Factors Associated With Decision Regret Among Patients With Diverticulitis in the Elective Setting.

BACKGROUND: We aimed to identify decision process measures associated with patient decisional regret regarding the decision to pursue elective colectomy or observation for diverticulitis. MATERIALS AND METHODS: This was a single-center cross-sectional survey study. We included adult patients treated for diverticulitis between 2014 and 2019 and excluded patients who required urgent or emergent colectomy. The primary outcome was regret regarding the decision to pursue elective surgery or observation for diverticulitis, measured using the Decision Regret Scale. We used multivariable linear regression to examine hypothesized predictors of decision regret, including decisional conflict (Decision Conflict Scale and its subscales), shared decision-making, and decision role concordance. RESULTS: Of 923 eligible patients, 133 were included in the analysis. Patients had a median of five episodes of diverticulitis (interquartile range 3-8), occurring a median of 2 y (interquartile range 1-3) before survey administration. Thirty-eight patients (29%) underwent elective surgery for diverticulitis. Decision regret (Decision Regret Scale score ≥25) was present in 42 patients (32%). After controlling for surgery, gender, health status, and years since treatment, decision regret was associated with decisional conflict and inversely associated with values clarity, decision role concordance, shared decision-making, and feeling informed, supported, and effective in decision-making (all P < 0.001). CONCLUSIONS: Nearly one-third of survey respondents experienced regret regarding the decision between elective surgery and observation for diverticulitis. Decision regret may be reduced through efforts to improve patient knowledge, values clarity, role concordance, and shared decision-making.

Can general surgeons perform laparoscopic surgery independently within 10 years of training? A nationwide survey on laparoscopic surgery training in Japan.

PURPOSE: There is no standard program for laparoscopic surgery training in Japan, and competency in these procedures does not require the acquisition of board certification. The purpose of this survey was to investigate the current status of laparoscopic surgery training in Japan. METHODS: A questionnaire survey was mailed to 2296 members of the Japan Society for Endoscopic Surgery who were between postgraduate year 3 and 10. The questionnaire inquired about laparoscopic surgical training conditions, operation case numbers, and autonomy in eight laparoscopic procedures. RESULTS: The total response rate was 28.1%. The number of cases required to perform procedures independently was demonstrated. Most participants felt confident in performing laparoscopic appendectomy and cholecystectomy; however, they felt less confident about performing laparoscopic colectomy and gastrectomy. CONCLUSIONS: The information from this survey may be useful for surgical educators, surgical societies, and the board certification council for rebuilding the surgical training system in Japan.

Quality of Life and Severity of Symptom Differences Between Post Open Colectomy and Laparoscopic Colectomy in Colorectal Cancer Patients.

BACKGROUND: Worldwide, colorectal cancer is the third most common cancer in men and the second in women. The main surgical methods for colorectal cancer patients include a conventional open colectomy and laparoscopic-assisted colectomy. Laparoscopic-assisted colectomy is associated with less blood loss, faster recovery of bowel function, and shorter hospital stays. OBJECTIVE: The aim of this study was to compare the quality of life and symptom severity in patients with colorectal cancer 1 month after conventional open colectomy or laparoscopic-assisted colectomy. METHODS: A comparative cross-sectional study design was conducted from September 2015 to May 2016. Participants were recruited through convenience sampling from the surgical outpatient department of a medical center in Northern Taiwan; 33 patients underwent each type of surgery. RESULTS: The laparoscopic-assisted colectomy group scored 9.39 points higher in quality of life and lower in symptom severity by 14.88 points than the conventional open colectomy group (P = .03 and P = .05, respectively). Both groups reported low symptom severity; "changes in bowel habits" was the symptom with the highest severity. The conventional open colectomy group had higher insomnia and worried about their future more than did the laparoscopic-assisted colectomy group. CONCLUSIONS: Patients who received the laparoscopic-assisted colectomy procedure reported a better quality of life and lower symptom severity than those who received the conventional open colectomy surgical method. IMPLICATIONS FOR PRACTICE: Patients who will have a conventional open colectomy will likely need enhanced management of symptoms and attention to their quality of life.

