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Sea level rise (SLR) is a long‐lasting consequence of climate change because global anthropogenic warming takes centuries to millennia to equilibrate for the deep ocean and ice sheets. SLR projections based on climate models support policy analysis, risk assessment and adaptation planning today, despite their large uncertainties. The central range of the SLR distribution is estimated by process‐based models. However, risk‐averse practitioners often require information about plausible future conditions that lie in the tails of the SLR distribution, which are poorly defined by existing models. Here, a community effort combining scientists and practitioners builds on a framework of discussing physical evidence to quantify high‐end global SLR for practitioners. The approach is complementary to the IPCC AR6 report and provides further physically plausible high‐end scenarios. High‐end estimates for the different SLR components are developed for two climate scenarios at two timescales. For global warming of +2°C in 2100 (RCP2.6/SSP1‐2.6) relative to pre‐industrial values our high‐end global SLR estimates are up to 0.9 m in 2100 and 2.5 m in 2300. Similarly, for a (RCP8.5/SSP5‐8.5), we estimate up to 1.6 m in 2100 and up to 10.4 m in 2300. The large and growing differences between the scenarios beyond 2100 emphasize the long‐term benefits of mitigation. However, even a modest 2°C warming may cause multi‐meter SLR on centennial time scales with profound consequences for coastal areas. Earlier high‐end assessments focused on instability mechanisms in Antarctica, while here we emphasize the importance of the timing of ice shelf collapse around Antarctica. This is highly uncertain due to low understanding of the driving processes. Hence both process understanding and emission scenario control high‐end SLR. Plain Language Summary: Taking a co‐production approach between scientists and practioners, we provide high‐end sea level rise (SLR) estimates for practitioner application based on an expert evaluation of physical evidence and approaches currently used in policy environments to understand high end risk. We do this for two global warming scenarios, a modest and a strong one, for two time slices 2100 and 2300. The large and growing differences between the scenarios beyond 2100 emphasize the long‐term benefits of mitigation. However, even a modest warming may cause multi‐meter SLR on centennial time scales with profound consequences for coastal areas. Earlier high‐end assessments focused on instability mechanisms in Antarctica, while here we emphasize the importance of the timing of ice shelf collapse around Antarctica as well as how practitioners use high end projections to frame risk. We stress that both emission scenario and limited physical understanding control the outcome. Key Points: A high‐end estimate of sea level rise in 2100 and 2300Decisionmaker/practitioner perspective on high‐endTiming of collapse of ice shelves critical [ABSTRACT FROM AUTHOR]

