Clinical utilization of magnetic resonance enterography in small bowel Crohn's disease management: a retrospective tertiary centre experience.

BACKGROUND: Magnetic resonance enterography (MRE) is the mainstay imaging modality in the evaluation of small bowel Crohn's disease (CD) activity and its associated complications. Few studies have assessed the indications for ordering it and its association with management changes. The objective was to identify the current clinical utilization of MRE and associated management changes in patients with established small bowel CD. METHODS: A retrospective audit was conducted on all patients with established CD who underwent MRE at a tertiary centre from November 2014 to December 2017. Clinical indications, radiological findings and management changes were obtained from patient records. RESULTS: A total of 220 patients underwent a total of 287 MRE examinations. The most common indications for ordering MREs were based on patient symptoms (n = 204, 71.1%) and routine disease surveillance (n = 57, 19.9%). The most common radiological findings were inflammation (n = 156, 54.4%) and strictures (n = 98, 34.1%). Management changes post MRE occurred in 152 of 287 (53%) cases. Of the 152 patients, 87 (57.2%) had changes in medical management, 40 (26.3%) had surgical or endoscopic intervention and 25 (16.4%) had both medical and surgical management changes. Management changes following MRE in patients with new or concerning symptoms were significantly higher than in surveillance patients (OR 4.1, P = 0.000003). CONCLUSION: This study provides a foundation for understanding the current utilization of MRE in small bowel CD at a tertiary centre. However, its role in altering management particularly within surveillance patients is yet to be defined. Future prospective trials are required to better delineate its role and develop an algorithm for small bowel CD management.

Using sacral nerve modulation to improve continence and quality of life in patients suffering from low anterior resection syndrome.

BACKGROUND: Sphincter preserving surgery for the treatment of rectal cancer is very often feasible, avoiding a permanent colostomy. It is well recognized that a large proportion of patients will experience altered bowel habit following low anterior resection (LAR). Faecal incontinence is a common symptom associated with LAR syndrome. The aim of this study is to evaluate the long-term improvement in continence and quality of life (QoL) in LAR patients treated with sacral nerve modulation. METHODS: Patients with ongoing faecal incontinence for >1 year after reversal of diverting ileostomy post ultra-LAR were selected for the study. Eligible patients underwent sacral nerve modulator implantation as a two-stage procedure. Bowel diaries and the Cleveland Clinic Faecal Incontinence Score were used to measure faecal incontinence and QoL. RESULTS: Twelve patients underwent permanent implantation of a sacral nerve stimulator. Median follow-up was 34 months (interquartile range (IQR) 20.25-62.5 months). The median improvement in faecal incontinence was 90% (IQR 76.25-98.75%) and the median improvement in patient QoL was 80% (IQR 71.25-93.75%). Patients who had previously been treated with biofeedback showed a median improvement in incontinence of 75% compared to 90% which was found in patients who had not had prior biofeedback treatment. The mean percentage improvement in patients with an internal anal sphincter defect was 80% compared to 90% seen in patients with an intact sphincter. CONCLUSIONS: The results of this study suggest that sacral nerve modulation should be more widely considered as an effective treatment strategy for patients with faecal incontinence following LAR.

Prevalence of low anterior resection syndrome at a regional Australian centre.

BACKGROUND: With decreasing indication for abdominoperineal resection and an increase in sphincter preserving surgery, there is a growing population of patients who suffer from low anterior resection syndrome (LARS). The aim of this study is to use the LARS score to determine the prevalence of LARS at a regional centre in Australia and determine the effect of short- and long-course neoadjuvant therapy, anastomotic technique and interval from surgery will also be assessed. METHODS: Patients who had undergone an anterior resection (high, low or ultralow) at a regional centre over an 11-year period were identified. Eligible patients were contacted to complete a LARS score questionnaire. Results were analysed to determine the rate of major LARS and possible causative roles of certain patient and treatment-related variables. RESULTS: A total of 64 of 76 patients (84%) returned completed questionnaires. The prevalence of major LARS was 37.5%. Short-course neoadjuvant therapy appeared to be more likely to be associated with major LARS compared to long course (odds ratio (OR) = 2.4, 95% confidence interval (CI) 0.37-15.3, P = 0.35); however, this did not reach statistical significance. Rates of major LARS appear to decrease slowly over time and J-pouch colonic anastomosis appears to be slightly protective against major LARS (OR = 0.7, 95% CI 0.12-3.9, P = 0.70); however, neither results were statistically significant. CONCLUSION: The rate of major LARS at this regional centre is 37.5%. Larger prospective multicentre studies are required to determine impact of variables such as type of neoadjuvant therapy, anastomotic techniques and progression of LARS over time.

A meta-analysis of the prevalence of Low Anterior Resection Syndrome and systematic review of risk factors.

AIM: To summarize the reported prevalence and causative factors of Low Anterior Resection Syndrome (LARS) from studies using the LARS score. METHODS: A systematic literature search was conducted using Pubmed, Ovid Medline and the Cochrane database. Searches were performed using a combination of MeSH (medical subject headings) terms and key terms. Studies that were included used the LARS score as their primary collection tool. Studies were excluded if initial surgery was not for malignancy, or if the majority of LARS scores were from patients less than 1 year post initial surgery or closure of diverting stoma. Eligible studies were assessed with a validated quality assessment tool prior to performing a meta-analysis with quality effects model. Meta-analysis was conducted with prevalence estimates that had been transformed using the double arcsine method. RESULTS: Following the initial search and implementation of inclusion and exclusion criteria 11 studies were deemed suitable for meta-analysis. Meta-analysis found the estimated prevalence of major LARS was 41% (95% CI 34 -48). Where possible outlier studies were excluded, the prevalence was 42% (95%CI 35-48). Radiotherapy and tumour height were the most consistently assessed variables, both showing a consistent negative effect on bowel function. Defunctioning ileostomy was found to have a statically significant negative impact on bowel function in 4 of 11 studies. The majority of reported data has been produced by groups in Denmark and the United Kingdom with limited numbers provided by other locations. Available data is heterogenous with some variables having limited numbers, making meta-analysis of certain variables impossible. CONCLUSIONS: There is significant prevalence of Low Anterior Resection Syndrome following oncological rectal resection. A low anastomotic height or history of radiotherapy are major risk factors.