Quality of Life After Surgery for Rectal Cancer: a Comparison of Functional Outcomes After Transanal and Laparoscopic Approaches.

BACKGROUND: The aim in rectal cancer surgery is to cure with minimal impact on the quality of life. Transanal total mesorectal excision (TaTME) seems to be a safe and feasible alternative to laparoscopic TME (LaTME). However, limited data are available on the functional outcomes after TaTME. We aimed to study the quality of life (QoL), through questionnaires, comparing different functional outcomes after TaTME and LaTME. METHODS: Consecutive patients who underwent TME between 2010 and 2017 at Slagelse Hospital, Denmark, were included based on certain criteria. Patients were divided according to the surgical technique (TaTME vs LaTME). The study was based on telephone interviews using the questionnaires: EORTC-QLQ C30, EORTC-QLQ C29, Low Anterior Resection Syndrome (LARS) score, and International Prostate Symptom Score (IPSS) for male patients. Patients in this study had a follow-up time of at least 8 months. RESULTS: Overall, global health status was similar between the groups (p = 0.625). Anorectal symptoms were significantly in disfavor of TaTME including buttock pain (p = 0.011), diarrhea (p = 0.009), clustering of stools (p = 0.017), and urgency (p = 0.032), yet total LARS score was comparable (p = 0.054). We found comparable sexual results and an overall higher satisfaction with urinary status in TaTME group (p = 0.010), yet no difference in IPSS symptoms (p = 0.236). CONCLUSIONS: Anorectal dysfunction may occur after total mesorectal excision (TME) regardless of surgical technique, frequently more in after TaTME. The LARS symptoms and the overall quality of life status were however comparable. TaTME had a positive impact on the reported QoL, related to urinary symptoms.

Robot-guided neuromapping during nerve-sparing taTME for low rectal cancer.

PURPOSE: Intraoperative pelvic neuromapping with electrophysiological evaluation of autonomic nerve preservation during robotic total mesorectal excision (TME) for rectal cancer is conventionally performed by the bedside assistant with a hand-guided probe. Our goal was to return autonomy over the neuromonitoring process to the colorectal surgeon operating the robotic console. METHODS: A recently described prototype microfork electrostimulation probe was evaluated intraoperatively during abdominal robotic-assisted transanal TME (taTME) surgery for low rectal cancer in three consecutive male patients. RESULTS: An intraoperative video demonstrates the good control and maneuverability of the prototype probe with electrophysiological confirmation of bilateral pelvic autonomic nerve preservation. CONCLUSIONS: This study presents the first in situ application of a new microfork probe for fully robot-guided neuromapping in three patients undergoing TME surgery for low rectal cancer.

Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN).

PURPOSE: The aim of this study was to determine whether patients that underwent ultra-low rectal resection for cancer can benefit from the recently reintroduced two-stage Turnbull-Cutait abdominoperineal pull-through procedure. METHODS: Patients with low rectal tumors undergoing radical sphincter-sparing resection are eligible for inclusion in a randomized multicenter study. Whether two-stage Turnbull-Cutait coloanal anastomosis provides significant benefits over hand-sewn coloanal anastomosis and associated lateral ileostomy in terms of postoperative morbidity is the primary endpoint. In addition, the study aims to assess secondary endpoints such as quality of life, fecal incontinence, and locoregional recurrence of the neoplasm. Patients with adenocarcinoma of the lower rectum diagnosed by rigid proctoscopy, with histological confirmation of malignancy, and who are candidates of rectal removal and coloanal anastomosis will be included in a randomized controlled and multicenter trial. Postoperative morbidity is defined as complications that occur within 30 days of the data of the second surgical procedure of the last patient included in the trial. Patients will be followed for a minimum period of 3 years. CONCLUSIONS: The two-stage Turnbull-Cutait coloanal anastomosis may constitute an effective surgical alternative in the current approach to the treatment of low rectal cancer without the need of a temporary loop colostomy, preventing the wide range of complications related to stoma surgery. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov (trial number: NCT01766661). This trial is registered in January 10, 2013.

