Honest, Open, Proud (HOP) for people with mental illness in Hong Kong: a randomized controlled trial.

BACKGROUND: Self-stigma among people with mental illness is negatively associated with personal and clinical recovery. Due to the concealable nature of mental illness, people with mental illness experience constant struggles between concealment and disclosure. Disclosure of mental health challenges can potentially minimize negative impacts of self-stigma and enhance self-esteem and sense of empowerment. Honest, Open, Proud (HOP) is a peer-led intervention that promotes autonomous and dignified decisions about disclosure. PURPOSE: This study examined the effectiveness of HOP on concealment motivation, empowerment, self-stigma, stigma stress, and recovery among people with lived experience of mental illness in Hong Kong. METHODOLOGY: A total of 162 participants with a mean age of 45.38 were recruited and randomized into intervention group and waitlist control group. Participants in the intervention group were invited to attend a 6-session HOP group intervention. RESULTS: Significant improvement in optimism score from the empowerment scale was found in the intervention group compared to the waitlist control group and the effect was sustained at 1-month follow-up. However, significant changes were not found in other outcome variables. CONCLUSION: Only improvement in optimism was observed in the current study. Future study needs to examine the effects of HOP with further modification to maximize the benefit for people with lived experience of mental illness in the local context.

Risk factors for symptomatic anastomotic postoperative recurrence following ileo-colic resection in Crohn's disease.

AIM: Crohn's disease is a chronic inflammatory bowel disease characterized by alternating periods of exacerbation and remission. Surgical resection is not curative and postoperative recurrence (POR) remains a challenge in these patients. The aim of this study was to identify clinical variables that influence the risk of symptomatic anastomotic POR in patients with ileo-colonic Crohn's disease. METHOD: A retrospective study of Crohn's disease patients who had undergone ileo-colic resection between January 2014 and December 2018 was performed. For each patient, data including demographic information, Crohn's disease clinical setting, preoperative radiological data, operative and histological data, pre- and postoperative medication history and postoperative clinical course, including recurrence of disease, were extracted. Symptomatic anastomotic POR was defined as symptoms of Crohn's disease in the presence of confirmed anastomotic POR (endoscopic and/or radiological POR). RESULTS: For the study period, 104 patients were eligible and included for analysis. The cumulative probability of symptomatic anastomotic POR was 14%, 30%, 42%, 50% and 50% at 1, 2, 3, 4 and 5 years, respectively. Two clinical variables on multivariate analysis were associated with increased risk of symptomatic anastomotic POR, namely age <17 years at diagnosis [hazard ratio (HR) 2.17, p = 0.019] and gastrointestinal involvement (extent) >30 cm (HR 1.85, p = 0.048). CONCLUSION: This study describes the natural history of POR after ileo-colic resection for Crohn's disease, as defined by endoscopic, radiological and clinical outcomes. Age <17 years at diagnosis and gastrointestinal involvement (extent) >30 cm were independent risk factors for symptomatic anastomotic POR.

Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique: A systematic review.

INTRODUCTION: The Anterior Perineal PlanE for ultra-low Anterior Resection of the rectum (APPEAR) technique utilises a perineal incision to facilitate resection of the distal rectum. The aim of this study was to review use of the APPEAR technique, assessing patient selection, indications, complications and outcomes, both oncological and functional. MATERIALS AND METHODS: A systematic review was carried out to identify studies reporting outcomes following rectal resection via an anterior perineal incision, with no limits on year or language. All studies were included. Quality of studies was assessed using the methodological index for non-randomised studies (MINORS) score. RESULTS: Thirteen studies were identified from 1985 to 2013. 174 patients (102 male), ranging from 21 to 82 years, underwent surgery at eleven centres in seven countries. Maximum experience at one centre is 60 cases. 9 cases were performed for rectal dysplasia, 141 for rectal cancer; 96 resections were R0 (remaining 45 unstated). 14 cases were carried out laparoscopically. 30-day mortality was 2.3% (4 patients); there were 2 further deaths from systemic recurrence. Permanent stoma rate was 8/155 (5%). The most frequent complication was perineal or vaginal fistulation (26 patients): 6 underwent reoperation; 15 healed with conservative management; 5 required a permanent stoma. Functional outcomes were variably reported; median stool frequency was 3/24hrs with average Wexner scores of 5-5.5. CONCLUSION: In selected patients the APPEAR technique offers avoidance of permanent colostomy with good oncological outcomes. The majority of studies had short follow up periods and longer-term outcomes will need evaluation.

