The Effect of a Temporary Stoma on Long-term Functional Outcomes Following Surgery for Rectal Cancer.

BACKGROUND: Patients with rectal cancer may undergo surgical resection with or without a temporary stoma. OBJECTIVE: This study primarily aimed to compare long-term functional outcomes between patients with and without a temporary stoma after surgery for rectal cancer. The secondary aim was to investigate the effect of time to stoma reversal on functional outcomes. DESIGN: This was a multicenter, cross-sectional study. SETTINGS: This study was conducted at 7 Dutch hospitals. PATIENTS: Included were patients who had undergone rectal cancer surgery (2009-2015). Excluded were deceased patients, who were deceased, had a permanent stoma, or had intellectual disability. MAIN OUTCOME MEASURES: Functional outcomes were measured using the Rome IV criteria for constipation and fecal incontinence and the low anterior resection syndrome score. RESULTS: Of 656 patients, 32% received a temporary ileostomy and 20% a temporary colostomy (86% response). Follow-up was at 56 (interquartile range, 38.5-79) months. Patients who had a temporary ileostomy experienced less constipation, more fecal incontinence, and more major low anterior resection syndrome than those without a temporary stoma. Patients who had a temporary colostomy experienced more major low anterior resection syndrome than those without a temporary stoma. A temporary ileostomy or colostomy was not associated with constipation or fecal incontinence after correction for confounding factors (eg, anastomotic height, anastomotic leakage, radiotherapy). Time to stoma reversal was not associated with constipation, fecal incontinence, or major low anterior resection syndrome. LIMITATIONS: Cross-sectional design. CONCLUSIONS: Although patients with a temporary ileostomy or colostomy have worse functional outcomes in the long term, it seems that the reason for creating a temporary stoma, rather than the stoma itself, underlies this phenomenon. Time to reversal of a temporary stoma does not influence functional outcomes. See Video Abstract . EL EFECTO DEL ESTOMA TEMPORAL SOBRE LOS RESULTADOS FUNCIONALES A LARGO PLAZO DESPUS DE LA CIRUGA POR CNCER DE RECTO: ANTECEDENTES:Los pacientes con cáncer de recto pueden someterse a resección quirúrgica con o sin un estoma temporal.OBJETIVO:El objetivo principal de este estudio fue comparar los resultados funcionales a largo plazo entre pacientes con y sin estoma temporal después de cirugía por cáncer de recto. El objetivo secundario fue investigar el efecto del tiempo transcurrido hasta la reversión del estoma sobre los resultados funcionales.DISEÑO:Este fue un estudio transversal multicéntrico.ESCENARIO:Este estudio se llevó a cabo en siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a cirugía de cáncer de recto (2009-2015). Se excluyeron pacientes fallecidos, pacientes con estoma permanente o discapacidad intelectual.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados funcionales se midieron utilizando los criterios de Roma IV para el estreñimiento y la incontinencia fecal y la puntuación del síndrome de resección anterior baja (LARS).RESULTADOS:De 656 pacientes, el 32% recibió una ileostomía temporal y el 20% una colostomía temporal (respuesta del 86%). El seguimiento fue de 56.0 (RIQ 38.5-79.0) meses. Los pacientes a los que se les realizó una ileostomía temporal experimentaron menos estreñimiento, más incontinencia fecal y más LARS mayor que los pacientes sin un estoma temporal. Los pacientes que tuvieron una colostomía temporal experimentaron más LARS mayor que los pacientes sin un estoma temporal. Una ileostomía o colostomía temporal no se asoció con estreñimiento o incontinencia fecal después de la corrección de factores de confusión (p. ej., altura anastomótica, fuga anastomótica, radioterapia). El tiempo hasta la reversión del estoma no se asoció con estreñimiento, incontinencia fecal o LARS mayor.LIMITACIONES:El presente estudio está limitado por su diseño transversal.CONCLUSIONES:Aunque los pacientes con una ileostomía o colostomía temporal tienen peores resultados funcionales a largo plazo, parece que la razón para crear un estoma temporal, más que el estoma en sí, se asocia a este fenómeno. El tiempo hasta la reversión de un estoma temporal no influye en los resultados funcionales. (Traducción-Dr. Jorge Silva Velazco ).

Phenolization of the sinus tract in recurrent sacrococcygeal pilonidal sinus disease: long-term results of a prospective cohort study.

AIM: In recent years, the paradigm for the treatment of sacrococcygeal pilonidal sinus disease (SPSD) has shifted from surgical excision toward more minimally invasive techniques. Although extensive research has been conducted on the minimal invasive phenolization technique for primary SPSD, literature in recurrent SPSD is lacking. The purpose of this study was to report the long-term outcomes of the phenolization technique for recurrent SPSD. METHOD: This study included all 57 patients who were initially prospectively included in this study for short-term follow-up after phenolization for recurrent SPSD. A questionnaire was sent out to all patients to obtain long-term outcome. The primary endpoint was recurrence. Secondary endpoints included quality of life and symptoms related to SPSD. RESULTS: A total of 47 patients (82.5%) were available for long-term follow-up. Recurrence needing further surgery developed in 7 patients (14.9%) after a mean follow-up of 76 (SD 21.7) months. At follow-up, there was improvement in the quality of life compared to preoperative levels (82.0, IQR 75.0-90.0 versus 74.0 IQR 52.5-80.0, p = 0.024). Additionally, symptoms associated with SPSD, including pain, fluid discharge, and itching sensation, also showed significant improvement. A total of 42 patients (89.4%) would undergo the same treatment again. No significant association was found between known risk factors and recurrence. CONCLUSION: Phenolization for recurrent SPSD showed a recurrence rate of 14.9% with significant improvement of natal cleft symptoms and quality of life at long-term follow-up. Therefore, phenolization should be considered as a feasible option for patients with recurrent SPSD.

