Sequential assessment of bowel function and anorectal physiology after anterior resection for cancer: a prospective cohort study.

AIM: The aim of this study was to investigate changes in bowel function and anorectal physiology (ARP) after anterior resection for colorectal cancer. METHOD: Patients were recruited from November 2006 to September 2008. Cleveland Clinic Incontinence (CCI) scores and stool frequency were determined by patient questionnaires before surgery (t0 ) and at three (t3 ), six (t6 ), nine (t9 ) and 12 (t12 ) months after restoration of intestinal continuity. ARP measurements were recorded at T0 , T3 and T12 . Endoanal ultrasound was performed at T0 and T12 . RESULTS: Eighty-nine patients were included. CCI score increased postoperatively then normalized, whereas stool frequency did not change. Patients who had neoadjuvant radiotherapy or a lower anastomosis had increased incontinence and stool frequency in the postoperative period, whereas those with defunctioning stomas or open surgery had increased stool frequency alone. Maximum resting pressure, volume at first urge and maximum rectal tolerance were reduced throughout the postoperative period. Radiotherapy, lower anastomosis and defunctioning stoma (but not operative approach) altered manometric parameters postoperatively. Maximum rectal tolerance correlated with incontinence and first urge with stool frequency. The length of the anterior internal anal sphincter decreased postoperatively. CONCLUSIONS: Incontinence recovers in the first year after anterior resection. Radiotherapy, lower anastomosis, defunctioning stoma and open surgery have a negative influence on bowel function. ARP may be useful if bowel dysfunction persists beyond 12 months.

Management guidelines for low anterior resection syndrome - the MANUEL project.

AIM: Little is known about the pathophysiology of low anterior resection syndrome (LARS), and evidence concerning the management of patients diagnosed with this condition is scarce. The aim of the LARS Expert Advisory Panel was to develop practical guidance for healthcare professionals dealing with LARS. METHOD: The 'Management guidelines for low anterior resection syndrome' (MANUEL) project was promoted by a team of eight experts in the assessment and management of patients with LARS. After a face-to-face meeting, a strategy was agreed to create a comprehensive, practical guide covering all aspects that were felt to be clinically relevant. Eight themes were decided upon and working groups established. Each working group generated a draft; these were collated by another collaborator into a manuscript, after a conference call. This was circulated among the collaborators, and it was revised following the comments received. A lay patient revised the manuscript, and contributed to a section containing a patient's perspective. The manuscript was again circulated and finalized. A final teleconference was held at the end of the project. RESULTS: The guidance covers all aspects of LARS management, from pathophysiology, to assessment and management. Given the lack of sound evidence and the often poor quality of the studies, most of the recommendations and conclusions are based on the opinions of the experts. CONCLUSIONS: The MANUEL project provides an up-to-date practical summary of the available evidence concerning LARS, with useful directions for healthcare professional and patients suffering from this debilitating condition.

Accuracy of integrated total pelvic floor ultrasound compared to defaecatory MRI in females with pelvic floor defaecatory dysfunction.

OBJECTIVE: Defaecatory MRI allows multicompartmental assessment of defaecatory dysfunction but is often inaccessible. Integrated total pelvic floor ultrasound (transperineal, transvaginal, endoanal) may provide a cheap, portable alternative. The accuracy of total pelvic floor ultrasound for anatomical abnormalities when compared with defaecatory MRI was assessed. METHODS: The dynamic images from 68 females who had undergone integrated total pelvic floor ultrasound and defaecatory MRI between 2009 and 2015 were blindly reviewed. The following were recorded: rectocoele, enterocoele, intussusception and cystocoele. RESULTS: There were 26 rectocoeles on MRI (49 rectocoeles on ultrasound), 24 rectocoeles with intussusception on MRI (19 rectocoeles on ultrasound), 23 enterocoeles on MRI (24 enterocoeles on ultrasound) and 49 cystocoeles on MRI (35 cystocoeles on ultrasound). Sensitivity and specificity of total pelvic floor ultrasound were 81% and 33% for rectocoele, 60% and 91% for intussusception, 65% and 80% for enterocoele and 65% and 84% for cystocoele when compared with defaecatory MRI. This gave a negative-predictive value and positive-predictive value of 74% and 43% for rectocoele, 80% and 79% for intussusception, 82% and 63% for enterocoele and 48% and 91% for cystocoele. CONCLUSION: Integrated total pelvic floor ultrasound may serve as a screening tool for pelvic floor defaecatory dysfunction; when normal, defaecatory MRI can be avoided, as rectocoele, intussusception and enterocoele are unlikely to be present. Advances in knowledge: This is the first study to compare integrated total pelvic floor ultrasound with defaecatory MRI. The results support the use of integrated total pelvic floor ultrasound as a screening tool for defaecatory dysfunction.