The diagnostic yield of preoperative staging computed tomography of the thorax in colorectal cancer patients without hepatic metastases.

BACKGROUND: National UK guidelines recommend preoperative computed tomography (CT) examination of the chest for all patients with colorectal cancer (CRC) as identification of thoracic metastatic disease may influence treatment plans. The diagnostic yield of this approach for patients without radiological evidence of hepatic metastases remains unclear. The aim of this study was to establish the impact upon treatment of chest CT examination for CRC patients without metastatic liver disease. PATIENTS AND METHODS: All patients diagnosed with CRC without liver metastases disease between December 2006 and December 2013 in a single institution were identified from a prospectively recorded departmental database. Data collected included patient demographics, disease stage and chest CT findings. RESULTS: There were 358 CRC patients (183 male, 175 female, median age 70 years, range 24-96 years) without liver metastases. Colon cancer accounted for 68% of cases with 32% of patients diagnosed with rectal cancer. The majority of patients (n=292, 81.6%) had no evidence of thoracic pathology during the study period. Lung metastases were identified in five (1.4%) patients, one of them subsequently diagnosed with benign pulmonary nodule. In 61 (17.0%) patients the lung nodules were classified as intermediate with only three subsequently reclassified as pulmonary metastases (n=1) or primary lung cancer (n=2). CONCLUSION: In the absence of liver metastases, CRC rarely spreads to the lung. Consequently, preoperative chest CT examination for patients without evidence of liver metastases may not be necessary in the majority of patients. Future studies are required to identify patients at high risk for pulmonary metastases who may benefit from this preoperative investigation.

Prospective clinical audit of two neuromodulatory treatments for fecal incontinence: sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS).

BACKGROUND AND PURPOSE: Two types of neuromodulation are currently practised for the treatment of fecal incontinence (FI): sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS). This study compares these therapies, as no data exist to prospectively assess their relative efficacy and costs. METHODS: The subjects of this study were two distinct cohorts undergoing SNS (between 2003 and 2008) or PTNS (2008-onwards) for FI. Clinical outcomes assessed at 3 months included incontinence scores and the number of weekly incontinence episodes. The direct medical costs for each procedure were calculated from the audited expenditure of our unit. RESULTS: Thirty-seven patients (94.6 % women) underwent permanent SNS and 146 (87.7 % women) underwent PTNS. The mean pre-treatment incontinence score (± SD) was greater in the SNS cohort (14 ± 4 vs. 12 ± 4) and the mean post-treatment incontinence scores were similar for the two therapies (9 ± 5 vs. 10 ± 4), with a greater effect size evident in the SNS patients. In a 'pseudo case-control' analysis with 37 "matched" patients, the effect of both treatments was similar. The cost of treating a patient for 1 year was £ 11,374 ($ 18,223) for permanent SNS vs. £ 1740 ($ 2784) for PTNS. CONCLUSION: Given the lesser cost and invasive nature of PTNS, where both techniques are available, a trial of PTNS could be considered for all patients.

Initial validation of the Chinese interRAI Mental Health in people with psychiatric illness.

