Stoma reversal after intended restorative rectal cancer resection in Denmark: nationwide population-based study.

BACKGROUND: Data on stoma reversal following restorative rectal resection (RRR) with a diverting stoma are conflicting. This study investigated a Danish population-based cohort of patients undergoing RRR to evaluate factors predictive of stoma reversal during 3 years of follow-up. METHODS: Patients from national registries with rectal cancer undergoing RRR or Hartmann's procedure with curative intent between May 2001 and April 2012 were included. Patients with a diverting stoma were followed from the time of primary rectal cancer resection to date of stoma reversal, death, emigration, or end of 3-year follow-up. The cumulative incidence proportion (CIP) of stoma reversal at 1 and 3 years was calculated, treating death as a competing risk. Factors predictive of stoma reversal were explored using Cox regression analysis. RESULTS: Of 6859 patients included, 35·7, 41·9 and 22·4 per cent respectively had a RRR with a diverting stoma, RRR without a stoma, and Hartmann's procedure with an end-colostomy. In patients with a diverting stoma, the CIP of stoma reversal was 70·3 (95 per cent c.i. 68·4 to 72·1) per cent after 1 year, and 74·3 (72·5 to 76·0) per cent after 3 years. Neoadjuvant treatment (hazard ratio (HR) 0·75, 95 per cent c.i. 0·66 to 0·85), blood loss greater than 300 ml (HR 0·86, 0·76 to 0·97), anastomotic leak (HR 0·41, 0·33 to 0·50), T3 category (HR 0·63, 0·47 to 0·83), T4 category (HR 0·62, 0·42 to 0·90) and UICC stage IV (HR 0·57, 0·41 to 0·80) were possible predictors of delayed stoma reversal. CONCLUSION: In one-quarter of the patients the diverting stoma had not been reversed 3 years after the intended RRR procedure.

ANTECEDENTES: Los datos sobre el cierre del estoma (stoma reversal, SR) tras la exéresis el recto con intención reconstructiva (restorative rectal resection, RRR) y estoma derivativo (diverting stoma, DS) son contradictorios. Este estudio analizó los factores predictivos del SR en una cohorte danesa de base poblacional de pacientes sometidos a RRR con un seguimiento de 3 años. MÉTODOS: Los pacientes con cáncer de recto a los que se realizó una RRR o una operación de Hartmann (Hartmann's operation, HO) con intención curativa desde mayo de 2001 hasta abril de 2012, se seleccionaron a partir de registros nacionales. Los pacientes con SD fueron seguidos desde la resección primaria del cáncer rectal hasta la fecha del SR, del fallecimiento, de su cambio de residencia o hasta el final del seguimiento (3 años). Se calculó la tasa de incidencia acumulada (cumulative incidence proportion, CIP) de RS a 1 y 3 años utilizando la muerte como factor de riesgo competitivo. Se identificaron los factores predictivos de SR mediante regresión múltiple de Cox. RESULTADOS: De los 6.859 pacientes incluidos, el 35,7%, 41,9% y 22,4% tenían una RRR con DS, una RRR sin estoma y una HO con colostomía terminal, respectivamente. En pacientes con SD, el CIP de SR fue del 70,3% (i.c. del 95%: 68,4-72,1) al año y del 74,3% (i.c. del 95%: 72,5-76,0) a los 3 años. Se identificaron como posibles factores predictivos relacionados con el retraso del SR, el tratamiento neoadyuvante (cociente de riesgos instantáneos, hazard ratio, HR 0,75; i.c. del 95% 0,66-0,85), una pérdida de sangre > 300 mL (HR 0,86; i.c. del 95% 0,76-0,97), la fuga anastomótica (HR 0,41; i.c. del 95% 0,33-0,50), las categorías T3 (HR 0,63; i.c. del 95% 0,47-0,83) y T4 (HR 0,62; i.c. del 95% 0,42-0,90) y el estadio IV UICC (HR 0,57; i.c. del 95%: 0,41-0,80). CONCLUSIÓN: En una cuarta parte de los pacientes no se había cerrado el estoma derivativo tres años después de la resección de cáncer rectal con intención reconstructiva.

Comparison of long-term outcome of sacral nerve stimulation for constipation and faecal incontinence with focus on explantation rate, additional visits, and patient satisfaction.