Functional Outcomes of Patients Treated with Intensive Medications for Bowel and Pain Control for Low-Lying Rectal Cancer Who Received Preoperative Chemoradiotherapy.

PURPOSE: The aim of this study was to assess the functional outcomes of patients treated with intensive medications for bowel and pain control for low-lying rectal cancer who received preoperative chemoradiotherapy (CRT). METHODS: The inclusion criterion was sphincter-preserving surgery following CRT for T3 middle and low rectal cancer. Postoperative defecation control was conducted using calcium polycarbophil and loperamide, and anal pain control was conducted using oxycodone hydrochloride hydrate. The functional outcomes were determined by an annual questionnaire after stoma closure. RESULTS: Of 64 patients evaluated, 33 were reconstructed using the double stapling technique (DST) and 31 were reconstructed using the intersphincteric resection (ISR) technique. The median Visual Analogue Scale at ISR was improved from 7 to 1.5 at 1 year after surgery. The median Wexner scores were 6.0, 6.0, 5.0 and 5.0 for DST and 14.5, 12.0, 10.0 and 8.0 for ISR for the first 4 years, respectively. The only independent predictor of a poor bowel function (Wexner score >10) according to a multivariate analyses was pelvic infection (OR 3.994, 95% CI 1.235-13.52, p = 0.021), while ISR was not a predictor. CONCLUSIONS: Anal pain following ISR can be controlled with oxycodone hydrochloride hydrate therapy. ISR is feasible following CRT for low-lying rectal cancer.

Sacral neuromodulation for fecal incontinence and "low anterior resection syndrome" following neoadjuvant therapy for rectal cancer.

BACKGROUND: It was the aim of this prospective study to analyze both feasibility and effectiveness of sacral neuromodulation for fecal incontinence and "low anterior resection syndrome" following neoadjuvant therapy for rectal cancer. METHODS: All patients who underwent sacral neuromdulation following neoadjuvant therapy for rectal cancer (preoperative radiochemotherapy, oncologic rectal resection with total mesorectal excision) were prospectively enrolled in the study. Only patients with failure of conservative treatment and without any evidence of residual or recurrent tumor disease were candidates for sacral neuromdulation which was performed by a two-stage procedure (diagnostic percutaneous test stimulation followed by definite implant). In addition to feasibility, primary end points included success (reduction of incontinent episodes), continence and defecation status (assessed by Cleveland Clinic Incontinence Score and Altomare score), and quality of life (EQ-5D). Anal manometry was performed preoperative and at 12-month follow-up. Follow-up information was derived from clinical examination 3, 6, and 12 months postoperatively. RESULTS: Nine patients (three females, six males) with a mean age of 61 years underwent sacral neuromodulation following neoadjuvant therapy for rectal cancer. Implantation rate was 100 %. No septic morbidity was observed. After a mean follow-up of 12 months, mean Cleveland Clinic Incontinence Score was reduced from 18.2 to 6.0 (p < 0.01). Incontinence episodes were significantly reduced from 7 to 0.5 (per day) and 20 to 8 (per week). Fecal urgency, fragmented defecation, and soiling were improved or resolved in two thirds. Altomare score was significantly reduced from 21.0 to 9.3 (p < 0.01). Anorectal manometry did not correlate with clinical success. Quality of life was significantly improved (EQ-5D generic: 0.42 vs. 0.74, EQ-5D-VAS score: 20 vs. 90, p < 0.01). CONCLUSIONS: Preliminary results of sacral neuromodulation in patients with fecal incontinence and symptoms of "low anterior resection syndrome" are promising and enrich the therapeutic modalities if conservative management has failed.

Self-care strategies for the management of bowel symptoms following sphincter-saving surgery for rectal cancer.