Association of laparoscopic colectomy versus open colectomy on the long-term health-related quality of life of colon cancer survivors.

BACKGROUND: Laparoscopic colectomy (LC) is a less invasive alternative to open colectomy (OC) in the treatment of stage I-III colon cancer. Research on the long-term (5-year post-diagnosis) health-related quality of life (HRQOL) of LC patients is scarce. Our study aimed to compare the long-term HRQOL and psychological well-being of stage I-III colon cancer survivors treated either with LC or OC. METHODS: This study used a German population-based cohort of patients treated with either LC (n = 86) or OC (n = 980). LC patients were matched to OC patients using a propensity score. At 5-year follow-up, patients completed assessments on HRQOL (EORTC QLQ-C30 and EORTC QLQ-CR29) and psychological well-being (distress and disease/treatment burden). Least square mean scores of HRQOL were derived using linear regression. Proportions of patients with moderate/high distress and disease/treatment burden were compared with Chi-square tests. RESULTS: In total, 81 LC patients were matched to 156 OC patients. Generally, LC patients had HRQOL comparable to OC patients, albeit LC patients reported significantly better body image (87.1 versus 81.0, p = 0.03). Distress levels were generally low and comparable between the two groups, even though LC patients were more likely to experience disease recurrence (16% versus 7%, p = 0.02) than OC patients. OC patients were more likely to feel moderate/high levels of burden associated with the treatment (72% versus 56%, p = 0.01) and the time after treatment completion (43% versus 28%, p = 0.02). CONCLUSION: LC patients reported comparable long-term HRQOL outcomes but higher levels of psychological well-being than OC patients 5 years after diagnosis, even though LC was associated with higher risk of disease recurrence.

Functional bowel complaints and quality of life after surgery for colon cancer: prevalence and predictive factors.

AIM: Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS-like symptoms and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery. METHOD: All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ-C30 and QLQ-CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories. RESULTS: A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392-2.528) and a previous diverting stoma (OR 1.84, CI 1.14-2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains. CONCLUSION: The results of this study highlight the presence of LARS-like symptoms after surgery for colonic cancer. Patients suffering from major LARS-like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients.

The low anterior resection syndrome in a reference population: prevalence and predictive factors in the Netherlands.

AIM: The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after colorectal cancer surgery. There are no data about these complaints and the association with QoL in a reference population. The aim of this study was to assess LARS and the association with QoL in a reference population. METHODS: Six hundred patients who visited the outpatient clinic because of general or trauma surgical indications were asked to participate in this study. They received an invitation letter containing three validated questionnaires to assess LARS (assessed with the LARS score) and both general [European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30] and colorectal-specific (EORTC QLQ-CR29) QoL. RESULTS: Five hundred and one respondents could be included for the analyses. The median age at inclusion was 68 years and 47.3% were men. Major LARS was observed in 15% of patients (11.4% in men and 18.9% in women, P = 0.021). Women reported more urgency (P = 0.070) and incontinence for both flatus (P < 0.001) and stool (P = 0.063) compared to men. In univariate analyses, women reported major LARS significantly more often than men (OR 1.82; 95% CI 1.10-3.01). Patients with major LARS scored significantly worse in most QoL domains compared to patients with no/minor LARS. CONCLUSION: This is the first study demonstrating major LARS and the association with QoL in a reference population of patients without colorectal cancer. Our data can assist in the interpretation of LARS in past and future research about abdominal complaints after colorectal cancer surgery.

Surgeon Workload in Colorectal Surgery: Perceived Drivers of Procedural Difficulty.

BACKGROUND: To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty. MATERIALS AND METHODS: For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys. RESULTS: Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases. CONCLUSIONS: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus.

Evaluating unmet needs in patients undergoing surgery for colorectal cancer: a patient reported outcome measures study.