Evaluation of National Surgical Practice for Lateral Lymph Nodes in Rectal Cancer in an Untrained Setting.

BACKGROUND: Involved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level. METHODS: Patients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either 'node-picking' (the removal of an individual LLN) or 'partial regional node dissection' (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those  undergoing only rectal resection. RESULTS: Out of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7-3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2-2.5, p = 0.874). CONCLUSION: Evaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.

Anastomotic Height Is a Valuable Indicator of Long-term Bowel Function Following Surgery for Rectal Cancer.

BACKGROUND: The exact relation between anastomotic height after rectal cancer surgery and postoperative bowel function problems has not been investigated in the long term, resulting in ineffective treatment. OBJECTIVE: The goal of this study was to determine the effect of anastomotic height on long-term bowel function and generic quality of life. DESIGN: This was a multicenter, cross-sectional study. SETTINGS: Seven hospitals in the north of the Netherlands participated. PATIENTS: All patients who underwent rectal cancer surgery between 2009 and 2015 in participating hospitals received the validated Defecation and Fecal Continence and Short-Form 36 questionnaires. Deceased patients, patients with a permanent stoma or an anastomosis >15 cm from the anal verge, patients with intellectual disability, and patients living abroad were excluded. MAIN OUTCOME MEASURES: Primary outcomes were constipation (Rome IV), fecal incontinence (Rome IV), and major low anterior resection syndrome. Secondary outcomes were the generic quality of life scores. RESULTS: The study population ( n = 630) had a median follow-up of 58.0 months. In multivariable analysis, constipation (OR = 1.08; 95% CI, 1.02-1.15; p = 0.011), fecal incontinence (OR = 0.91; 95% CI, 0.84-0.97; p = 0.006), and major low anterior resection syndrome (OR = 0.93; 95% CI, 0.87-0.99; p = 0.027), were significantly associated with anastomotic height. The curves illustrating the probability of constipation and fecal incontinence crossed at an anastomotic height of 7 cm, with 95% CIs overlapping between 4.5 and 9.5 cm. There was no relation between quality-of-life scores and anastomotic height. LIMITATIONS: The study is limited by its cross-sectional design. CONCLUSIONS: This study might serve as a guide for the clinician to effectively screen and treat fecal incontinence and constipation during patient follow-up after rectal cancer surgery. More attention should be paid to fecal incontinence in patients with an anastomosis below 4.5 cm and toward constipation in patients with an anastomosis above 9.5 cm. See Video Abstract at http://links.lww.com/DCR/B858 . LA ALTURA ANASTOMTICA ES UN INDICADOR VALIOSO DE LA FUNCIN INTESTINAL A LARGO PLAZO DESPUS DE LA CIRUGA PARA EL CNCER DE RECTO: ANTECEDENTES:La relación exacta entre la altura anastomótica después de la cirugía de cáncer de recto y los problemas posoperatorios de la función intestinal no se ha investigado a largo plazo, lo que causa un tratamiento ineficaz.OBJETIVO:Determinar el efecto de la altura anastomótica sobre la función intestinal a largo plazo y la calidad de vida genérica.DISEÑO:Estudio multicéntrico transversal.DISEÑO DEL ESTUDIO:Participaron siete hospitales holandeses en el norte de los Países Bajos.PACIENTES:Todos los pacientes que se sometieron a cirugía de cáncer de recto entre 2009 y 2015 en los hospitales participantes recibieron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36. Se excluyeron pacientes fallecidos, pacientes con estoma permanente o anastomosis > 15 cm del borde anal, discapacidad intelectual o residentes en el extranjero.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron estreñimiento (Roma IV), incontinencia fecal (Roma IV) y síndrome de resección anterior baja mayor. Los resultados secundarios fueron las puntuaciones genéricas de calidad de vida.RESULTADOS:La población de estudio (N = 630) tuvo una mediana de seguimiento de 58.0 meses. En el análisis multivariable el estreñimiento (OR = 1,08, IC del 95%, 1,02-1,15, p = 0,011), incontinencia fecal (OR = 0,91, IC del 95%, 0,84-0,97, p = 0,006) y síndrome de resección anterior baja mayor (OR = 0,93, IC del 95%, 0,87-0,99, p = 0,027) se asociaron significativamente con la altura anastomótica. Las curvas que ilustran la probabilidad de estreñimiento e incontinencia fecal se cruzaron a una altura anastomótica de 7 cm, con IC del 95% superpuestos entre 4,5 y 9,5 cm. No hubo relación entre las puntuaciones de calidad de vida y la altura anastomótica.LIMITACIONES:El estudio está limitado por su diseño transversal.CONCLUSIONES:Este estudio podría servir como una guía para que el médico evalúe y trate eficazmente la incontinencia fecal y el estreñimiento durante el seguimiento de los pacientes después de la cirugía de cáncer de recto. Se debe prestar más atención a la incontinencia fecal en pacientes con anastomosis por debajo de 4,5 cm y al estreñimiento en pacientes con anastomosis por encima de 9,5 cm. Consulte Video Resumen en http://links.lww.com/DCR/B858 . (Traducción-Dr. Yazmin Berrones-Medina ).

