Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection.

OBJECTIVE: To describe the management of recurrent bowel endometriosis after previous colorectal resection. DESIGN: Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. SETTING: A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. INTERVENTION: Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. CONCLUSION: Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

Thoracolumbar epidural stimulation effects on bladder and bowel function in uninjured and chronic transected anesthetized rats.

Pre-clinical studies have shown that spinal cord epidural stimulation (scES) at the level of pelvic and pudendal nerve inputs/outputs (L5-S1) alters storage and/or emptying functions of both the bladder and bowel. The current mapping experiments were conducted to investigate scES efficacy at the level of hypogastric nerve inputs/outputs (T13-L2) in male and female rats under urethane anesthesia. As found with L5-S1 scES, T13-L2 scES at select frequencies and intensities of stimulation produced an increase in inter-contraction interval (ICI) in non-injured female rats but a short-latency void in chronic T9 transected rats, as well as reduced rectal activity in all groups. However, the detrusor pressure during the lengthened ICI (i.e., urinary hold) remained at a low pressure and was not elevated as seen with L5-S1 scES, an effect that's critical for translation to the clinic as high fill pressures can damage the kidneys. Furthermore, T13-L2 scES was shown to stimulate voiding post-transection by increasing bladder activity while also directly inhibiting the external urethral sphincter, a pattern necessary to overcome detrusor-sphincter dyssynergia. Additionally, select scES parameters at T13-L2 also increased distal colon activity in all groups. Together, the current findings suggest that optimization of scES for bladder and bowel will likely require multiple electrode cohorts at different locations that target circuitries coordinating sympathetic, parasympathetic and somatic outputs.

Percutaneous tibial nerve stimulation in patients with severe low anterior resection syndrome: randomized clinical trial.

BACKGROUND: Treatment of low anterior resection syndrome (LARS) is challenging. Percutaneous tibial nerve stimulation (PTNS) can improve select bowel disorders. An RCT was conducted to assess the efficacy of PTNS compared with sham stimulation in patients with severe LARS. METHOD: This was a multicentre, double-blind RCT. Patients with major LARS score were allocated to receive PTNS or sham therapy (needle placement simulation without nerve stimulation). The study included 16 sessions of 30 min once a week for 12 consecutive weeks, followed by four additional sessions once a fortnight for the following 4 weeks. The primary endpoint was efficacy of PTNS defined by the LARS score 12 months after treatment. Secondary endpoints included faecal incontinence, quality of life (QoL), and sexual function. RESULTS: Between September 2016 and July 2018, 46 eligible patients were assigned randomly in a 1 : 1 ratio to PTNS or sham therapy. Baseline characteristics were similar. LARS scores were reduced in both groups, but only patients who received PTNS maintained the effect in the long term (mean(s.d.) score 36.4(3.9) at baseline versus 30.7(11.5) at 12 months; P = 0.018; effect size -5.4, 95 per cent c.i. -9.8 to -1.0), with a mean reduction of 15.7 per cent at 12-month follow-up. The faecal incontinence score was improved after 12 months in the PTNS group (mean(s.d.) score 15.4(5.2) at baseline versus 12.5(6.4) at 12 months; P = 0.018). No major changes in QoL and sexual function were observed in either group. There was no therapy-associated morbidity. Three patients discontinued the study, but none owing to study-related issues. CONCLUSION: PTNS has positive effects in some patients with major LARS, especially in those with faecal incontinence. Registration number: NCT02517853 (http://www.clinicaltrials.gov).

The use of hyperbaric oxygen to treat actinic rectal fistula after SpaceOAR use and radiotherapy for prostate cancer: a case report.

