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Patient reported outcomes refer to, "Any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else" (US Food and Drug Administration, 2009) [1]. These outcomes can include anything that matters to patients including quality of life, pain, number of bowel movements. Patient reported outcome measures refer to tools or instruments that help to measure these outcomes. These measures can be done using validated tools, those that have undergone rigorous testing and psychometric validation, and non-validated tools such as may exist in a practice to rate practice or physician/staff care quality. For this paper, we will discuss the role of patient reported outcomes measures in colon and rectal surgery.
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INTRODUCTION: Current understanding of bowel function after colectomy for colon cancer is informed by conflicting data, making preoperative patient counseling difficult. Our previous work demonstrates bowel movement frequency increases by postoperative follow-up, while overall function does not change. Long-term changes are unknown. We aimed to evaluate changes to patient-reported bowel function after colectomy for colon malignancy. METHODS: This is an observational study of patients that underwent colectomy for colon malignancy and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative and 30-d postoperative clinic visits. Long-term bowel function was assessed using the same questionnaire via telephone or surveillance clinic visit. Mean domain and Total COREFO scores were compared baseline to long-term using paired t-tests. Quality of life analysis was obtained using the Patient Reported Outcome Measurement Information System-10 Global Health questionnaire for patients who completed this measure at surveillance visits or via telephone. RESULTS: Sixty-six patients met inclusion criteria. Median time between baseline and long-term questionnaire completion was 16 mo (interquartile range 11-30). Stool-related aspects (pain and bleeding with bowel movements, anal skin irritation) improved significantly from baseline to long-term. There were no other differences in any domain or Total COREFO score. Patient Reported Outcome Measurement Information System-10 scores demonstrated quality of life equivalent to the general US population. CONCLUSIONS: Over the long-term, after colectomy for colon cancer, patients report improvements in stool-related aspects (pain and bleeding with bowel movements, anal skin irritation). Evidence-based preoperative patient counseling should include these findings.
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Neoplasias del Colon , Defecación , Humanos , Calidad de Vida , Resultado del Tratamiento , Neoplasias del Colon/cirugía , Colectomía/efectos adversos , Dolor , Colon/cirugíaRESUMEN
OBJECTIVES: The aim of this study was to determine the frequency and reasons for long-term opioid prescriptions (rxs) after surgery in the setting of guideline-directed prescribing and a high rate of excess opioid disposal. BACKGROUND: Although previous studies have demonstrated that 5% to 10% of opioid-naïve patients prescribed opioids after surgery will receive long-term (3-12 months after surgery) opioid rxs, little is known about the reasons why long-term opioids are prescribed. METHODS: We studied 221 opioid-naïve surgical patients enrolled in a previously reported prospective clinical trial which used a patient-centric guideline for discharge opioid prescribing and achieved a high rate of excess opioid disposal. Patients were treated on a wide variety of services; 88% of individuals underwent cancer-related surgery. Long-term opioid rxs were identified using a Prescription Drug Monitoring Program search and reasons for rxs and opioid adverse events were ascertained by medical record review. We used a consensus definition for persistent opioid use: opioid rx 3 to 12 months after surgery and >60day supply. RESULTS: 15.3% (34/221) filled an opioid rx 3 to 12 months after surgery, with 5.4% and 12.2% filling an rx 3 to 6 and 6 to 12 months after surgery, respectively. The median opioid rx days supply per patient was 7, interquartile range 5 to 27, range 1 to 447 days. The reasons for long-term opioid rxs were: 51% new painful medical condition, 40% new surgery, 6% related to the index operation; only 1 patient on 1 occasion was given an opioid rx for a nonspecific reason. Five patients (2.3%) developed persistent opioid use, 2 due to pain from recurrent cancer, 2 for new medical conditions, and 1 for a chronic abscess. CONCLUSIONS: In a group of prospectively studied opioid-naïve surgical patients discharged with guideline-directed opioid rxs and who achieved high rates of excess opioid disposal, no patients became persistent opioid users solely as a result of the opioid rx given after their index surgery. Long-term opioid use did occur for other, well-defined, medical or surgical reasons.
