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Aim: The aim of this study was to measure the impact of bowel dysfunction and a poorly functioning stoma on the risk of sexual inactivity and sexual dysfunction in female patients. Method: In a population‐based cross‐sectional study, Danish rectal cancer patients diagnosed between 2001 and 2014 were invited to answer a comprehensive questionnaire regarding cancer‐ and treatment‐related late side effects after rectal cancer treatment. Bowel function was assessed using the Low Anterior Resection score and stoma function using the Colostomy Impact score. Female sexuality was measured by sexual activity, overall sexual dysfunction (the Rectal Cancer Female Sexuality score) and by different domains of sexual dysfunction (Sexual Vaginal Changes questionnaire). Results: Eight‐hundred and thirteen female patients completed the questionnaire (response rate 49.2%). Major bowel dysfunction did not significantly increase the risk of sexual inactivity (OR 1.39, 95% CI 0.93–2.07) but clearly increased the risk of sexual dysfunction (OR 3.03, 95% CI 1.67–5.51). The most distinct problems were dyspareunia and inability to complete intercourse. On the contrary, poor stoma function increased the risk sexual inactivity (OR 2.26, 95% CI 1.16–4.40) but not the risk of sexual dysfunction (OR 0.74, 95% CI 0.27–1.99). The most distinct problem was dissatisfaction with own physical appearance. Conclusions: Both bowel dysfunction and stoma dysfunction negatively, but differently, affect sexuality. After restorative surgery, bowel dysfunction was primarily associated with sexual dysfunction while poor stoma function after abdominoperineal excision was associated with sexual inactivity. [ABSTRACT FROM AUTHOR]

The article presents the results of an online Delphi survey and meetings to develop an international consensus definition of low anterior resection syndrome (LARS). It states the pragmatic definition of LARS is a disordered bowel function following rectal resection which impacts quality of life. It mentions the Delphi survey, patient consultation, and consensus meeting refined priorities to eight consequences and eight symptoms.

Aim: Sacral nerve stimulation (SNS) for faecal incontinence (FI) at subsensory amplitudes as low as 50% of the sensory threshold has been found to be effective at 3 months' follow‐up. Furthermore, alternative pacemaker settings may improve functional outcome in patients with suboptimal treatment efficacy. In this work we aim to explore if sub‐sensory stimulation as low as 50% of sensory threshold is effective at 1‐year follow‐up. We also aimed to investigate if 31 Hz (frequency) or 90 µs (pulse width) stimulation improved treatment efficacy in dissatisfied patients. Method: All patients in whom the stimulation was effective in controlling FI (satisfied group) were encouraged to have the stimulation amplitude reduced. Those in whom the device was less effective (dissatisfied group) were offered alternative frequency settings or pulse width (31 Hz or 90 µs). Patients were follow‐up after 12 months and evaluated by a visual analogue scale (VAS) for patient satisfaction, the Cleveland Clinic Continence Score (CCCS), Rockwood Faecal Incontinence Quality of Life Scale (QoL) and a bowel habit diary. Results: Two hundred and nineteen patients were contacted, with a response rate of 71% (n = 155). Those who were successfully contacted comprised 110 (71%) patients classed as satisfied and 45 (29%) as dissatisfied. Seventy‐five (68%) of the satisfied patients agreed to have their stimulation amplitude reduced. At 1‐year follow‐up the median amplitude had reduced from 1.5 V [interquartile range (IQR) 0.85–2.0 V] to 0.75 V (IQR 0.45–1.4 V) (P‐value < 0.001) representing an overall reduction of 39% (6.6–62.5%). There were no significant differences in VAS, CCCS or QoL despite subsensory stimulation at 1‐year follow‐up. In 28% of the dissatisfied patients alternative pacemaker settings improved VAS to satisfactory levels. Conclusion: Subsensory stimulation is as effective as stimulation at or above the sensory threshold. High‐frequency stimulation (31 Hz) can improve functional outcome in patients with loss of efficacy. [ABSTRACT FROM AUTHOR]

Aim: There has been limited focus on female sexuality after treatment for colorectal cancer. The aim of this study was to investigate long‐term female sexual dysfunction in disease‐free colorectal cancer survivors in the Danish population. Method: All female Danish patients treated for colorectal cancer between 2001 and 2014 were included if they reported to have been sexually active at the time of diagnosis. They were requested to answer the validated Sexual Vaginal Changes Questionnaire. Results: A total of 2402 patients were included for analysis (43%). Overall, rectal cancer patients reported more sexual inactivity and problems compared to colon cancer patients, but there were no differences in any sexual function domains when excluding irradiated patients and patients with a permanent stoma. A permanent stoma was associated with sexual inactivity [OR 2.56 (95% CI 1.42–4.70)] and overall sexual dysfunction [OR 2.95 (95% CI 1.05–6.38)] in colon cancer patients, as well as inactivity [OR 1.43 (95% CI 1.01–2.04)] and overall dysfunction [OR 2.0 (95% CI 1.18–3.41)] in rectal cancer patients. Furthermore, a permanent stoma was associated with dyspareunia [OR 2.17 (95% CI 1.39–3.38)] and reduced vaginal dimension [OR 3.16 (95% CI 1.99–5.01)]. In rectal cancer patients, radiotherapy exposure increased the odds for overall sexual dysfunction [OR 1.80 (95% CI 1.02–3.16)] and was associated with dyspareunia [OR 1.72 (95% CI 0.95–3.12)]. Conclusion: Sexual problems after treatment of colorectal cancer are common. Major risk factors are a permanent stoma and radiotherapy. Relevant patients should be offered professional counselling and treatment. [ABSTRACT FROM AUTHOR]

Aim: The aim of this investigation was to examine quality of life after surgical treatment for low rectal cancer. Method: This was a population‐based, cross‐sectional study on quality of life in patients treated for rectal cancer from 2001 to 2007. The European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ‐C30) and a single question on the impact of bowel/stoma function on quality of life were sent to patients who had undergone abdominoperineal excision (APE) or low anterior resection (LAR) for rectal cancer with tumours below 10 cm from the anal verge. Results: Informative answers were obtained from 898 patients (87%). EORTC QLQ‐C30 outcomes were very similar for APE and LAR patients in univariate analysis. When adjusted for neoadjuvant radiotherapy and gender, multivariate analysis showed that LAR patients had lower global health status (OR 1.32, 95% CI 1.03; 1.68, P = 0.026) and higher occurrence of constipation (OR 0.47, 95% CI 0.32; 0.69, P < 0.001) and diarrhoea (OR 0.47, 95% CI 0.35; 0.64, P < 0.001). Analysis of the anchor question showed that LAR patients had significantly higher negative impact of bowel function on quality of life in both univariate (OR 3.38, 95% CI 2.62; 4.37, P < 0.001) and multivariate analysis (OR 3.71, 95% CI 2.86; 4.83, P < 0.001) compared with APE. Conclusion: For patients with low rectal cancer, we found LAR patients had worse global health status and problems with diarrhoea and constipation compared with APE patients. [ABSTRACT FROM AUTHOR]

Aim: It is common clinical practice to follow patients for a period of years after treatment with curative intent of nonmetastatic colorectal cancer, but follow‐up strategies vary widely. The aim of this systematic review was to provide an overview of recommendations on this topic in guidelines from member countries of the European Society of Coloproctology, with supporting evidence. Method: A systematic search of Medline, Embase and the guideline databases Trip database, BMJ Best Practice and Guidelines International Network was performed. Quality assessment included use of the AGREE‐II tool. All topics with recommendations from included guidelines were identified and categorized. For each subtopic, a conclusion was made followed by the degree of consensus and the highest level of evidence. Results: Twenty‐one guidelines were included. The majority recommended that structured follow‐up should be offered, except for patients in whom treatment of recurrence would be inappropriate. It was generally agreed that clinical visits, measurement of carcinoembryoinc antigen and liver imaging should be part of follow‐up, based on a high level of evidence, although the frequency is controversial. There was also consensus on imaging of the chest and pelvis in rectal cancer, as well as endoscopy, based on lower levels of evidence and with a level of intensity that was contradictory. Conclusion: In available guidelines, multimodal follow‐up after treatment with curative intent of colorectal cancer is widely recommended, but the exact content and intensity are highly controversial. International agreement on the optimal follow‐up schedule is unlikely to be achieved on current evidence, and further research should refocus on individualized 'patient‐driven' follow‐up and new biomarkers. [ABSTRACT FROM AUTHOR]