BACKGROUND: In definitive radiation therapy for prostate cancer, the SpaceOAR® System, a hydrogel spacer, is widely used to decrease the irradiated dose and toxicity of rectum. On the other hand, periprostatic abscesses formation and rectal perforation are known as rare adverse effects of SpaceOAR. Nevertheless, there is a lack of reports clarifying the association between aggravation of abscesses and radiation therapy, and hyperbaric oxygen therapy (HBOT) is effective for a peri-SpaceOAR abscess and rectal perforation. CASE PRESENTATION: We report a case of a 78-year-old high-risk prostate cancer patient. After SpaceOAR insertion into the correct space, he started to receive external beam radiation therapy (EBRT). He developed a fever, perineal pain and frequent urination after the completion of EBRT, and the magnetic resonance imaging (MRI) revealed a peri-SpaceOAR abscess. Scheduled brachytherapy was postponed, administration of antibiotics and opioid via intravenous drip was commenced, and transperineal drainage was performed. After the alleviation of the abscess, additional EBRT instead of brachytherapy was performed with MRI-guided radiation therapy (MRgRT). On the last day of the MRgRT, perineal pain reoccurred, and MRI and colonoscopy detected the rectal perforation. He received an intravenous antibiotics drip and HBOT, and fully recovered from the rectal perforation. CONCLUSIONS: Our report indicates that EBRT can lead to a severe rectum complication by causing inflammation for patients with a peri-SpaceOAR abscess. Furthermore, HBOT was effective for the peri-SpaceOAR abscess and rectal perforation associated with EBRT.

Gastrointestinal Bleeding in Patients With Coronavirus Disease 2019: A Matched Case-Control Study.

INTRODUCTION: Although current literature has addressed gastrointestinal presentations including nausea, vomiting, diarrhea, abnormal liver chemistries, and hyperlipasemia as possible coronavirus disease 2019 (COVID-19) manifestations, the risk and type of gastrointestinal bleeding (GIB) in this population is not well characterized. METHODS: This is a matched case-control (1:2) study with 41 cases of GIB (31 upper and 10 lower) in patients with COVID-19 and 82 matched controls of patients with COVID-19 without GIB. The primary objective was to characterize bleeding etiologies, and our secondary aim was to discuss outcomes and therapeutic approaches. RESULTS: There was no difference in the presenting symptoms of the cases and controls, and no difference in severity of COVID-19 manifestations (P > 0.05) was observed. Ten (32%) patients with upper GIB underwent esophagogastroduodenoscopy and 5 (50%) patients with lower GIBs underwent flexible sigmoidoscopy or colonoscopy. The most common upper and lower GIB etiologies were gastric or duodenal ulcers (80%) and rectal ulcers related to rectal tubes (60%), respectively. Four of the esophagogastroduodenoscopies resulted in therapeutic interventions, and the 3 patients with rectal ulcers were referred to colorectal surgery for rectal packing. Successful hemostasis was achieved in all 7 cases that required interventions. Transfusion requirements between patients who underwent endoscopic therapy and those who were conservatively managed were not significantly different. Anticoagulation and rectal tube usage trended toward being a risk factor for GIB, although it did not reach statistical significance. DISCUSSION: In COVID-19 patients with GIB, compared with matched controls of COVID-19 patients without GIB, there seemed to be no difference in initial presenting symptoms. Of those with upper and lower GIB, the most common etiology was peptic ulcer disease and rectal ulcers from rectal tubes, respectively. Conservative management seems to be a reasonable initial approach in managing these complex cases, but larger studies are needed to guide management.

[Argon plasma coagulation effective treatment of solitary rectal ulcer syndrome]. / Argonplasmakoagulation effektiv vid solitärt rektalt ulkussyndrom.

Solitary rectal ulcer syndrome (SRUS) is a rare disorder likely to be caused by a traumatic and ischemic mucosal injury related to latent or overt rectal prolapse. Mucosal damage can vary between erythema and up to intractable ulceration. The typical symptoms of SRUS may resemble those of inflammatory bowel disease (IBD)-related proctitis or rectal malignancy with mucus- and blood-mixed defecation with urgency and sometimes transient incontinence. The purpose of this paper is to raise awareness of this rare, quality-of-life impacting and difficult-to-treat disease and the not so well-known argon plasma coagulation (APC) treatment that can provide very good and long lasting symptom relief.

