Karen Nugent

Quality of life in stoma patients.

BACKGROUND: Patients with stomas face many difficulties both physical and psychological. Little is known about the long-term problems and the impact on patient lifestyle of a permanent stoma. This study was designed to address the problems faced by patients with stomas. METHODS: Patients were identified from the Stoma Care Department records for the years 1985 to 1992 and were contacted by mail. A questionnaire was designed to assess postoperative care, quality of life issues, and equipment problems. Responses were recorded on either a visual analog scale, a choice of yes-or-no alternatives, or by selection from a list of responses. RESULTS: A total of 542 eligible patients were contacted, and 391 replies were received. Major stomal problems included rashes (51 percent), leakage (36 percent), and ballooning (90 percent of patients with ileostomy). The majority of patients experienced some change in lifestyle (80 percent), and more than 40 percent of patients had problems with their sex lives. CONCLUSION: Many patients cope extremely well with a stoma; however, some patients experience considerable difficulty and distress. Improved preoperative assessment and counseling with longer follow-up by the stoma department would be helpful in the management of these patients and probably would contribute to improvement in the quality of their lives.

Results of salvage abdominoperineal resection for anal cancer after radiotherapy.

PURPOSE: Nonsurgical treatment of anal cancer by radiotherapy alone or combined with chemotherapy is the standard therapy for epidermoid carcinoma of the anal canal. Surgery is only recommended for treatment failures. Very few studies have been devoted to the outcome of this salvage surgery. The aim of this study is to evaluate these results. METHODS: A retrospective review from 1986 to 1995 revealed 21 patients with residual or recurrent anal canal carcinoma after initial radiotherapy, operated on by abdominoperineal resection. Patients were reviewed as to age, gender, initial treatment, any symptoms of recurrence, duration until recurrence, any diagnosis imaging, treatment, and outcome. RESULTS: None of these 21 patients had known lymph node involvement or metastases at radiotherapy or at salvage abdominoperineal resection. Eleven patients had residual disease (positive biopsy less than 6 months after the end of radiotherapy) and 10 had tumor recurrence (more than 6 months after cessation of treatment). Recurrence occurred at a mean of 15 (range, 9–41) months after radiotherapy. All 21 patients underwent an abdominoperineal resection. Pathologic examination of the 21 specimens showed complete excision in all cases except one and lymph node metastases in two cases. There was no perioperative mortality. The mean follow-up after surgery was 40 months; no patients were lost to follow-up. Of the 21 patients, 10 died and 11 lived, of whom 9 are disease free. The overall survival rate at three years after salvage abdominoperineal resection was 58 percent. The overall survival rate for patients with residual disease (vs. recurrence) at three years was 72 percent (vs. 29 percent) and at five years was 60 percent (vs. 0 percent;P=0.06). CONCLUSIONS: Salvage abdominoperineal resection for anal cancer can be expected to yield a number of survivors from residual disease, but the low rate of survival after abdominoperineal resection for recurrent disease suggests the need for additional postoperative treatment if salvage abdominoperineal resection is performed.

Decision-making algorithm for the STARR procedure in obstructed defecation syndrome: position statement of the group of STARR Pioneers.

Internal rectal prolapse (rectal intussusception) and rectocele are frequent clinical findings in patients suffering from refractory constipation that may be best characterized as obstructive defecation syndrome. However, there is still no clear evidence whether the stapled transanal rectal resection (STARR) procedure provides a safe and effective surgical option for symptom resolution in patients with obstructive defecation syndrome, as evidence-based guidelines and functional long-term results are still missing. On the basis of the need for objective evaluation, a European group of experts was founded (Stapled Transanal Rectal Resection Pioneers). Derived from 2 meetings (October 26-28, 2006, Gouvieux, France and November 28-29, 2007, St Gallen, Switzerland) a concept for treatment options in patients suffering from obstructive defecation syndrome was developed, including a clear decision-making algorithm specifically focusing on the role of the stapled transanal rectal resection procedure based on clinical symptoms and dynamic imaging and inclusion and exclusion criteria for the stapled transanal rectal resection procedure.