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Analgésicos Opioides , Trastornos Relacionados con Opioides , Humanos , Analgésicos Opioides/uso terapéutico , Estudios Prospectivos , Dolor Postoperatorio/tratamiento farmacológico , Prescripciones de Medicamentos , Pautas de la Práctica en Medicina , Estudios RetrospectivosRESUMEN
AIM: The aim of this work was to evaluate physicians' perceptions of ostomates' quality of life (QoL) and comfort of care among an international sample of physicians caring for ostomates. METHOD: This was a cross-sectional survey study. We conducted a survey of primary care physicians (PCP), gastroenterologists (GI), and general surgeons (GS) from three continents using the SERMO online physician platform. We piloted the survey for content, clarity and domain development using a pilot sample of physicians from each speciality before use. We summarized responses to questions related to physician comfort of ostomate care with descriptive statistics. We conducted multiple logistic regression with the primary outcome of physician perception of ostomate QoL. RESULTS: A total of 617 physicians (PCP 264, GI 176, GS 177) completed the survey representing North America, Europe and Australia similarly. The average age was 46 years and 21% were women. Ninety per cent of physicians care for an ostomate at least once per month. Eighty eight per cent had access to enterostomal nurses. Eighty two per cent of physicians believed that ostomates have decreased QoL. Forty seven per cent believed that ostomates have decreased overall health. Almost half of respondents answered incorrectly to a 'bogus question' citing fake clinical evidence supporting a negative impact of ostomies on social relationships. Increased physician comfort in ostomy care (OR 1.30, p = 0.04) and US-based physicians (OR 1.75, p = 0.01) were associated with increased odds of answering that ostomates have no decreased QoL. CONCLUSION: Among a diverse international sample, most physicians believe that ostomates have decreased QoL but not overall health. Physician implicit bias, physician comfort and geographical variability account for these findings. Targeted efforts to increase physician comfort in ostomate care and establish universal best practices is needed.
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Estomía , Médicos , Humanos , Femenino , Persona de Mediana Edad , Masculino , Calidad de Vida , Estudios Transversales , Encuestas y CuestionariosRESUMEN
BACKGROUND: Enhanced Recovery After Surgery protocols have demonstrated decreased complication rates and length of stay. However, the influence of mental health on Enhanced Recovery After Surgery success is unknown. METHOD: A retrospective study of patient-reported outcomes for physical and mental health. We included patients who underwent elective minimally invasive colon resections, who completed the Patient-Reported Outcomes Measurement Information System 10 questionnaire preoperatively, and who had successful implementation of perioperative Enhanced Recovery After Surgery components. We evaluated the predictors of having successful expected Enhanced Recovery After Surgery outcomes using a multiple logistic regression, controlling for baseline patient characteristics, history of a mental health diagnosis, inpatient opiate use, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores. RESULTS: In total, 163 patients met inclusion criteria, with 23% failing Enhanced Recovery After Surgery, and 32% having a preoperative mental health diagnosis. The most common reason for failure of expected Enhanced Recovery After Surgery outcomes was length of stay (55.3%) followed by postoperative ileus (31.6%). Age, sex, the American Society of Anesthesiologists physical status classification, and preoperative Patient-Reported Outcomes Measurement Information System 10 scores were not significantly different between those who failed or succeeded, whereas length of stay was typically longer for those who failed Enhanced Recovery After Surgery (5.7 days failure vs 2.2 days success, P < .001). Patients with a previous mental health diagnosis, where depression and anxiety were most common, had significantly lower odds of successfully meeting expected Enhanced Recovery After Surgery outcomes (odds ratio of 0.23, 95% confidence interval: 0.09-0.55, P = .001). CONCLUSION: Patients with a mental health diagnosis have a lower likelihood of successfully meeting expected Enhanced Recovery After Surgery outcomes. The majority of these patients self-report normal mental and physical health preoperatively, indicating that even well-controlled mental health diagnoses have a negative impact on Enhanced Recovery After Surgery success.
