Fecal Incontinence: The Importance of a Structured Pathophysiological Model.

Fecal incontinence has an enormous social and economic impact and may significantly impair quality of life. Even though fecal incontinence is a common complaint in (aging) adults, a structured pathophysiological model of the clinical presentations of fecal incontinence is missing in current literature. The most frequent manifestations of fecal incontinence are passive fecal loss, urge incontinence, or mixed fecal incontinence. At our institution, we treat 400 patients per year with defecation disorders, including a significant number of patients with fecal incontinence. On the basis of this experience, we have tried to create a concept that merges current insight in causes and treatment options in a clinically useful algorithm. By applying the system of anamnesis and physical examination described in this article and expanding it with simple additional anorectal examination, in most patients, one can determine the type of fecal incontinence and choose a targeted therapy.

Psychological distress and quality of life following positive fecal occult blood testing in colorectal cancer screening.

OBJECTIVE: This study aimed to assess psychological functioning, quality of life, and regret about screening after a positive fecal immunochemical test (FIT) and subsequent colonoscopy, and to evaluate changes over time. METHODS: This is a prospective cohort study. Individuals aged 55 to 75 with a positive FIT that were referred for colonoscopy between July 2017 and November 2018, were invited to complete questionnaires related to psychological distress and health-related quality of life at three predefined time points: before colonoscopy, after histopathology result notification, and after 6 months. Four questionnaires were used: the Psychological Consequences Questionnaire (PCQ), the six-item Cancer Worry Scale (CWS), the Decision Regret Scale (DRS), and the 36-item Short-Form (SF-36). RESULTS: A total of 1066 participants out of 2151 eligible individuals were included. Patients with cancer showed a significant increase in psychological dysfunction (P = .01) and cancer worry (P = .008) after colonoscopy result notification, and a decline to pre-colonoscopy measurements after 6 months. In the no-cancer groups, psychological dysfunction and cancer worry significantly decreased over time (P < .05) but there was no ongoing decline. After 6 months, 17% of participants with no cancer experienced high level of cancer worry (CWS ≥ 10). Yet, only 5% reported high level of regret about screening participation (DRS > 25). A good global quality of life was reported in participants with no cancer. CONCLUSION: Some psychological distress remains up to 6 months after colonoscopy in participants who tested false-positive in the Dutch bowel cancer screening program.

Clinical Relevance of a Grading System for Anastomotic Leakage After Low Anterior Resection: Analysis From a National Cohort Database.

BACKGROUND: Anastomotic leakage is a severe complication after low anterior resection for rectal cancer. With a global increase in registration initiatives, adapting uniform definitions and grading systems is highly relevant. OBJECTIVE: This study aimed to provide clinical parameters to categorize anastomotic leakage into subcategories according to the International Study Group of Rectal Cancer. DESIGN: All of the patients who underwent a low anterior resection in the Netherlands with primary anastomosis were included using the population-based Dutch Surgical Colorectal Audit. SETTINGS: Data were derived from the Dutch Surgical Colorectal Audit. MAIN OUTCOME MEASURES: The development of grade B anastomotic leakage (requiring invasive treatment but no surgery) versus grade C anastomotic leakage (requiring reoperation) was measured. RESULTS: Overall, 4287 patients underwent low anterior resection with primary anastomosis. A total of 159 patients (4%) were diagnosed with grade B anastomotic leakage versus 259 (6%) with grade C. Hospital stay and intensive care unit visits were significantly higher in patients with grade C anastomotic leakage compared with patients with grade B leakage. Mortality in patients with grade C leakage was higher compared with grade B leakage, although nonsignificant (5.8% vs 2.5%; p = 0.12). Multivariate analysis showed that patients with diverting stomas (n = 2866) had a decreased risk of developing grade C leakage compared with grade B (OR = 0.17 (95% CI, 0.10-0.29)). Male patients had an increased risk of developing grade C anastomotic leakage, and patients receiving neoadjuvant treatment before surgery had an increased risk of developing grade B anastomotic leakage. LIMITATIONS: Some possibly relevant variables, such as smoking and nutritional status, were not recorded in the database. CONCLUSIONS: Anastomotic leakage after low anterior resection for rectal cancer was a frequent observed complication in this cohort. Differences in clinical outcome suggest that grade B and C leakage should be considered separate entities in future registrations. In patients with a diverting stoma, the chances of experiencing grade C anastomotic leakage were reduced. See Video Abstract at http://links.lww.com/DCR/A315.