Aim: The aim was to develop and validate a scoring system for the assessment of chronic pain on quality of life (QoL) following surgical treatment of rectal cancer (RC). Method: Patients diagnosed with RC between 2001 and 2014 in Denmark were evaluated for inclusion. Eligible patients were mailed questionnaires concerning pain and QoL. Questionnaire items were associated with QoL by odds ratio using regression analyses. The patients were randomized into a development group and a validation group. The most significant items were each assigned a score value based on multivariate‐adjusted odds ratio. Validity was tested in the validation group using receiver operating characteristic curves and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire – Core 30 (EORTC QLQ‐30). Results: A total of 1928 eligible patients completed the questionnaire; 1072 were randomized to the development group and 856 to the validation group. The calculated scores included the six most important questionnaire items giving a score range of 0–45 which identified three groups: no significant pain, minor pain syndrome and major pain syndrome. Our results suggest a significant correlation between QoL assessment and the presence of major pain. Conclusion: We have developed and validated a reliable, QoL‐based scoring system for chronic post‐surgical pain following RC. [ABSTRACT FROM AUTHOR]

Aim: There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. Method: Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side‐to‐side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. Results: One thousand three hundred and forty‐seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54–1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52–1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46–4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04–2.64, P = 0.04). Conclusion: This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high‐risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration. [ABSTRACT FROM AUTHOR]

Abstract: Aim: The aim of this prospective case–control study was to evaluate the rate of pelvic insufficiency fractures (PIFs) in Denmark using MRI at the 3‐year follow‐up. All patients had rectal cancer and had undergone surgery with or without preoperative chemo‐radiotherapy (CRT). Method: Patients registered with primary rectal cancer in the Danish Colorectal Cancer Group database, who underwent rectal cancer resection from April 2011 through August 2012, were invited to participate in a national MRI study aiming to detect local recurrence and evaluate quality of the surgical treatment. Pelvic MRI including bone‐specific sequences 3 years after treatment was obtained. The primary outcome was the rate of PIFs; secondary outcome was risk factors of PIFs evaluated in multivariate analysis. Results: During the study period, 890 patients underwent rectal cancer surgery. Of these, 403 patients were included in the MRI study and had a 3‐year follow‐up MRI. PIFs were detected in 49 (12.2%; 95% CI 9.0–15.4) patients by MRI. PIFs were detected in 39 patients (33.6%; 95% CI 24.9–42.3) treated with preoperative CRT compared to 10 (3.5%; 95% CI 1.3–5.6) non‐irradiated patients (P < 0.001). In a multivariate analysis female gender (OR = 3.52; 95% CI 1.7–7.5), age above 65 years (OR = 3.20; 95% CI 1.5–6.9) and preoperative CRT (OR = 14.20; 95% CI 6.1–33.1) were significant risk factors for PIFs. Conclusion: Preoperative CRT in the treatment of rectal cancer was associated with a 14‐fold higher risk of PIFs after 3 years, whereas female gender and age above 65 years each tripled the risk of PIFs. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To investigate whether complete mesocolic excision (CME) might carry a higher risk of bowel dysfunction and subsequent reduction in quality of life compared with conventional resection. Method: A cross‐sectional questionnaire study based on data from a national survey regarding long‐term bowel function and a population‐based cohort study comparing CME (study group) with conventional resection (control group). A total of 622 patients undergoing elective resection for Stage I–III sigmoid adenocarcinoma at four university colorectal centres between June 2008 and December 2014 were eligible to receive the questionnaire in mid‐November 2015. Primary outcomes were four or more bowel movements daily, nocturnal bowel movements, unproductive call to stool, obstructive sensation and impact of bowel function on quality of life (QOL). Results: One hundred and twenty‐seven (69.0%) and 289 (66.0%) patients in the study and control groups, respectively, responded to the questionnaire after medians of 4.41 [interquartile range (IQR) 2.50, 5.83] and 4.57 (IQR 3.15, 5.82) years, respectively (P = 0.048). CME was not associated with: increased risk of four or more bowel movements daily [adjusted OR 1.14 (95% CI 0.59–2.14; P = 0.68)], nocturnal bowel movements [adjusted OR 1.31 (0.66–2.53; P = 0.43)], unproductive call to stool [adjusted OR 0.99 (0.54–1.77; P = 0.97)] or obstructive sensation [adjusted OR 1.01 (0.56–1.78; P = 0.96)]. While one in five patients in both groups had moderate to severe impact of bowel function on QOL, there was no association with CME. Conclusion: For patients with sigmoid cancer, CME is associated with neither higher risk of bowel dysfunction nor impaired QOL. [ABSTRACT FROM AUTHOR]

Abstract: Aim: Sacral nerve stimulation has been recognized as an effective treatment option for faecal incontinence when conservative therapy has failed. Refinement of the procedural technique and the use of a curved stylet may improve the functional outcome. Our aim was to explore the relationship between lead model, functional outcome, stimulation amplitude and the need for extra visits during the first year of follow‐up. Method: Patient data from May 2009 to February 2017, which were prospectively collected in a local database, were extracted and analysed for differences between lead model and improvement in incontinence scores, stimulation amplitude and the need for additional visits during the first year of follow‐up. Results: A foramen lead model 3093(straight stylet) was used in 134 patients and lead model 3889(curved stylet) was used in 40 patients. There were no differences in baseline characteristics or incontinence scores. Comparing results between the two lead models we found that the improvement (delta value) in the Wexner score at 6 months’ follow‐up (P = 0.05) and the St Mark's score at 12 months’ follow‐up (P = 0.02) was greater in patients implanted with lead model 3889(curved stylet) compared with patients implanted with lead model 3093(straight stylet). Patients implanted with lead model 3889 (curved stylet) were less likely to have to alter the stimulation amplitude or pole configuration during the first year of follow‐up (P = 0.04). No difference was found for stimulation amplitude (P = 0.170) or the need for additional visits (P = 0.663). Conclusion: Lead model 3889 (curved stylet) improves functional results compared with lead model 3093 (straight stylet) during the first year of follow‐up. Lead model 3889 (curved stylet) reduces the need for reprogramming but has no influence on stimulation amplitude or the number of additional visits required. [ABSTRACT FROM AUTHOR]

Abstract: The improvements in surgical technique brought about by the widespread adoption of total mesorectal excision plane dissection in rectal cancer has substantially improved survival and recurrence rates from this disease. For the first time in 50 years, the outcomes in rectal cancer have overtaken those of colon cancer. Professor Madoff's overview lecture and the experts’ round table discussion address whether applying the surgical principles already achieved in rectal cancer can meet with similar success in colon cancer, how this can be achieved and the challenges we face. [ABSTRACT FROM AUTHOR]

Abstract: The process of determining the best treatments that should be offered to patients with newly diagnosed colon and rectal cancer remains highly variable around the world. The aim of this expert review was to agree the key elements of good quality preoperative treatment decision making. [ABSTRACT FROM AUTHOR]

Aim Ileal pouch-anal anastomosis is a procedure offered to patients with ulcerative colitis who opt for restoration of bowel continuity. The aim of this study was to determine the risk of pouch failure and ascertain the risk factors associated with failure. Method The study included 1991 patients with ulcerative colitis who underwent ileal pouch-anal anastomosis in Denmark in the period 1980-2013. Pouch failure was defined as excision of the pouch or presence of an unreversed stoma within 1 year after its creation. We used Cox proportional hazards regression to explore the association between pouch failure and age, gender, synchronous colectomy, primary faecal diversion, annual hospital volume (very low, 1-5 cases per year; low, 6-10; intermediate 11-20; high > 20), calendar year, laparoscopy and primary sclerosing cholangitis. Results Over a median 11.4 years, 295 failures occurred, corresponding to 5-, 10- and 20-year cumulative risks of 9.1%, 12.1% and 18.2%, respectively. The risk of failure was higher for women [adjusted hazard ratio ( aHR) 1.39, 95% CI 1.10-1.75]. Primary non-diversion ( aHR 1.63, 95% CI 1.11-2.41) and a low hospital volume ( aHR, very low volume vs high volume 2.30, 95% CI 1.26-4.20) were also associated with a higher risk of failure. The risk of failure was not associated with calendar year, primary sclerosing cholangitis, synchronous colectomy or laparoscopy. Conclusion In a cohort of patients from Denmark (where pouch surgery is centralized) with ulcerative colitis and ileal pouch-anal anastomosis, women had a higher risk of pouch failure. Of modifiable factors, low hospital volume and non-diversion were associated with a higher risk of pouch failure. [ABSTRACT FROM AUTHOR]