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Recuperación Mejorada Después de la Cirugía , Colon , Humanos , Tiempo de Internación , Salud Mental , Medición de Resultados Informados por el Paciente , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Estudios RetrospectivosRESUMEN
BACKGROUND: Postoperative bowel function is a common concern for patients undergoing a sigmoidectomy. We have previously demonstrated that patients with symptomatic bowel function preoperatively have substantial improvement at long-term follow-up. However, the effect of the operative approach on patient-reported bowel function is largely unknown. We aimed to evaluate the differences in long-term patient-reported bowel function after robotic or laparoscopic sigmoid colectomies for benign and malignant disease. MATERIALS AND METHODS: A retrospective analysis of a prospectively collected institutional database from July 2015 to July 2020. Patients included underwent a sigmoid colectomy for benign or malignant disease and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation, postoperatively, and long-term follow-up. Differences between preoperative and postoperative scores, as well as differences between the robotic and laparoscopic cohorts, were compared using paired t-tests. RESULTS: A total of 169 patients met inclusion criteria with a median age of 61 y, and 55% of the patients underwent robotic sigmoid colectomy, with the most common diagnosis being diverticular disease (62%). There was no significant difference between the presentation, short-term, or long-term follow-up total COREFO scores or subdomains based on the surgical technique. Patients that present asymptomatic remain asymptomatic, while those that are symptomatic demonstrate improvements for both the robotic and laparoscopic groups. CONCLUSIONS: Patient-reported long-term global bowel function does not appear to differ between patients who underwent elective robotic or laparoscopic sigmoid colectomy for benign or malignant disease. Patients that present asymptomatic remain asymptomatic, while those that are symptomatic demonstrate improvements, regardless of surgical technique.
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Laparoscopía , Procedimientos Quirúrgicos Robotizados , Colectomía/métodos , Colon Sigmoide/cirugía , Humanos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Medición de Resultados Informados por el Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Resultado del TratamientoRESUMEN
OBJECTIVE: To assess the current barriers in robotic surgery training for general surgery residents. DESIGN: Multi-institutional web-based survey. SETTING: 9 academic medical centers with a general surgery residency. PARTICIPANTS: General surgery residents of at least PGY-3 training level. RESULTS: 163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console. CONCLUSIONS: General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.
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Cirugía General , Internado y Residencia , Procedimientos Quirúrgicos Robotizados , Robótica , Competencia Clínica , Curriculum , Educación de Postgrado en Medicina , Cirugía General/educación , Humanos , Procedimientos Quirúrgicos Robotizados/educación , Robótica/educaciónRESUMEN
CASE SUMMARY: A 59-year-old previously healthy, asymptomatic man initially presented for his first screening colonoscopy. At this time, a friable, partially obstructing tumor was encountered in his proximal rectum. Final workup demonstrated a mrT2N1M0 upper rectal cancer. The patient went on to successfully complete total neoadjuvant chemoradiation therapy and was taken to the operating room for an uncomplicated robotic-assisted low anterior resection with primary anastomosis. His final pathology revealed an ypT2N1M0 rectal cancer, and he was subsequently followed in surveillance per National Comprehensive Cancer Network guidelines. At long-term follow-up visits he continued to report significant depressive symptoms and functional impairment. Despite aggressive medical management with fiber supplementation and antidiarrheal medications, the patient continued to struggle with bowel movement frequency and urgency. He reported having 4 to 6 clustered bowel movements during the day and 1 to 2 stools at night that significantly limited his ability to perform normal day-to-day activities.