Large variation in the use of defunctioning stomas after rectal cancer surgery. A lack of consensus.

BACKGROUND AND OBJECTIVES: When deciding about the use of a defunctioning stoma in rectal cancer surgery, benefits and risks need to be weighed. This study investigated: (1a) factors associated with the use of defunctioning stomas; (1b) hospital variation; and (2) surgeons' perceptions regarding factors that determine this decision. METHODS: Population-based data from the Dutch Surgical Colorectal Audit were used. Factors for receiving a defunctioning stoma were analyzed with multivariate logistic regression analysis. Hospital variation was assessed before and after case-mix adjustment. A survey was performed among gastroenterological surgeons on the importance of factors for the decision to construct a defunctioning stoma. RESULTS: In total 4368 patients were analyzed and 103 (34%) surgeons participated. Male gender, higher body mass index, lower tumors, preoperative radiotherapy, and treatment in a teaching/university hospital increased the odds for a defunctioning stoma. Unadjusted hospital variation ranged from 0% to 98%. Variation remained after case-mix adjustment (0-100%). There was large variation in factors considered important for the decision; almost all factors were ranked as 'most important' at least once. CONCLUSIONS: There is large variation in the use of defunctioning stomas for patients with rectal cancer, and a lack in uniformity of the selection criteria. These results underline the need to improve current decision making and identification of high-risk patients.

Optimal Treatment Strategy in Rectal Cancer Surgery: Should We Be Cowboys or Chickens?

BACKGROUND AND PURPOSE: Surgeons and hospitals are increasingly accountable for their postoperative complication rates, which may lead to risk adverse treatment strategies in rectal cancer surgery. It is not known whether a risk adverse strategy leads to providing better care. In this study, the association between the strategy of hospitals regarding defunctioning stoma construction and postoperative outcomes in rectal cancer treatment was evaluated. METHODS: Population-based data of the Dutch Surgical Colorectal Audit, including 3,104 patients undergoing rectal cancer resection between January 2009 and July 2012 in 92 hospitals, were used. Hospital variation in (case-mix-adjusted) defunctioning stoma rates was calculated. Anastomotic leakage and 30-day mortality rates were compared in hospitals with a high and low tendency towards stoma construction. RESULTS: Of all patients, 76 % received a defunctioning stoma; 9.6 % of all patients developed anastomotic leakage. Overall postoperative mortality rate was 1.8 %. The hospitals' adjusted proportion of defunctioning stomas varied from 0 to 100 %, and there was no significant correlation between the hospitals' adjusted stoma and anastomotic leakage rate. Severe anastomotic leakage was similar (7.0 vs. 7.1 %; p = 0.95) in hospitals with the lowest and highest stoma rates. Mild leakage and postoperative mortality rates were higher in hospitals with high stoma rates. CONCLUSIONS: A high tendency towards stoma construction in rectal cancer surgery did not result in lower overall anastomotic leakage or mortality rates. It seems that the ability to select patients for stoma construction is the key towards preferable outcomes, not a risk adverse strategy.

Ranking and rankability of hospital postoperative mortality rates in colorectal cancer surgery.

OBJECTIVES: To examine to what extent random variation and variation in case-mix influence hospital rankings on the basis of mortality rates and to determine the suitability of mortality for ranking hospitals in colorectal surgery. BACKGROUND: Comparing and ranking postoperative mortality rates between hospitals becomes increasingly popular. Differences in hospital case-mix, and chance variation related to caseload, may influence rankings. The suitability of mortality for rankings remains unclear. METHODS: Data were derived from the Dutch Surgical Colorectal Audit. Hospital rankings based on fixed- and random-effects logistic regression models, unadjusted and adjusted for case-mix were compared with the percentile based on expected ranks (the chance that a hospital performs better than a random hospital). Rankability, measuring which part of variation between hospitals is not due to chance, was calculated. RESULTS: Some 25,591 patients undergoing colorectal resections in 92 hospitals were evaluated. Postoperative mortality rates ranged between 0% and 8.8%. Adjustment for case-mix with a fixed-effects model caused large changes in rankings. A smaller additional effect on changes in rankings occurred after adjusting with a random-effects model, with lower volume hospitals moving toward the mean. Percentile based on expected ranks ranged between 10% and 85%. Rankability was 38%, meaning that 62% of hospital variation in mortality was due to chance. CONCLUSIONS: Hospital ranks changed after case-mix adjustment and random-effects models, compared with unadjusted analysis. A large proportion of hospital variation in mortality was due to chance. Caution should be warranted when interpreting hospital rankings on the basis of postoperative mortality. Percentiles of expected ranks may help identify hospitals with exceptional performance.