STARR with Contour® Transtar™: prospective multicentre European study

Objective  The stapled transanal rectal resection (STARR) in patients with defecation disorders is limited by the shape and capacity of the circular stapler. A new device has been recently developed, the Contour® Transtar™ stapler, in order to improve the safety and effectiveness of the STARR technique. The study has been designed to confirm this declaration.

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. ACTH = adrenocorticotropin hormone; CRF = corticotrophin releasing factor; DAB = diaminobenzidine; IL = interleukin; SNS = sympathetic nervous system; VEGF = vascular endothelial growth factor.

Early experience with laparoscopic extralevator abdominoperineal excision within an enhanced recovery setting: analysis of short-term outcomes and quality of life

INTRODUCTION Conventional abdominoperineal excision for low rectal cancer has a higher local recurrence and reduced survival compared to anterior resection. An extralevator abdominoperineal excision (ELAPE) may improve outcome through removal of increased tissue in the distal rectum. Experience with ELAPE is limited and no studies have reported on quality of life (QOL) following this procedure. We describe a minimally invasive approach to ELAPE within an enhanced recovery programme, and present short-term results and QOL analyses. METHODS All laparoscopic ELAPEs were included in a prospective database. Demographics, intra-operative and post-operative outcomes were evaluated. Postoperative QOL was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) questionnaires QLQ-C30 and QLQ-CR29. RESULTS Thirteen laparoscopic ELAPEs were performed over a two-year period. All were enrolled in an enhanced recovery programme. The median age was 76. The median tumour height was 20 mm (range: 0-50 mm) from the dentate line and all patients received neoadjuvant treatment. The median duration of surgery was 300 minutes (range: 120-488 minutes), the mean blood loss was 150 ml and one procedure was converted to open surgery. There was no circumferential resection margin involvement or tumour perforation. The median duration of use of intravenous fluid, patient controlled analgesia and urinary catheterisation was 2, 2 and 2.5 days respectively and the median length of hospital stay was 7.5 days. Two patients developed perineal wound dehiscence. QOL analysis revealed high global health status (90.8), physical (91.3), emotional (98.3) and social functioning (100) scores, which compared favourably with EORTC reference values and published QOL scores following conventional abdominoperineal excision. CONCLUSIONS Laparoscopic ELAPE within an enhanced recovery setting is a feasible and safe approach with acceptable short-term outcomes and post-operative quality of life.

Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study.

Aim  Accurate and reliable imaging of pelvic floor dynamics is important for tailoring treatment in pelvic floor disorders; however, two imaging modalities are available. Barium proctography (BaP) is widely used, but involves a significant radiation dose. Magnetic resonance (MR) proctography allows visualization of all pelvic midline structures but patients are supine. This project investigates whether there are measurable differences between BaP and MR proctography. Patient preference for the tests was also investigated.

Systematic review of the quality of life issues associated with anal cancer and its treatment with radiochemotherapy.

PurposeRadiochemotherapy is the standard of care for the treatment of anal carcinoma achieving good loco-regional control and sphincter preservation. This approach is however associated with acute and late toxicities including haematological, skin, bowel function and genito-urinary complications. This paper systematically reviews studies addressing the quality of life (QoL) implications of anal cancer and radiochemotherapy. The paper also evaluates how QoL is assessed in anal cancer.MethodsMedline, EMBASE, CINAHL, PsycInfo, Web of Science and the Cochrane Library were searched for publications (1996–2014) reporting the effects on patients of anal cancer and radiochemotherapy.ResultsOf the 152 papers reporting treatment-related effects on patients, only 11 provided a formal assessment of QoL. In the absence of an anal cancer-specific measure, QoL was assessed using generic cancer instruments such as the core EORTC quality of life questionnaire (EORTC QLQ-C30) or colorectal cancer tools such as the EORTC QLQ-CR29. Bowel function, particularly diarrhoea, and sexual problems were the most commonly reported QoL concerns. The review of QoL issues of anal cancer patients treated with radiochemotherapy is limited by the QoL assessment measures used. It is argued that certain treatment-related toxicities, for example skin-induced radiation problems, are overlooked or inadequately represented in existing measures.ConclusionsThis review emphasises the need to develop an anal cancer-specific QoL measure and to incorporate QoL as an outcome of future trials in anal cancer. The results of this review are informative to clinicians and patients in terms of treatment decision-making.