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Supervivientes de Cáncer/psicología , Proctectomía/efectos adversos , Neoplasias del Recto/cirugía , Procedimientos Quirúrgicos Robotizados/instrumentación , Cuidados Posteriores , Anastomosis Quirúrgica , Colonoscopía/normas , Humanos , Masculino , Persona de Mediana Edad , Terapia Neoadyuvante/métodos , Estadificación de Neoplasias , Proctectomía/métodos , Calidad de Vida/psicología , Neoplasias del Recto/tratamiento farmacológico , Neoplasias del Recto/patología , Neoplasias del Recto/radioterapiaRESUMEN
OBJECTIVE: To (1) characterise (A) the lived experiences and (B) information needs of patients with rectal cancer; and (2) compare to the perceived lived experiences and information needs of colorectal surgeons. DESIGN: We conducted 1-hour semistructured qualitative interviews, dual independent transcript coding and thematic analysis. SETTING/PARTICIPANTS: Interviews included rectal cancer survivors (stages I-III), some accompanied by caregivers, at Dartmouth-Hitchcock Medical Center and experienced colorectal surgeons. RESULTS: We performed 25 interviews involving 30 participants, including 15 patients with 5 caregivers, plus 10 physicians. Two major themes emerged. First, patients reported major impacts on their lives following rectal cancer, including on their everyday lives and leisure activities; identity, self-confidence and intimacy; mental health, especially anxiety. These impacts were mediated by their medical experiences, lifestyle and attitudes. Second, the diversity of effects on patients' lives means that care, counselling and information needs should be personalised for a better medical experience and outcomes. Surgeons did not report knowledge of the full range of patient experiences and reported limited counselling in key areas, particularly concerning intimacy and mental health. CONCLUSION: Rectal cancer diagnosis, treatment and survivorship dramatically affect all people, regardless of which surgical treatment they undergo. Effects are varied and necessitate customised care, counselling and information, which surgeons are not currently providing. Because rectal cancer affects every part of patients' lives, they need holistic support and information. Patients would benefit from substantial support after treatment as they establish a new normal.
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Supervivientes de Cáncer , Neoplasias del Recto , Cuidadores , Humanos , Investigación Cualitativa , Neoplasias del Recto/terapia , SobrevivientesRESUMEN
Purpose. The primary aim of the study was to review the existing literature about patient-reported outcome measures (PROMs) in colorectal cancer and IBD. The secondary aim was to present a road map to develop a core outcome set via opinion gathering using social media. Method. This study is the first step of a three-step project aimed at constructing simple, applicable PROMs in colorectal surgery. This article was written in a collaborative manner with authors invited both through Twitter via the #OpenSourceResearch hashtag. The 5 most used PROMs were presented and discussed as slides/images on Twitter. Inputs from a wide spectrum of participants including researchers, surgeons, physicians, nurses, patients, and patients' organizations were collected and analyzed. The final draft was emailed to all contributors and 6 patients' representatives for proofreading and approval. Results. Five PROM sets were identified and discussed: EORTC QLQ-CR29, IBDQ short health questionnaire, EORTC QLQ-C30, ED-Q5-5L, and Short Form-36. There were 315 tweets posted by 50 tweeters with 1458 retweets. Awareness about PROMs was generally limited. The general psycho-physical well-being score (GPP) was suggested and discussed, and then a survey was conducted in which more than 2/3 of voters agreed that GPP covers the most important aspects in PROMs. Conclusion. Despite the limitations of this exploratory study, it offered a new method to conduct clinical research with opportunity to engage patients. The general psycho-physical well-being score suggested as simple, applicable PROMs to be eventually combined procedure-specific, disease-specific, or symptom-specific PROMs if needed.