Comparison of functional and oncological outcome of conformal sphincter preservation operation, low anterior resection, and abdominoperineal resection in very low rectal cancer: a retrospective comparative cohort study with propensity score matching.

PURPOSE: Conformal sphincter preservation operation (CSPO) procedure is a sphincter preservation procedure for preserving the anal canal function for very low rectal cancers. This study investigated the functional and oncological outcome of conformal sphincter preservation operation by comparing with low anterior resection (LAR) and abdominoperineal resection (APR). METHODS: This is a retrospective comparative study. Patients who received conformal sphincter preservation operation (n = 52), low anterior resection (n = 54), or abdominoperineal resection (n = 69) were included between 2011 and 2016 in a tertiary referral hospital. Propensity score matching was applied to adjust the baseline characteristics which may influence the choice of the surgical procedure. RESULTS: Twenty-one pairs of conformal sphincter preservation operation vs. low anterior resection and 29 pairs of conformal sphincter preservation operation vs. abdominoperineal resection were selected. The first group had a higher tumor location than the second group. Compared with the low anterior resection group, the conformal sphincter preservation operation group had shorter distal resection margins; however, no significant differences were identified in daily stool frequency, Wexner incontinence score, local recurrence, distant metastasis, overall survival, and disease-free survival between both groups. Compared with the abdominoperineal resection group, the conformal sphincter preservation operation group had shorter operative time and shorter postoperative hospital stay. No significant differences were identified in local recurrence, distant metastasis, overall survival, and disease-free survival. CONCLUSION: Conformal sphincter preservation operation is oncologically safe compared to APR and LAR, and has similar functional findings to LAR. Studies comparing CSPO with intersphincteric resection should be performed.

Long-term Outcome of Radical Excision Versus Phenolization of the Sinus Tract in Primary Sacrococcygeal Pilonidal Sinus Disease: A Randomized Controlled Trial.

BACKGROUND: Phenolization of pilonidal sinus disease has been shown to have advantages over radical excision with regard to short-term outcome; however, long-term outcomes are essentially lacking. OBJECTIVE: The aim of this randomized controlled trial was to compare the long-term outcome of pit excision and phenolization of the sinus tracts vs radical excision with primary wound closure in pilonidal sinus disease. DESIGN: Single-center, randomized controlled trial. SETTINGS: A primary teaching hospital in the Netherlands. PATIENTS: The study population included patients with primary pilonidal sinus disease presented between 2013 and 2017. INTERVENTIONS: Patients were randomly assigned to either pit excision with phenolization of the sinus tract(s) or excision with primary off-midline wound closure. MAIN OUTCOME MEASURES: The main outcomes included recurrence, quality of life (Short-Form 36), and patient's satisfaction. RESULTS: A total of 100 patients were randomized. Seventy-four patients (77.1%) were available for long-term follow-up. The mean (±SD) time to follow-up was 48.4 (±12.8) months for the phenolization group and 47.8 (±13.5) months for the excision group. No significant difference was found between both groups regarding quality of life. Two patients in the phenolization group (5.6%) and 1 in the excision group (2.6%) developed a recurrence ( p = 0.604). The impact of the whole treatment was significantly less after phenolization ( p = 0.010). LIMITATIONS: The response rate was almost 80% in this young patient population, patients and assessors were not blinded for the type of surgery, and the results are only applicable to primary pilonidal sinus disease. CONCLUSIONS: Because of the previously shown favorable short-term results and the currently reported comparable long-term recurrence rate and quality of life between phenolization and excision, phenolization should be considered the primary treatment option in patients with pilonidal sinus disease. See Video Abstract at http://links.lww.com/DCR/C27 . DUTCH TRIAL REGISTER ID: NTR4043. RESULTADO A LARGO PLAZO DE LA ESCISIN RADICAL FRENTE AL TRATAMIENTO CON FENOL DEL TRACTO SINUSAL EN LA ENFERMEDAD DEL SENO PILONIDAL SACRO COCCGEO PRIMARIO UN ENSAYO ALEATORIO CONTROLADO: ANTECEDENTES:El tratamiento con fenol de la enfermedad del seno pilonidal ha demostrado tener ventajas sobre la escisión radical con respecto al resultado a corto plazo; sin embargo, los resultados a largo plazo aún se encuentran escasos.OBJETIVO:El objetivo de este ensayo aleatorio controlado fue comparar el resultado a largo plazo de la escisión de la fosa del quiste y el tratamiento con fenol de los trayectos sinusales frente a la escisión radical con cierre primario de la herida en la enfermedad del seno pilonidal.DISEÑO:Ensayo aleatorio controlado de un solo centro.AJUSTES:Hospital de enseñanza primaria en los Países Bajos.PACIENTES:Pacientes con enfermedad primaria del seno pilonidal presentados entre 2013 y 2017.INTERVENCIONES:Los pacientes fueron asignados de manera aleatoria a la escisión de la fosa del quiste y posterior administración de fenol de los tractos sinusales o a la escisión con cierre primario de la herida fuera de la línea media.PRINCIPALES MEDIDAS DE RESULTADO:Recurrencia, calidad de vida (Short-Form 36) y satisfacción del paciente.RESULTADOS:Un total de 100 pacientes con enfermedad primaria del seno pilonidal fueron aleatorizados; 50 pacientes fueron sometidos al tratamiento con fenol y 50 a la escisión radical. Eventualmente, 74 pacientes (77,1%) estuvieron disponibles para seguimiento a largo plazo; 36 pacientes después del uso del fenol y 38 después de la escisión. El tiempo medio (± desviación estándar) de seguimiento fue de 48,4 (± 12,8) y 47,8 (± 13,5) meses, respectivamente. No hubo diferencia significativa entre ambos grupos con respecto a la calidad de vida. En el grupo tratado con fenal, dos pacientes (5,6%) desarrollaron recurrencia y un paciente (2,6%) en el grupo de escisión ( p = 0,604). El impacto de todo el tratamiento fue significativamente menor después del uso del fenol (p = 0,010).LIMITACIONES:La tasa de respuesta fue de casi el 80% en esta población de pacientes jóvenes, los pacientes y los evaluadores no estaban cegados por el tipo de cirugía, los resultados son solo aplicables a la enfermedad primaria del seno pilonidal.CONCLUSIONES:Debido a los resultados favorables a corto plazo descritos y a la tasa de recurrencia a largo plazo y la calidad de vida comparables actualmente informadas entre la administración de fenol y la escisión con cierre primario de la herida para la enfermedad primaria del seno pilonidal, la administración de fenol del tracto sinusal debe considerarse como opción de tratamiento primario en pacientes con enfermedad del seno pilonidal. Consulte Video Resumen en http://links.lww.com/DCR/C27 . (Traducción-Dr. Osvaldo Gauto )Registro de prueba holandés-ID:NTR4043.

