Peter Christensen

Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence.

PURPOSE: This study evaluated long-term results of transanal irrigation for defecation disturbances. METHODS: Three hundred and forty-eight patients [248 women and 100 men; median age 52 years (range, 5-85)] suffering from constipation and fecal incontinence were introduced to transanal irrigation. Patients using transanal irrigation at follow-up received a mailed questionnaire describing bowel function and practical procedures. Results from patients not responding and patients no longer using transanal irrigation were drawn from hospital records and telephone interviews. Background variables were analysed using multivariate logistic regression. RESULTS: After a mean follow-up of 21 months (range, 1-116) 163 of 348 patients (47 percent) had a successful outcome from treatment with transanal irrigation. Success rates varied between patients with different underlying pathology: neurogenic bowel dysfunction, 67 of 107 (63 percent); anal insufficiency, 36 of 70 (51 percent); sequela to anorectal surgery, 14 of 48 (29 percent); idiopathic constipation, 27 of 79 (34 percent); and miscellaneous, 19 of 44 (43 percent). Factors correlating with positive outcome were neurogenic bowel dysfunction and anal insufficiency as underlying pathology, low rectal volume at urge to defecate, low maximal rectal capacity, and low anal squeeze pressure increment. Two nonfatal bowel perforations were found in approximately 110,000 irrigation procedures. CONCLUSIONS: Transanal irrigation is simple and safe for long-term treatment for defecation disturbances with greatest benefit in patients with neurogenic bowel dysfunction.

Low anterior resection syndrome and quality of life: an international multicenter study.

BACKGROUND: An increasing number of patients are surviving a diagnosis of rectal cancer. The majority of the patients are treated with the sphincter-sparing surgical procedure low anterior resection, and 50% to 90% of these patients experience bowel dysfunction, known as the low anterior resection syndrome. No previous studies have investigated the association between the low anterior resection syndrome and quality of life in an international setting with the use of a validated instrument for the classification of the low anterior resection syndrome. OBJECTIVE: The aim of this study was to investigate the association between quality of life and the low anterior resection syndrome in European patients who have had rectal cancer. DESIGN: The study was designed as an international cross-sectional study involving 5 centers in 4 European countries. PATIENTS: All patients had undergone low anterior resection for rectal cancer, had no stoma, had no dissemination or recurrence at the time of the study, and were at least 16 months past surgery. INTERVENTIONS: The patients received by mail the Low Anterior Resection Syndrome Score and the quality-of-life questionnaire EORTC QLQ-C30. MAIN OUTCOME MEASURES: Eight subscales were selected to be the focus of this study: global quality of life; physical, role, emotional, and social functioning; fatigue; constipation; and diarrhea. RESULTS: A total of 796 patients were included, which corresponds to a response rate of 75.0%. In comparison with patients without low anterior resection syndrome, patients with major low anterior resection syndrome fared substantially worse in all selected subscales (difference ≥ 10 points, p < 0.01), with the exception of constipation. LIMITATIONS: The cross-sectional design prevents an evaluation of causality. CONCLUSIONS: The quality of life of patients who have had rectal cancer is closely associated with the severity of the low anterior resection syndrome. Therefore, it is important that clinicians and researchers focus on this syndrome to improve the prevention and the treatment of bowel dysfunction and the information given to patients.

International Validation of the Low Anterior Resection Syndrome Score

Objective:The aims of this study were to investigate the convergent and discriminative validity and reliability of the low anterior resection syndrome (LARS) score in an international setting. Background:The LARS score is a simple self-administered questionnaire measuring bowel dysfunction after rectal cancer surgery. The score is intended to be commonly used in international research and clinical practice in the future. Therefore, a thorough validation in an international setting is of utmost importance. Methods:The LARS score was translated using methods in keeping with current international recommendations. A total of 801 patients operated for rectal cancer in Sweden, Spain, Germany, and Denmark completed the LARS score questionnaire, including an anchor question assessing the impact of bowel function on quality of life. A subgroup of 218 patients completed the LARS score twice. Data were analyzed per country. Results:The LARS score has demonstrated a high convergent validity in terms of a high correlation between LARS score and quality of life (P < 0.001). Sensitivity ranged from 67.7% to 88.3% and specificity from 58.1% to 86.3%. The LARS score was able to discriminate between groups of patients differing with regard to radiotherapy, surgery, and age (P < 0.05). The score also demonstrated high reliability at test-retest with narrow limits of agreement and no statistically significant difference between scores at the first and second test. Conclusions:The Swedish, Spanish, German, and Danish versions of the LARS score have proven to be valid and reliable tools for measuring LARS in European rectal cancer patients.