OBJECTIVE: The purpose of this study was to determine the reliability and validity of the Chinese interRAI Mental Health (MH) among people with psychiatric illnesses. METHODS: Study participants were 157 individuals with psychiatric illnesses living in a psychiatric long-term care facility or halfway house in Hong Kong. The authors prepared the Chinese interRAI MH. A panel of bilingual healthcare professionals examined the quality of the translation. The reliability of the 6 scales embedded in the instrument was examined using Cronbach's alphas, intraclass correlations, and Kappa coefficients. Pearson's product moment correlations, Spearman's order correlations, and independent t-tests were used to determine the concurrent and construct validity of the scales. RESULTS AND CONCLUSIONS: Internal consistency values (α = 0.66-0.95) and test-retest reliability coefficients (ICC = 0.76-0.97; κ = 0.75-1.00) of the scales were found to be satisfactory. All 6 scales correlated significantly with the criterion measures. As expected, 3 scales relating to cognition, activities of daily living (ADL), and instrumental ADL discriminated among individuals living in two types of residential setting. Chinese interRAI MH was found to be a valid and reliable tool useful for the clinicians in Hong Kong.

Electrically stimulated gracilis neosphincter for end-stage fecal incontinence: the long-term outcome.

BACKGROUND: Electrically stimulated gracilis neosphincter is an established treatment for patients with end-stage fecal incontinence. Few data, however, describe its long-term efficacy. OBJECTIVE: This study aimed to assess the long-term functional outcome associated with this procedure. DESIGN: Patients who underwent gracilis neosphincter construction between1989 and 2001 were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiologic data were available for all patients. SETTINGS: This study was conducted at an academic colorectal unit in a tertiary center. PATIENTS: Sixty patients (median age, 42 years; 46 females) with fecal incontinence and a Williams continence score ≥5 were recruited to the study. The causes of incontinence included obstetric injury (n = 22), anal surgery (n = 17), atresia (n = 7), idiopathic incontinence (n = 6), anorectal excision (n = 4), and ileoanal pouch incontinence (n = 4). MAIN OUTCOME MEASURE: The primary outcomes measured were the Williams continence score and the proportion of patients with a Williams score ≤3 who avoided permanent stoma formation. RESULTS: Continence improved for the cohort postoperatively at 2 years (2(2-5); p < 0.001) but no significant difference was found between continence scores preoperatively and at 13 years (5(3-6); p = not significant). However, a sustained improvement at 13 years was noted for patients in the anal surgery (3(2-5);p < 0.001) and obstetric injury groups (4.5(3-6); p = 0.001). Twenty-six patients (43%) had a Williams score ≤3 and avoided permanent stoma after 13 years. Eighteen patients developed postoperative rectal evacuatory disorder; 10 of them required a conduit to facilitate colonic irrigation. Postoperative evacuatory disorder was more frequent in patients with a history of obstetric injury (p = 0.008). LIMITATIONS: This study was limited by the lack of bowel diaries and quality-of-life scores. CONCLUSION: Gracilis neosphincter is associated with clinically significant and sustained symptom improvement in patients with end-stage fecal incontinence secondary to obstetric injury or anal surgery. These data support the continued use of this procedure in highly selected patients.

Symptom distribution and anorectal physiology results in male patients with rectal intussusception and prolapse.

BACKGROUND: Rectal intussusception and external rectal prolapse are uncommon proctographic findings in men reflecting the lack of studies investigating such patients. The aim of this study was to identify the demographic, clinical, and physiological characteristics of this population with a view to appreciate the mechanism of development of this condition. METHODS: All men, presenting with symptoms of constipation or fecal incontinence, who were diagnosed proctographically with recto-rectal intussusception (RRI)/recto-anal intussusception (RAI) or external rectal prolapse (ERP) between 1994 and 2007 at a tertiary academic colorectal unit were studied. Demographics, relevant comorbidities, distribution and symptom duration, and anorectal physiology results were analyzed retrospectively for each proctographic group and intergroup comparisons performed. RESULTS: Two hundred five men (median age 50 y; range, 13-86) including 155 (75.6%) without any relevant comorbidities were studied. A significant proportion of patients in all proctographic groups reported rectal evacuatory difficulty ([RRI, 46.4%], [RAI, 39.4%], [ERP, 44.8%]; P = 0.38,analysis of variance). Patients also reported a combination of fecal incontinence symptoms (e.g., urge, passive, postdefecatory leakage) that did not differ across the proctographic groups. Anorectal physiological parameters were within normal range and were not found to be statistically different between the proctographic groups with the exception of anal resting pressure, which was lowest in ERP patients (62 cm H2O; range, 14-155) compared with patients with RRI (89 cm H2O; range, 16-250; P = 0.003) and RAI (92 cm H2O; range, 38-175; P = 0.006). CONCLUSIONS: Men with rectal intussusception and prolapse present with a combination of symptoms, predominantly defective rectal evacuation. Anorectal physiological assessment has failed to shed light into the mechanism of development of this condition and thus, the need for large observational studies incorporating integrated defecographic and manometric assessments of the evacuation process.