This study provides a literature‐based comparative assessment of uncertainties and biases in global to world‐regional scale assessments of current and future coastal flood risks, considering mean and extreme sea‐level hazards, the propagation of these into the floodplain, people and coastal assets exposed, and their vulnerability. Globally, by far the largest bias is introduced by not considering human adaptation, which can lead to an overestimation of coastal flood risk in 2100 by up to factor 1300. But even when considering adaptation, uncertainties in how coastal societies will adapt to sea‐level rise dominate with a factor of up to 27 all other uncertainties. Other large uncertainties that have been quantified globally are associated with socio‐economic development (factors 2.3–5.8), digital elevation data (factors 1.2–3.8), ice sheet models (factor 1.6–3.8) and greenhouse gas emissions (factors 1.6–2.1). Local uncertainties that stand out but have not been quantified globally, relate to depth‐damage functions, defense failure mechanisms, surge and wave heights in areas affected by tropical cyclones (in particular for large return periods), as well as nearshore interactions between mean sea‐levels, storm surges, tides and waves. Advancing the state‐of‐the‐art requires analyzing and reporting more comprehensively on underlying uncertainties, including those in data, methods and adaptation scenarios. Epistemic uncertainties in digital elevation, coastal protection levels and depth‐damage functions would be best reduced through open community‐based efforts, in which many scholars work together in collecting and validating these data. Plain Language Summary: One of the main impacts of climate change is sea‐level rise leading to more frequent flooding of low lying coastal areas through higher tides, storm surges and waves. In this context, assessments of current and future coastal flood risk at global to world‐regional scales are needed to inform policy decisions on greenhouse gas reduction targets and finance of adaptation and flood disaster risk reduction. A key requirement for such assessments is that they consider all major uncertainties in models, methods and data applied, because the failure to do so may lead to poor policy outcomes. So far, this key requirement has not been met. To address this limitation, this paper provides the first comparative assessment of uncertainties in global to world‐regional scale studies of current and future coastal flood risks based on the published literature. We find that globally, by far the largest uncertainty concerns how coastal societies will adapt to sea‐level rise, which can influence future flood risk by factors 20–27. Other large global uncertainties are associated with socio‐economic development, digital elevation data, greenhouse gas emissions, and ice sheet evolution, influencing global exposure and flood risk by factors of up to 2 to 6. Key Points: We present the first comparison of uncertainties in global to world‐regional scale assessments of current and future coastal flood riskThe largest uncertainty relates to future coastal adaptation, which can influence future coastal flood risk by factors of 20–27Uncertainties in socioeconomic development, elevation data, defense levels, emissions and ice sheets can affect risks by factors of 2–6 [ABSTRACT FROM AUTHOR]

An approach to analyze high‐end sea level rise is presented to provide a conceptual framework for high‐end estimates as a function of time scale, thereby linking robust sea level science with stakeholder needs. Instead of developing and agreeing on a set of high‐end sea level rise numbers or using an expert consultation, our effort is focused on the essential task of providing a generic conceptual framework for such discussions and demonstrating its feasibility to address this problem. In contrast, information about high‐end sea level rise projections was derived previously either from a likely range emerging from the highest view of emissions in the Intergovernmental Panel on Climate Change assessment (currently the Representative Concentration Pathway 8.5 scenario) or from independent ad hoc studies and expert solicitations. Ideally, users need high‐end sea level information representing the upper tail of a single joint sea level frequency distribution, which considers all plausible yet unknown emission scenarios as well as involved physical mechanisms and natural variability of sea level, but this is not possible. In the absence of such information we propose a framework that would infer the required information from explicit conditional statements (lines of evidence) in combination with upper (plausible) physical bounds. This approach acknowledges the growing uncertainty in respective estimates with increasing time scale. It also allows consideration of the various levels of risk aversion of the diverse stakeholders who make coastal policy and adaptation decisions, while maintaining scientific rigor. Key Points: Previous publication of high end sea level differs in their meaningDevelopment of new concept for high‐end sea level estimatesHigh‐end estimates have to be a function of scenario and time frame considered [ABSTRACT FROM AUTHOR]

Abstract: We use multiple synthetic mitigation sea‐level scenarios, together with a non‐mitigation sea‐level scenario from the Warming Acidification and Sea‐level Projector model. We find sea‐level rise (SLR) continues to accelerate post‐2100 for all but the most aggressive mitigation scenarios indicative of 1.5°C and 2.0°C. Using the Dynamic Interactive Vulnerability Assessment modeling framework, we project land and population exposed in the 1 in 100 year coastal flood plain under SLR and population change. In 2000, the flood plain is estimated at 540 × 103 km2. By 2100, under the mitigation scenarios, it ranges between 610 × 103 and 640 × 103 km2 (580 × 103 and 700 × 103 km2 for the 5th and 95th percentiles). Thus differences between the mitigation scenarios are small in 2100. However, in 2300, flood plains are projected to increase to between 700 × 103 and 960 × 103 km2 in 2300 (610 × 103 and 1290 × 103 km2) for the mitigation scenarios, but 1630 × 103 km2 (1190 × 103 and 2220 × 103 km2) for the non‐mitigation scenario. The proportion of global population exposed to SLR in 2300 is projected to be between 1.5% and 5.4% (1.2%–7.6%) (assuming no population growth after 2100) for the aggressive mitigation and the non‐mitigation scenario, respectively. Hence over centennial timescales there are significant benefits to climate change mitigation and temperature stabilization. However, sea‐levels will continue to rise albeit at lower rates. Thus potential impacts will keep increasing necessitating adaptation to existing coastal infrastructure and the careful planning of new coastal developments. [ABSTRACT FROM AUTHOR]