Background Abnormal central nervous system processing of visceral sensation may be a part of the pathogenesis behind idiopathic fecal incontinence ( IFI). Our aim was to characterize brain differences in patients with IFI and healthy controls by means of structural magnetic resonance imaging ( MRI) and diffusion tensor imaging ( DTI). Methods In 21 female patients with IFI and 15 female healthy controls, whole-brain structural differences in gray matter volume (GMV), cortical thickness, and white matter tracts fractional anisotropy ( FA) were quantified. For this purpose, we used voxel-based morphometry, surface based morphometry and tract-based spatial statistic, respectively. Furthermore, associations between structural brain characteristics and latencies of rectal sensory evoked electroencephalography potentials were determined. Key Results Compared to healthy controls, IFI patients had significantly reduced FA values, reflecting reduced white matter tract integrity, in the left hemisphere superior longitudinal fasciculus (SLF), posterior thalamic radiation, and middle frontal gyrus (MFG), all P<.05. No differences were observed in GMV or in cortical thickness. The reduced FA values in the SLF and MFG were correlated with prolonged latencies of cortical potentials evoked by rectal stimuli (all P<.05). Conclusions & Inferences This explorative study suggests that IFI patients have no macrostructural brain changes, but exhibit microstructural changes in white matter tracts relevant for sensory processing. The clinical relevance of this finding is supported by its correlations with prolonged latencies of cortical potentials evoked by rectal stimulation. This supports the theories of central nervous system changes as part of the pathogenesis in IFI patients. [ABSTRACT FROM AUTHOR]

Aim The anastomosis technique used following right-sided colonic resection is widely variable and may affect patient outcome. This study aimed to assess the association between leak and anastomosis technique (stapled vs handsewn). Method This was a prospective, multicentre, international audit including patients undergoing elective or emergency right hemicolectomy or ileo-caecal resection operations over a 2-month period in early 2015. The primary outcome measure was the presence of anastomotic leak within 30 days of surgery, determined using a prespecified definition. Mixed effects logistic regression models were used to assess the association between leak and anastomosis method, adjusting for patient, disease and operative cofactors, with centre included as a random-effect variable. Results This study included 3208 patients, of whom 78.4% ( n = 2515) underwent surgery for malignancy and 11.7% ( n = 375) underwent surgery for Crohn's disease. An anastomosis was performed in 94.8% ( n = 3041) of patients, which was handsewn in 38.9% ( n = 1183) and stapled in 61.1% ( n = 1858). Patients undergoing handsewn anastomosis were more likely to be emergency admissions (20.5% handsewn vs 12.9% stapled) and to undergo open surgery (54.7% handsewn vs 36.6% stapled). The overall anastomotic leak rate was 8.1% (245/3041), which was similar following handsewn (7.4%) and stapled (8.5%) techniques ( P = 0.3). After adjustment for cofactors, the odds of a leak were higher for stapled anastomosis (adjusted OR = 1.43; 95% CI: 1.04-1.95; P = 0.03). Conclusion Despite being used in lower-risk patients, stapled anastomosis was associated with an increased anastomotic leak rate in this observational study. Further research is needed to define patient groups in whom a stapled anastomosis is safe. [ABSTRACT FROM AUTHOR]

Aim In aiming to cure patients with colorectal cancer surgery, the surgeon must carefully dissect the mesocolon and mesorectum and divide the vascular pedicle near to its origin so as to include all local lymph nodes. This has been termed complete mesocolic excision. The distance from the distal vascular tie to the bowel wall in the fixed specimen is an indication as to the quality of surgery but this does not assess the length of the residual vascular pedicle and, by implication, residual lymph nodes. The aim of this study was to establish if our surgeons were carrying out complete mesocolic excision by assessing the length of the proximal arterial pedicle and relating this to arterial length in the fixed specimen. Method This was a single centre prospective study of patients undergoing elective surgery for locally advanced colorectal cancer. An abdominal and pelvic CT scan was performed 2 days postoperatively and a radiologist blinded to the operative procedure measured the length of the residual arterial stump. Similarly, the length of the vessel in the fixed resected specimen and lymph node yield were also recorded. Results Fifty-two patients were recruited. The mean length of the residual arterial stump was 38 mm (95% CI: 33-43), which was significantly longer than the < 10 mm recommended in guidelines ( P < 0.0001). The mean length was 31 mm (95% CI: 25-37) and 49 mm (95% CI: 40-57) for left and right sided resections respectively. There was no correlation between the residual arterial stump and the pathology. Conclusions The residual arterial length was greater than suggested by guidelines and may indicate that our surgery is less radical than we planned. Caution should be taken when using pathological measurements of vascular ligation as it may not reflect the height of the pedicle division. [ABSTRACT FROM AUTHOR]

Aim The study investigated the effect of collagen mesh-assisted closure at the donor site in preventing the formation of incisional hernia following construction of a vertical rectus abdominis myocutaneus (VRAM) flap as part of pelvic surgery for recurrent colorectal cancer. Method The study was a double-blinded randomized controlled superiority trial that was designed and performed according to the Consolidated Standards of Reporting Trials ( CONSORT) Statement. Eligible patients undergoing surgery that included a VRAM flap for advanced colorectal pelvic malignancy were prospectively randomized to conventional abdominal wound closure or collagen mesh-assisted closure. The primary end-point was incisional herniation at 1 year confirmed by CT. Secondary end-points were CT-verified incisional herniation at 3 and 36 months, clinically recognizable incisional herniation, donor-site and reconstructive-site complications, surgical mortality, postoperative morbidity, postoperative recovery and survival. Results In total, 58 (29 conventional closure; 29 mesh-assisted closure) patients were included. At 1 year, incisional herniation on the CT scan was found in 12 (50%) of 24 patients in the conventional closure group, and in 8 (33%) of 24 in the mesh-assisted closure group ( P = 0.38). No significant difference between the groups was found in surgical mortality, early or late complications or survival. Donor-site morbidity was comparable between the two groups. Conclusion No preventative effect of collagen mesh-assisted closure was observed following VRAM flap reconstruction. [ABSTRACT FROM AUTHOR]

Aim This systematic review aimed to provide an overview of (inter)national guidelines on the treatment of peritoneal metastases of colorectal cancer origin ( PMCRC) and to determine the degree of consensus and available evidence with identification of topics for future research. Method A systematic search of MEDLINE, Embase, PubMed as well as Tripdatabase, National Guideline Clearinghouse, BMJ Best Practice and Guidelines International Network was performed to identify (inter)national guidelines and consensus statements from oncological or surgical societies on PMCRC. The quality of guidelines was assessed using the AGREE- II score. Topics followed by recommendations were extracted from the guidelines. The recommendations, highest level of supporting evidence and the degree of consensus were determined for each topic. Results Twenty-one guidelines were included, in most (15) of which cytoreductive surgery with hyperthermic intraperitoneal chemotherapy ( CRS/ HIPEC) was recommended in selected patients based on level 1b evidence. Substantial consensus was also reached on the benefit of multidisciplinary team discussion and the achievability of a (near) complete cytoreduction ( CC0-1) without supporting evidence. Both evidence and consensus were lacking regarding other aspects including preoperative positron emission tomography/ CT, second look surgery in high risk patients, the optimal patient selection for CRS/ HIPEC, procedural aspects of HIPEC and (perioperative) systemic therapy. Conclusion In currently available guidelines, evidence and consensus on the treatment strategy for PMCRC are lacking. Updates of guidelines are ongoing and future (randomized) clinical trials should contribute to multidisciplinary and international consensus on treatment strategies for PMCRC. [ABSTRACT FROM AUTHOR]

Aim Our unit has recently shown that sacral nerve stimulation ( SNS) has a significantly positive short-term effect on selected patients with diarrhoea-predominant or mixed irritable bowel syndrome ( IBS). The aim of the present prospective study was to evaluate the medium-term efficacy of SNS for IBS to establish whether SNS could have a future role in the treatment of IBS. Method Patients with IBS who had previously been implanted with a permanent neurostimulator as part of a randomized, controlled, crossover study, were assessed for medium-term follow-up. The primary end-point was change in the IBS-specific symptom score (Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire) from baseline to 3-year follow-up. The secondary end-point was a change in the IBS-specific quality of life score (Irritable Bowel Syndrome-Impact Scale questionnaire) from baseline to 3-year follow-up. Results Of 26 patients, 20 were eligible for 3-year follow-up. The median IBS-specific symptom score was significantly lower at 3-year follow-up (30, range 13-71) than at baseline (62, 45-80) ( P = 0.0001). The effect was observed in all symptom clusters within the score. Also, the median IBS-specific quality of life score was significantly improved at 3-year follow-up (52, 26-169) compared with baseline (135, 82-180, P = 0.0002). The effect was observed in all domains of the score. As per the protocol, 75% of patients were judged therapeutic successes. Seventy per cent of patients had a more than 50% reduction in daily IBS symptoms. Conclusion At medium-term follow-up, SNS continues to be an effective treatment for highly selected patients with diarrhoea-predominant or mixed IBS. [ABSTRACT FROM AUTHOR]

