performed a systematic review based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Comprehensive literature searches were conducted using PubMed, Embase and Cochrane databases for articles published from 1989 up to August 2019. Analysis was performed using Review Manager (version 5.3) using a random-effects model. RESULTS: The search yielded 11 studies (1400 patients) that reported on functional outcome after LAR with at least 1 year follow-up, except for one study. Five scales were used: the Low Anterior Resection Syndrome (LARS) score, the Wexner score, the Memorial Sloan Kettering Cancer Centre Bowel Function Instrument, the Fecal Incontinence Quality of Life scale, and the Hallbook questionnaire. Based on seven studies, major LARS occurred more often in the ileostomy group (OR 2.84, 95% CI, 1.70-4.75, p < 0.0001: I2 = 60%, X2 = 0.02). Based on six studies, a longer time to stoma closure increased the risk of major LARS with a mean difference in time to closure of 2.39 months (95% CI, 1.28-3.51, p < 0.0001: I2 = 21%, X2 = 0.28) in the major vs. no LARS group. Other scoring systems could not be pooled, but presence of an ileostomy predicted poorer bowel function except with the Hallbook questionnaire. CONCLUSIONS: The risk of developing major LARS seems higher with a defunctioning ileostomy. A prolonged time to ileostomy closure seems to reinforce the negative effect on bowel function; therefore, early reversal should be an important part of the patient pathway.

Psychological sequelae of colonic resections.

AIM: The prevalence of anxiety, depression and post-traumatic stress disorder (PTSD) in the general population has been estimated to be 5.9%, 3.3% and 4.4% respectively. The aim of this study was to determine whether psychological problems are more prevalent following colorectal surgery. METHOD: Patients who had undergone colorectal resection in a 2-year period across four centres were asked to complete validated screening questionnaires for anxiety, depression and PTSD (GAD-7, PHQ-9, PCL-5) 12-48 months after surgery. Risk factors were identified using multiple linear regression analysis. RESULTS: After excluding those who had died or received palliative diagnoses, questionnaires were sent to 1150 patients. 371 responded (32.3% response rate); median age 67 (20-99) years; 51% were men. 58% of patients underwent surgery for cancer; 23% had emergency surgery. 28% of patients screened positive for at least one psychological condition, with 20% screening positive for anxiety, 22% for depression and 14% for PTSD. Patients who were younger, women, had surgery as an emergency, for benign conditions, had stomas and had critical care stay were more likely to have poorer psychological outcomes. Multiple linear regression found that only younger age (P = 0.000) and female gender (P = 0.048) were significant risk factors. CONCLUSION: The prevalence of anxiety, depression and PTSD appears to be high in patients who have undergone colorectal surgery. Younger patients and women are particularly at risk. Further work is needed to determine how best to prevent, detect and treat people with adverse psychological outcomes following colorectal surgery.

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

AIM: Low Anterior Resection Syndrome (LARS) following rectal cancer surgery impairs the patient's quality of life (QoL). Rectal Irrigation has been demonstrated to be effective for anterior resection syndrome but many surgeons do not suggest it as a treatment. This feasibility study aimed to explore treatment acceptability and the benefit of rectal irrigation in patients who developed LARS following an anterior resection for rectal cancer. METHODS: This was a qualitative study, involving semi-structured interviews. Twenty-one patients diagnosed with LARS following anterior resection for rectal cancer in a single tertiary centre were offered rectal irrigation as a treatment option. Qualitative interviews (n=17) were conducted at baseline to explore patient reported impact of LARS on QoL, treatment acceptability and factors influencing the decision to accept/decline treatment. Follow up interviews were carried out at six months for the treatment group only (n=12), to assess its practicality and impact on QoL. RESULTS: Qualitative interview findings suggest rectal irrigation is an acceptable method of treatment for LARS. Participants who perceived their symptoms to be more severe or poorly controlled were most likely to consider rectal irrigation as a treatment option. The patients who completed treatment reported improvements in their QoL, the ability to control the time of defaecation being the key benefit CONCLUSION: Clinicians should consider offering rectal irrigation as a treatment option to patients presenting with bowel dysfunction following anterior resection as it can improve symptoms. Patients who perceive that their symptoms are severe are more likely to consider treatment. This article is protected by copyright. All rights reserved.

Female infertility following restorative proctocolectomy.

AIM: Females of child-bearing age have been reported to have a two to three-fold increase in infertility after restorative proctocolectomy (RPC). This study aimed to assess aspects of infertility and pregnancy. METHOD: A postal questionnaire was sent to 790 females who had undergone primary RPC in two tertiary centres. Infertility, the number and outcome of pregnancies, delivery method and the use of fertility treatments were determined. RESULTS: Three hundred and six (38.5%) females responded (median age 47.9 years at follow up; 35.3 years at the time of RPC). Eighty-two per cent (n=250) had ulcerative colitis. Forty-five per cent (n=138) had conceived prior to RPC, 5.2% (n=16) conceived both before and after RPC, 5.5% (n=17) conceived after RPC only and 44.1% (n=135) had never conceived. Females delivering before RPC had significantly more vaginal deliveries than those conceiving after (pre-RPC 69.6%, n=96 vs post-RPC 35.3%, n=6; P=0.001). Fifty-seven patients stated they had attempted to conceive after RPC, with 25 (45.5%) being successful. Eighteen females had been referred to a fertility specialist, of whom 16 received in vitro fertilization (IVF). Four (30.7%) females conceived using IVF. CONCLUSION: While RPC is known to be associated with infertility, only a small proportion of patients are referred for fertility management. IVF outcomes and success rates after RPC are similar to the general population. Patients are more likely to have a Caesarean section following RPC.