Abstract: Coastal flood assessments are often required to describe networks of flood sources, pathways and receptors. This can be challenging within traditional numerical modelling approaches. In this paper, we assess coastal flood plains as networks of interlinked elements using a Bayesian network (Bn) model. The Bn model describes flood pathways and estimate flood extents for different extreme events and is constructed from a quasi‐two‐dimensional Source – Pathway – Receptor (2D SPR) systems diagram. The Bn model is applied in Teignmouth in the UK, a coastal flood plain of typical complexity. It identifies two key flood pathways and assesses their sensitivity to changes in sea levels, beach widths and coastal defences. The process of 2D SPR and Bn model construction helps identify gaps in flood plain understanding and description. The Bn model quantifies inundation probabilities and facilitates the rapid identification of critical pathways and elements before committing resources to further detailed analysis. The advantages, utility and limitations of the Teignmouth Bn model are discussed. The approach is transferable and can be readily applied in localscale coastal flood plains to obtain a systems‐level understanding and inform numerical modelling assumptions. [ABSTRACT FROM AUTHOR]

The T3 category of the TNM classification includes over 60% of all rectal tumours and encompasses the greatest variance in cancer-specific end-points than any other T category. The most recent edition of the cancer staging handbook of the American Joint Committee on Cancer ( AJCC) dated 2010 does not divide T3 tumours into subgroups which reflect cancer-specific outcome more sensitively. The original aim of the present study was to review the literature to assess the influence of the degree of extramural extent of T3 rectal cancer on local recurrence and survival. An article written by the authors was accepted for publication but was withdrawn immediately after they became aware of the publication of the 4th edition of the TNM Supplement by the Union for International Cancer Control dated 2012, which was not accessible by the search system used. This article dealt with the subdivision of the T3 category although this was not included in the most up-to-date AJCC guidelines and was stated to be 'entirely optional'. Medline, PubMed and Cochrane Library searches were performed to identify all studies that investigated the degree of extramural spread and its relationship to survival and local recurrence. Twenty-two studies were identified of which 12 assessed the degree of histopathological extramural spread measured in millimetres. In 18 of the 22 studies the degree of extramural spread was a statistically significant prognostic factor for survival and local recurrence. Analysis of the studies indicated that the subdivision of category T3 rectal cancer into two subgroups of extramural spread ≤ 5 mm or more than 5 mm resulted in markedly different survival and local recurrence rates. The data were insufficient to allow validation of any greater subdivision. Measurement of the extent of extramural spread by MRI before any treatment agreed with the histopathological measurement in the surgical specimen to within 1 mm. The extent of extramural spread in T3 rectal cancer measured in millimetres is a powerful prognostic factor. A subdivision of T3 into T3a and T3b of less than or equal to or more than 5 mm appears to give the greatest discrimination of local recurrence and survival. Preoperative T3 subdivision by MRI has the same sensitivity as histopathological examination of the resected specimen. Given the clinical need for the pretreatment classification of the T3 category for oncological management planning, the evidence strongly indicates that the subdivision of the T3 category by MRI should be formally considered as part of the TNM staging system for rectal cancer. [ABSTRACT FROM AUTHOR]