Background Sacral nerve stimulation ( SNS) is a well-established treatment for fecal incontinence but its mode of action remains obscure. Anal sphincter function is usually evaluated with manometry but resistance to distension may be a more appropriate parameter than luminal pressure. The functional lumen imaging probe allows detailed description of distension properties of the anal canal. Our objective in this study was to characterize the impact of SNS on distension properties of the anal canal in patients with idiopathic fecal incontinence. Methods We studied 10 women (median age 64 [44-79] years) with idiopathic fecal incontinence at baseline and during SNS. The luminal geometry of the anal canal was examined with the FLIP at rest and during squeeze and the distensibility of the anal canal was investigated during filling of the bag. Key results All patients were successfully treated with SNS and the mean Wexner Incontinence Score was reduced from 14.9 ± 4 to 7.1 ± 4.8 ( P<.001). The pressure required to open the narrowest point of the anal canal during distension (yield pressure) increased from 14.5 ± 12.2 mmHg at baseline to 20.5 ± 13.3 mmHg during SNS ( P<.01). The pressure-strain elastic modulus increased non-significantly from 2.2 ± 0.5 to 2.9 ± 1.6 kPa, indicating increased stiffness of the anal canal. Conclusion and inferences The yield pressure and the resistance to distension increased in response to SNS for idiopathic fecal incontinence. This will inevitably increase the resistance to flow through the anal canal, which may contribute to the benefits of sacral nerve stimulation. [ABSTRACT FROM AUTHOR]

Aim The aim was to develop and validate a simple scoring system evaluating the impact of colostomy dysfunction on quality of life (QOL) in patients with a permanent stoma after rectal cancer treatment. Method In this population-based study, 610 patients with a permanent colostomy after previous rectal cancer treatment during the period 2001-2007 completed two questionnaires: (i) the basic stoma questionnaire consisting of 22 items about stoma function with one anchor question addressing the overall stoma impact on QOL and (ii) the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30. Answers from half of the cohort were used to develop the score and subsequently validated on the remaining half. Logistic regression analyses identified and selected items for the score and multivariate analysis established the score value allocated to each item. Results The colostomy impact score includes seven items with a total range from 0 to 38 points. A score of ≥ 10 indicates major colostomy impact (Major CI). The score has a sensitivity of 85.7% for detecting patients with significant stoma impact on QOL. Using the EORTC QLQ scales, patients with Major CI experienced significant impairment in their QOL compared to the Minor CI group. Conclusion This new scoring system appears valid for the assessment of the impact on QOL from having a permanent colostomy in a Danish rectal cancer population. It requires validation in non-Danish populations prior to its acceptance as a valuable patient-reported outcome measure for patients internationally. [ABSTRACT FROM AUTHOR]

Aim Sacral nerve stimulation (SNS) is effective for faecal incontinence (FI). Little is known about the relationship between the implantation technique and the functional outcome. This study aimed to explore the relationship between the numbers of active electrode poles (AEP) achieved during permanent lead placement and subsequent function, therapeutic amplitude and the need for extra appointments between scheduled follow-up visits. Method One hundred and eighty-six patients with FI who underwent permanent implantation between May 2009 and March 2015 with a tined (barbed) lead (3093/3080, Medtronic) using the straight stylet were registered on the European two-centre SNS prospective database (SNSPD). Correlation between the number of AEP, function, stimulation amplitude and the need for extra visits was analysed. Results The numbers of patients having an intra-operative motor response on stimulation of one, two, three and four poles were 18 (9.7%), 75 (40.3%), 61 (32.8%) and 32 (17.2%). The Wexner incontinence score was significantly reduced from 15 (±2.8) at baseline to 9.2 (±4.8) at the latest follow-up after a mean 878 ± 561 days (SD; P < 0.001). No correlation was found between the number of AEP and the functional outcome ( P > 0.05). Patients with four-AEP had a reduced therapeutic amplitude up to 289 (±146) days of follow-up ( P < 0.03). The number of AEP did not influence the need for extra follow-up visits ( P < 0.223). Conclusion The functional outcome and number of extra visits after SNS for FI did not depend on the number of AEP achieved. The therapeutic amplitude was reduced during the first postoperative year if four AEP were achieved during lead placement. [ABSTRACT FROM AUTHOR]

Aim Early results from sacral nerve stimulation (SNS) for severe irritable bowel syndrome (IBS) are promising but estimates of cost-effectiveness are lacking. Our object was to perform a cost-effectiveness analysis for SNS as an alternative to no treatment of IBS. Method This retrospective analysis was based on the results from a randomized controlled crossover study with a cost-utility analysis performed on patient-level data and modelling of censored data over a projected period of time of up to 20 years. The analysis was conducted on an intention-to-treat approach. For estimation of the uncertainty of the incremental cost-effectiveness ratio a bias corrected bootstrap analysis was performed. Results Cost-effectiveness was not reached for 4 years after permanent implantation (£31 270 per quality-adjusted life years), which was the upper limit for patient follow-up, but our data imply a cost-effectiveness from a 7-year perspective onwards. Conclusion The study indicates the SNS treatment for IBS is cost effective from a 7-year perspective onwards. [ABSTRACT FROM AUTHOR]

Aim This randomized single-blinded crossover study aimed to investigate whether bilateral sacral nerve stimulation ( SNS) is more efficient than unilateral stimulation for faecal incontinence ( FI). Method Patients with FI who responded during a unilateral test stimulation, with a minimum improvement of 50% were eligible. Twenty-seven patients who were accepted to enter the trial were bilaterally implanted with two permanent leads and pacemakers. Patients were randomized into three periods of 4 weeks' stimulation including unilateral right, unilateral left and bilateral stimulation. Symptoms scores and bowel habit diaries were collected at baseline and in each study period. A 1-week washout was introduced between each study period. Results Twenty-seven (25 female) patients with a median age of 63 (36-84) years were bilaterally implanted from May 2009 to June 2012. The median number of episodes of FI per 3 weeks significantly decreased from 17 (3-54) at baseline to 2 (0-20) during stimulation on the right side, 2 (0-42) during stimulation on the left side and 1 (0-25) during bilateral stimulation. The Wexner incontinence score improved significantly from a median of 16 (10-20) at baseline to 9 (0-14) with right-side stimulation, 10 (0-15) with left-side stimulation and 9 (0-14) with bilateral stimulation. The differences between unilateral right or unilateral left and bilateral stimulation were non-significant, for FI episodes ( P = 0.3) or for Wexner incontinence score ( P = 0.9). Conclusion Bilateral SNS therapy for FI is not superior to standard unilateral stimulation in the short term. Equal functional results can be obtained regardless of the side of implantation. [ABSTRACT FROM AUTHOR]

Aim Sacral nerve stimulation ( SNS) may be offered to patients with constipation who have failed to improve with conservative treatment. The response to SNS is variable, with a significant loss of efficacy in some patients. An increased frequency of stimulation may improve the efficacy of SNS for faecal incontinence. This study aimed to see if alteration of the pulse width or frequency improved the outcome for those with constipation. Method Eleven patients with constipation currently being treated by SNS were recruited from three centres. They were randomized to five different protocols of stimulation each applied for 5 weeks. Group 1 used standard settings (pulse width 210 μs, frequency 14 Hz); in the other four groups (Groups 2-5) the pulse width and/or frequency were halved or doubled. Patients and investigators were blinded to the group allocation. Results The Cleveland Clinic constipation score varied significantly between the five groups. Group 1 achieved the lowest score mean (± SD) 13.4 (± 4.4) ( P = 0.03). The number of digitations per defaecation was the lowest in Group 4, 90 μs and 14 Hz ( P < 0.01). No other variable changed significantly. Standard settings were the most preferred by the recruited patients. Conclusion Alteration of pulse width or frequency of stimulation had no significant effect on the outcome of SNS for constipation. [ABSTRACT FROM AUTHOR]