The primary aim of this article is to identify the self-care strategies that patients use to manage bowel symptoms experienced following sphincter-saving surgery for rectal cancer. Comparisons will be made with self-care strategies used by patients to manage chronic fecal incontinence and the bowel symptoms associated with other chronic bowel diseases, such as irritable bowel syndrome and inflammatory bowel disease. Published studies and conceptual literature from 2000-2010 were the data sources. Three major themes emerged from the literature reflecting the self-care strategies used by patients to manage bowel symptoms: functional self-care strategies (e.g., taking medication), social activity-related self-care strategies (e.g., planning social events), and alternative self-care strategies (e.g., complementary therapies). An analysis of studies highlighted that, through the process of trial and error, patients learned the strategies that were most effective in the management of their bowel symptoms. Knowledge of such strategies will be beneficial to healthcare professionals when educating patients about effective management of bowel symptoms following sphincter-saving surgery.

Oral glutamine supplementation during preoperative radiochemotherapy in patients with rectal cancer: a randomised double blinded, placebo controlled pilot study.

BACKGROUND & AIMS: Enteral glutamine may have protective effects on gut function and reduce metabolic stress in patients receiving radiochemotherapy. The aim of our study was to evaluate its influence in patients with rectal cancer undergoing preoperative radiochemotherapy. METHODS: We performed a randomized double blind, placebo controlled pilot study in 33 patients. 30 g of glutamine, average dose 0.41 g/kg (SD = 0.07) g/kg/day was administered orally in three doses per day for five weeks during preoperative radiochemotherapy of rectal cancer. 30 g of maltodextrin was given as placebo. Body weight was measured and NRS 2002 screening was performed before and after treatment. Bowel function was evaluated by stool consistency and frequency. Plasma levels of inflammatory parameters and hormones were measured. RESULTS: There was no difference between groups in frequency and severity of diarrhoea during radiochemotherapy (p = 0.5 and p = 0.39 respectively), insulin levels significantly increased in both groups, IL-6 only in glutamine group. CONCLUSION: Results of this small pilot study in rectal cancer patients receiving preoperative radiochemotherapy, showed that ingestion of larger quantities of glutamine given more often as previously reported did not diminish the incidence and severity of diarrhoea and did not affect inflammatory and metabolic activity compared to the placebo treatment with maltodextrin.

Effects of preoperative chemoradiotherapy on anal sphincter functions and quality of life in rectal cancer patients.

PURPOSE: Deterioration of anorectal function after long-course preoperative chemoradiotherapy combined with surgery for rectal cancer is poorly defined. We conducted a prospective study to evaluate the acute and long term effects of preoperative chemoradiotherapy on anorectal function and quality of life of the patients. METHODS: There were 26 patients in surgery group and 31 patients in preoperative chemoradiotherapy group. Anorectal function and quality of life of the patients were assessed by anorectal manometry, incontinence score, quality of life questionnaire. RESULTS: Significant lower resting pressures in both groups and lower maximal squeeze pressures in the preoperative chemoradiotherapy group were observed after postsurgical evaluations compared with the paired pretreatment ones. In the surgery group, both the Wexner continence score, FIQL score, and the rectoscopy score were comparable before and after surgery, whereas significant worsening in the Wexner score was observed in the preoperative chemoradiotherapy group postoperatively (P < 0.01). Significant reduction in anal canal resting pressures and squeeze pressures, Wexner score, and FIQL score were observed immediately after the completion of preoperative chemoradiotherapy. Significant lower maximal squeeze pressures and worsening of the Wexner scores were observed in the preoperative chemoradiotherapy group compared to the surgery group during the postoperative assessments (P < 0.05 and P < 0.01, respectively). CONCLUSIONS: Both total mesorectal excision and preoperative chemoradiotherapy may adversely affect the anorectal function. Careful selection of the patients who will benefit from neoadjuvant therapy and identifying the patients with a high risk of developing functional problems may help to improve functional outcomes for the treatment of rectal cancer.

Sacral nerve function in patients with soiling more than 10 years after low anterior resection for lower rectal cancer.