Aim Chronic constipation is difficult to treat when symptoms are intractable. Colonic propulsion may be altered by distal neuromodulation but this is conventionally delivered percutaneously. Transcutaneous tibial nerve stimulation is noninvasive and cheap: this study aimed to assess its efficacy in chronic constipation. Method Eighteen patients (median age 46 years, 12 female) with chronic constipation were recruited consecutively. Conservative and behavioural therapy had failed to improve symptoms in all 18. Thirty minutes of daily bilateral transcutaneous tibial nerve stimulation was administered by each patient at home for 6 weeks. The primary outcome measure was a change in the Patient Assessment of Constipation Quality of Life ( PAC-QoL) score. Change in Patient Assessment of Constipation Symptoms ( PAC- SYM), weekly bowel frequency and visual analogue scale ( VAS) score were also measured. Results Fifteen patients (12 female) completed the trial. The PAC-QoL score improved significantly with treatment [pretreatment, median 2.95, interquartile range ( IQR) 1.18; posttreatment, median 2.50, IQR 0.70; P = 0.047]. There was no change in PAC- SYM score (pretreatment, median 2.36, IQR 1.59; posttreatment, median 2.08, IQR 0.92; P = 0.53). Weekly stool frequency improved as did VAS score, but these did not reach statistical significance ( P = 0.229 and 0.161). The PAC-QoL and PAC- SYM scores both improved in four (26%) patients. Two patients reported complete cure. There were no adverse events reported. Conclusion Bilateral transcutaneous tibial nerve stimulation appears to be effective in a quarter of patients with chronic constipation. Carefully selected patients with less severe disease may benefit more. This requires further study. [ABSTRACT FROM AUTHOR]

Aim This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer. Method Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 ( supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision). Results Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival. Conclusion CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients. [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 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 Symptomatic diverticular disease ( DD) may be increasing in incidence in western society particularly in younger age groups. This study aimed to describe hospital admission rates and management for DD in Scotland between 2000 and 2010. Method Data were obtained from the Scottish Morbidity Records ( SMR01). The study cohort included all patients with a hospital admission and a primary diagnosis of DD of the large intestine ( ICD-10 primary code K57). Results Scottish NHS hospitals reported 90 990 admissions for DD (in 87 314 patients) from 2000 to 2010. The annual number of admissions increased by 55.2% from 6591 in 2000 to 10,228 in 2010, an average annual increase per year of 4.5%. Most of the increase attributable to DD was due to elective day cases (3618 in 2000; 6925 in 2010) a likely consequence of a greater proportion of the population accessing colonoscopy over that time period. There was an 11% increase in inpatient admissions (2973-3303), 60% of these patients being women. Admissions in younger age groups increased proportionally in the later years of the study, and there was an association between DD admissions and greater deprivation. Despite an increase in complicated DD from 22.9% in 2000 to 27.1% in 2010 and a 16.8% increase in emergency inpatient admissions, the rate of surgery fell during the period of study. Conclusion This report supports findings of other population-based studies of western countries indicating that DD is an increasing burden on health service resources, particularly in younger age groups. [ABSTRACT FROM AUTHOR]

Aim The study aimed to define the learning curve required to gain satisfactory training to perform pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer. Method Consecutive patients undergoing exenterative pelvic surgery for recurrent and locally advanced primary rectal cancer, by one surgical team, between 2006 and 2011 were studied. They were divided into quartiles (Q1-Q4) according to the date of surgery. A risk-adjusted cumulative sum ( RA- CUSUM) model was used to evaluate the learning curve. The chi-squared test with gamma ordinal was used to assess the change with time in the four quartiles. Results One hundred patients (70 males; median age 61 (25-85) years; 55 primary cancers) were included in the study. Thirty patients underwent abdominosacral resection. The number of patients who underwent plastic reconstruction ( n = 53) increased from 12 in Q1 to 15 in Q4 ( P = 0.781). The median operation time, intra-operative blood loss and hospital stay were 8 (3-17) h, 1.5 (0.1-17) l and 15 (9-82) days respectively. There was no significant change with time. Complete resection (R0) was achieved in 78 patients. Microscopic (R1) or macroscopic (R2) residual disease was present in 15 and seven patients respectively. The number of major complications was 20, and minor 30. RA- CUSUM analysis demonstrated an improvement in any complications after 14, in major after 12 and in minor after 25 operations. Conclusion Pelvic exenterative surgery for recurrent or locally advanced primary rectal cancer is complex and requires a minimum of 14 cases for an expert colorectal surgeon to gain the desirable training and experience to improve morbidity. [ABSTRACT FROM AUTHOR]