Long-term Bowel Dysfunction and Decline in Quality of Life Following Surgery for Colon Cancer: Call for Personalized Screening and Treatment.

BACKGROUND: Differences in long-term outcomes regarding types of colon resections are inconclusive, precluding patient counseling, effective screening, and personalized treatment. OBJECTIVE: This study aimed to compare long-term bowel function and quality of life in patients who underwent right or left hemicolectomy or sigmoid colon resection. DESIGN: This was a multicenter cross-sectional study. SETTINGS: Seven Dutch hospitals participated in this study. PATIENTS: This study included patients who underwent right or left hemicolectomy or sigmoid colon resection without construction of a permanent stoma between 2009 and 2015. Patients who were deceased, mentally impaired, or living abroad were excluded. Eligible patients were sent the validated Defecation and Fecal Continence and Short-Form 36 questionnaires. MAIN OUTCOME MEASURES: Constipation, fecal incontinence (both Rome IV criteria), separate bowel symptoms, and generic quality of life were the main outcomes assessed. RESULTS: This study included 673 patients who underwent right hemicolectomy, 167 who underwent left hemicolectomy, and 284 who underwent sigmoid colon resection. The median follow-up was 56 months. Sigmoid colon resection increased the likelihood of constipation compared to right and left hemicolectomy (OR, 2.92; 95% CI, 1.80-4.75; p < 0.001 and OR, 1.93; 95% CI, 1.12-3.35; p = 0.019). Liquid incontinence and fecal urgency increased after right hemicolectomy compared to sigmoid colon resection (OR, 2.15; 95% CI, 1.47-3.16; p < 0.001 and OR, 2.01; 95% CI, 1.47-2.74; p < 0.001). Scores on quality-of-life domains were found to be significantly lower after right hemicolectomy. LIMITATIONS: Because of the cross-sectional design, longitudinal data are still lacking. CONCLUSIONS: Different long-term bowel function problems occur after right or left hemicolectomy or sigmoid colon resection. The latter seems to be associated with more constipation than right or left hemicolectomy. Liquid incontinence and fecal urgency seem to be associated with right hemicolectomy, which may explain the decline in physical and mental generic quality of life of these patients. See Video Abstract at http://links.lww.com/DCR/C13 . DISFUNCIN INTESTINAL A LARGO PLAZO Y DISMINUCIN DE LA CALIDAD DE VIDA DESPUS DE LA CIRUGA DE CNCER DE COLON SOLICITUD DE DETECCIN Y TRATAMIENTO PERSONALIZADOS: ANTECEDENTES:Las diferencias en los resultados a largo plazo con respecto a los tipos de resecciones de colon no son concluyentes, lo que impide el asesoramiento preoperatorio del paciente y la detección eficaz y el tratamiento personalizado de la disfunción intestinal postoperatoria durante el seguimiento.OBJETIVO:Comparar la función intestinal a largo plazo y la calidad de vida en pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide.DISEÑO:Estudio transversal multicéntrico.AJUSTES:Participaron siete hospitales holandeses.PACIENTES:Se incluyeron pacientes sometidos a hemicolectomía derecha o izquierda, o resección de colon sigmoide sin construcción de estoma permanente entre 2009 y 2015. Se excluyeron pacientes fallecidos, con discapacidad mental o residentes en el extranjero. A los pacientes elegibles se les enviaron los cuestionarios validados de Defecación y Continencia Fecal y Short-Form 36.PRINCIPALES MEDIDAS DE RESULTADO:Se evaluaron el estreñimiento, la incontinencia fecal (ambos criterios de Roma IV), los síntomas intestinales separados y la calidad de vida genérica.RESULTADOS:Se incluyeron 673 pacientes con hemicolectomía derecha, 167 con hemicolectomía izquierda y 284 con resección de colon sigmoide. La mediana de seguimiento fue de 56 meses (RIC 41-80). La resección del colon sigmoide aumentó la probabilidad de estreñimiento en comparación con la hemicolectomía derecha e izquierda (OR, 2,92, IC 95%, 1,80-4,75, p < 0,001 y OR 1,93, IC 95%, 1,12-3,35, p = 0,019). La incontinencia de líquidos y la urgencia fecal aumentaron después de la hemicolectomía derecha en comparación con la resección del colon sigmoide (OR, 2,15, IC 95%, 1,47-3,16, p < 0,001 y OR 2,01, IC 95%, 1,47-2,74, p < 0,001). Las puntuaciones en los dominios de calidad de vida fueron significativamente más bajas después de la hemicolectomía derecha.LIMITACIONES:Debido al diseño transversal, aún faltan datos longitudinales.CONCLUSIONES:Se producen diferentes problemas de función intestinal a largo plazo después de la hemicolectomía derecha o izquierda, o la resección del colon sigmoide. Este último parece estar asociado con más estreñimiento que la hemicolectomía derecha o izquierda. La incontinencia de líquidos y la urgencia fecal parecen estar asociadas a la hemicolectomía derecha, lo que puede explicar el deterioro de la calidad de vida física y mental en general de estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/C13 . (Traducción-Dr. Yolanda Colorado ).