Fermentation of crude glycerol from biodiesel production by Clostridium pasteurianum

Clostridium pasteurianum can utilize glycerol as the sole carbon source for the production of butanol and 1,3-propanediol. Crude glycerol derived from biodiesel production has been shown to be toxic to the organism even in low concentrations. By examination of different pretreatments we found that storage combined with activated stone carbon addition facilitated the utilization of crude glycerol. A pH-controlled reactor with in situ removal of butanol by gas stripping was used to evaluate the performance. The fermentation pattern on pretreated crude glycerol was quite similar to that on technical grade glycerol. C. pasteurianum was able to utilize 111xa0g/l crude glycerol. The average consumption rate was 2.49xa0g/l/h and maximum consumption rate was 4.08xa0g/l/h. At the maximal glycerol consumption rate butanol was produced at 1.3xa0g/l/h. These rates are higher than those previously reported for fermentations on technical grade glycerol by the same strain. A process including pretreatment and subsequent fermentation of the crude glycerol could be usable for industrial production of butanol by C. pasteurianum.

Transanal irrigation for disordered defecation: a systematic review.

Abstract Transanal irrigation for treatment of disordered defecation has been widely used among caregivers. Unique in its simplicity, reversible and minimally invasive, transanal irrigation has begun to find its place in the treatment hierarchy. Scheduled transanal irrigation aims to ensure emptying of the left colon and rectum. This prevents faecal leakage between washouts, providing a state of pseudocontinence, and re-establishes control over the time and place of defecation. Furthermore, regular evacuation of the rectosigmoid prevents constipation. The studies presented in this review represent the continuum of increasing evidence and knowledge of transanal irrigation for disordered defecation: from proof in principle through better knowledge of the physiology, towards establishing the indications and ensuring the safety of the treatment. Evidence of the superiority of transanal irrigation in spinal cord injury patients with neurogenic bowel dysfunction is provided, also from a health-economic perspective. Finally, a proposal is presented for an algorithm for the introduction of transanal irrigation for disordered defecation before irreversible surgery is considered.

Flocculation, coagulation, and precipitation of manure affecting three separation techniques.

The effects of polymer flocculation before manure separation were investigated, through testing both a linear and a branched polymer. Centrifugation removed 60% of phosphorus from raw manure (control), whereas raw manure clogged the filters during gravity drainage and pressure filtration. At optimum flocculation, 95% of phosphorus was removed using any of the three methods. Optimum flocculation was achieved when 2.8meq of polymer charge was added per kg of manure, corresponding to 0.6g/kg of highly charged, branched polymer or 0.85g/kg of less-charged, linear polymer. If 10mmol of ferric chloride was added per kg of manure, 2% more phosphorus was precipitated and removed. The linear polymer formed loose flocs and was superior for reducing turbidity, whereas the branched polymer formed compact flocs that deflocculated at high polymer doses. The branched polymer, however, was best for pressure filtration, as overdosing with the linear polymer resulted in high resistance.

Predicting the Risk of Bowel-related Quality-of-life Impairment After Restorative Resection for Rectal Cancer: A Multicenter Cross-sectional Study