BACKGROUND/AIMS: To assess the neurological function of the puborectalis muscles (PM) in patients with or without soiling after low anterior resection (LAR) for lower rectal cancer, we examined the sacral nerve terminal motor latency (SNTML) of the PM. METHODOLOGY: The latency of the response in the PM following transcutaneous magnetic stimulation of the cauda equina at the levels from S3 to S4 by SNTML was measured in 24 patients after LAR. They were divided into a group with soiling (10 cases; 8 men and 2 women, aged 55 to 70 years with a mean age of 61.6 years) and one without soiling (14 cases; 10 men and 4 women, aged 50 to 69 years with a mean age of 60.3 years), and results were compared with data obtained from 25 control subjects (16 men and 9 women, aged 48 to 71 years with a mean age of 62.1 years). Postoperative monitoring of patients was initiated after a period of more than 10 years (121-144 months; mean: 128.2 months). RESULTS: 1) Distance of anastomosis from the dentate line measured with rectoscopy: Patients with and without soiling registered respective coloproctostomy distances of 2.5 +/- 0.6 (2-3.8) and 5.1 +/- 1.2 (3.0-6.5) cm, with the former showing a tendency (p < 0.0001) toward shorter distances. 2) Values of the SNTML: Patients with soiling (6.9 +/- 2.1 ms) exhibited significant extensions compared with patients without soiling (4.2 +/- 0.6 ms), and control subjects (3.9 +/- 0.6ms) (p < 0.0001, respectively). Moreover, patients without soiling showed more extended SNTML than control subjects at all sites. The conduction delay of SNTML in the patients with soiling was longest, followed by that in those without any soiling, then that in the control subjects. CONCLUSIONS: Soiling after LAR may be caused by damage to the sacral motor nerves.

Bowel dysfunction after treatment for rectal cancer.

INTRODUCTION: Rectal cancer is a common disease in Western populations. Improved treatment modalities have resulted in increased survival and tumour control. With increasing survival there is a growing need for knowledge about the long-term side effects and functional results after the treatment. AIM: To describe the long-term functional outcome in patients treated for rectal cancer through a systematic review of the current literature and to provide an outline of the promising developments within this area. RESULTS: Standard resectional surgery with loss of the rectal reservoir function results in poor functional results in up to 50-60% of the patients. New methods of surgery including the construction of a neoreservoir and improvement of the technique for local excision have been developed to minimize the functional disturbances without compromising the oncological result. The addition of chemo and/or radiotherapy approximately doubles the risk of poor functional results. During the last decades the techniques for chemo/radiotherapy has been markedly improved with a positive impact on functional outcome. New methods for treatment of functional disturbances e.g. bowel irrigation and sacral nerve stimulation are currently under development. PERSPECTIVES: To improve the functional outcome in this growing patient population several approaches can be taken. The primary cancer treatment must be improved by minimizing the surgical trauma and optimizing the imaging and radiation techniques. Population screening should be considered in order to find the cancers at an earlier stage, hereby increasing the proportion of patients eligible for local excision without the need for chemo/irradiation. All patients recovering from rectal resection should be examined and registered systematically regarding their functional results and treatment should be offered to the severely affected patients. More studies are still needed to evaluate the efficacy of irrigation and nerve stimulation in this patient group.

Radiochemotherapy in combination with regional hyperthermia in preirradiated patients with recurrent rectal cancer.

BACKGROUND AND PURPOSE: Encouraging results of phase II studies combining chemotherapy with radiotherapy have been published. In this study, the results of a multimodal salvage therapy including radiochemotherapy (RCT) and regional hyperthermia (RHT) in preirradiated patients with recurrent rectal cancer are reported. PATIENTS AND METHODS: All patients enrolled had received previous pelvic irradiation (median dose 50.4 Gy). The median time interval between prior radiotherapy and the onset of local recurrence was 34 months. The combined treatment consisted of reirradiation with a median dose of 39.6 Gy (30.0-45.0 Gy), delivered in fractions of 1.8 Gy/day. 5-fluorouracil was given as continuous infusion 350 mg/m(2)/day five times weekly, and RHT (BSD-2000 system) was applied twice a week within 1 h after radiotherapy. The primary endpoint was local progression-free survival (LPFS); secondary endpoints were overall survival, symptom control, and toxicity. RESULTS: 24 patients (median age 59 years) with a previously irradiated locally recurrent adenocarcinoma of the rectum were enrolled. The median LPFS was 15 months (95% confidence interval 12-18 months] with a median follow-up of 27 months (16-37 months). The overall 1-year and 3-year survival rates were 87% and 30%, respectively. Pain was the main symptom in 17 patients. Release of pain was achieved in 12/17 patients (70%). No grade 3 or 4 hematologic or skin toxicity occurred. Grade 3 gastrointestinal acute toxicity was observed in 12.5% of the patients. Paratumoral thermometry revealed a homogeneous distribution of temperatures. CONCLUSION: RCT combined with RHT is an efficient salvage therapy showing high efficacy with acceptable toxicity and can be recommended as treatment option for this unfavorable group of preirradiated patients with local recurrence of rectal cancer.