Life with a stoma across five European countries-a cross-sectional study on long-term rectal cancer survivors.

PURPOSE: Stoma-related problems are known to be important to patients and potentially affect everyday life. The prevalence of stoma-related problems in rectal cancer survivors remains undetermined. This study aimed to examine aspects of life with a long-term stoma, stoma management, and stoma-related problems and explore the impact of stoma-related problems on daily life. METHODS: In total, 2262 patients from 5 European countries completed a multidimensional survey. Stoma-related problems were assessed using the Colostomy Impact score. Multivariable regression analysis, after adjusting for potential confounding factors, provided odds ratio (OR) and 95% confidence intervals (CI) for stoma-related problems' association with restrictions in daily life. RESULTS: The 2262 rectal cancer survivors completed the questionnaire at a median of 5.4 years (interquartile range 3.8-7.6) after stoma formation. In the total sample, leakage (58%) and troublesome odour (55%) were most prevalent followed by skin problems (27%) and pain (21%). Stoma-related problems were more prevalent in patients with parastomal bulging. A total of 431 (19%) reported feeling restricted in daily activities in life with a stoma. Leakage, odour, skin problems, stool consistency, and frequent appliance changes were significantly associated with restrictions in daily life. The highest risk of experiencing restrictions was seen for patients having odour (OR 2.74 [95% CI: 1.99-3.78]) more than once a week and skin problems (OR 1.77 [95% CI: 1.38-2.27]). CONCLUSION: In this large cohort with rectal cancer, stoma-related problems were highly prevalent and impacted daily life. Supportive care strategies should entail outreach to patients with a long-term stoma.

Clinical and Radiologic Predictors of Parastomal Hernia Development After End Colostomy.

OBJECTIVE. Parastomal hernia (PSH) is a common complication that can occur after end colostomy and may result in considerable morbidity. To select the best candidates for prophylactic measures, knowledge of preoperative PSH predictors is important. This study aimed to determine the value of clinical parameters, preoperative CT-based body metrics, and size of the abdominal wall defect created during end colostomy and measured at postoperative CT for predicting PSH development. MATERIALS AND METHODS. Sixty-five patients who underwent permanent end colostomy with at least 1 year of follow-up were included. On preoperative CT, waist circumference, abdominal wall and psoas muscle indexes, rectus abdominis muscle diameter and diastasis, intra- and extraabdominal fat mass, and presence of other hernias were assessed. On postoperative CT, size of the abdominal wall defect and the presence of PSH were determined. To identify independent predictors of PSH development, univariate analysis with the Kaplan-Meier method and multivariate Cox regression analysis were performed. RESULTS. PSH developed after surgery in 30 patients (46%). Three independent risk factors were identified: chronic obstructive pulmonary disease (COPD) as a comorbidity (hazard ratio [HR], 6.4; 95% CI, 1.9-22.0; p = 0.003), operation time longer than 395 minutes (HR, 3.9; 95% CI, 1.5-10.0; p = 0.005), and maximum aperture diameter of more than 34 mm (HR, 5.2; 95% CI, 2.1-12.7; p < 0.001). PSH developed in all nine patients with a maximum abdominal wall defect diameter of more than 50 mm at the ostomy site. CONCLUSION. COPD, longer operation time, and larger abdominal wall defect at the colostomy site can predict PSH development. Intraoperative creation of an abdominal wall ostomy opening that is more than 34 mm in diameter should be avoided.

Translation and international validation of the Colostomy Impact score.