The National Bowel Cancer Audit Project: what do trusts think of the National Bowel Cancer Audit and how can it be improved?

PURPOSE: The National Bowel Cancer Audit Project (NBOCAP) collects data from hospitals in the UK and aims to improve surgical outcomes and quality of care for patients. The aims of this study were to understand why trusts were/were not participating in the NBOCAP and how to improve the quality of data collected and feedback. METHODS: This was a prospective e-survey on colorectal surgeons' attitudes towards and opinions of the NBOCAP, within trusts in the UK. A questionnaire was emailed to members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI). RESULTS: Of the 171 trusts contacted by email, 66% of trusts (n = 117) had at least 1 consultant respond. Of the 117 trusts that responded, 60 (51.2%) had submitted data to the NBOCAP. A total of 549 consultants received the questionnaire, and 159 (29.0%) consultants responded. Fifty-one per cent (n = 60) of the trusts had submitted data to the NBOCAP. Reasons for data submission included the following: comparison of a units' data with national data (56.8%), a national audit improves outcomes (45.9%) and generation of information for use at a local level (42.6%). The main reasons for non-submission were as follows: lack of technical support (23.6%), lack of funding (19.6%) and lack of dedicated audit time (18.9%). Ninety-six (60.4%) consultants felt that the audit report should identify individual trust results. Fifty-three per cent of consultants (n = 87) rated their trusts' resources for audit as being very poor or poor. CONCLUSION: Consultant members of the Association of Coloproctology of Great Britain and Ireland (ACPGBI) within hospital trusts in the UK feel participation in the National Bowel Cancer Audit improves patients' quality of care and surgical outcomes. Increased awareness of the benefits of the NBOCAP and improved allocation of resources from hospital trusts could improve participation.

Measuring sexual and urinary outcomes in women after rectal cancer excision.

PURPOSE: This study was designed to investigate sexual and urinary dysfunction in women who underwent rectal cancer excision, and the influence of tumor and treatment variables on long-term outcomes. METHODS: Data were prospectively collected on 295 women who underwent rectal cancer excision at a tertiary referral colorectal center from 1998 to 2006. Sexual and urinary function was assessed preoperatively and at intervals up to five years after surgery. Functional outcomes were assessed by using univariate and multivariate regression analysis, chi-squared test for trend, or Kruskal-Wallis test. RESULTS: The mean age of the patients was 60.9 years. Anterior resection was performed in 222 patients (75.2 percent) and abdominoperineal resection in 73 patients (24.7 percent). Patients who underwent abdominoperineal resection were less sexually active (25 vs. 50 percent; P = 0.02) and had a lower frequency of intercourse than anterior resection patients at one year after surgery (anterior resection, 3 (0-5) (median interquartile range); abdominoperineal resection 0 (0-4); P = 0.029). The frequency of intercourse improved over time for abdominoperineal resection (4 months, 0 (0-0) median interquartile range; 5 years, 3 (0.25-4) median interquartile range; P = 0.028). Abdominoperineal resection was associated with increased dyspareunia (odds ratio, 5.75; 95 percent confidence interval (CI), 1.87-17.6; P = 0.002), urinary urgency (odds ratio, 8.52; 95 percent CI, 2.81-25.8; P < 0.001), incontinence (odds ratio, 2.41; 95 percent CI, 1.11-5.26; P = 0.026), poor stream (odds ratio, 5.64, 95 percent CI, 2.55-12.5; P

The national bowel cancer audit project: the impact of organisational structure on outcome in operative bowel cancer within the United Kingdom.