Daily low-dose/continuous capecitabine combined with neo-adjuvant irradiation reduces VEGF and PDGF-BB levels in rectal carcinoma patients.

UNLABELLED: Metronomic low-dose chemotherapy regimen was found to have an antiangiogenic effect in tumors. However, its effect on levels of circulating pro-angiogenic and anti-angiogenic factors is not fully explored. MATERIALS AND METHODS: The levels of both VEGF and PDGF-BB were measured in three time points, in the serum of 32 rectal carcinoma patients receiving daily reduced-dose/continuous capecitabine in combination with preoperative pelvic irradiation. RESULTS: We found a significant decrease in VEGF and PDGF-BB serum levels during the combination treatment (p < 0.0001), followed by an increase in the successive rest-period (p < 0.0001). In addition, substantial changes in platelets counts were observed during treatment in correlation with the changes of VEGF and PDGF-BB serum levels. DISCUSSION: These results suggest that combined chemo-irradiation affect levels of pro-angiogenic factors during treatment, and may reflect an anti-angiogenic window induced during this treatment. The potential implications of this inducible phenomenon, including a possible clinical benefit from the administration of long lasting metronomic chemotherapy immediately following combined chemo-irradiation, would warrant further investigation.

Comparison of intratumor and intraluminal temperatures during locoregional deep hyperthermia of pelvic tumors.

PURPOSE: To investigate whether intraluminal thermometry provides sufficient information to apply high quality deep hyperthermia in pelvic tumors. PATIENTS AND METHODS: The intratumor and intraluminal temperatures of 48 patients were analyzed per cancer type: rectum (21 male, 14 female), cervix (n=8), and bladder (n=5). Temperature-dose parameters were calculated, temperature curves within each treatment session were compared, and correlation between intratumor and intraluminal temperatures was analyzed. RESULTS: Intratumor and intraluminal temperatures at the same time points during individual treatments were highly correlated (mean correlation coefficient: 0.93). However, the quantitative level differed from 0.1 to 1.1 degrees C and the differences of the time-temperature graphs varied per tumor group. Average intratumor and intraluminal temperatures were not different in the four groups. Intratumor thermometry was found not superior over intraluminal thermometry to improve tumor temperature level and homogeneity by SAR steering. CONCLUSION: Intraluminal thermometry provides sufficient information to apply deep hyperthermia to individual patients with centrally located rectum, cervix or bladder cancer.

[Gabapentin mitigates neuropathic pain in cancer patients--a case report].

A 64-year-old male underwent low anterior resection of the rectum for rectal cancer. Five years later, he suffered neuropathic cancer pain on the left-posterior surface of his thigh caused by sacral invasion of the recurrence site. His neuropathic pain was not sufficiently responsive to the combination therapy of opioids, non-steroidal antiinflammatory drugs (NSAIDs), continuous infusion of subcutaneous ketamine and oral mexiletine. Gabapentin, which has been suggested as an adjuvant analgesic for neuropathic pain introduced orally, rapidly and significantly alleviated his pain and we could subsequently dispense with ketamine and mexiletine. No adverse effect was seen during this treatment. The present case indicates that gabapentin would be one of the most effective adjuvant analgesics for neuropathic cancer pain.

A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers.