AIM: Patient reported outcome measures (PROMs) are self-reported measures of patients' health status or health-related quality of life at a single point in time. We aimed to evaluate the use of a colorectal PROM and conducted a focus group to further explore this and other unmet needs in our patient population treated surgically for colorectal cancer. METHOD: A multidisciplinary research group consisting of colorectal surgeons, nurse specialists, psychologists, sociologists and patient representatives devised a composite tool of new and existing outcome measures which was piloted in our local population (n = 35). Participants were subsequently invited to attend a semi-structured focus group during which the PROM was reviewed and an unmet needs analysis was performed. Thematic analysis of focus group transcripts was undertaken for emergent themes. RESULTS: Initial consensus was for a tool including the EQ-5D, Functional Assessment of Cancer Therapy - Colorectal (FACT-C), the distress thermometer, a validated measure of stigma, an unmet needs analysis, and questions assessing the psychological impact of cancer. Median and interquartile range values suggested that all metrics were discriminatory with the exception of FACT-C. All participants agreed that the tool was acceptable and reflected the current state of their health and emotions. Thematic analysis of focus group transcripts identified four major themes: physical symptoms, emotional response, information provision and coping mechanisms. CONCLUSION: Through expert consensus, local piloting and patient focus groups we have evaluated a novel PROM for colorectal cancer. Furthermore, through our direct engagement with patients we have identified several unmet needs which we are currently exploring within the clinical service.

Patient and Physician Preferences for Nonoperative Management for Low Rectal Cancer: Is It a Reasonable Treatment Option?

BACKGROUND: Although the body of evidence supporting nonoperative management for rectal cancer has been accumulating, there has been little systematic investigation to explore how physicians and patients value the tradeoffs between oncologic and functional outcomes after abdominal perineal resection and nonoperative management. OBJECTIVE: The purpose of this study was to elicit patient and physician preferences for nonoperative management relative to abdominal perineal resection in the setting of low rectal cancer. DESIGN: We conducted a standardized interviews of patients and a cross-sectional survey of physicians. SETTINGS: Patients from 1 tertiary care center and physicians from across Canada were included. PATIENTS: The study involved 50 patients who were previously treated for rectal cancer and 363 physicians who treat rectal cancer. INTERVENTIONS: Interventions included standardized interviews using the threshold technique with patients and surveys mailed to physicians. MAIN OUTCOMES MEASURES: We measured absolute increase risk in local regrowth and absolute decrease in overall survival that patients and physicians would accept with nonoperative management relative to abdominal perineal resection. RESULTS: Patients were willing to accept a 20% absolute increase for local regrowth (ie, from 0% to 20%) and a 20% absolute decrease in overall survival (ie, from 80% to 60%) with nonoperative management relative to abdominal perineal resection, whereas physicians were willing to accept a 5% absolute increase for local regrowth (ie, from 0% to 5%) and a 5% absolute decrease in overall survival (ie, from 80% to 75%) with nonoperative management relative to abdominal perineal resection. LIMITATIONS: Data were subject to response bias and generalizable to only a select group of patients with low rectal cancer. CONCLUSIONS: Offering nonoperative management as an option to patients, even if oncologic outcomes are not equivalent, may be more consistent with the values of patients in this setting. See Video Abstract at http://links.lww.com/DCR/A688.

Patient Perceptions and Quality of Life After Colon and Rectal Surgery: What Do Patients Really Want?