OBJECTIVES: To investigate the relationship between organisational structure, process and surgical outcomes for bowel cancer surgery. METHODS: An e-survey was sent to the members of the Association of Coloproctology of Great Britain and Ireland to determine the organisational structure of their Trusts. Responses were combined with the National Bowel Cancer Audit (NBOCAP) data. Items investigated included; number of consultants, nurse specialists, volume of cases and intensive care facilities. Main outcome measures included: 30-day risk-adjusted mortality, length of stay (LOS), lymph node yield and circumferential margin involvement (CRM). RESULTS: One hundred and seventeen Trusts responded (65.8%), matched to 7666 patient episodes (NBOCAP data) from 54 (62.8%)Trusts who submitted data to the audit. Trusts treating <190 cases/annum (p > 0.001), <4 colorectal consultants (p > 0.001), <4 HDU beds (p > 0001) and <8 ITU beds (p > 0001) were more likely to have a 30-day-risk-adjusted mortality twice that of the national mean. Sixty five percent (n = 1603) of Trusts treating ≥ 190 cases/annum harvested ≥ 12 lymph nodes vs. 58.3% (n = 1435) in Trusts <190 cases/annum (p < 0.001). Trusts with ≥ 2 pathologists with an interest in bowel cancer harvested ≥ 12 lymph nodes more frequently (p=<0.001) and were more likely to identify extramural vascular invasion in the specimen (p = 0.015). Negative CRM was achieved in 81.4% (n = 81.4) of patients in Trusts treating ≥ 190 cases vs. 66.5% (n = 569) in Trusts<190 cases/annum (p < 0.001). Trusts offering fast track discharge were more likely to have a LOS < 15 days (p = 0.006). Surgeons treating ≤ 35 cases/annum had increased major post-operative complications (<35 cases = 70.2% vs. ≥ 35 cases = 21.9%; p < 0.001), however 30 day risk adjusted mortality was not increased in surgeons treating <35 cases/annum. CONCLUSIONS: This study shows that the organisational infrastructure of hospitals appears to have as great an impact on patient outcomes as the volume of cases performed by hospital Trusts.

The formation of the pronephric duct in Xenopus involves recruitment of posterior cells by migrating pronephric duct cells.

Cell migration and cell-cell interactions play important roles in numerous processes during embryogenesis. One of these is the formation of the pronephric (Wolffian) duct (PD), which connects the pronephros to the cloaca. It is currently accepted that in most amphibians the pronephric duct is formed by active migration of the pronephric duct rudiment (PDR) cells along a predetermined pathway. However, there is evidence that in Xenopus, the PD may be formed entirely by in situ segregation of cells out of the lateral mesoderm. In this study, we show, using PDR ablation and Xenopus laevis-Xenopus borealis chimeras, that PD elongation in Xenopus requires both active cell migration and an induced recruitment of cells from the posterior. We also show that PDR cell migration is limited to only a few stages during development and that this temporal control is due, at least in part, to changes in the competence of the PD pathway to support cell migration.

Expression of the Drosophila gonadal gene: alternative promoters control the germ-line expression of monocistronic and bicistronic gene transcripts.

The Drosophila gonadal (gdl) gene is differentially expressed in the male and female germ lines. In males, expression in the gdlM mode results in a 1200-/1500-nucleotide RNA pair, whereas in females, expression in the gdlF mode results in a 1000-/1300-nucleotide RNA pair. Since the two expression modes are a result of alternative promoter usage, the sex-specific transcripts differ at their 5' ends. These sequence differences affect the coding capacity of the gene. A common open reading frame (ORF) of 193 codons (ORF193) is present in all four gdl transcripts; a consequence of the additional sequences at the 5' end of the gdlM transcripts is the presence of an additional ORF of 39 codons (ORF39). Translation of gdlF and gdlM cRNAs in a reticulocyte lysate reveals that these transcripts can serve as monocistronic and bicistronic mRNAs in vitro. An analysis of germ-line transformants harboring gdl-lacZ gene fusions provides information on gdl gene expression during gametogenesis. The fusion genes are transcribed and translated in the germ line; beta-galactosidase activity is detected in premeiotic and postmeiotic spermatogenic stages in males, and in nurse cells and oocytes of developing egg chambers in females. Both gdlM ORFs are used because transformant lines expressing the lacZ gene, fused in frame with either ORF39 or ORF193, are positive for beta-galactosidase activity in the testes. These studies also reveal that separable transcription control elements are responsible for gdl expression in the male and female germ lines.

Xlcaax-1 is localized to the basolateral membrane of kidney tubule and other polarized epithelia during Xenopus development.

Xlcaax-1 is a novel, maternally expressed, 110-kDa, CAAX box containing protein that undergoes isoprenylation and palmitoylation through which it associates with the plasma membrane. We report here the cellular and subcellular localization of the xlcaax-1 protein during development of Xenopus laevis. Whole-mount immunocytochemistry and immunoperoxidase staining of tissue sections show that during development the xlcaax-1 protein accumulation is coincident with the differentiation of the epidermis, pronephros, and mesonephros. In the pronephros and mesonephros the xlcaax-1 protein is localized to the basolateral membrane of differentiated tubule epithelial cells. Thus, the xlcaax-1 protein serves as a marker for tubule formation and polarization during Xenopus kidney development. Xlcaax-1 may also be used as a marker for the functional differentiation of the epidermis and the epidermally derived portions of the lens and some cranial nerves. Western blot analysis shows that in the adult the xlcaax-1 protein is most abundant in kidney. Immunogold EM analysis shows that the xlcaax-1 protein is highly enriched in the basal infoldings of the basolateral membrane of the epithelial cells in adult kidney distal tubules. In addition, immunoperoxidase staining of tissue sections detected low levels of xlcaax-1 protein in the epithelial cells of skin, urinary bladder, gall bladder, and parietal glands of the stomach. The localization pattern of xlcaax-1 suggests that the protein may function in association with an ion transport channel or pump.