Risk factors for failure of hydrostatic reduction of intussusception in pediatric patients: A retrospective study.

The aim of this current study was to explore the risk factors associated with failure of hydrostatic reduction of intussusception in pediatric patients.Patients with intussusception treated with hydrostatic reduction from January 2010 to December 2016 were retrospectively analyzed. Candidates for inclusion in the study were children from 0 to 18 who were diagnosed with intussusception and treated with hydrostatic reduction. We excluded the patients who had contraindications for hydrostatic reduction, which included peritonitis, perforation signs, and non-responsive shock that required surgery. The data collected included: demographic data (sex, age, and bodyweight), symptoms (vomiting, abdominal pain, rectal bleeding, diarrhea, distention, constipation, and duration of symptoms), signs (temperature, palpable mass, and location of the mass), and other investigations (white blood cell counts, neutrophils, electrolytes, and ultrasound findings).The risk factors for failure of hydrostatic reduction of intussusception were analyzed using the univariable analysis and the multivariable analysis. In the univariable model, the significant risk factors for failure of hydrostatic reduction of intussusception analyzed were age, bodyweight, duration of symptoms, rectal bleeding, constipation, palpable abdominal mass, poor prognosis signs on ultrasound scans and location of mass (the P value for each parameter are stated in ). After the multivariable analysis was done, we found that the significant risk factors for failure of hydrostatic reduction of intussusception were an age of under 1-year-old (OR = 3.915, P = .027), duration of symptoms more than or equal to 48 h (OR = 0.056, P < .001), rectal bleeding (OR = 0.283, P = .003), constipation (OR = 0.086, P < .001), palpable abdominal mass (OR = 0.370, P = .010), and location of mass (left over right side) (OR = 13.782, P < .001).(Table is included in full-text article.)Our study found that an age of under 1-year-old, a duration of symptoms of more than or equal to 48 h, rectal bleeding, constipation, palpable abdominal mass and location of mass (left over right side) were risk factors for the failure of hydrostatic reduction of intussusception.

Role of transanal irrigation in the treatment of anterior resection syndrome.

BACKGROUND: Transanal irrigation(TAI) has been reported to be an inexpensive and effective treatment for low anterior resection syndrome(LARS). The aim of the present prospective study was to evaluate the use of TAI in patients with significant LARS symptoms at a single medical center. METHODS: Patients who had low anterior resection for rectal cancer between April 2015 and May 2016 at the Careggi University Hospital were assessed for LARS using the LARS and the Memorial Sloan-Kettering Cancer Center Bowel Function Instrument (MSKCC BFI) questionnaires 30-40 days after  surgery or ileostomy closure (if this was done). Quality of life was evaluated using a visual analog scale and the Short Form-36 Health Survey. All patients with LARS score of 30 or higher were included (early LARS) as were all patients with a LARS score of 30 or higher referred 6 months or longer after surgery performed elsewhere (chronic LARS) in the same study period. Study participants were trained to perform TAI using the Peristeen™ System for 6 months, followed by 3 months of enema therapy following a similar protocol. RESULTS: Thirty-three patients were enrolled in the study. Six patients stopped the treatment. The 27 patients (19 early LARS and 8 chronic LARS) who completed the study had a significant decrease in the number of median daily bowel movements [baseline 7 (range 0-14); 6 months 1 (range 0-4); 9 months 4 (range 0-13)]. The median LARS Score fell from 35.1 (range 30-42) (baseline) to 12.2 (range 0-21) after 6 months (p < 0.0001) and then rose to 27 (range 5-39) after 3 months of enema therapy. There was no difference in LARS score decrease at 6 months between the patients with early and chronic LARS (22.5 and 23.9 respectively; p=0.7) and there were no predictors of score decrease. Four components of the SF-36 significantly improved during the TAI period. The MSKCC BFI score significantly improved in several domains. Twenty-three patients (85%) asked to continue the treatment with TAI after the study ended. CONCLUSIONS: TAI appears to be an effective treatment for LARS and results in a marked improvement of continence and quality of life.  Patients may be assessed and treated for LARS early after surgery since the treatment benefit is similar to that observed in patients with LARS diagnosed  6 months or longer after surgery. The potential rehabilitative role of TAI for LARS is promising and should be further investigated.