Aim The aim of the investigation was to examine life with a stoma after rectal cancer surgery. Method This was a population-based, cross-sectional study of patients with a stoma treated for rectal cancer from 2001 to 2007. A questionnaire was mailed to patients who had undergone abdominoperineal excision, Hartmann's procedure and anterior resection with a permanent stoma. Results Informative answers were obtained from 644 (88%) of 732 patients. Most (91%) managed the stoma on their own. There was an impact of the stoma on the quality of life in 68% of patients but this was minor in 50%. Leakage of the appliance was reported in 59%, and 58% of patients were disturbed by the smell of faeces. A parastomal hernia was reported in 57% and pain at the stoma site in 30%. There was no association between the impact of the stoma on the quality of life and gender, type of surgery, use of radiochemotherapy or the interval from surgery. Conclusion Most patients reported little or no impact on quality of life resulting from the stoma, but many patients were disturbed by the smell or leakage of faeces. The parastomal hernia rate was extremely high. [ABSTRACT FROM AUTHOR]

Aim The objective of primary radiotherapy for anal cancer is to remove cancer while maintaining anorectal function. However, little is known about anorectal function among long-term survivors without colostomy. Using a cross-sectional questionnaire study, we examined symptoms and distress related to the dysfunction of pelvic organs after radiotherapy for anal cancer. Method A questionnaire regarding anorectal, urinary and sexual symptoms was sent to anal cancer patients without recurrence or colostomy, diagnosed during 1996-2003, and treated with curative intent (chemo)radiotherapy at three Danish centres. For each symptom we assessed frequency and severity and the level of symptom-induced distress (no, little, moderate or great distress). Results Of 94 eligible patients, 84 (89%) returned the completed questionnaire at a median of 33 months after radiotherapy. Incontinence for solid stools, liquid stools and gas occurred at least monthly in 31%, 54% and 79% of patients, respectively. Overall 40% of patients reported great distress from incontinence for solid or liquid stools at least monthly. Faecal urgency occurring at least monthly was experienced by 87% of patients and caused great distress in 43%. Stress, urge or another type of urinary incontinence occurred at least monthly in 45% and caused great distress in 21%. Urinary urgency occurred at least monthly in 48% but only caused great distress in 14%. Sexual desire was severely decreased in 58% and only 24% were satisfied with their sexual function. Conclusion Distressing long-term anorectal and sexual dysfunction was common after radiotherapy for anal cancer, and morbidity due to urinary dysfunction was moderate. [ABSTRACT FROM AUTHOR]

Aim Many patients having anterior resection for rectal cancer suffer from severe long-term bowel dysfunction, known as low anterior resection syndrome ( LARS). The LARS score was developed in Denmark, and Swedish, Spanish and German versions have been validated. The aim of this study was to validate the English translation of the LARS score in British rectal cancer patients. Method Rectal cancer patients who underwent an anterior resection in 12 UK centres received the LARS score questionnaire, the EORTC QLQ-C30 and a single ad hoc quality of life question. A subgroup of patients received the LARS score questionnaire twice. Results The response rate was 80% and 451 patients were included in the analyses. A strong association between LARS score and quality of life (convergent validity) was found ( P < 0.01), discriminative validity was good ( P < 0.02) and the test-retest reliability was high (intraclass correlation coefficient 0.83). Conclusion The English translation of the LARS score has shown good psychometric properties comparable with recently published results from an international multicentre study. Thus, the English translation of the LARS score can be considered a valid and reliable tool for measuring LARS. [ABSTRACT FROM AUTHOR]

Aim In May 2010, a specialist nurse-initiated assessment and treatment algorithm for faecal incontinence ( FI) was introduced at the department of Anal Physiology, Aarhus University Hospital, Denmark. This study aimed to evaluate the effectiveness of and patient satisfaction with the program. Method A medical file audit was preformed on patients evaluated and treated for FI and discharged after September 2010. Patients were invited to participate in a structured telephone interview. This study aimed to enrol 100 patients. Patients were asked if they were satisfied with their current level of continence status (yes/no), and a numerical satisfaction score and Wexner score were recorded. These results were compared to baseline and at time of discharge. Results One-hundred patients completed the telephone interview; 73 of these patients were satisfied after a median of 420 (range: 114-586) days following discharge from the program. A median of one outpatient consultation followed by one telephone follow-up was required before the patients were discharged. The Wexner score was significantly reduced by 3.9 (±4.4) ( P < 0.001) points among the satisfied and non-significantly reduced by 0.52 (± 3.3) ( P = 0.42) points among the dissatisfied patients at follow-up compared to baseline. The satisfied and dissatisfied patients at follow-up did not differ in baseline characteristics including Wexner score. Conclusions FI can successively be evaluated and conservatively managed by specialist nurses, and these nurses achived high satisfaction rates among their patients. The concept of specialist nurse-led clinics will reduce waiting lists, and descrease the number of patients needing to be evaluated by a surgeon. [ABSTRACT FROM AUTHOR]

Background The pathophysiology behind idiopathic fecal incontinence ( IFI) is poorly understood. We hypothesized abnormal sensory pathways along the brain-gut axis as a key player in this disease, reflected in cortical evoked potentials ( CEP) from mechanical stimuli of the rectum and the anal canal. Methods CEPs were recorded during repeated rapid balloon distensions of the rectum and anal canal in 19 women with IFI (mean age: 60 ± 14, mean Wexner score: 14.7 ± 2.9) and in 19 healthy women (mean age: 56 ± 11, mean Wexner score: 1.1 ± 1.3). Latencies, amplitudes and topography of CEPs elicited by rectal distension were compared between the groups. CEPs from both rectal and anal distensions were examined using spectral band analysis of single sweeps determining the relative amplitude of five spectral bands as a proxy of neuronal processing. Key Results Compared to controls IFI patients had prolonged latency of CEPs from rectal distension by up to 27% ( p < 0.001) while amplitudes and topography were similar (all p > 0.7 and all p > 0.23). Spectral analysis of CEPs from rectal distensions showed no difference (all p > 0.1) between groups. However, analysis of CEPs following distension of the anal canal resulted in abnormally low activity in beta (8-12 Hz; p < 0.001) band and high activity in the gamma (32-70 Hz; p = 0.04) band in patients. Conclusions & Inferences IFI seems to be associated with impaired ano-rectal sensory functions in both the afferent fibers to the brain and the cortical processing of anal sensory pathways. This may play a central role for the pathogenesis of IFI. [ABSTRACT FROM AUTHOR]

Aim The Pouch Dysfunction Score (PDS) is a five-item instrument that evaluates bowel function and quality of life following restorative proctocolectomy for ulcerative colitis. The PDS includes items that have a significantly negative impact on quality of life from the patient's point of view. The study aimed to establish how pouch dysfunction is perceived by clinicians in relation to patients experience. Method Fifty-eight leading clinicians in the field of inflammatory bowel disease were invited to complete two PDS-based exercises. In part 1, they received a list of the 12 bowel symptoms from which the PDS had been developed and were asked to identify and rank (in order of severity) the five they thought had the most significantly negative impact on quality of life. In part 2, they were given the list of symptoms perceived by patients to be most troublesome and were then required to enter a score that they thought was appropriate for each item according to the impact on quality of life. Results Forty-three clinicians responded, and each correctly identified one to three items selected by patients and included in the PDS. Severity of urgency was selected by 29 (67%) clinicians, and four (9%) rated it to be the most important. Incomplete emptying after defaecation was selected by 10 (23%). Frequency of defaecation and the use of anti-diarrhoeal medication were selected by 14 (33%) and three (7%) clinicians, respectively. Twenty-six (60%) did not include incomplete emptying and 25 (58%) did not include uncontrolled loss of stool in their selection. Conclusion This study demonstrates that clinicians do not have a great understanding of the symptoms of pouch dysfunction that really matter to the patient. [ABSTRACT FROM AUTHOR]

Aim In Europe during the last decade sacral nerve stimulation ( SNS) or sacral neuromodulation ( SNM) has been used to treat faecal incontinence ( FI) and constipation. Despite this, there is little consensus on baseline investigations, patient selection and operative technique. A modified Delphi process was conducted to seek consensus on the current practice of SNS/ SNM for FI and constipation. Method A systematic literature search of SNS for FI and constipation was conducted using PubMed. A set of questions derived from the search and expert opinion were answered on-line on two occasions by an international panel of specialists from Europe. A 1-day face-to-face meeting of the experts finalized the discussion. Results Three hundred and ninety-three articles were identified from the literature search, of which 147 fulfilled the inclusion criteria. Twenty-two specialists in FI and constipation from Europe participated. Agreement was achieved on 43 (86%) of 50 domains including the set-up of service, patient selection, baseline investigations, operative technique and programming of the device. The median of agreement was 95% (35-100%). Conclusion Consensus was achieved on the majority of domains of SNS/ SNM for FI and constipation. This should serve as a benchmark for safe and quality practice of SNS/ SNM in Europe. [ABSTRACT FROM AUTHOR]