Outcome of percutaneous tibial nerve stimulation (PTNS) for fecal incontinence: a prospective cohort study.

OBJECTIVES: The aim of this study was to assess the long-term efficacy of percutaneous tibial nerve stimulation (PTNS) in fecal incontinence (FI). BACKGROUND: There is extensive evidence regarding the efficacy of PTNS in urinary incontinence. Data on the efficacy of PTNS for FI are limited to a few small case series with relatively short-follow up. METHODS: A prospective cohort of patients with FI was studied. Incontinence scores were measured using a validated questionnaire (Cleveland Clinic Florida-FI score) at specific time points: before treatment, after completion of a treatment course (12 PTNS sessions), and before the last maintenance ("top-up") therapy. Deferment time and average number of weekly incontinence episodes were also estimated from a prospective bowel dairy kept by the patient at these time points. Quality of life was assessed with the Rockwood Fecal Incontinence Quality of Life questionnaire. RESULTS: A total of 150 patients were recruited to the study between January 2008 and June 2012. Analysis was performed on 115 patients who continued to receive PTNS after a median follow-up of 26 (range, 12-42) months. The baseline Cleveland Clinic Florida-FI score ±SD (12.0 ± 3.9) improved after 12 PTNS sessions (9.4 ± 4.6, P < 0.0001) and after "top-up" treatments (10.0 ± 4.3, P < 0.0001). The increase in the Cleveland Clinic Florida-FI score between the end of the 12th session and the last "top-up" therapy was also significant (P = 0.04). A similar pattern was seen for the deferment time and the quality of life scores. The median time between "top-up" sessions was 12 months (range, 1-40 months), significantly longer than the recommended interval of 6 months. CONCLUSIONS: PTNS is a well-tolerated treatment with high acceptability in the majority of patients. It provides a sustained improvement in FI up to 42 months in a relatively noninvasive manner. The effect of PTNS diminishes with time and additional therapy sessions at 6 monthly intervals may result in greater improvements. PTNS ought to be considered as the first step in all patients with FI refractory to maximum conservative therapies.

Establishing a regional enterocutaneous fistula service: the Royal London hospital experience.

BACKGROUND: The development of enterocutaneous fistula (ECF) is one of the most challenging complications encountered in colorectal surgery. Currently, only two supra-regional centres are nationally designated in the United Kingdom to treat ECF patients. The aim of this study was to assess clinical outcome measures following the implementation of an ECF service at The Royal London Hospital. METHODS: All patients diagnosed with enterocutaneous fistula between December 2005 and November 2011 were recruited to the study. Clinical outcomes analysed included successful ECF closure, number of surgical procedures required for successful ECF closure, re-fistulation rates and morbidity/mortality data. RESULTS: 41 patients (20 M:21 F) of median age 54 years (range, 16-81) were studied. Patients had undergone a median of 4 (range, 1-18) operations prior to referral. Eleven fistulas (27%) healed spontaneously. Of the remaining 30 patients, 5 (17%) died before surgery due to uncontrollable sepsis and 6 (20%) refused surgical intervention and were managed conservatively. Nineteen patients (63%) underwent definitive surgical repair requiring a median of 1 (range, 1-2) operations, with recurrent fistulation reported in 4 patients (21%). No intra-operative mortality was encountered. Two (11%) patients died postoperatively due to cardio-respiratory complications. CONCLUSIONS: These data compare favourably with outcome measures reported by designated national centres, suggesting ECF patients can be safely managed closer to home in regional units that have the appropriate expertise. Nevertheless, management of this condition remains critically dependent upon a dedicated multidisciplinary team approach.