INTRODUCTION: Colonic pouches have been used for 20 years to provide reservoir function after reconstructive proctectomy for rectal cancer. More recently coloplasty has been advocated as an alternative to a colonic pouch. However there have been no long-term randomized, controlled trials to compare functional outcomes of coloplasty, colonic J-Pouch (JP), or a straight anastomosis (SA) after the treatment of low rectal cancer. AIM: : To compare the complications, long-term functional outcome, and quality of life (QOL) of patients undergoing a coloplasty, JP, or an SA in reconstruction of the lower gastrointestinal tract after proctectomy for low rectal cancer. METHODS: A multicenter study enrolled patients with low rectal cancer, who were randomized intraoperatively to coloplasty (CP-1) or SA if JP was not feasible, or JP or coloplasty (CP-2) if a JP was feasible. Patients were followed for 24 months with SF-36 surveys to evaluate the QOL. Bowel function was measured quantitatively and using Fecal Incontinence Severity Index (FISI). Urinary function and sexual function were also assessed. RESULTS: Three hundred sixty-four patients were randomized. All patients were evaluated for complications and recurrence. Mean age was 60 +/-12 years, 71% were male. Twenty-three (7.4%) died within 24 months of surgery. No significant difference was observed in the complications among the 4 groups. Two hundred ninety-seven of 364 were evaluated for functional outcome at 24 months. There was no difference in bowel function between the CP-1 and SA groups. JP patients had fewer bowel movements, less clustering, used fewer pads and had a lower FISI than the CP-2 group. Other parameters were not statistically different. QOL scores at 24 months were similar for each of the 4 groups. CONCLUSIONS: In patients undergoing a restorative resection for low rectal cancer, a colonic JP offers significant advantages in function over an SA or a coloplasty. In patients who cannot have a pouch, coloplasty seems not to improve the bowel function of patients over that with an SA.

Anorectal reconstruction by electrostimulated graciloplasty as part of abdominoperineal resection.

AIMS: To report the outcomes of anorectal reconstruction by electrostimulated graciloplasty as part of abdominoperineal resection, on data prospectively collected over 10 years. PATIENTS AND METHODS: Twenty-three abdominoperineal resections were associated to coloperineal pull through, double graciloplasty and loop abdominal stoma. Fifteen patients also received an implantable pulse generator, either for unsatisfactory result after external-source intermittent electrostimulation and biofeedback (five cases) or during graciloplasty (10 cases). Follow-up was to a maximum of 10 years. Functional outcome was followed up in sixteen patients who underwent stoma takedown. RESULTS: Mean actuarial survival at 5 years was 72.3%. Satisfactory results (score < or =8) occurred in 75% of patients (three without and 13 with stimulator) in the early stages, decreasing to 57% at 1 year and gradually increasing up to 100% at 5 years and over. CONCLUSIONS: Total anorectal reconstruction yields a good functional outcome over time. Thus, despite, and because of, a high complication rate and a great drain on resources, it should be considered a suitable procedure only for selected, strongly motivated patients.

Elaps in advanced pathology--a case study.

The case of a patient with severe complications after rectal adenocarcinoma surgery is reported. Homeopathic treatment was selected on the basis of individualization of symptoms ('minimum syndrome of maximum value') and prescribed in Korsakovian potencies. It is discussed what it may be expected in the treatment of severely ill patients.

Quantitative short-term study of anal sphincter function after chemoradiation for rectal cancer.