[10-year series studies of chronic radiation proctopathy from The Sixth Affiliated Hospital of Sun Yat-sen University].

Chronic radiation proctopathy (CRP) is the delayed adverse effect after radiotherapy for pelvic malignancies. It is characterized as progressive fibrosis in pathology. The symptoms are usually unspecific which include rectal bleeding, perianal pain, tenesmus, stool frequencies and so on. The course of CRP can present from months to years after radiation. Severe complications can occur in the late stage and will greatly affect the quality of life. Currently, there is no standard guides for diagnosis and treatment of CRP. For advancing the knowledge and proposing new treatment modalities of CRP, this article summarizes our 10-year experience as follows: (1) Except the existence of vessel damage, interstitial fibrosis, mucous ulcer, edema and inflammatory cell infiltration in the radiation-injury area, the capillary count was obviously reduced in mucous substratum and angiostatin expression up-regulated remarkably in above area, resulting in the continuous development of compensatory capillary expansion and interstitial fibrosis in mucous layer. (2) Rectal ultrasound examination was used the first time to diagnose CRP. According to thickness change of rectal wall layer and increase of blood signal, severity of CRP activity was evaluated with good diagnostic value. (3) For slight-moderate rectal bleeding, moderate-heavy bleeding and heavy bleeding, application of retention enema with compound preparation based on mucoprotective agents, regional perfusion hemostasis with formaldehyde and proximal colostomy gained satisfactory efficacy. (4) Improved Parks operation should be recommended for CRP patients with advanced complications. (5) For rectal cancer patients receiving neoadjuvant chemoradiotherapy, "proximal extended excision" should be performed innovatively to decrease the risk of anastomotic complications (Tianhe Procedure).

A pilot study assessing the efficacy of posterior tibial nerve stimulation in the treatment of low anterior resection syndrome.

BACKGROUND: Low anterior resection for rectal cancer often results in severe bowel dysfunction, specifically low anterior resection syndrome (LARS), with symptoms such as incontinence, urgency, and frequent bowel movements. Percutaneous tibial nerve stimulation (PTNS) resulted in a high rate of success in patients with fecal incontinence. The aim of this study was to evaluate the effectiveness of treatment with PTNS in LARS and to identify predictors of the outcome of the technique. METHODS: The study was conducted from May 2012 to April 2015 at the Alvaro Cunqueiro Hospital, University Hospital Complex of Vigo, Spain. Ten patients with LARS were recruited consecutively. All patients underwent 2 sessions per week (30 min each one) for 6 weeks. Patients were followed for 3 weeks, and those who had a significant clinical improvement were recruited to a second phase of PTNS. Some patients presenting with relapse during follow-up underwent an additional phase of PTNS. Outcome measures included Wexner scores, quality of life scores, and urgency of defecation. RESULTS: Three patients did not complete the treatment due to poor response in the first phase. Incontinence was reduced in the remaining seven of ten patients. The median Wexner score at initial patient evaluation was 14 (IQR 10.75-18.5), which decreased to 10 (IQR 6.5-18) after treatment (p = 0.034). A statistically significant improvement was demonstrated in quality of life scale, lifestyle, depression, and daily defecation urgency (p < 0.05). LARS Score improvement was observed in five patients (50%) with a total resolution of LARS in 2 (20%). CONCLUSIONS: PTNS is an ambulatory treatment that could play an important role in the context of a multimodal treatment approach in patients with LARS. It could be a first-line treatment to identify non-responders to conservative management who need different and more invasive treatments.