Synchronous colorectal carcinoma: a risk factor in colorectal cancer surgery.

BACKGROUND: Synchronous colorectal carcinoma occurs in 1% to 8% of cases. There are little data on the impact of synchronous colorectal cancer on surgical treatment and short-term postoperative outcomes. OBJECTIVE: The purpose of this work was to evaluate clinical characteristics and treatment patterns of synchronous colorectal carcinoma and their influence on short-term postoperative outcomes in comparison with solitary colorectal carcinoma. DESIGN: This was a population-based observational study. Patient and tumor characteristics, treatment patterns, and postoperative outcomes are described for patients with a solitary and synchronous colorectal carcinoma separately. Multivariable logistic regression analysis was used to analyze the association between synchronous colorectal carcinoma and postoperative complications in comparison with a solitary colorectal carcinoma. SETTINGS: The study included in-hospital registration for the Dutch Surgical Colorectal Audit. PATIENTS: Patients were those with primary colorectal carcinoma from 2009 to 2011. MAIN OUTCOME MEASURES: Severe postoperative complications, reinterventions, and 30-day mortality were measured. RESULTS: Of 25,413 patients with colorectal cancer, 884 (3.5%) had synchronous colorectal tumors. Patients with synchronous colorectal carcinoma were older and more often of male sex compared with patients with solitary colorectal carcinoma. In ≥ 35% of cases, an extended surgical procedure was conducted (n = 310). In multivariable logistic regression analysis, synchronous colorectal carcinoma was associated with a higher risk of severe postoperative complications (OR, 1.40; 95% CI, 1.20-1.63) and reinterventions (OR, 1.37; 95% CI, 1.14-1.65) compared with solitary colorectal carcinoma but not with higher 30-day mortality (OR, 1.34; 95% CI, 0.96-1.88). LIMITATIONS: This study was limited by the data being self-reported. Case-mix adjustment was limited to information available in the data set, and no long-term outcome data were available. CONCLUSIONS: Synchronous colorectal carcinomas are prevalent in 3.5% of patients and require a different treatment strategy in comparison with solitary colorectal carcinoma. Postoperative outcomes are unfavorable, most likely because of extensive surgery.

Safety of elective colorectal cancer surgery: non-surgical complications and colectomies are targets for quality improvement.

BACKGROUND: Mortality following severe complications (failure-to-rescue, FTR) is targeted in surgical quality improvement projects. Rates may differ between colon- and rectal cancer resections. METHODS: Analysis of patients undergoing elective colon and rectal cancer resections registered in the Dutch Surgical Colorectal Audit in 2011-2012. Severe complication- and FTR rates were compared between the groups in univariate and multivariate analysis. RESULTS: Colon cancer (CC) patients (n = 10,184) were older and had more comorbidity. Rectal cancer (RC) patients (n = 4,906) less often received an anastomosis and had more diverting stomas. Complication rates were higher in RC patients (24.8% vs. 18.3%, P < 0.001). However, FTR rates were higher in CC patients (18.6% vs. 9.4%, P < 0.001). Particularly, FTR associated with anastomotic leakage, postoperative bleeding, and infections was higher in CC patients. Adjusted for casemix, CC patients had a twofold risk of FTR compared to RC patients (OR 1.89, 95% CI 1.06-3.37). CONCLUSIONS: Severe complication rates were lower in CC patients than in RC patients; however, the risk of dying following a severe complication was twice as high in CC patients, regardless of differences in characteristics between the groups. Efforts should be made to improve recognition and management of postoperative (non-)surgical complications, especially in colon cancer surgery.