HYPOTHESIS: Pelvic irradiation adversely affects anal sphincter function after proctectomy with coloanal anastomosis for low rectal and middle rectal (<10 cm from the anal verge) tumors. DESIGN: Case-control study. SETTING: Private, tertiary care referral center. PATIENTS: Patients treated for low rectal adenocarcinoma between January 1, 1994, and October 31, 1999. INTERVENTIONS: Anal manometric data were prospectively collected at the time of initial diagnosis and before ileostomy closure. MAIN OUTCOME MEASURES: Mean and maximum resting pressures (RPs) and squeeze pressures, threshold volume for sensation, and maximal tolerable volume. RESULTS: Twenty-three patients in the surgery group and 19 in the chemoradiotherapy group were considered for analysis; 15 patients had preoperative radiotherapy and 4 had postoperative radiotherapy. At the time of ileostomy closure, RPs were significantly lower in the chemoradiotherapy group than in the surgery group (32.7 +/- 17 vs 45.3 +/- 18 mm Hg; P =.03). Squeeze pressures were not significantly different between the surgery and chemoradiotherapy groups (108.7 +/- 56.7 vs 102.0 +/- 52.6 mm Hg; P =.69). The ratios of postresection to preresection RPs were also significantly lower in the chemoradiotherapy group (0.49 +/- 0.29) than in the surgery group (0.76 +/- 0.22) (P =.005). Eight to 12 weeks after proctectomy with coloanal anastomosis, a 24% decrease in RP was noted in the surgery group. The addition of adjuvant pelvic irradiation decreased RP by another 27%. CONCLUSION: Adequate shielding of the anal sphincter should be performed for low rectal cancers whenever a sphincter-preserving procedure is considered.

Colorectal cancer--chemoprevention.

Colorectal cancer is the second leading cause of death from cancer in The United States. During the last fifteen years, emphasis has been placed on identification of high risk patients and families and outline of appropriate surveillance regimens for normal and high risk patients for colorectal cancer. Parallel to this effort, abundant clinical data has been accumulated that chemoprevention of colorectal cancer with nonsteroidals and aspirin may be possible. Interruption of prostaglandin metabolism appears to be one of the mechanisms of action but not the only therapeutic arm. Currently, sulindac, aspirin, calcium and selenium supplementation are attractive recommendations to at risk patients awaiting results of clinical trials. Other agents in development add excitement to the concept of colorectal cancer chemoprevention.

Restoration of anal sphincter function by single-stage dynamic graciloplasty with a modified (split sling) technique.

BACKGROUND: Controlled muscle fiber conversion by electrostimulation makes transformation of fast twitching type II muscle fibers to slow twitching type I fibers possible, which gives skeletal muscles the capacity for tetanic contraction. This phenomenon has been recently applied in the so-called "dynamic graciloplasty" to restore function of an insufficient or excised anal sphincter. This paper describes our results with this method in patients with fecal incontinence or following an abdomino-perineal resection (APR) of the anorectum. METHODS: From April 1992 through April 1997, 28 patients (12 women and 16 men) were treated by dynamic graciloplasty. The median age was 53.5 years (range 16 to 79). Indications were as follows: APR + synchronous restoration of the excised sphincter by graciloplasty (n = 12); total anorectal reconstruction (TAR) following APR in the past (n = 6); Patients with acquired fecal incontinence (n = 4); and Congenital atresia (n = 6). Muscle transposition, implantation of stimulation electrodes and pulse generator were done as a single-stage procedure, the "neosphincter" was wrapped in a modified technique (split-sling technique). Muscle transformation was performed by controlled neuromuscular stimulation during 8 weeks (from 1992 to 1995) and 4 weeks (since 1996), respectively. RESULTS: No postoperative mortality (90 days) was observed in either group. In our early experience, rectal injury occurred in 4 patients as the most prominent complication. Evaluation of the functional outcome showed the best results in patients operated either for congenital of acquired incontinence who achieved a continence for solids and liquids or solids alone, respectively (1 or 2 according to Williams' score) in 90%, while patients following APR showed a satisfying outcome (continence for solids and liquids, solids alone or with occasional episodes for liquids) in only 55.5%. In patients following APR, defecation disorders turned out to be the most prominent functional problem and had to be treated by enemas. CONCLUSION: In this series, we have been able to perform dynamic graciloplasty as a one-stage procedure using a modified muscle wrap (split-sling-technique) thus reducing the time period until continence could be achieved to 7 weeks. We found the appropriate tension of the muscle wrap essential to prevent direct injury to the rectum as it was seen in our early experience. For this reason, we have introduced a modified device to perform intraoperative anal manometry and to measure pressures created by the neosphincter objectively.