BACKGROUND: Restorative anterior resection is considered the optimal procedure for most patients with rectal cancer and is frequently preceded by radiotherapy. Both surgery and preoperative radiotherapy impair bowel function, which adversely affects quality of life. OBJECTIVE: This study aimed to report symptoms associated with and key predictors for bowel-related quality-of-life impairment. DESIGN: The study included a cross-sectional cohort. SETTINGS: This was a multicenter study from 12 United Kingdom centers. PATIENTS: A total of 578 patients with rectal cancer underwent curative restorative anterior resection between 2001 and 2012 (median, 5.25 years postsurgery). MAIN OUTCOME MEASURES: Patients completed outcome measures that assessed bowel dysfunction (low anterior resection syndrome score), incontinence (Wexner score), and quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30), plus an anchor question: “Overall how does bowel function affect your quality of life?” RESULTS: The response rate was 80% (462/578). Overall, 85% (391/462) of patients reported bowel-related quality-of-life impairment, with 40% (187/462) reporting major impairment. A large difference in global quality of life (22 points; p < 0.001) was reported for “none” versus “major” impairment, with greatest symptom severity being diarrhea (25 points; p < 0.001), insomnia (24 points; p < 0.001), and fatigue (20 points; p < 0.001). Regression analysis identified major impairment in 60% and 45% of patients with low rectal cancer treated with and without preoperative radiotherapy compared with 47% and 33% of middle/upper rectal cancers with and without preoperative radiotherapy. LIMITATIONS: Advances in radiotherapy delivery and improvements in posttreatment symptom control, although currently of limited efficacy, imply that the content of this consent aid should be re-evaluated in 5 to 10 years. CONCLUSIONS: Before a restorative anterior resection, patients with rectal cancer should be informed that bowel-related quality-of-life impairment is common. The key risk factors are neoadjuvant therapy and a low tumor height. This study presents quality-of-life and functional outcome data, along with a consent aid, that will enhance this preoperative patient discussion.

Outcome of transanal irrigation for bowel dysfunction in patients with spinal cord injury.

Abstract Background/Objective: To compare symptoms of neurogenic bowel dysfunction in patients with spinal cord injury (SCI) at baseline and after 10 weeks of treatment with transanal irrigation and to identify possible factors that could predict outcome of the treatment. Methods: Sixty-two patients with SCI (45 men and 17 women; mean age, 47.5 ± 15.5 [SD] years) from 5 specialized European SCI centers were offered treatment with transanal irrigation for a 10-week period. Bowel function was assessed at baseline and at termination using the Cleveland Clinic Constipation Scoring System (CCCSS; 0–30, 30 = severe symptoms), St. Marks Fecal Incontinence Grading System (FIGS; 0-24, 24 = severe symptoms), and the Neurogenic Bowel Dysfunction score (NBD; 0–47, 47 severe symptoms). Factors predicting improvement in bowel function scores were identified using a general linear model. Results: Severity of symptoms at termination was significantly reduced compared with baseline values (CCCSS: −3.4; 95% confidence interval [CI], −4.6 to −2.2; FIGS: −4.1; 95% Cl, −5.2 to −2.9; NBD: −4.5; 95% Cl, −6.6 to −2.4; all P < 0.0001). Although several factors were associated with positive outcome, no consistent and readily explainable pattern could be identified. Surprisingly, hand function, level of dependency, predominant symptom, and colonic transit time were not associated with outcome. Conclusions: Transanal irrigation in patients with SCI reduces constipation, improves anal continence, and improves symptom-related quality of life. No readily obtainable factors could predict outcome, which might be because of the relatively low number of patients. This supports the use of trial and error as a strategy in deciding on a bowel management method for neurogenic bowel dysfunction.

Colorectal transport in normal defaecation.

Objectiveu2002 Colorectal luminal transport during defaecation can be assessed by means of scintigraphy. However, normal values remain to be established and inter‐ and intra‐subjective variation is unknown. The aim of the study was to describe colorectal transport during normal defaecation by means of a new method for colorectal scintigraphy and to determine inter‐ and intrasubjective variation.

The use of dielectric spectroscopy in the investigation of the effect of polymer choice on the flocculation of polystyrene particles.

The flocculation of colloidal suspensions using synthetic polymeric flocculants is an important operation in separation processes. Optimizing flocculant use requires insight into the underlying mechanisms governing flocculation. As most existing methods for the online characterization of flocculation processes can only be used on dilute suspensions, new methods applicable at high solid content levels are of interest. This study used dielectric spectroscopy to investigate the mechanisms involved in the flocculation of polystyrene particles with three different cationic polymers. We observed that the relaxation time of the dielectric dispersion increased as particle flocculation was initiated. Reduction of particle charge due to polymer addition was found to reduce the magnitude of the dielectric dispersion, whereas the formation of aggregates increased it. This resulted in decreasing magnitude when charge reduction was the primary cause of flocculation, whereas the magnitude increased when the particles were flocculated by bridging.