BACKGROUND: The aim of the present study was to compare sacral nerve stimulation (SNS) for constipation (SNS-C) with SNS for idiopathic faecal incontinence (SNS-IFI) regarding explantation rate, additional visits, and improvement of patient satisfaction 5 years after implantation. METHODS: From our prospective database (launched in 2009), we extracted all SNS-C patients 5 years post-implantation, and the SNS-IFI patients implanted just before and just after each SNS-C patient. We retrospectively evaluated the explantation rate, number of additional visits, and patient satisfaction using a visual analogue scale (VAS). We hypothesized that compared with those in the SNS-IFI group: (1) the explantation rate would be higher in SNS-C patients, (2) the number of additional visits would be higher in SNS-C patients, and (3) in patients with an active implant at 5 years, the improvement in VAS would be the same. RESULTS: We included 40 SNS-C patients and 80 SNS-IFI patients. In the SNS-C group 7/40 (17.5%), patients were explanted, compared to 10/80 (12.5%) patients in the SNS-IFI group (p = 0.56). The mean number of additional visits in the SNS-C group was 3.5 (95% CI 2.8-4.1)) and 3.0 (95% CI 2.6-3.6)) in the SNS-IFI group (p = 0.38). Additional visits due to loss of efficacy were significantly higher in the SNS-C patients (p = 0.03). The reduction in VAS score (delta VAS) at 5 years was 37.1 (95% CI 20.9-53.3) in the SNS-C group, and 46.0 (95% CI 37.9-54.0) in the SNS-IFI group (p = 0.27). CONCLUSIONS: No significant difference was found regarding explantation rate, number of additional visits, or improvement of VAS at 5 years after SNS implantation between SNS-C patients and SNS-IFI patients.

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

BACKGROUND: Bowel dysfunction is common after surgery for rectal cancer, especially when neoadjuvant radiotherapy is used. The role of sensory function in the pathogenesis remains obscure, and the aim of the present study was to characterize the sensory pathways of the brain-gut axis in rectal cancer patients treated with resection ± radiotherapy compared with healthy volunteers. METHODS: Sensory evaluation by (neo)rectal distensions was performed and sensory evoked potentials (SEPs) were recorded during rapid balloon distensions of the (neo)rectum and anal canal in resected patients with (n = 8) or without (n = 12) radiotherapy. Twenty healthy volunteers were included for comparison. (Neo)rectal latencies and amplitudes of SEPs were compared and spectral band analysis from (neo)rectal and anal distensions was used as a proxy of neuronal processing. RESULTS: Neorectal sensation thresholds were significantly increased in both patient categories (all p < 0.008). There were no differences in (neo)rectal SEP latencies and amplitudes between groups. However, spectral analysis of (neo)rectal SEPs showed significant differences between all groups in all bands (all p < 0.01). On the other hand, anal SEP analyses only showed significant differences between the delta (0-4 Hz), theta (4-8 Hz) and, gamma 32-50 Hz) bands (all p < 0.02) between the subgroup of patients that also received radiotherapy and healthy volunteers. CONCLUSIONS: Surgery for rectal cancer leads to abnormal cortical processing of neorectal sensation. Additional radiotherapy leads to a different pattern of central sensory processing of neorectal and anal sensations. This may play a role in the functional outcome of these patients.

Impact of a multidisciplinary training programme on outcome of upper rectal cancer by critical appraisal of the extent of mesorectal excision with postoperative MRI.

BACKGROUND: Optimal management of patients with upper rectal cancer remains unclear. Partial mesorectal excision (PME) without neoadjuvant therapy is currently advocated for the majority of patients. Recent studies, however, reported a high risk of local recurrence and suboptimal surgery. The aim of this study was to evaluate the effects of a quality assurance initiative with postoperative MRI to improve outcomes in these patients. METHODS: Patients who underwent mesorectal excision with curative intent for rectal cancer in 2007-2013 were included. Postoperative MRI of the pelvis was performed 1 year after surgery. In 2011, a multidisciplinary workshop with focus on extent and completeness of surgery was held for training surgeons, pathologists and radiologists involved in treatment planning. Images of residual mesorectum and histopathological reports were reviewed with regard to the distal resection margin. Local recurrence after a minimum of 3 years' follow-up was compared between two cohorts from 2007-2010 and 2011-2013. RESULTS: A total of 627 patients were included; postoperative MRI of the pelvis was done in 381 patients. The 3-year actuarial local recurrence rate in patients with upper rectal cancer improved from 12·9 to 5·0 per cent (P = 0·012). After the workshop, fewer patients with cancer of the upper rectum were selected to have PME (90·8 per cent in 2007-2010 versus 80·2 per cent in 2011-2013; P = 0·023), and fewer patients who underwent PME had an insufficient distal resection margin (61·7 versus 31 per cent respectively; P < 0·001). CONCLUSION: Quality assessment of surgical practice may have a major impact on oncological outcome after surgery for upper rectal cancer.