Efficacy of hyperbaric oxygen therapy in patients with radiation-induced rectal ulcers: Report of five cases.

For decades, hyperbaric oxygen therapy has been considered a treatment option in patients with chronic radiation-induced proctitis after pelvic radiation therapy. Refractory cases of chronic radiation-induced proctitis include ulceration, stenosis, and intestinal fistulas with perforation. Appropriate treatment needs to be given. In the present study, we assessed the efficacy of hyperbaric oxygen therapy in five patients with radiation-induced rectal ulcers. Significant improvement and complete ulcer resolution were observed in all treated patients; no side-effects were reported. Hyperbaric oxygen therapy has a low toxicity profile and appears to be highly effective in patients with radiation-induced rectal ulcers. However, hyperbaric oxygen therapy alone failed to improve telangiectasia and easy bleeding in four of the five patients; these patients were further treated with argon plasma coagulation (APC). Although hyperbaric oxygen therapy may be effective in healing patients with ulcers, it seems inadequate in cases with easy bleeding. Altogether, these data suggest that combination therapy with hyperbaric oxygen therapy and APC may be an effective and safe treatment strategy in patients with radiation-induced rectal ulcers.

Predictive Parameters of Symptomatic Hematochezia Following 5-Fraction Gantry-Based SABR in Prostate Cancer.

PURPOSE: This study identified predictors of high-grade late hematochezia (HH) following 5-fraction gantry-based stereotactic ablative radiation therapy (SABR). METHODS AND MATERIALS: Hematochezia data for 258 patients who received 35 to 40 Gy SABR in 5-fractions as part of sequential phase 2 prospective trials was retrieved. Grade 2 or higher late rectal bleeding was labeled HH. Hematochezia needing steroid suppositories, 4% formalin, or 1 to 2 sessions of argon plasma coagulation (APC) was labeled grade 2. More than 2 sessions of APC, blood transfusion, or a course of hyperbaric oxygen was grade 3 and development of visceral fistula, grade 4. Various dosimetric and clinical factors were analyzed using univariate and multivariate analyses. Receiver operating characteristic (ROC) curve analysis and recursive partitioning analysis were used to determine clinically valid cut-off points and identify risk groups, respectively. RESULTS: HH was observed in 19.4%, grade ≥3 toxicity in 3.1%. Median follow-up was 29.7 months (interquartile range [IQR]: 20.6-61.7) Median time to develop HH was 11.7 months (IQR: 9.0-15.2) from the start of radiation. At 2 years, cumulative HH was 4.9%, 27.2%, and 42.1% in patients who received 35 Gy to prostate (4-mm planning target volume [PTV] margin), 40 Gy to prostate (5-mm PTV margin), and 40 Gy to prostate/seminal vesicles (5-mm PTV margin), respectively (P<.0001). In the ROC analysis, volume of rectum receiving radiation dose of 38 Gy (V38) was a strong predictor of HH with an area under the curve of 0.65. In multivariate analysis, rectal V38 (≥2.0 cm(3); odds ratio [OR]: 4.7); use of anticoagulants in the follow-up period (OR: 6.5) and presence of hemorrhoids (OR: 2.7) were the strongest predictors. Recursive partitioning analysis showed rectal V38 < 2.0 cm(3), and use of anticoagulants or rectal V38 ≥ 2.0 cm(3) plus 1 other risk factor resulted in an HH risk of >30%. CONCLUSIONS: Rectal V38 and 2 clinical factors were strong predictors of HH following 5-fraction SABR. Planning constraints should keep rectal V38 below 2.0 cm(3).