Multidisciplinary team meetings for pelvic floor disorders

Dear Sir, Windsor and Forbes [1] make a compelling case for the implementation of multidisciplinary team (MDT) meetings for patients with inflammatory bowel disease. We would like to draw attention to another group of patients that benefit from an MDT approach to their management, namely those with pelvic floor disorders. Estimates suggest that one in every nine women will undergo surgery for pelvic floor disorders during their lifetime and that 30% of these will require additional surgery for the same condition [2]. These patients have an underappreciated and complex group of problems characterized by anal and ⁄ or urinary incontinence, obstructive defaecation, pelvic organ prolapse and pelvic pain. Often there is abnormality in both anterior and posterior compartments. Historically, patients have been managed by specialists in colorectal surgery, gynaecology, urology and gastroenterology. However, this focused organ-specific approach fails to recognize a more global problem of pelvic floor dysfunction and results in partial treatment. The involvement of a MDT enables appropriate patient-centred treatment across traditional disciplines aimed at improving quality of life. Given the proven benefits of the MDT approach in cancer care [3] and some benign disorders [4–7], there is now a contemporary movement to evolve such an approach to patients with pelvic floor disorders. Furthermore, the escalating number of surgical procedures (such as STARR, EXPRESS, sacral nerve stimulation and anterior rectopexy) and medical treatment options (botox, biofeedback and irrimatic pumps) available mean that no one centre or specialist can deliver the full breadth of treatment options at the present time, and further argues the need for specialist pelvic floor MDTs. The Southern Region Pelvic Floor MDT is the first of its kind in the UK and has been running for 1 year with meetings every 3 months. New cases with complex pelvic floor dysfunction are discussed and feedback on previous cases is provided. Core members of the team include colorectal surgeons with a special interest in pelvic floor pathology, urogynaecologists, gastroenterologists with an interest in bowel motility, specialist radiologists and nurse specialists. This team coordinates the involvement of other specialist services such as physiotherapy and clinical psychologists to fully meet the needs of this challenging group of patients. Between meetings, the group interacts via email to discuss cases. For the colorectal surgeons involved, the opportunity to operate in tandem on selected patients is encouraged. This MDT approach has encouraged best evidence-led practise, standardization of patient care across different units, building of cross-specialty bridges, and most importantly, improved patient satisfaction and management (in an era of increased patient expectation). Other benefits have been improved individual and trust risk management for the newer procedures introduced in the management of these patients. It is our belief that the shortcomings in cancer care that led to the widespread implementation of MDT’s in the UK over a decade ago [8] are present in the contemporary management of patients with pelvic floor pathologies. Parallel to Windsor and Forbes who initiate a debate on the role and future of MDT meetings outside of cancer care, we would like to recommend extension of the MDT approach to pelvic floor disorders.

Anal Cancer. Position Statement of the Association of Coloproctology of Great Britain and Ireland Introduction

Development of these written guidelines followed the anal cancer consensus meeting held in October 2008 at the Royal College of Surgeons of England under the guidance of the Association of Coloproctology of Great Britain and Ireland. Multi-disciplinary team working has become established in the last 10 years for colorectal cancer, and several sets of Local, National, and International Guidelines have been developed for the management of colorectal cancer. In the existing guidelines, anal cancer receives only limited coverage because it is a rare tumour. The relative rarity of anal cancer means that clinicians are more likely to face uncertainty in the management of these tumours when they do occur. Anal cancer accounts for approximately 4% of large bowel malignancies; however, there is some evidence that its incidence is increasing. Over 80% of anal cancers are of squamous origin arising from the squamous epithelium of the anal canal and perianal area; 10% are adenocarcinomas arising from the glandular mucosa of the upper anal canal, the anal glands and ducts. A very rare and particularly malignant tumour is anal melanoma. Lymphomas and sarcomas of the anus are even less common but have increased in incidence in recent years, particularly among patients with human immunodeficiency virus (HIV). There has also been a rise in the incidence of other anal epidermoid tumours among patients with HIV.