AIM: Optimal oncological resection in cancers of the lower rectum often requires a permanent colostomy. However, in some patients a colostomy may have a negative impact on health-related quality of life (HRQoL). The Colostomy Impact (CI) score is a simple questionnaire that identifies patients with stoma dysfunction that impairs HRQoL by dividing patients into 'minor' and 'major' CI groups. This aim of this study is to evaluate construct and discriminative validity, sensitivity, specificity and reliability of the CI score internationally, making it applicable for screening and identification of patients with stoma-related impaired HRQoL. METHOD: The CI score was translated in agreement with WHO recommendations. Cross-sectional cohorts of rectal cancer survivors with a colostomy in Australia, China, Denmark, the Netherlands, Portugal, Spain and Sweden were asked to complete the CI score, the European Organization for Research and Treatment of Cancer (EORTC) quality of life 30-item core questionnaire, the stoma-specific items of the EORTC quality of life 29-item colorectal-specific questionnaire and five anchor questions assessing the impact of colostomy on HRQoL. RESULTS: A total of 2470 patients participated (response rate 51%-93%). CI scores were significantly higher in patients reporting reduced HRQoL due to their colostomy than in patients reporting no reduction. Differences in EORTC scale scores between patients with minor and major CI were significant and clinically relevant. Sensitivity was high regarding dissatisfaction with a colostomy. Regarding evaluation of discriminative validity, the CI score relevantly identified groups with differences in HRQoL. The CI score proved reliable, with equal CI scores between test and retest and an intraclass correlation coefficient in the moderate to excellent range. CONCLUSION: The CI score is internationally valid and reliable. We encourage its use in clinical practice to identify patients with stoma dysfunction who require further attention.

Abandonment of Routine Radiotherapy for Nonlocally Advanced Rectal Cancer and Oncological Outcomes.

Importance: Neoadjuvant short-course radiotherapy was routinely applied for nonlocally advanced rectal cancer (cT1-3N0-1M0 with >1 mm distance to the mesorectal fascia) in the Netherlands following the Dutch total mesorectal excision trial. This policy has shifted toward selective application after guideline revision in 2014. Objective: To determine the association of decreased use of neoadjuvant radiotherapy with cancer-related outcomes and overall survival at a national level. Design, Setting, and Participants: This multicenter, population-based, nationwide cross-sectional cohort study analyzed Dutch patients with rectal cancer who were treated in 2011 with a 4-year follow-up. A similar study was performed in 2021, analyzing all patients that were surgically treated in 2016. From these cohorts, all patients with cT1-3N0-1M0 rectal cancer and radiologically unthreatened mesorectal fascia were included in the current study. The data of the 2011 cohort were collected between May and October 2015, and the data of the 2016 cohort were collected between October 2020 and November 2021. The data were analyzed between May and October 2022. Main Outcomes and Measures: The main outcomes were 4-year local recurrence and overall survival rates. Results: Among the 2011 and 2016 cohorts, 1199 (mean [SD] age, 68 [11] years; 430 women [36%]) of 2095 patients (57.2%) and 1576 (mean [SD] age, 68 [10] years; 547 women [35%]) of 3057 patients (51.6%) had cT1-3N0-1M0 rectal cancer and were included, with proportions of neoadjuvant radiotherapy of 87% (2011) and 37% (2016). Four-year local recurrence rates were 5.8% and 5.5%, respectively (P = .99). Compared with the 2011 cohort, 4-year overall survival was significantly higher in the 2016 cohort (79.6% vs 86.4%; P < .001), with lower non-cancer-related mortality (13.8% vs 6.3%; P < .001). Conclusions and Relevance: The results of this cross-sectional study suggest that an absolute 50% reduction in radiotherapy use for nonlocally advanced rectal cancer did not compromise cancer-related outcomes at a national level. Optimizing clinical staging and surgery following the Dutch total mesorectal excision trial has potentially enabled safe deintensification of treatment.

Evaluation of gastrectomy in patients with delayed gastric emptying after antireflux surgery or large hiatal hernia repair.

BACKGROUND: Revision antireflux surgery and large hiatal hernia repair require extensive dissection at the gastroesophageal junction. This may lead to troublesome symptoms due to delayed gastric emptying, eventually requiring gastrectomy. The aim of this study was to evaluate the outcome of gastrectomy for severely delayed gastric emptying after large hiatal hernia repair or redo antireflux surgery. METHODS: Eleven patients were treated between 1995 and 2010 and entered in the study. Preoperative and operative data were retrospectively collected. Standardized questionnaires were sent to all of the patients to evaluate symptomatic outcome. RESULTS: The primary intervention was Nissen fundoplication in nine patients, Toupet fundoplication in one, and cruroplasty in another. The repairs were for refractory gastroesophageal reflux disease in five patients and a symptomatic large hiatal hernia in six. Subsequent gastrectomy was partial in four patients, subtotal in six, and total in one. There was one minor postoperative complication. After a mean (±SD) duration of 102 ± 59 months, nine patients were available for symptomatic follow-up. Eight patients experienced daily symptoms related to dumping. Daily symptoms indicative of delayed gastric emptying were present in seven patients at follow-up. Mean general quality of life was increased from 3.8 ± 2.2 before gastrectomy to 5.4 ± 1.8 at follow-up. Eight patients reported gastrectomy as worthwhile. CONCLUSION: Gastrectomy after previous antireflux surgery or large hiatal hernia repair is safe with the potential to improve quality of life. Although upper gastrointestinal symptoms tend to persist, gastrectomy can be considered a reasonable, last-resort surgical option for alleviating upper gastrointestinal symptoms after this kind of surgery.

Surviving rectal cancer at the cost of a colostomy: global survey of long-term health-related quality of life in 10 countries.