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Cirugía Colorrectal , Humanos , Medición de Resultados Informados por el Paciente , Calidad de Vida , Encuestas y CuestionariosRESUMEN
BACKGROUND: Patients often desire restorative reconstruction following total mesorectal excision. Reconstruction has become synonymous with providing high-quality rectal cancer care. However, the bowel functional outcomes of restoration from presentation are unknown. We aimed to evaluate the bowel functional effects of rectal cancer treatment from presentation through surveillance. METHODS: This was a retrospective cohort study from 2014 to 2019 using prospectively collected data. Patients underwent treatment for rectal adenocarcinoma including restorative reconstruction. Patients completed the validated Colorectal Functional Outcome questionnaire during clinic visits (1) at presentation, (2) after neoadjuvant therapy, (3) after restoration of continuity, and (4) at surveillance. Scores range from 0 to 100 with a higher score indicating worse bowel function. RESULTS: Sixty-eight patients (age: 62⯱â¯12â¯years, 40% female) were included. The mean tumor height was 7⯱â¯4â¯cm with 85% symptomatic. Bowel function did not worsen from presentation to after neoadjuvant therapy in Total Colorectal Functional Outcome and most domain scores; there was improvement in frequency and stool-related aspects. Bowel function worsened in all scores from after neoadjuvant to restoration of continuity (mean anastomotic height: 5⯱â¯2â¯cm); there were similar findings between presentation and restoration of continuity. At surveillance, there was improvement in most domains compared with restoration of continuity. There remained significant worsening of incontinence, social impact, and need for medication scores at surveillance compared with presentation. CONCLUSION: Restorative reconstruction after total mesorectal excision is associated with significant bowel dysfunction. For some patients, restorative reconstruction may not be high-quality rectal cancer care.
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BACKGROUND: To optimize responsible opioid prescribing after inpatient operation, we implemented a clinical trial with the following objectives: prospectively validate patient-centered opioid prescription guidelines and increase the FDA-compliant disposal rate of leftover opioid pills to higher than currently reported rates of 20% to 30%. STUDY DESIGN: We prospectively enrolled 229 patients admitted for 48 hours or longer after elective general, colorectal, urologic, gynecologic, or thoracic operation. At discharge, patients received a prescription for both nonopioid analgesics and opioids based on their opioid usage the day before discharge: if 0 oral morphine milligram equivalents (MME) were used, then five 5-mg oxycodone pill-equivalents were prescribed; if 1 to 29 MME were used, then fifteen 5-mg oxycodone pill-equivalents were prescribed; if 30 or more MME were used, then thirty 5-mg oxycodone pill-equivalents were prescribed. We considered patients' opioid pain medication needs to be satisfied if no opioid refills were obtained. To improve FDA-compliant disposal of leftover pills, we implemented patient education, convenient drop-box, reminder phone call, and questionnaire. RESULTS: Our opioid guideline satisfied 93% (213 of 229) of patients. Satisfaction was significantly higher in lower opioid usage groups (p = 0.001): 99% (99 of 100) in the 0 MME group, 90% (91 of 101) in the 1 to 29 MME group, and 82% (23 of 28) in the 30 or more MME group. Overall, 95% (217 of 229) of patients used nonopioid analgesics. Sixty percent (138 of 229) had leftover pills; 83% (114 of 138) disposed of them using an FDA-compliant method and 51% (58 of 114) used the convenient drop-box. Of 2,604 prescribed pills, only 187 (7%) were kept by patients. CONCLUSIONS: This clinical trial prospectively validated a patient-centered opioid discharge prescription guideline that satisfied 93% of patients. FDA-compliant disposal of excess pills was achieved in 83% of patients with easily actionable interventions.