Aim Knowledge of urinary and sexual dysfunction in women after rectal cancer treatment is limited. This study addresses this in relation to the use of preoperative radiotherapy, type of surgery and the presence of bowel dysfunction. Method All living female patients who underwent abdominoperineal excision ( APE) or low anterior resection ( LAR) for rectal cancer in Denmark between 2001 and 2007 were identified. Validated questionnaires (the ICIQ- FLUTS and the SVQ) on urinary and sexual function were completed by 516 (75%) and 482 (72%) recurrence-free patients in 2009. Results Urgency and incontinence were reported by 77 and 63% of respondents, respectively. Vaginal dryness, dyspareunia and reduced vaginal dimensions occurred in 72, 53 and 29%, respectively, and 69% reported that they had little/no sexual desire. Preoperative radiotherapy was associated with voiding difficulties ( OR = 1.63, 95% CI 1.09-2.44), reduced vaginal dimensions ( OR = 4.77, 95% CI 1.97-11.55), dyspareunia ( OR = 2.76, 95% CI 1.12-6.79), lack of desire ( OR = 2.22, 95% CI 1.09-4.53) and reduced sexual activity ( OR = 0.55, 95% CI 0.30-0.98). Patients undergoing APE had a higher risk of dyspareunia ( OR = 2.61, 95% CI 1.00-6.85). Bowel dysfunction after LAR was associated with bladder storage difficulties ( OR = 1.64, 95% CI 1.01-2.65), symptoms of incontinence ( OR = 2.17, 95% CI 1.35-3.50), lack of sexual desire ( OR = 2.69, 95% CI 1.21-5.98), sexual inactivity ( OR = 0.48, 95% CI 0.24-0.96) and sexual dissatisfaction ( OR = 0.40, 95% CI 0.20-0.82). Conclusion Urinary and sexual problems are common in women after treatment for rectal cancer. Preoperative radiotherapy interferes with several aspects of urinary and sexual functioning. Bowel dysfunction after LAR is associated with urinary dysfunction and a reduction in sexual desire, activity and satisfaction. [ABSTRACT FROM AUTHOR]

Background Sacral nerve stimulation (SNS) has been demonstrated to alleviate symptoms and improve quality of life in selected patients with irritable bowel syndrome (IBS). The mechanisms of action, however, remain unknown. The aim of the study was to evaluate the effects of SNS on rectal sensitivity and biomechanical properties in patients with IBS. Methods Twenty patients with diarrhea-predominant (n = 11) or mixed (n = 9) IBS were treated with SNS in a controlled, randomized crossover trial. They were randomized to either 1 month of SNS (ON) or placebo (OFF) with the opposite setting for the next month. Sensory and biomechanical parameters were assessed by multimodal rectal stimulation at the end of each period. IBS-specific symptoms were evaluated at baseline and at the end of each treatment period. Key Results Cold stimuli were better tolerated in the ON period (19.9 °C[±0.6]) compared to the OFF period (21.8 °C[±0.6]; p = 0.03). Significantly lower crosssectional areas were needed to elicit sensory responses in the ON period (1545 mm2[±95]) compared to the OFF period (1869 mm2[±92]; p = 0.015). The association between reduced sensory threshold and improvement of constipation was of borderline significance (p = 0.05). Wall stiffness was significantly lower in the ON period (192 mmHg[±10]) compared to the OFF period (234 mmHg[±10]; p = 0.004). Reduced wall stiffness was significantly associated with improved overall GSRS-IBS symptom score (p = 0.01). Reduced sensory threshold to stretch (p = 0.02) and reduced wall stiffness (p < 0.001) were predictors of the GSRSIBS symptom score. Conclusions & Inferences SNS for diarrhea-predominant and mixed IBS relaxes the rectal wall, while making it more sensitive to stretch and less sensitive to cold. Reduced wall stiffness and increased sensitivity to stretch are associated with improved GSRS-IBS symptom score. [ABSTRACT FROM AUTHOR]

Aim More than 50% of women experience deteriorating continence over time following primary repair of obstetric anal sphincter injuries. The objectives of this study were to assess the function and morphology of the anal sphincters and pelvic floor in women with long-term faecal incontinence after sphincter repair (primary end-point) and to evaluate their correlation with severity of incontinence (secondary end-point). Method The participants in this prospective study were recruited from a cohort of all women who sustained third or fourth degree obstetric sphincter injury reconstruction (cases) from January 1976 to November 1991. The women who delivered immediately before and after each case, without sustaining obstetric damage, were included as controls. Cases and controls were stratified into three categories: (i) continent; (ii) minor incontinence; and (iii) severe incontinence. The function and morphology of the anal sphincters and pelvic floor were evaluated by MRI, three-dimensional endoanal ultrasonography and anorectal physiology tests. Results Fifty-nine women (29 cases/30 controls; mean age 51/53 years; mean follow-up 23.7/24.1 years, respectively) were assessed. Morphologically, cases had a significantly shorter anterior external anal sphincter length compared with controls when evaluated by three-dimensional endoanal ultrasonography (8.6 vs 10.2 mm; P = 0.03). Functionally, cases with severe incontinence had a significantly shorter anterior sphincter length compared with cases with minor incontinence (7.7 vs 10.4 mm; P = 0.04). No correlation could be found between anal pressures and severity of incontinence in the case group. Conclusions Cases had a significantly shorter anterior external anal sphincter length. Functionally, anterior sphincter length correlated with increased severity of incontinence. [ABSTRACT FROM AUTHOR]

Aim Advances in the treatment of rectal cancer have made it possible to perform complex rectal cancer surgery ( COMP- RCS) in patients with primary advanced rectal cancer penetrating beyond the total mesorectal excision planes and in patients with locally recurrent rectal cancer. The aim of this study was to examine health-related quality of life ( HRQoL) before and during the first 2 years after COMP- RCS. Method Between 2001 and 2008, 180 patients were treated with COMP- RCS at Aarhus University Hospital. HRQoL was assessed preoperatively and 3, 6, 12, 18 and 24 months after surgery using three questionnaires. The results were compared with those for patients treated with standard rectal cancer surgery ( STAN- RCS) and with data from the general Danish population ( NORM-data). Results One hundred and twenty-two (68%) patients responded to the questionnaires. Of these 80 (66%) with disease-free survival for 2 years after surgery were included in the main analysis. The lowest level of functioning and the highest degree of symptoms were reported preoperatively. The majority of the HRQo L scales improved or remained stable during the first postoperative year; a decrease was observed for body image only. One year after surgery, HRQoL in patients treated with COMP- RSC was comparable to that for patients treated with STAN- RCS. Lower levels were found for physical and emotional role functioning, compared with NORM-data. Conclusion Patients treated with COMP- RCS experienced improvement in HRQoL in the first year after surgery. One year after surgery, HRQoL was similar to that of patients treated with STAN- RCS. Compared with NORM-data, lower levels were found for physical and emotional role functioning. [ABSTRACT FROM AUTHOR]

Background Neurophysiological evaluation of anorectal sensory function is hampered by a paucity of methods. Rapid balloon distension ( RBD) has been introduced to describe the cerebral response to rectal distension, but it has not successfully been applied to the anal canal. Methods Nineteen healthy women received 30 RBDs in the rectum and the anal canal at intensities corresponding to sensory and unpleasantness thresholds, and response was recorded as cortical evoked potentials ( CEPs) in 64-channels. The anal canal stimulations at unpleasantness level were repeated after 4 min to test the within-day reproducibility. CEPs were averaged, and to overcome latency variation related to jitter the spectral content of single sweeps was also computed. Key Results Repeated stimulation of the anal canal generated CEPs with similar latencies but smaller amplitudes compared to those from the rectum. Due to latency jitter, reproducibility of averaged CEPs was lower than what was found in the rectum. The most reproducible feature was N2P2 peak-to-peak amplitude with intra-class correlation coefficient ( ICC) of 0.7 and coefficient of variation ( CV) of 18%. Spectral content of the single sweeps showed reproducibility with ICCs for all bands >0.8 and corresponding CVs <7%. Conclusions & Inferences Cortical potentials evoked from the anal canal are challenged by latency jitter likely related to variability in muscle tone due to the distensions. Using single-sweep analysis, anal CEPs proved to be reproducible and should be used in future evaluation of the anal function. [ABSTRACT FROM AUTHOR]