BACKGROUND: Colorectal cancer management may require an ostomy formation; however, a stoma may negatively impact health-related quality of life (HRQoL). This study aimed to compare generic and stoma-specific HRQoL in patients with a permanent colostomy after rectal cancer across different countries. METHOD: A cross-sectional cohorts of patients with a colostomy after rectal cancer in Denmark, Sweden, Spain, the Netherlands, China, Portugal, Australia, Lithuania, Egypt, and Israel were invited to complete questionnaires regarding demographic and socioeconomic factors along with the Colostomy Impact (CI) score, European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and five anchor questions assessing colostomy impact on HRQoL. The background characteristics of the cohorts from each country were compared and generic HRQoL was measured with the EORTC QLQ-C30 presented for the total cohort. Results were compared with normative data of reference European populations. The predictors of reduced HRQoL were investigated by multivariable logistic regression, including demographic and socioeconomic factors and stoma-related problems. RESULTS: A total of 2557 patients were included. Response rates varied between 51-93 per cent. Mean time from stoma creation was 2.5-6.2 (range 1.1-39.2) years. A total of 25.8 per cent of patients reported that their colostomy impairs their HRQoL 'some'/'a lot'. This group had significantly unfavourable scores across all EORTC subscales compared with patients reporting 'no'/'a little' impaired HRQoL. Generic HRQoL differed significantly between countries, but resembled the HRQoL of reference populations. Multivariable logistic regression showed that stoma dysfunction, including high CI score (OR 3.32), financial burden from the stoma (OR 1.98), unemployment (OR 2.74), being single/widowed (OR 1.35) and young age (OR 1.01 per year) predicted reduced stoma-related HRQoL. CONCLUSION: Overall HRQoL is preserved in patients with a colostomy after rectal cancer, but a quarter of the patients interviewed reported impaired HRQoL. Differences among several countries were reported and socioeconomic factors correlated with reduced quality of life.

Tailored or routine addition of an antireflux fundoplication in laparoscopic large hiatal hernia repair: a comparative cohort study.

BACKGROUND: There is controversy about the tailored or routine addition of an antireflux fundoplication in large hiatal hernia (type II-IV) repair. We investigated the strategy of selective addition of a fundoplication in patients with a large hiatal hernia and concomitant gastroesophageal reflux disease. METHODS: Between 2002 and 2008, 60 patients with a large hiatal hernia were evaluated preoperatively and 12 months after surgery by reflux-related symptoms, upper endoscopy, and esophageal 24-h pH monitoring. In patients with preoperatively documented gastroesophageal reflux disease, an antireflux fundoplication was added during hiatal hernia repair. RESULTS: An antireflux procedure was added in 35 patients and 25 patients underwent hiatal hernia repair only. Preoperative symptoms were improved or resolved in 31 patients (88.6%) in the group who had fundoplication and in 20 patients (87.0%) in the group who did not have fundoplication. In patients with fundoplication, esophagitis was present in 6 patients (22.2%) after surgery and abnormal esophageal acid exposure persisted in 11 (39.3%). Seven patients (38.9%) with hernia repair only developed abnormal esophageal acid exposure, and esophagitis was postoperatively generated in five (27.8%). In neither group did patients have new onset of daily heartburn or dysphagia. CONCLUSIONS: In patients with a large hiatal hernia associated with gastroesophageal reflux disease, addition of a fundoplication during hernia repair yields acceptable reduction of symptoms and does not generate symptomatic side effects. Objective control of reflux, however, is only moderate. Omission of an antireflux procedure in the absence of gastroesophageal reflux disease induced esophagitis in 28% and abnormal esophageal acid exposure in 39% of patients. Therefore, routine addition of an antireflux fundoplication should be recommended.

Prognostic factors in patients with complete response of the tumour (ypT0) after neoadjuvant chemoradiotherapy and radical resection of rectal cancer.

BACKGROUND: There are only a few studies on the prognosis of patients with complete response of the tumour (ypT0) after neoadjuvant chemoradiotherapy (NCRT) and radical resection of rectal cancer. The aim of the study was to identify prognostic factors with regard to oncological outcome in ypT0 patients after NCRT and radical resection. METHODS: All ypT0 patients with rectal cancer after NCRT and radical resection between January 2010 and June 2019 were included. Cox univariate and multivariate regression analyses were used to determine the prognostic factors of these patients. RESULTS: Seventy-six patients with ypT0 rectal cancer were included. In nine patients (11.8%), lymph node metastasis was identified. Age, gender, elevated carcinoembryonic antigen (CEA) and ypN+ were risk factors associated with a worse 5-year disease-free survival (DFS) rate in univariate analysis (P = 0.08, 0.14, 0.007 and 0.003, respectively). In multivariate analysis, ypN+ and elevated CEA before NCRT were independent risk factors for worse 5-year DFS (P = 0.005 and 0.021, respectively). Elevated CEA before NCRT, post-operative chemotherapy and ypN+ were risk factors associated with worse overall survival in univariate analysis (P = 0.14, 0.002 and 0.17, respectively). However, in multivariate analysis, none of these three factors were independent risk factors for worse overall survival (P = 0.20, 0.34 and 0.06, respectively). CONCLUSION: ypN+ and elevated CEA before NCRT were found to be independent risk factors for an unfavourable DFS in ypT0 patients with complete response of the tumour after neoadjuvant chemoradiotherapy for rectal cancer.

Functional outcomes of surgery for colon cancer: A systematic review and meta-analysis.