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Analgésicos Opioides/uso terapéutico , Eliminación de Residuos Sanitarios/normas , Dolor Postoperatorio/tratamiento farmacológico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Femenino , Guías como Asunto , Humanos , Masculino , Persona de Mediana Edad , Alta del Paciente , Satisfacción del Paciente , Estudios Prospectivos , Procedimientos Quirúrgicos Operativos , Encuestas y Cuestionarios , Estados Unidos , United States Food and Drug AdministrationRESUMEN
AIM: We aimed to evaluate long-term changes in patient-reported bowel function from presentation of anal canal squamous cell carcinoma (SCC) successfully treated with the modified Nigro protocol using a patient-reported outcome measure for bowel function. METHOD: This is a retrospective study of prospectively collected patient-reported outcomes for bowel function. We included patients that were successfully treated with the modified Nigro protocol for anal SCC and had completed the Colorectal Functional Outcomes (COREFO) questionnaire at presentation, following the modified Nigro treatment (post-Nigro), and at subsequent surveillance visits (medium and long term). We compared the differences in mean domain and total COREFO scores using a paired t test for each paired time point. RESULTS: Twenty-seven patients met inclusion criteria. Time from completion of the modified Nigro was post-Nigro at 3-6 months, medium-length follow-up at 8-12 months and long-term follow-up at 12-18 months. There was significant improvement in the stool-related aspects domain (pain, bleeding and anal skin irritation) from presentation to our short- and medium-length follow-up (42.5 to 23.7, P = 0.01). There was worsening in the frequency domain in the medium term (7.23 to 14.5, P = 0.02). There were no differences in any other domain or time point. CONCLUSION: Global bowel function does not appear to change following successful treatment of anal canal SCC with the modified Nigro protocol in the long term. There are some improvements in stool-related aspects and worsening in bowel movement frequency at medium-length follow-up. These findings should help surgeons counsel patients with regard to bowel function expectations for those with anal canal SCC in the long term.
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Neoplasias del Ano , Carcinoma de Células Escamosas , Canal Anal , Neoplasias del Ano/terapia , Carcinoma de Células Escamosas/terapia , Humanos , Medición de Resultados Informados por el Paciente , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Background: Many patients with inflammatory bowel disease (IBD) are referred to surgeons when medical treatments are ineffective, signifying poor disease control. We aimed to assess the association of IBD diagnosis with physical and mental health upon presentation to a colorectal surgeon. Methods: We included all new patients presenting to colorectal surgery clinic over 1.5 years. During registration, patients completed the PROMIS Global-10, a validated outcome measure assessing physical and mental health. We grouped patients by diagnosis: IBD, anorectal, benign colorectal, and malignancy. Details on IBD patients were obtained via chart review. We evaluated the interaction between PROMIS scores and diagnosis through ANOVA analysis and post hoc Tukey-Kramer pairwise comparison. We estimated the strength of association of age, sex, and visit diagnosis with poor physical and mental health (PROMIS: -1 SD) through logistic regression. Results: Eight hundred ninety-seven patients were included. The cohort was as follows: IBD (99) (Crohn = 73; ulcerative colitis = 26), anorectal (378), benign colorectal (224), and malignancy (196). The mean age of patients was 56 (±17) years. Fifty-seven percent were female. The IBD group was youngest (P < 0.001). IBD had significantly lower PROMIS scores on pairwise comparison; anorectal had the highest scores. Controlling for age and sex, the IBD group had 4.1× odds of poor physical health (95% confidence interval 2.46-6.76) and 2.9× odds of poor mental health (95% confidence interval 1.66-5.00). Conclusions: Patients with IBD, specifically Crohn disease, have worse physical and mental health on presentation to a colorectal surgeon compared to patients presenting with other colorectal diagnoses. These patients considering surgery might benefit from added support during the perioperative period.