BACKGROUND: Colorectal surgery outcomes must be accurately assessed and aligned with patient priorities. No study to date has investigated the patient's subjective assessment of outcomes most important to them during and following their surgical recovery. Although surgeons greatly value the benefits of laparoscopy, patient priorities remain understudied. OBJECTIVE: This study aimed to assess what aspects of patients' perioperative care and recovery they value most when queried in the postoperative period. DESIGN: This study is an exploratory cross-sectional investigation of a defined retrospective patient population. Enrollees were stratified into subcategories and analyzed, with statistical analysis performed via χ test and unpaired t test. SETTINGS: This study was conducted at a single academic medical center in New England. PATIENTS: Patients who underwent a colorectal surgical resection between 2009 and 2015 were selected. INTERVENTIONS: Patients within a preidentified population were asked to voluntarily complete a 32-item questionnaire regarding their surgical care. MAIN OUTCOME MEASURES: The primary outcomes measured were patient perioperative and postoperative quality of life and satisfaction on selected areas of functioning. RESULTS: Of 167 queried respondents, 92.2% were satisfied with their recovery. Factors considered most important included being cured of colorectal cancer (76%), not having a permanent stoma (78%), and avoiding complications (74%). Least important included length of stay (13%), utilization of laparoscopy (14%), and incision appearance and length (2%, 4%). LIMITATIONS: The study had a relatively low response rate, the study is susceptible to responder's bias, and there is temporal variability from surgery to questionnaire within the patient population. CONCLUSIONS: Overall, patients reported high satisfaction with their care. Most important priorities included being free of cancer, stoma, and surgical complications. In contrast, outcomes traditionally important to surgeons such as laparoscopy, incision appearance, and length of stay were deemed less important. This research helps elucidate the outcomes patients truly consider valuable, and surgeons should focus on these outcomes when making surgical decisions. See Video Abstract at http://links.lww.com/DCR/A596. See Visual Abstract at https://tinyurl.com/yb25xl66.

Sources of distress among patients undergoing surgery for colorectal cancer: a qualitative study.

BACKGROUND: Distress is common among cancer and surgical patients and can lead to worse outcomes if untreated. The objective of this study was to explore sources of distress among colorectal cancer patients undergoing surgery. MATERIALS AND METHODS: This was a qualitative study using in-depth, semistructured, one-on-one interviews in an academic setting. Patients were recruited if they had a pathologically confirmed diagnosis of colon or rectal cancer. Purposive sampling was used to recruit patients who were about to undergo (preoperative), or had recently undergone (postoperative), curative resection for colorectal cancer. RESULTS: All participants (n = 24) reported experiencing distress during treatment. Participants identified sources of distress preoperatively (negative emotional reaction to diagnosis, distress from preconception of cancer diagnosis, and distress interacting with healthcare system). Sources of distress during in-hospital recovery included negative emotional reaction to having a surgery and negative emotions experienced in the hospital. Postoperative sources of distress included mismatch of expectations and experience of recovery, dealing with distressing physical symptoms and complications after surgery, and distress worrying about recurrence. Participants identified other sources of distress that were not time-specific (distress related to social support network, from disruption of life, and worrying about death). CONCLUSIONS: Our results highlight a potential role for a comprehensive screening program to identify which patients require assistance with addressing sources of distress during the surgical experience. Understanding how sources of distress may vary by time will help us tailor interventions at different time points of the surgical experience.

Ileocaecal valve syndrome after surgery in adult patients: myth or reality?

AIM: The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires. METHOD: In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data. RESULTS: We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant. CONCLUSION: We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings.

The Effect of Surgical Stress on Postoperative Tαß and Tγδ Cell Distribution.

BACKGROUND: It was previously shown that appropriate distribution of immune cells between different tissues and organs of the body is required for proper function of the immune system. Our previous experiments demonstrated that surgical trauma in mice induces Tγδ lymphocyte migration from peripheral blood to peritoneal lymphoid organs. Tγδ cells have regulatory activity as they suppress the cell-mediated immune response in vitro via TGF-ß. In the current study, we aim to evaluate the influence of surgery on both Taß and Tγδ lymphocyte distribution in patients that underwent operation. MATERIALS AND METHODS: We investigated the percentage of Tαß and Tγδ cells in peripheral blood of patients undergoing standard surgical procedures (gastric resection, colorectal resection, cholecystectomy, and strumectomy) before and 3 days after operation. The percentage of Tαß and Tγδ cells was evaluated by FACS Canto II cytofluorimeter. RESULTS: We showed that only major surgery located in the peritoneal cavity (gastric and colorectal surgery) decreases the percentage of Tγδ cells in peripheral blood as opposed to less traumatic surgery (strumectomy and cholecystectomy) which does not have such effect. However, significant reduction of Tγδ cells after operation was only observed in a group of patients that underwent gastrectomy. Additionally, we found that gastrectomy results in significant reduction of cumulative Tγδ CD4 and Tγδ CD25 lymphocyte counts. CONCLUSION: Surgery results in decreased percentage of Tγδ lymphocytes in peripheral human blood, and this correlates with the severity and location of the surgical trauma. This observation may help to predict postoperative recovery after gastroabdominal surgery.