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

BACKGROUND: Anterior resection syndrome (ARS) is common after sphincter-saving surgery for rectal cancer. It includes changes in the frequency and urgency of bowel movements and fecal incontinence. The therapeutic efficacy of biofeedback on ARS is unclear. We sought to evaluate the effectiveness of biofeedback therapy in patients with ARS after anterior resection for rectal cancer and to investigate the associated factors for therapeutic success. PATIENTS AND METHODS: The study was designed as a retrospective review of the data from 61 patients with ARS collected from a prospectively maintained institutional cancer database. Therapeutic efficacy was evaluated using anorectal manometry, the number of bowel movements daily, and fecal incontinence scoring systems (Vaizey and/or Wexner scores). Changes of > 15% in the Vaizey and/or Wexner scores were considered to indicate effectiveness. Stepwise logistic regression models were performed to evaluate whether the associated factors influenced therapeutic efficacy. RESULTS: The parameters of anorectal manometry in patients with rectal cancer were significantly lower than those in control group (P < .01). After biofeedback therapy, significant improvements were observed in the incontinence scale scores (P < .001), number of bowel movements (P < .001), and anorectal manometry data (maximum resting pressure, P < .001; maximum squeeze pressure, P = .001; and rectal capacity, P = .015). In contrast, no significant difference in the rectal initial sensation threshold was observed (P = .089). Patients with fecal incontinence as the primary symptom experienced significant improvements in all variables (P < .01), except for the rectal initial sensation threshold (P = .125). Age at surgery, current smoking status, diabetes, treatment cycles, laparoscopic surgery, interval from surgery to biofeedback therapy, and the use of radiation therapy were closely associated with therapeutic success. On multivariate analysis, current smoking status (odds ratio [OR], 0.09; 95% confidence interval [CI], 0.01-0.87), number of biofeedback therapy cycles (OR, 0.01; 95% CI, 0.00-0.06), and laparoscopic surgery (OR, 11.53; 95% CI, 1.17-113.61) were factors contributing to biofeedback therapeutic success. CONCLUSION: Biofeedback therapy can improve the anal function of patients after restorative resection for rectal cancer.

Health-related quality-of-life changes due to high-dose-rate brachytherapy, low-dose-rate brachytherapy, or intensity-modulated radiation therapy for prostate cancer.

PURPOSE: To compare urinary, bowel, and sexual health-related quality-of-life (HRQOL) changes due to high-dose-rate (HDR) brachytherapy, low-dose-rate (LDR) brachytherapy, or intensity-modulated radiation therapy (IMRT) monotherapy for prostate cancer. METHODS AND MATERIALS: Between January 2002 and September 2013, 413 low-risk or favorable intermediate-risk prostate cancer patients were treated with HDR brachytherapy monotherapy to 2700-2800 cGy in two fractions (n = 85), iodine-125 LDR brachytherapy monotherapy to 14,500 cGy in one fraction (n = 249), or IMRT monotherapy to 7400-8100 cGy in 37-45 fractions (n = 79) without pelvic lymph node irradiation. No androgen deprivation therapy was given. Patients used an international prostate symptoms score questionnaire, an expanded prostate cancer index composite-26 bowel questionnaire, and a sexual health inventory for men questionnaire to assess their urinary, bowel, and sexual HRQOL, respectively, pretreatment and at 1, 3, 6, 9, 12, and 18 months posttreatment. RESULTS: Median follow-up was 32 months. HDR brachytherapy and IMRT patients had significantly less deterioration in their urinary HRQOL than LDR brachytherapy patients at 1 and 3 months after irradiation. The only significant decrease in bowel HRQOL between the groups was seen 18 months after treatment, at which point IMRT patients had a slight, but significant, deterioration in their bowel HRQOL compared with HDR and LDR brachytherapy patients. HDR brachytherapy patients had worse sexual HRQOL than both LDR brachytherapy and IMRT patients after treatment. CONCLUSIONS: IMRT and HDR brachytherapy cause less severe acute worsening of urinary HRQOL than LDR brachytherapy. However, IMRT causes a slight, but significant, worsening of bowel HRQOL compared with HDR and LDR brachytherapy.