ANTECEDENTES: El tratamiento óptimo para los pacientes con cáncer del tercio superior de recto no está claro. En este momento, la conducta más empleada es la exéresis parcial del mesorrecto (partial mesorectal excision, PME) sin tratamiento neoadyuvante. Sin embargo, estudios recientes han apuntado que se trata de una cirugía subóptima con un elevado riesgo de recidiva local. El objetivo de este estudio fue evaluar los efectos de una iniciativa de control de calidad con una resonancia magnética (magnetic resonance imaging, MRI) postoperatoria para mejorar los resultados en estos pacientes. MÉTODOS: Se incluyeron los pacientes con cáncer rectal a los que se realizó una exéresis del mesorrecto con intención curativa entre los años 2007 y 2013. Un año después de la cirugía se realizó una MRI de la pelvis. En el 2011, se organizó un taller multidisciplinario para educar a los cirujanos, patólogos y radiólogos involucrados en la planificación del tratamiento, en el que se discutieron la extensión y la radicalidad de la cirugía. Se revisaron las imágenes de mesorrecto residual y los informes histopatológicos respecto al margen de resección distal. Se comparó la recidiva local después de más de 3 años de seguimiento entre dos cohortes temporales, 2007-2010 y 2011-2013, respectivamente. RESULTADOS: Se incluyeron un total de 627 pacientes, en los que en 381 se realizó una MRI postoperatoria de la pelvis. Las tasa actuarial de recidiva local a 3 años en pacientes con cáncer del tercio superior de recto mejoraron del 12,9% al 5,0% (P = 0,012). Después del taller, se realizaron menos PME en pacientes con cáncer del tercio superior de recto (91% versus 80%, P = 0,023) y menos pacientes en los que se realizó una PME presentaron un margen de resección distal insuficiente (62% versus 31%, P < 0,001). CONCLUSIÓN: La evaluación de la calidad de la práctica quirúrgica puede tener un gran impacto en los resultados oncológicos después de la cirugía del cáncer del tercio superior de recto.

International consensus definition of low anterior resection syndrome.

AIM: Low anterior resection syndrome (LARS) is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The LARS score was designed as a simple tool for clinical evaluation of LARS. Although the LARS score has good clinical utility, it may not capture all important aspects that patients may experience. The aim of this collaboration was to develop an international consensus definition of LARS that encompasses all aspects of the condition and is informed by all stakeholders. METHOD: This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting. Three expert groups participated: patients, surgeons and other health professionals from five regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in three languages (English, Spanish, and Danish). The primary outcome measured was the priorities for the definition of LARS. RESULTS: Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96% and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to eight symptoms and eight consequences that capture essential aspects of the syndrome. Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this. CONCLUSION: This is the first definition of LARS developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of LARS. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in LARS over time and with intervention.

Impact of bowel and stoma dysfunction on female sexuality after treatment for rectal cancer.

AIM: The aim of this study was to measure the impact of bowel dysfunction and a poorly functioning stoma on the risk of sexual inactivity and sexual dysfunction in female patients. METHOD: In a population-based cross-sectional study, Danish rectal cancer patients diagnosed between 2001 and 2014 were invited to answer a comprehensive questionnaire regarding cancer- and treatment-related late side effects after rectal cancer treatment. Bowel function was assessed using the Low Anterior Resection score and stoma function using the Colostomy Impact score. Female sexuality was measured by sexual activity, overall sexual dysfunction (the Rectal Cancer Female Sexuality score) and by different domains of sexual dysfunction (Sexual Vaginal Changes questionnaire). RESULTS: Eight-hundred and thirteen female patients completed the questionnaire (response rate 49.2%). Major bowel dysfunction did not significantly increase the risk of sexual inactivity (OR 1.39, 95% CI 0.93-2.07) but clearly increased the risk of sexual dysfunction (OR 3.03, 95% CI 1.67-5.51). The most distinct problems were dyspareunia and inability to complete intercourse. On the contrary, poor stoma function increased the risk sexual inactivity (OR 2.26, 95% CI 1.16-4.40) but not the risk of sexual dysfunction (OR 0.74, 95% CI 0.27-1.99). The most distinct problem was dissatisfaction with own physical appearance. CONCLUSIONS: Both bowel dysfunction and stoma dysfunction negatively, but differently, affect sexuality. After restorative surgery, bowel dysfunction was primarily associated with sexual dysfunction while poor stoma function after abdominoperineal excision was associated with sexual inactivity.