INTRODUCTION: As survival rates of colon cancer increase, knowledge about functional outcomes is becoming ever more important. The primary aim of this systematic review and meta-analysis was to quantify functional outcomes after surgery for colon cancer. Secondly, we aimed to determine the effect of time to follow-up and type of colectomy on postoperative functional outcomes. MATERIALS AND METHODS: A systematic literature search was performed to identify studies reporting bowel function following surgery for colon cancer. Outcome parameters were bowel function scores and/or prevalence of bowel symptoms. Additionally, the effect of time to follow-up and type of resection was analyzed. RESULTS: In total 26 studies were included, describing bowel function between 3 to 178 months following right hemicolectomy (n = 4207), left hemicolectomy/sigmoid colon resection (n = 4211), and subtotal/total colectomy (n = 161). In 16 studies (61.5%) a bowel function score was used. Pooled prevalence for liquid and solid stool incontinence was 24.1% and 6.9%, respectively. The most prevalent constipation-associated symptoms were incomplete evacuation and obstructive, difficult emptying (33.3% and 31.4%, respectively). Major Low Anterior Resection Syndrome was present in 21.1%. No differences between time to follow-up or type of colectomy were found. CONCLUSION: Bowel function problems following surgery for colon cancer are common, show no improvement over time and do not depend on the type of colectomy. Apart from fecal incontinence, constipation-associated symptoms are also highly prevalent. Therefore, more attention should be paid to all possible aspects of bowel dysfunction following surgery for colon cancer and targeted treatment should commence promptly.

Dyspeptic symptoms after laparoscopic large hiatal hernia repair and primary antireflux surgery for gastroesophageal reflux disease: a comparative study.

BACKGROUND: Several patients with gastroesophageal reflux disease suffer from functional dyspepsia. After laparoscopic Nissen fundoplication, these symptoms persist in a substantial number of patients. We hypothesized that, due to a higher chance of vagal nerve impairment during extensive hernia sac resection and esophageal mobilization, dyspeptic symptoms are more frequent after laparoscopic large hiatal hernia (types II-IV) repair than after primary antireflux surgery. METHODS: From January 2003 to December 2007, 60 consecutive patients who primarily underwent an antireflux fundoplication for gastroesophageal reflux disease and 22 consecutive patients who had large hiatal hernia repair with fundoplication for concomitant gastroesophageal reflux disease were included. According to a system combining frequency and severity, patients scored 8 dyspeptic symptoms. Additionally, symptoms presenting preoperatively were scored according to the Visick grading system. RESULTS: In 43 of the 49 available patients (87.8%) who primarily underwent antireflux surgery and in all 20 available patients who had hiatal hernia repair, preoperative symptoms resolved or improved. Mean symptom scores of all dyspeptic symptoms after surgery were comparable between both cohorts. General quality of life was equal in both cohorts. CONCLUSION: After laparoscopic large hiatal hernia repair, dyspeptic symptoms were present in similar frequencies as after primary antireflux surgery.

[Chronic pilonidal sinus disease: overview of treatment options]. / Chronische sinus pilonidalis.

Chronic pilonidal sinus disease: overview of treatment options Pilonidal sinus disease is a common disease in predominantly young men; this condition can have a significant socio-economic impact. Although excision with primary or secondary wound healing is often applied, there is no consensus on the treatment of first choice for pilonidal sinus disease. Minimally invasive techniques, such as phenolisation, laser, and endoscopic treatments are increasingly applied, since these are associated with less pain, faster wound healing and facilitating a more rapid return to work for patients. Skin advancement flap techniques, considering they cause morbidity and large wounds, should only be considered in case of recurrent pilonidal sinus disease. Laser hair removal at the natal cleft after surgical treatment appears to reduce the risk of recurrence.

Influence of Conversion and Anastomotic Leakage on Survival in Rectal Cancer Surgery; Retrospective Cross-sectional Study.

BACKGROUND: Conversion and anastomotic leakage in colorectal cancer surgery have been suggested to have a negative impact on long-term oncologic outcomes. The aim of this study in a large Dutch national cohort was to analyze the influence of conversion and anastomotic leakage on long-term oncologic outcome in rectal cancer surgery. METHODS: Patients were selected from a retrospective cross-sectional snapshot study. Patients with a benign lesion, distant metastasis, or unknown tumor or metastasis status were excluded. Overall (OS) and disease-free survival (DFS) were compared between laparoscopic, converted, and open surgery as well as between patients with and without anastomotic leakage. RESULTS: Out of a database of 2095 patients, 638 patients were eligible for inclusion in the laparoscopic, 752 in the open, and 107 in the conversion group. A total of 746 patients met the inclusion criteria and underwent low anterior resection with primary anastomosis, including 106 (14.2%) with anastomotic leakage. OS and DFS were significantly shorter in the conversion compared to the laparoscopic group (p = 0.025 and p = 0.001, respectively) as well as in anastomotic leakage compared to patients without anastomotic leakage (p = 0.002 and p = 0.024, respectively). In multivariable analysis, anastomotic leakage was an independent predictor of OS (hazard ratio 2.167, 95% confidence interval 1.322-3.551) and DFS (1.592, 1077-2.353). Conversion was an independent predictor of DFS (1.525, 1.071-2.172), but not of OS. CONCLUSION: Technical difficulties during laparoscopic rectal cancer surgery, as reflected by conversion, as well as anastomotic leakage have a negative prognostic impact, underlining the need to improve both aspects in rectal cancer surgery.