Outcome of sacral nerve stimulation for fecal incontinence in patients refractory to percutaneous tibial nerve stimulation.

BACKGROUND: Percutaneous tibial nerve stimulation and sacral nerve stimulation are both second-line treatments for fecal incontinence, but the comparative efficacy of the 2 therapies is unknown. In our institution, patients with refractory fecal incontinence are generally treated with percutaneous tibial nerve stimulation before being considered for sacral nerve stimulation. OBJECTIVE: The aim of this study was to assess the outcome associated with this treatment algorithm in order to guide future management strategies. DESIGN: All patients with fecal incontinence treated over a 3-year period with tibial nerve stimulation before receiving sacral nerve stimulation were identified from a prospectively recorded database. Demographics and pretreatment anorectal physiological data were available for all patients. SETTINGS: This study was conducted at an academic colorectal unit in a tertiary center. PATIENTS: Twenty patients (17 female:3 male, median age 55 (33-79) years) were identified to be refractory to percutaneous tibial nerve stimulation. MAIN OUTCOME MEASURES: Clinical outcome data were collected prospectively before and after treatment, including 1) Cleveland Clinic Florida-Fecal Incontinence scores and 2) number of incontinence episodes per week. RESULTS: The mean (±SD) pretreatment incontinence score (11.7 ± 3.5) did not differ from the mean incontinence score after 12 sessions of tibial nerve stimulation (10.9 ± 3.6, p = 0.42). All patients were subsequently counseled for sacral nerve stimulation, and 68.4% of them reported a significant therapeutic benefit with an improved incontinence score (7.7 ± 4.1, p = 0.014). LIMITATIONS: This was a nonrandomized study with a relatively small number of patients CONCLUSION: Sacral nerve stimulation appears to be an effective treatment for patients who do not gain an adequate therapeutic benefit from percutaneous tibial nerve stimulation and, thus, should be routinely considered for this patient cohort.

Assessment of female patients with rectal intussusception and prolapse: is this a progressive spectrum of disease?

BACKGROUND: Rectal intussusception may be the initial abnormality of a progressive pelvic floor disorder culminating in external prolapse. The evidence, however, is unclear, and the pathophysiological mechanisms underlying this condition are unknown. OBJECTIVE: The aim of this study is to identify the relationship between age, symptom duration, anorectal physiology parameters, and type of intussusception/prolapse in order to appreciate the natural history of the condition. DESIGN: All female patients diagnosed proctographically with rectorectal/rectoanal intussusception or external prolapse between 1994 and 2007 were studied. Demographics, symptom duration, and anorectal physiology results were compared between these proctographic groups. Patients with repeat proctographic evaluation were also analyzed separately. SETTINGS: This investigation was conducted at a tertiary academic colorectal center. PATIENTS: A total of 1014 women (median age, 51; range, 16-96), including 32 who underwent repeat proctography, were analyzed. MAIN OUTCOME MEASURES: The primary outcomes measured were the differences in median age, symptom duration, and anorectal physiology parameters between the proctographic groups. RESULTS: The cohort exhibited a statistically significant difference (p = 0.0001) in the median age of the proctographic groups with older patients diagnosed with rectoanal rather than rectorectal intussusception, which was supported by uni- and multivariate modeling. Symptom duration was statistically different (p = 0.0002) between the rectorectal intussusception (60 months; range, 1-936) and external rectal prolapse patient groups (36 months; range, 2-732). Patients with external rectal prolapse had statistically lower anal resting (median, 41 versus 77 cmH2O) and squeeze pressures (median 40 versus 56 cmH2O) than patients with rectorectal intussusception. Within 2 years, 19.2% and 3.8% of patients with rectorectal intussusception on the initial proctogram demonstrated progression to rectoanal intussusception and external prolapse. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSION: Rectal intussusception may be an initial abnormality leading to external prolapse, but this appears to happen infrequently. Long-term observational studies are required to fully understand its natural history.