Background Anatomical structures and their distensibility vary along the length of the anal canal. The anal sphincter muscles have dynamic properties that are not well-reflected by standard manometry. Abnormal distensibility of the anal canal may be of importance in idiopathic fecal incontinence ( IFI). The functional lumen imaging probe ( FLIP) allows detailed studies of the distensibility and axial variation of sphincters. We aimed at comparing segmental distensibility of the anal canal in patients with IFI and healthy subjects. Methods The FLIP was used for distension of the anal canal in 22 patients with IFI (17 female, age 27-82 years) and 21 healthy volunteers (18 female, age 32-73 years). The distensibility was determined from changes in luminal diameter. Closure of the anal canal during voluntary squeeze was computed as the combined length of closed anal canal and time. Pressure-strain elastic modulus was computed at rest. Key Results In all subjects, the proximal anal canal was the most distensible segment. During distension at rest and during squeeze the middle and distal anal canal became significantly larger in IFI than in healthy (F < 22.4, p < 0.05). The closure of the anal canal during voluntary squeeze did not differ between healthy (75.9 ± 92.9 mm s) and IFI patients (90.4 ± 105 mm s; p = 0.6). Compared with healthy, IFI patients had lower pressure-strain elastic modulus of the middle and distal (q > 4.5, p < 0.05) but not the proximal anal canal (q < 0.7, p > 0.05). Conclusions & Inferences Patients with IFI have increased distensibility of the middle and distal parts of the anal canal. [ABSTRACT FROM AUTHOR]

Aim The purpose of this study was to develop and validate a pouch dysfunction score that could identify the aspects of function which have the greatest impact on quality of life as perceived by the patient. Method All ( n = 1757) patients having restorative proctocolectomy in Denmark between 1980 and 2010 were identified. Of these, 1229 were available for study and were sent a questionnaire on bowel function and quality of life ( QoL) designed specifically for this study. Function was correlated with QoL in a multivariate model using ordinal logistic regression with QoL as a dependent variable. The pouch dysfunction score was developed from a randomly selected half of the study population and the validity was tested on the other half. Results 1047 (85%) patients returned the questionnaire. On multivariate analysis, the symptom domains of 'incomplete emptying', 'severity of urgency', 'number of bowel movements/24 h', 'major incontinence' and 'use of anti-diarrhoeal medication' were associated with reduced QoL. The score was divided into three categories including 'none', 'minor' and 'some/major' pouch dysfunction. The corresponding coefficients gave the score a range from 0 to 7.5. There was a highly significant difference ( P < 0.001) in score between the categories. The area under the receiver operating curve was 0.81. Conclusion Urgency, incomplete emptying, number of bowel movements/24 h, major incontinence and use of anti-diarrhoeal medication have a major impact on QoL. There was a high accuracy for the score, demonstrating its potential clinical usefulness in relating symptoms to QoL. [ABSTRACT FROM AUTHOR]

Aim To investigate neorectal properties regarding biomechanical, sensory and postprandial response in patients after total mesorectal excision without neoadjuvant radiotherapy in groups of no low anterior resection syndrome ( LARS) patients and major LARS patients. Method Patients without LARS ( n = 9) and patients with major LARS ( n = 23) were investigated by multimodal rectal stimulation and standard anorectal physiological tests, and results were compared. Results Patients with major LARS had an increased postprandial response with a significant increase in pressure in the neorectum after a meal compared with patients without LARS ( P = 0.017). No biomechanical differences could be detected. Conclusion Low anterior resection syndrome seems to be caused by physiological changes due to neural damage more than structural changes in the ano-neorectum. [ABSTRACT FROM AUTHOR]

Aim Bowel dysfunction was assessed after low anterior resection with and without neoadjuvant therapy ( NT) for rectal cancer using a novel symptom-based scoring system correlated with quality of life. Method We identified all patients who underwent curative resection for rectal cancer in Denmark between 2001 and 2007. A questionnaire on bowel function and quality of life, including the recently validated low anterior resection syndrome score ( LARS score; range 0-42) was administered to recurrence-free patients in 2009. We used multivariate analysis to examine the association between major LARS ( LARS score ≥ 30) and a number of patient and treatment-related factors. Results Of 1087 eligible patients, 980 agreed to participate and, of these, 938 were included in the analysis. Major LARS was observed in 41%. The use of NT ( OR = 2.48; 95% CI: 1.73-3.55), long-course chemoradiotherapy vs short-course radiotherapy ( OR = 0.90; 95% CI: 0.44-1.87), total mesorectal excision ( TME) vs partial mesorectal excision ( PME) ( OR = 2.31; 95% CI: 1.69-3.16), anastomotic leakage ( OR = 2.06; 95% CI: 0.93-4.55), age ≤ 64 years at surgery ( OR = 1.90; 95% CI: 1.43-2.51) and female gender ( OR = 1.35; 95% CI 1.02-1.79) were associated with major LARS. No association was found between major LARS and the time since surgery ( OR = 0.78; 95% CI: 0.59-1.04) or neorectal reconstruction (colonic pouch vs straight colorectal or side-to-end anastomosis ( OR = 0.96; 95% CI: 0.63-1.46). Conclusion Severe bowel dysfunction is a frequent long-term outcome after resection for rectal cancer. Use of NT, regardless of a long- or short-course protocol, and TME (compared with PME) are strong independent risk factors for major LARS. [ABSTRACT FROM AUTHOR]

Aim The study evaluated function and quality of life ( Qo L) in all patients having restorative proctocolectomy ( RPC) in Denmark for ulcerative colitis ( UC) from 1980 to 2010. Inclusion of all patients in one country has never previously been achieved. Method All patients who had had a RPC in Denmark, from the first case in 1980 to the last case in 2010, were studied. A cross-sectional questionnaire survey was performed, and function and Qo L were assessed using a standardized questionnaire - the Short- Form 36 ( SF36) - and the inflammatory bowel disease questionnaire ( IBDQ). Results The median duration of follow up was 11 (range, 1-30) years. Apart from deaths, pouch failures and research protection, data on function and Qo L were obtained from 1047 (85%) of 1229 patients who had a functioning pouch at the time of the investigation. More female patients than male patients experienced urgency (56% vs 44%, P = 0.0021). The median number of bowel movements per 24 h was 7 (range, 1-23) in female patients and 6 (range, 1-20) in male patients ( P < 0.001). Pad usage was more frequent among female patients than among male patients (62% vs 38%, P < 0.001). A higher incidence of major incontinence ( P = 0.009) and use of pads ( P = 0.01) was found among patients who had been operated on 21-30 years previously compared with those operated on 11-20 years previously. The prevalence of urgency was higher in patients who received surgery 0-10 years previously compared with 11-20 years previously ( P = 0.009). The total IBDQ score was higher in male patients than in female patients ( P < 0.001). Male patients scored higher in five of eight SF36 domains ( P < 0.001). Conclusion Female patients had more urgency, a higher frequency of defaecation and higher pad usage. This was associated with a reduced Qo L. Nevertheless, RPC resulted in good function and a high degree of satisfaction in most patients. [ABSTRACT FROM AUTHOR]

Aim Cytoreductive surgery ( CRS) combined with hyperthermic intraperitoneal chemotherapy ( HIPEC) is a treatment option with curative intent for selected patients with peritoneal carcinomatosis ( PC). CRS and HIPEC have been implemented in Denmark at a single centre since 2006. Six years of data on these patients were analysed. Method Patients with PC from colorectal or appendiceal cancer, pseudomyxoma peritonei or malignant peritoneal mesothelioma referred to the single national HIPEC centre were prospectively registered from June 2006 to July 2012. Morbidity, 30-day mortality and long-term survival of patients who underwent CRS and HIPEC were analysed. Results In total, 80 patients underwent CRS and HIPEC. PC originated from colorectal cancer in 34 patients, pseudomyxoma peritonei in 29, appendiceal cancer in 13 and malignant peritoneal mesothelioma in four patients. Thirty-two patients had one or more complications during the hospital stay. The 30-day mortality rate was 1.3%. The predicted 2-, 3- and 5-year survival was 60%, 47% and 38% in patients with PC from colorectal cancer, and 100%, 93% and 73% in pseudomyxoma peritonei patients. Conclusion CRS and HIPEC is a safe procedure when centralized as in Denmark. Favourable long-term outcome was achieved in selected patients with PC from colorectal cancer and pseudomyxoma peritonei. Short-term and long-term outcomes were comparable to results from international centres. [ABSTRACT FROM AUTHOR]