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Objective: To evaluate long-term changes to bowel function after elective sigmoidectomy for diverticular disease. Background: For patients with diverticular disease, choosing surgery is often based on the presumption of improvement in preoperative symptoms. Our group previously reported bowel function does not change in the early perioperative period; however, studies of long-term outcomes are limited. Methods: This is an observational study of patients that underwent elective sigmoidectomy for diverticular disease and completed the Colorectal Functional Outcome (COREFO) questionnaire before surgery. Patients were stratified into two groups based on presence or absence of a preoperative symptomatic score (i.e., total COREFO ≥ 15). Long-term bowel function (>1 year from surgery) was assessed using the COREFO questionnaire via telephone or subsequent clinic visit. Paired t-tests compared mean preoperative scores to mean long-term scores. Results: Fifty-one patients met inclusion criteria (21 symptomatic, 30 asymptomatic). All symptomatic patients had uncomplicated disease, whereas 90% of asymptomatic patients had complicated disease. Median time from operation to questionnaire completion was 23 months (IQR = 13-34). Asymptomatic patients demonstrated impaired bowel function, predominantly driven by changes in the social impact domain. Symptomatic patients demonstrated improved bowel function, driven by changes in the incontinence, social impact, stool-related aspects, and need for medication domains. Conclusions: In the long-term after elective sigmoidectomy for diverticular disease, patients with symptomatic bowel function preoperatively improve substantially, while those with asymptomatic preoperative scores demonstrate statistically significant impairment. Patients determined to be symptomatic with patient-reported outcomes likely benefit long-term from sigmoid resection.Mini-Abstract: In this manuscript, long-term changes to patient-reported bowel function were assessed using a validated questionnaire after sigmoidectomy for diverticular disease. We found that in patients with symptomatic preoperative bowel function, long-term bowel function improved after elective resection. Alternatively, patients with asymptomatic preoperative bowel function demonstrated long-term impairment in bowel function.
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BACKGROUND: Colon cancer patients often ask how surgery will affect bowel function. Current understanding is informed by conflicting data, making preoperative patient counseling difficult. We aimed to evaluate patient-reported bowel function changes after colectomy for colon malignancy. MATERIAL AND METHODS: This was a retrospective analysis of a prospectively collected institutional database from July 2015 to June 2019. The included patients underwent colectomy for adenocarcinoma of the colon, and completed the Colorectal Functional Outcome (COREFO) questionnaire at preoperative presentation and postoperative followup. Preoperative and postoperative scores were compared using paired t-tests. Multivariable analysis was performed using domains demonstrating statistical significance on bivariate analysis, assessing the factors that were associated with symptomatic bowel function. RESULTS: We identified 117 patients with a mean age of 64 ± 13 y. The median time between preoperative and postoperative questionnaire completion was 52 d (interquartile range 45-70). Bowel movement frequency increased significantly from a mean preoperative score of 9.72 to a mean postoperative score of 14.2 (P = 0.003). There were no significant differences in the remaining four domains of bowel function or global function. Multivariable analysis demonstrated higher likelihood of symptomatic postoperative frequency scores in male patients (OR 3.85, 95% CI 1.44-11.11, P = 0.007) and patients with symptomatic preoperative frequency (OR 5.56, 95% CI 1.62-19.02, P = 0.006). CONCLUSIONS: Patient-reported bowel movement frequency worsens at postoperative follow-up after colectomy for colon cancer, while overall bowel function does not change. Men and patients with preoperative symptomatic frequency have an increased likelihood of reporting symptomatic postoperative frequency. These findings should guide more personalized and evidence-based preoperative patient counseling.
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Adenocarcinoma/cirugía , Colectomía/rehabilitación , Neoplasias del Colon/cirugía , Anciano , Colon/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
A quality metric for centers performing rectal cancer surgery is a high percentage of sphincter sparing procedures. These procedures often involve temporary bowel diversion to minimize the complications of an anastomotic leak. The most common strategy is a diverting loop ileostomy which is then closed after completion of adjuvant therapy or the patient recovers from surgery. Loop ileostomy is not without complications and the closure is complicated by a one in three chance of incisional hernia development. Strategies to prevent this problem have been designed using a variety of techniques with and without mesh placement. This proposed pilot study will test the safety and efficacy of a novel stoma closure technique involving permanent mesh in the retro rectus position during ileostomy closure. The study will prospectively follow 20 patients undergoing ileostomy closure using this technique and evaluate for safety of the procedure, quality of life, and feasibility for a larger randomized controlled trial. Patients will be followed post procedurally and evaluated for 30-day complications, as well as followed up with routine cancer surveillance computed tomography every 6 months in which the presence of stoma site incisional hernias will be evaluated. The results of this pilot study will inform the design of a multiple center, blinded randomized controlled trial to evaluate the utility of permanent mesh placement to decrease the incidence of prior stoma site incisional hernias.