Long-term impact of incisional hernia on quality of life after colonic cancer resection.

PURPOSE: The objective of the current study was to examine the long-term quality of life (QOL) after colonic cancer resection according to whether or not the patients developed incisional hernia. Furthermore, the impact of incisional hernia repair on QOL was examined in the patient group diagnosed with an incisional hernia. METHODS: This was a nationwide register-based study including patients undergoing colonic cancer resection identified in the Danish Colorectal Cancer Group database. Surviving patients were contacted and answered the EORTC QLQ-C30 questionnaire and grouped according to subsequent incisional hernia diagnosis, and in a subgroup analysis of patients with subsequent incisional hernia according to incisional hernia repair or not. RESULTS: A total of 2466 patients were included. The median time from colonic cancer resection to QOL assessment was 9.9 years, during which a total of 215 (8.7%) patients were diagnosed with incisional hernia, and 156 (72.6%) of these underwent incisional hernia repair. After adjustment for confounders, incisional hernia subsequent to colonic cancer resection was significantly associated with reduced QOL in the domains Global health, Physical functioning, Role functioning, Emotional functioning and Social functioning, as well as significantly associated with increased symptoms in the scales of pain, dyspnoea and insomnia. Of patients with incisional hernia, surgical repair was associated with increased QOL in the domains Physical functioning and Role functioning. CONCLUSIONS: Incisional hernia subsequent to colonic cancer resection was associated with reduced QOL several years after surgery and should be considered taken into account when evaluating the long-term outcome of colonic cancer resection.

Improved longevity and efficacy of sacral nerve stimulation by simple adjustments at follow-up.

AIM: Sacral nerve stimulation (SNS) for faecal incontinence (FI) at subsensory amplitudes as low as 50% of the sensory threshold has been found to be effective at 3 months' follow-up. Furthermore, alternative pacemaker settings may improve functional outcome in patients with suboptimal treatment efficacy. In this work we aim to explore if sub-sensory stimulation as low as 50% of sensory threshold is effective at 1-year follow-up. We also aimed to investigate if 31 Hz (frequency) or 90 µs (pulse width) stimulation improved treatment efficacy in dissatisfied patients. METHOD: All patients in whom the stimulation was effective in controlling FI (satisfied group) were encouraged to have the stimulation amplitude reduced. Those in whom the device was less effective (dissatisfied group) were offered alternative frequency settings or pulse width (31 Hz or 90 µs). Patients were follow-up after 12 months and evaluated by a visual analogue scale (VAS) for patient satisfaction, the Cleveland Clinic Continence Score (CCCS), Rockwood Faecal Incontinence Quality of Life Scale (QoL) and a bowel habit diary. RESULTS: Two hundred and nineteen patients were contacted, with a response rate of 71% (n = 155). Those who were successfully contacted comprised 110 (71%) patients classed as satisfied and 45 (29%) as dissatisfied. Seventy-five (68%) of the satisfied patients agreed to have their stimulation amplitude reduced. At 1-year follow-up the median amplitude had reduced from 1.5 V [interquartile range (IQR) 0.85-2.0 V] to 0.75 V (IQR 0.45-1.4 V) (P-value < 0.001) representing an overall reduction of 39% (6.6-62.5%). There were no significant differences in VAS, CCCS or QoL despite subsensory stimulation at 1-year follow-up. In 28% of the dissatisfied patients alternative pacemaker settings improved VAS to satisfactory levels. CONCLUSION: Subsensory stimulation is as effective as stimulation at or above the sensory threshold. High-frequency stimulation (31 Hz) can improve functional outcome in patients with loss of efficacy.

Quality of life with or without sphincter preservation for rectal cancer.