Long-term Outcomes of Sphincter-Saving Procedures for Diffuse Crohn's Disease of the Large Bowel.

BACKGROUND: Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease. OBJECTIVE: The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease. DESIGN: Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included. SETTINGS: The study was conducted at a tertiary care research center. PATIENTS: Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA. MAIN OUTCOME MEASURES: Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy. RESULTS: Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis. LIMITATIONS: The study was limited by its retrospective nature and small sample size. CONCLUSIONS: Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

Greatest Challenges of Rectal Cancer Survivors: Results of a Population-Based Survey.

BACKGROUND: Eliciting the priorities of cancer survivors is essential to address the specific needs of cancer survivor subgroups. OBJECTIVE: The purpose of this study was to describe the greatest challenges related to treatment for long-term rectal cancer survivors. DESIGN: This was an observational study with a cross-sectional survey. SETTINGS: The study included members of Kaiser Permanente Northern California and Northwest health plans. PATIENTS: A survey was mailed to long-term (≥5 years postdiagnosis) survivors of rectal cancer who had an anastomosis, temporary ostomy, or permanent ostomy. MAIN OUTCOME MEASURES: The main outcome was measured with an open-ended question about the greatest challenge related to cancer surgery. We categorized responses using a grounded theory approach with double coding for reliability. Bonferroni-adjusted χ values were used to assess differences in the proportions of subgroups who mentioned challenges within each response category. RESULTS: The survey completion rate was 61% (577/953); 76% (440/577) of participants responded to the greatest challenge question. The greatest challenges for respondents were bowel/ostomy management (reported by 44%), negative psychosocial effects (37%), late effects of treatment (21%), comorbidities and aging (13%), postoperative recovery (5%), and negative healthcare experiences (5%). Survivors with temporary ostomy or anastomosis were more likely than survivors with permanent ostomy to report late effects (p < 0.0001 and p = 0.01). Survivors with anastomosis were less likely than survivors with permanent ostomy to report negative psychosocial impacts (p = 0.0001). LIMITATIONS: Generalizability is restricted by the lack of ethnically and racially diverse, uninsured (non-Medicare-eligible population), and non-English-speaking participants. Because the survey was cross-sectional and included respondents at different times since diagnosis, we could not adequately address changes in the greatest challenges over time. CONCLUSIONS: Our results reveal the need for bowel/ostomy management, psychosocial services, and surveillance for late effects in survivorship and supportive care services for all survivors of rectal cancer, regardless of ostomy status. The perspective of long-term survivors with anastomosis reveals challenges that may not be anticipated during decision making for treatment (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A254).

Patient-Reported Roles, Preferences, and Expectations Regarding Treatment of Stage I Rectal Cancer in the Cancer Care Outcomes Research and Surveillance Consortium.