The cost of anal cancer in England: retrospective hospital data analysis and Markov model.

BACKGROUND: Anal cancer requires a multidisciplinary approach to treatment with often complex interventions. Little is known regarding the associated costs and resource use. METHODS: Patient records were extracted from a national hospital database to estimate the number of patients treated for anal cancer in England. Identified resource use was linked to published UK cost estimates to quantify the reimbursement of treatment through the Payment by Results system. A mathematical model was developed simultaneously to validate findings and to calculate the average 10-year cost of treating a squamous cell anal carcinoma case from diagnosis. The model utilised data from the Association of Coloproctology of Great Britain and Ireland's anal cancer position statement. RESULTS: On average, 1,564 patients were admitted to hospital and 389 attended an outpatient facility per year. The average annual cost per inpatient and outpatient ranged from £4,562-£5,230 and £1,146-£1,335, respectively. Based on the model estimates, the inflated cost per case was between £16,470-£16,652. Results were most sensitive to the mode of admission for primary treatment and the costs of staging/diagnosis (inflated range: £14,309-£23,264). CONCLUSIONS: Despite limitations in the available data, these results indicate that the cost of treating anal cancer is significant. Further observational work is required in order to verify these findings.

Reduced parenteral nutrition requirements following anastomosis of a short residual colonic segment to a short jejunum.

A 22-year-old man suffered an acute small bowel infarct leading to extensive bowel resection, resulting in only 20 cm of jejunum to a jejunostomy, although he also had 50 cm of residual colon with a mucous fistula. The patient was out on long-term home parenteral nutrition (PN) but endured high stomal losses of 5-6 L per day and, despite all conventional measures, required 6.1 L of fluid (including PN) and 555 mmol sodium per day. Although body mass index was maintained, he suffered debilitating malaise and recurrent episodes of catheter-related sepsis and also developed persistently abnormal liver function tests. He was considered a potential intestinal transplant patient, but before taking that step, he opted for reanastomosis of his residual colon to his jejunum, ending in a colostomy. At surgery, only 30 cm of additional bowel lengthening could be achieved, but despite this, the patient's stomal losses reduced to 2.5 L per day, intravenous fluid requirements reduced to 4.1 L per day, and liver function normalized. The patient also gained 7.5 kg despite no change in PN caloric prescription, and his quality of life was dramatically enhanced. The case illustrates that even a small length of colon can grant significant improvements, probably via improvements in small bowel transit and adaptive changes, better sodium and water resorption with decreased hyperaldosteronism, and enhanced energy and nitrogen recovery. Reanastomosis of defunctioned colon should therefore always be considered a management option in short bowel syndrome.

Relationship between loneliness and proangiogenic cytokines in newly diagnosed tumors of colon and rectum.

OBJECTIVE: To investigate the association of serum levels of proangiogenic cytokines with different indices of social support and loneliness by measuring the levels of expression of two important proangiogenic cytokines, vascular endothelial growth factor (VEGF), and interleukin-6 in tumors of colon and rectum. Lack of social support has been prospectively associated with cancer progression. METHODS: Fifty-one newly diagnosed patients with colorectal tumors (mean age, 68.3 years) completed two measures of loneliness 1 to 2 days before their surgical treatment. The first was an explicit self-report questionnaire, which tapped into negative feelings as a result of low social support. The second was a standardized computer-based task, which measured loneliness implicitly. Immunohistochemical analyses were performed on tumor tissues post surgery to determine the expression of cytokines. RESULTS: Logistic regression showed that higher levels of implicit loneliness independently predicted stronger expression of VEGF, controlling for Dukes stage and explicit loneliness, both of which were nonsignificant predictors. No significant relationships were found between the loneliness measures and interleukin-6. CONCLUSIONS: The results of this study suggest VEGF to be an angiogenic mechanism through which loneliness may lead to worse cancer-related outcomes. Implications are discussed in terms of devising targeted psychosocial and immunotherapeutic interventions for cancer patients with low social support.