AIM: The aim of this investigation was to examine quality of life after surgical treatment for low rectal cancer. METHOD: This was a population-based, cross-sectional study on quality of life in patients treated for rectal cancer from 2001 to 2007. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and a single question on the impact of bowel/stoma function on quality of life were sent to patients who had undergone abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer with tumours below 10 cm from the anal verge. RESULTS: Informative answers were obtained from 898 patients (87%). EORTC QLQ-C30 outcomes were very similar for APE and LAR patients in univariate analysis. When adjusted for neoadjuvant radiotherapy and gender, multivariate analysis showed that LAR patients had lower global health status (OR 1.32, 95% CI 1.03; 1.68, P = 0.026) and higher occurrence of constipation (OR 0.47, 95% CI 0.32; 0.69, P < 0.001) and diarrhoea (OR 0.47, 95% CI 0.35; 0.64, P < 0.001). Analysis of the anchor question showed that LAR patients had significantly higher negative impact of bowel function on quality of life in both univariate (OR 3.38, 95% CI 2.62; 4.37, P < 0.001) and multivariate analysis (OR 3.71, 95% CI 2.86; 4.83, P < 0.001) compared with APE. CONCLUSION: For patients with low rectal cancer, we found LAR patients had worse global health status and problems with diarrhoea and constipation compared with APE patients.

Female sexual problems after treatment for colorectal cancer - a population-based study.

AIM: There has been limited focus on female sexuality after treatment for colorectal cancer. The aim of this study was to investigate long-term female sexual dysfunction in disease-free colorectal cancer survivors in the Danish population. METHOD: All female Danish patients treated for colorectal cancer between 2001 and 2014 were included if they reported to have been sexually active at the time of diagnosis. They were requested to answer the validated Sexual Vaginal Changes Questionnaire. RESULTS: A total of 2402 patients were included for analysis (43%). Overall, rectal cancer patients reported more sexual inactivity and problems compared to colon cancer patients, but there were no differences in any sexual function domains when excluding irradiated patients and patients with a permanent stoma. A permanent stoma was associated with sexual inactivity [OR 2.56 (95% CI 1.42-4.70)] and overall sexual dysfunction [OR 2.95 (95% CI 1.05-6.38)] in colon cancer patients, as well as inactivity [OR 1.43 (95% CI 1.01-2.04)] and overall dysfunction [OR 2.0 (95% CI 1.18-3.41)] in rectal cancer patients. Furthermore, a permanent stoma was associated with dyspareunia [OR 2.17 (95% CI 1.39-3.38)] and reduced vaginal dimension [OR 3.16 (95% CI 1.99-5.01)]. In rectal cancer patients, radiotherapy exposure increased the odds for overall sexual dysfunction [OR 1.80 (95% CI 1.02-3.16)] and was associated with dyspareunia [OR 1.72 (95% CI 0.95-3.12)]. CONCLUSION: Sexual problems after treatment of colorectal cancer are common. Major risk factors are a permanent stoma and radiotherapy. Relevant patients should be offered professional counselling and treatment.

Bowel dysfunction after sigmoid resection for cancer and its impact on quality of life.

BACKGROUND: Several studies have explored functional outcomes after rectal cancer surgery, but bowel dysfunction after sigmoid resection for cancer has hardly been considered. The aim of this study was to identify the prevalence and pattern of bowel dysfunction after resection for sigmoid cancer, and the impact of bowel function on quality of life (QoL) by comparison with patients who had polypectomy for cancer. METHODS: This was a national cross-sectional study. Data were collected from the Danish Colorectal Cancer Group database, and a questionnaire regarding bowel function and European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 QoL questionnaire was sent to all Danish colonic cancer survivors treated with sigmoid resection or polypectomy between 2001 and 2014. RESULTS: A total of 3295 patients (3061 sigmoid resection, 234 polypectomy) responded to the questionnaire (response rate 63·8 per cent). Twelve bowel symptoms were more prevalent after sigmoid resection, including: excessive straining, fragmentation, bloating, nocturnal defaecation, bowel false alarm, liquid stool incontinence, incomplete evacuation and sense of outlet obstruction. QoL impairment owing to bowel symptoms was reported in 16·6 per cent of patients in the resection group and 10·1 per cent after polypectomy (P = 0·008). Obstructed defaecation symptoms (ODS) were encountered significantly more often after sigmoid resection than following polypectomy (17·9 versus 7·3 per cent; P < 0·001). In the resection group, patients with ODS had substantial impairment on most aspects of QoL assessed by the EORTC QLQ-C30. CONCLUSION: Sigmoid resection for cancer is associated with an increased risk of long-term bowel dysfunction; obstructed defaecation is prevalent and associated with substantial impairment of QoL.