BACKGROUND: Historically, stage I rectal cancer was treated with total mesorectal excision. However, there has been growing use of local excision, with and without adjuvant therapy, to treat these early rectal cancers. Little is known about how patients and providers choose among the various treatment approaches. OBJECTIVE: The purpose of this study was to identify patient roles, preferences, and expectations as they relate to treatment decision making for patients with stage I rectal cancer. DESIGN: This is a population-based study. SETTINGS: The study included a geographically diverse population and health-system-based cohort. PATIENTS: A total of 154 adults with newly diagnosed and surgically treated stage I rectal cancer between 2003 and 2005 were included. MAIN OUTCOME MEASURES: We compared patients by surgical treatment groups, including total mesorectal excision and local excision. Clinical, sociodemographic, and health-system factors were assessed for association with patient decision-making preferences and expectations. RESULTS: A total of 80% of patients who underwent total mesorectal excision versus 63% of patients who underwent local excision expected that surgery would be curative (p = 0.04). The total mesorectal excision group was less likely to report that radiation would cure their cancer compared with the local excision group (27% vs 63%; p = 0.004). When asked about their preferred role in decision making, 28% of patients who underwent total mesorectal excision preferred patient-controlled decision making compared with 48% of patients who underwent local excision (p = 0.046). However, with regard to the treatment actually received, 38% of the total mesorectal excision group reported making their own surgical decision compared with 25% of the local excision group (p = 0.18). LIMITATIONS: The study was limited by its sample size. CONCLUSIONS: The preferred decision-making role for patients did not match the actual decision-making process. Future efforts should focus on bridging the gap between the decision-making process and patient preferences regarding various treatment approaches. This will be particularly important as newer innovative procedures play a more prominent role in the rectal cancer treatment paradigm.

Long-term functional outcome of colonic resections: how much does faecal impairment influence quality of life?

AIM: Older data suggest that colonic resection has a negative impact on continence and quality of life. The aim of this study was to evaluate the functional outcome of colonic resections for colonic cancer and diverticulitis and its influence on quality of life. METHODS: Patients who underwent colonic resection between 2005 and 2013 were identified from a prospective database. A survey with two questionnaires [Faecal Incontinence Quality of Life (FIQL) scale, Short Form 12 (SF-12)] and additional questions concerning bowel function was sent to all patients. RESULTS: Colonic resection was performed in 362 patients in the study period; 297 patients returned the questionnaires (response rate 82.0%). Faecal urgency or incontinence more than once a month was present in 15% of patients and 25% of patients reported that bowel symptoms limited their quality of life. The mean total FIQL score for all patients was 3.58. The SF-12 score was comparable to a reference population without prior colonic resection. Patients after right-sided resections had liquid stool more often than others (45.3% vs 38.7%, P = 0.011). No differences in bowel function and quality of life were detected between resections for colonic cancer and diverticulitis. CONCLUSION: Most patients experience no limitation in bowel function after segmental colectomy. Those with limitations in bowel function still seem to cope well, as the quality of life is not severely affected. Nevertheless, most patients with lower functional scores also had lower quality of life scores. Whether surgery is a relevant factor has to be questioned, as the prevalence of faecal incontinence in a comparable population without prior surgery is almost identical.

Patients' knowledge and fear of colorectal cancer risk in inflammatory bowel disease.

OBJECTIVE: To investigate knowledge and fear of colorectal cancer (CRC) risk in inflammatory bowel disease (IBD) patients. METHODS: A 12-item self-administered questionnaire, developed after a careful literature review, was administered to all consecutive IBD patients treated with infliximab who were followed up at Nancy University Hospital (Vandoeuvre-lès-Nancy, France) between February and May 2012. RESULTS: Altogether 100 patients including 72 with Crohn's disease (CD) were included. Only 7.0% of patients spontaneously mentioned CRC risk as a main feature of IBD and 37.0% as a potential IBD complication. CRC was the most feared complication by 26 patients [ulcerative colitis (UC) 46.4% vs CD 18.1%, P < 0.01]. Two-thirds of patients knew that IBD increases CRC risk (UC 81.9% vs CD 57.1%, P = 0.02). Their main source of information was their gastroenterologist (52.0%). On the best screening method for CRC, 86.0% of the respondents mentioned colonoscopy. Only 32.0% of patients knew that it has to be performed 10 years after diagnosis. In case of dysplasia, 51.0% of the patients would not undergo colectomy (CD 59.7% vs UC 28.6%, P < 0.01), mainly due to the fear of having ostomy bags. Only one-quarter of UC patients were aware of the chemopreventive effect of 5-aminosalicylates on CRC risk. CONCLUSIONS: Two-thirds of IBD patients are aware of the risk of CRC. UC patients have a better knowledge of this risk and are more afraid of this complication. Our results underscore the need for therapeutic education about CRC in IBD patients.