Aim Systemic sclerosis ( SSc) is a generalized connective tissue disease that affects smooth muscle cells. Patients with SSc often have faecal incontinence caused by fibrotic degeneration of the internal anal sphincter ( IAS). The functional lumen imaging probe ( FLIP) is a novel method that allows the segmental biomechanical properties of the anal canal to be dynamically evaluated. The aim of the present study was to compare the segmental biomechanical properties of the anal canal in incontinent SSc patients and healthy controls. We hypothesized that the FLIP would reveal weaknesses of the IAS in the SSc patients. Method We performed FLIP distensions, endoanal ultrasonography and standard anal manometry on 14 incontinent SSc patients [11 women, median age 60 years (range 35-80)] and 15 healthy volunteers [12 women, median age 54 years (range 33-67)]. The anal canal was divided into three parts for the biomechanical analysis: upper (surrounded by the IAS and the puborectalis), middle ( IAS and external anal sphincter) and lower (external sphincter only). Results The middle anal canal was the segment most resistant to distension in all of the subjects, but it was less resistant in the SSc patients than in the controls ( P < 0.01). Correspondingly, the endoanal ultrasonography showed that the IAS of the SSc patients was thinner than normal ( P < 0.05), and the anal resting and squeeze pressures were lower ( P < 0.05). Only minor distensibility differences were found in the upper anal canal. No changes were found in the lower anal canal. Conclusion Faecal incontinence in SSc patients is associated with poor IAS function, causing increased distensibility of the middle anal canal. [ABSTRACT FROM AUTHOR]

Aim Sacral nerve stimulation (SNS) reduces symptoms in up to 80% of patients with faecal incontinence (FI). Its effects are not limited to the distal colon and the pelvic floor. Accordingly, spinal or supraspinal neuromodulation have been suggested as part of the mode of action. The effect of SNS on gastric and small-intestinal motility was studied. Method Using the magnet tracking system, MTS-1, a small magnetic pill was tracked twice through the upper gastrointestinal tract of eight patients with FI successfully treated with SNS. Following a randomized double-blind crossover design, the stimulator was either left active or was turned off for 1 week before investigations with MTS-1. Results The median (range) frequency of gastric con-tractions was 3.05 (2.83-3.40) per min during SNS and 3.04 (2.79?-3.76) per min without ( P = NS). The median (range) frequency of contractions in the small intestine during the first 2 h after pyloric passage was 10.005 (9.68-10.70) per min during SNS and 10.09 (9.79-10.29) per min without SNS ( P = NS). The median (range) velocity of the magnetic pill during the first 2 h in the small intestine was 1.6 (1.2-2.8) cm/min during SNS and 1.7 (0.8-3.7) cm/min without SNS ( P = NS). Small-intestinal propagation mainly occurred during very fast movements (> 15 cm/min), accounting for 51% (42-60%) of the distance 3% (2-4%) of the time during SNS and for 53% (18-73%) of the distance 3% (1-8%) of the time without SNS ( P = NS). Conclusion Turning off SNS for 1 week did not affect gastric or small-intestinal motility patterns. [ABSTRACT FROM AUTHOR]

Aim The study was conducted in a dedicated centre treating the majority of Danish patients with intended curative total pelvic exenteration for primary advanced (PARC) or locally recurrent (LRRC) rectal cancer. We compared PARC and LRRC and analysed postoperative morbidity and mortality, and long-term outcome. Method There were 90 consecutive patients (PARC/LRRC 50/40) treated between January 2001 and October 2010, recorded on a prospectively maintained database. Results The median age was 63 (32-75) years with a gender ratio of 7 women to 83 men. All patients were American Society of Anesthesiologists level I or II. Sacral resection was performed in five patients with PARC and 15 with LRRC ( P = 0.002). R0 resection was achieved in 33 (66%) patients with PARC and in 15 (38%) with LRRC, R1 resection in 17 (34%) with PARC and 20 (50%) with LRRC and R2 resection in five (13%) with LRRC. R0 resection was more frequent in PARC ( P = 0.007). Forty-four (49%) patients had no postoperative complications. Fifty-five major complications were registered. Two (2.2%) patients died within 30 days, and the total in-hospital mortality was 5.6%. The median follow-up was 12 (0.4-91) months. The 5-year survival was 46% for PARC and 17% for LRRC ( P = 0.16). Conclusion Pelvic exenteration is associated with considerable morbidity but low mortality in an experienced centre. Pelvic exenteration can improve long-term survival, especially for patients with PARC. However, pelvic exenteration is also justified for patients with LRRC. [ABSTRACT FROM AUTHOR]

Aim Health-related quality of life is an important outcome measure in treatment of cancer. A review of the literature was undertaken to provide an overview of health-related quality of life (HRQoL) after surgery for primary advanced or recurrent rectal cancer and to outline proposals for future HRQoL studies in this area. Method A systematic literature search was undertaken. Only studies concerning surgery for primary advanced or recurrent rectal cancer and describing methods used for measuring HRQoL were considered. Results Seven studies were identified, including two prospective longitudinal studies, three cross-sectional studies and two based on qualitative data. Global quality of life, and physical, social, role and sexual function seemed to be impaired for a varying time after surgery. All the studies had methodical problems due to small sample size (12-44 patients) and different points of time for the assessment of HRQoL (12.3-47 months), which made it difficult to determine the period of time of impaired HRQoL and also if this is different after surgery for locally advanced or recurrent disease compared with after total mesorectal excision used for earlier tumours. Conclusion Several aspects of HRQoL are impaired for a variable time after treatment for locally advanced or recurrence of rectal cancer. Larger prospective longitudinal studies are needed to provide further information regarding the effects of this extensive surgery on quality of life. [ABSTRACT FROM AUTHOR]

Aim Sacral nerve stimulation (SNS) is an established treatment for faecal incontinence (FI) when conservative modalities have failed to restore continence. This two-centre study aimed to document functional outcome and its relationship to patient satisfaction. Method Patients treated with SNS for idiopathic FI in Aarhus (Denmark) and Maastricht (The Netherlands) were included. At the most recent follow-up appointment, 127 patients (80%) were identified as receiving active SNS therapy. A questionnaire considering bowel habits, quality of life, and self-reported satisfaction and a 3-week bowel-habit diary were mailed to these patients, and 85% responded. Results Patient satisfaction was clearly related to the number of FI episodes. Patients experiencing full continence were all satisfied, and although the satisfaction rate decreased as the number of FI episodes increased, 46% of the patients with more FI episodes at follow-up than at baseline were still satisfied. Per-protocol analysis resulted in a satisfaction rate of 57.3%. In total, 74.7% of the patients receiving active SNS therapy reported a reduction of ≥ 50% in FI episodes, 10.3% of whom were dissatisfied after a median of 46 months of follow-up. Conclusion There is a clear relationship between patient satisfaction and improved continence. A total of 57.3% of the patients offered SNS therapy were satisfied at follow-up. However, 46% of the patients with more FI episodes at follow-up than at baseline were also satisfied. Therefore, functional outcome of SNS therapy cannot be based only on bowel-habit diaries and bowel scores. [ABSTRACT FROM AUTHOR]

Aim Faecal incontinence (FI) has a significant impact on quality of life. This study investigates whether stimulation of the dorsal genital nerve (DGN) improves FI symptoms. Method Ten female patients suffering from idiopathic FI (median age 60 years) were included in the study. Stimulation was applied twice daily for 3 weeks at the maximal tolerable stimulation amplitude (pulse width, 200 μs; pulse rate, 20 Hz). Patients kept a 3-week bowel diary prior to stimulation, during stimulation and after the final stimulation. FI severity scores, FI Severity Visual-Analogue Score (VAS), FI Quality of Life Score (FIQL), sphincter function and rectal volume tolerance were assessed at baseline, immediately after stimulation and 3 weeks after stimulation. Results Nine patients completed the study. The Wexner score ( P = 0.027) and the St Mark's score ( P = 0.035) improved after stimulation in seven and six of the patients and improvement was maintained 3 weeks after stimulation ( P = 0.048 and P = 0.049, respectively). The number of incontinent episodes was reduced in seven out of nine patients ( P = 0.025). Improvement was maintained for 3 weeks after stimulation ( P = 0.017). Subjective assessments of FI severity using the VAS score and the FIQl score did not improve during stimulation. Sphincter function and rectal volume tolerability were unaffected. Conclusion DGN stimulation reduced the number of FI episodes in most patients suffering from idiopathic FI. Sphincter function and rectal volume tolerability were not affected. DGN stimulation may represent a new treatment for idiopathic FI. [ABSTRACT FROM AUTHOR]