Chronic pain after rectal cancer surgery - development and validation of a scoring system.

AIM: The aim was to develop and validate a scoring system for the assessment of chronic pain on quality of life (QoL) following surgical treatment of rectal cancer (RC). METHOD: Patients diagnosed with RC between 2001 and 2014 in Denmark were evaluated for inclusion. Eligible patients were mailed questionnaires concerning pain and QoL. Questionnaire items were associated with QoL by odds ratio using regression analyses. The patients were randomized into a development group and a validation group. The most significant items were each assigned a score value based on multivariate-adjusted odds ratio. Validity was tested in the validation group using receiver operating characteristic curves and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire - Core 30 (EORTC QLQ-30). RESULTS: A total of 1928 eligible patients completed the questionnaire; 1072 were randomized to the development group and 856 to the validation group. The calculated scores included the six most important questionnaire items giving a score range of 0-45 which identified three groups: no significant pain, minor pain syndrome and major pain syndrome. Our results suggest a significant correlation between QoL assessment and the presence of major pain. CONCLUSION: We have developed and validated a reliable, QoL-based scoring system for chronic post-surgical pain following RC.

Consensus and controversies regarding follow-up after treatment with curative intent of nonmetastatic colorectal cancer: a synopsis of guidelines used in countries represented in the European Society of Coloproctology.

AIM: It is common clinical practice to follow patients for a period of years after treatment with curative intent of nonmetastatic colorectal cancer, but follow-up strategies vary widely. The aim of this systematic review was to provide an overview of recommendations on this topic in guidelines from member countries of the European Society of Coloproctology, with supporting evidence. METHOD: A systematic search of Medline, Embase and the guideline databases Trip database, BMJ Best Practice and Guidelines International Network was performed. Quality assessment included use of the AGREE-II tool. All topics with recommendations from included guidelines were identified and categorized. For each subtopic, a conclusion was made followed by the degree of consensus and the highest level of evidence. RESULTS: Twenty-one guidelines were included. The majority recommended that structured follow-up should be offered, except for patients in whom treatment of recurrence would be inappropriate. It was generally agreed that clinical visits, measurement of carcinoembryoinc antigen and liver imaging should be part of follow-up, based on a high level of evidence, although the frequency is controversial. There was also consensus on imaging of the chest and pelvis in rectal cancer, as well as endoscopy, based on lower levels of evidence and with a level of intensity that was contradictory. CONCLUSION: In available guidelines, multimodal follow-up after treatment with curative intent of colorectal cancer is widely recommended, but the exact content and intensity are highly controversial. International agreement on the optimal follow-up schedule is unlikely to be achieved on current evidence, and further research should refocus on individualized 'patient-driven' follow-up and new biomarkers.

Patient and healthcare professional perceptions of colostomy-related problems and their impact on quality of life following rectal cancer surgery.

BACKGROUND: The perception of colostomy-related problems and their impact on health-related quality of life (QoL) may differ between patients and healthcare professionals. The aim of this study was to investigate this using the Colostomy Impact Score (CIS) tool. METHODS: Healthcare professionals including consultant colorectal surgeons, stoma nurses, ward nurses, trainees and medical students were recruited. An online survey was designed. From the 17 items used to develop the CIS, participants chose the seven factors they thought to confer the strongest negative impact on the QoL of patients with a colostomy. They were then asked to rank the 12 responses made by patients to the final seven factors contained in the CIS. Results were compared with the original patient rankings at the time of development of the CIS. RESULTS: A total of 156 healthcare professionals (50·4 per cent of the pooled professionals) from 17 countries completed the survey. Of the original seven items in the CIS, six were above the threshold for random selection. Ranking the responses, a poor match between participants and the original score was detected for 49·7 per cent of the professionals. The most under-rated item originally present in the CIS was stool consistency, reported by 47 of the 156 professionals (30·1 per cent), whereas frequency of changing the stoma bag was the item not included in the CIS that was chosen most often by professionals (124, 79·5 per cent). Significant differences were not observed between different groups of professionals. CONCLUSION: The perspective of colostomy-related problems differs between patients with a colostomy and healthcare professionals.

The risk of long-term bowel dysfunction after resection for sigmoid adenocarcinoma: a cross-sectional survey comparing complete mesocolic excision with conventional surgery.

AIM: To investigate whether complete mesocolic excision (CME) might carry a higher risk of bowel dysfunction and subsequent reduction in quality of life compared with conventional resection. METHOD: A cross-sectional questionnaire study based on data from a national survey regarding long-term bowel function and a population-based cohort study comparing CME (study group) with conventional resection (control group). A total of 622 patients undergoing elective resection for Stage I-III sigmoid adenocarcinoma at four university colorectal centres between June 2008 and December 2014 were eligible to receive the questionnaire in mid-November 2015. Primary outcomes were four or more bowel movements daily, nocturnal bowel movements, unproductive call to stool, obstructive sensation and impact of bowel function on quality of life (QOL). RESULTS: One hundred and twenty-seven (69.0%) and 289 (66.0%) patients in the study and control groups, respectively, responded to the questionnaire after medians of 4.41 [interquartile range (IQR) 2.50, 5.83] and 4.57 (IQR 3.15, 5.82) years, respectively (P = 0.048). CME was not associated with: increased risk of four or more bowel movements daily [adjusted OR 1.14 (95% CI 0.59-2.14; P = 0.68)], nocturnal bowel movements [adjusted OR 1.31 (0.66-2.53; P = 0.43)], unproductive call to stool [adjusted OR 0.99 (0.54-1.77; P = 0.97)] or obstructive sensation [adjusted OR 1.01 (0.56-1.78; P = 0.96)]. While one in five patients in both groups had moderate to severe impact of bowel function on QOL, there was no association with CME. CONCLUSION: For patients with sigmoid cancer, CME is associated with neither higher risk of bowel dysfunction nor impaired QOL.

Session 1: Colon cancer - 10 years behind the rectum.

The improvements in surgical technique brought about by the widespread adoption of total mesorectal excision plane dissection in rectal cancer has substantially improved survival and recurrence rates from this disease. For the first time in 50 years, the outcomes in rectal cancer have overtaken those of colon cancer. Professor Madoff's overview lecture and the experts' round table discussion address whether applying the surgical principles already achieved in rectal cancer can meet with similar success in colon cancer, how this can be achieved and the challenges we face.

Session 1: The evolution and development of the multidisciplinary team approach: USA, European and UK experiences - what can we do better?

The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review was to agree the key elements of good quality preoperative treatment decision making.

The functional outcome of sacral nerve stimulation for faecal incontinence can be improved by using lead model 3889 and a standardized implantation technique.

AIM: Sacral nerve stimulation has been recognized as an effective treatment option for faecal incontinence when conservative therapy has failed. Refinement of the procedural technique and the use of a curved stylet may improve the functional outcome. Our aim was to explore the relationship between lead model, functional outcome, stimulation amplitude and the need for extra visits during the first year of follow-up. METHOD: Patient data from May 2009 to February 2017, which were prospectively collected in a local database, were extracted and analysed for differences between lead model and improvement in incontinence scores, stimulation amplitude and the need for additional visits during the first year of follow-up. RESULTS: A foramen lead model 3093(straight stylet) was used in 134 patients and lead model 3889(curved stylet) was used in 40 patients. There were no differences in baseline characteristics or incontinence scores. Comparing results between the two lead models we found that the improvement (delta value) in the Wexner score at 6 months' follow-up (P = 0.05) and the St Mark's score at 12 months' follow-up (P = 0.02) was greater in patients implanted with lead model 3889(curved stylet) compared with patients implanted with lead model 3093(straight stylet). Patients implanted with lead model 3889 (curved stylet) were less likely to have to alter the stimulation amplitude or pole configuration during the first year of follow-up (P = 0.04). No difference was found for stimulation amplitude (P = 0.170) or the need for additional visits (P = 0.663). CONCLUSION: Lead model 3889 (curved stylet) improves functional results compared with lead model 3093 (straight stylet) during the first year of follow-up. Lead model 3889 (curved stylet) reduces the need for reprogramming but has no influence on stimulation amplitude or the number of additional visits required.