Background Scottish nationwide linkage data from 1998 to 2000 demonstrated high 3-year mortality in patients hospitalised with ulcerative colitis ( UC). Aim To compare 3-year mortality, and factors related to mortality, in Scottish patients hospitalised with UC between 1998-2000 and 2007-2009. Methods The Scottish Morbidity Records and linked datasets were used to assess 3-year mortality, standardised mortality ratio ( SMR) and multivariate analyses of factors associated with 3-year mortality. The 3-year mortality was determined after four admission types: surgery-elective or emergency; medical-elective or emergency. Age-standardised mortality rates ( ASR) were used to compare mortality rates between periods. Results Ulcerative colitis admissions increased from 10.6 in Period 1 to 11.6 per 100 000 population per year in Period 2 ( P = 0.046). Crude and adjusted 3-year mortality fell between time periods (crude 12.2% to 8.3%; adjusted OR 0.59, CI 0.42-0.81, P = 0.04). Adjusted 3-year mortality following emergency medical admission ( OR 0.58, CI 0.39-0.87, P = 0.003) and in patients >65 years (38.8% to 28.7%, P = 0.02) was lower in Period 2. The SMR in period 1 was 3.04 and 2.96 in Period 2. Directly age-standardised mortality decreased from 373 ( CI 309-437) to 264 ( CI 212-316) per 10 000 person-years. On multivariate analysis, increasing age (50-64 years OR 7.11 ( CI 2.77-18.27, P < 0.05); 65-74 years OR 14.70 ( CI 5.65-38.25 P < 0.05); >75 years OR 46.42 ( CI 18.29-117.78, P < 0.001) and co-morbidity ( OR 3.02, CI 1.72-5.28, P < 0.001) were significantly associated with 3-year mortality in Period 2. Conclusions Comparisons of crude and adjusted mortality rates suggest significant improvement in outcome over the last decade - however, mortality remains high, and older age and co-morbidity are important predictors of outcome. [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 Posterior tibial nerve stimulation ( PTNS) has been shown to improve faecal incontinence in the short term. The optimal treatment regimen is unclear with wide variations in protocol reported in the literature. The study aimed to assess two different regimens of transcutaneous PTNS and to establish whether increasing the frequency of stimulation increases the effectiveness. Method Thirty patients were randomized to receive once daily or twice weekly PTNS for a 6-week period. The treatment was carried out by the patient at home after instruction. The primary investigator was blinded to the patient allocation until the study had ended, at which point the symptoms were assessed. No further stimulation was given after 6 weeks and the patients were followed until their symptoms returned to the pre-stimulation state (baseline). The primary outcome measure was a change in the frequency of incontinent episodes. Results Three patients in the daily group and none in the twice weekly group achieved complete continence. Only patients from the daily group showed a significant reduction in median (interquartile range) incontinent episodes per week from 5 (11.13) to 3.5 (4.31) ( P = 0.025). There was no significant change in the frequency of defaecation nor in the ability to defer defaecation. Patients in the daily group experienced a significant improvement in the domains of lifestyle [2.2 (1.7) to 2.6 (1.65), P = 0.04] and embarrassment [1.7 (0.85) to 2.15 (0.4), P = 0.04] on the Rockwood Fecal Incontinence Quality of Life assessment. No adverse events were reported. Conclusion Transcutaneous PTNS can safely be used by the patient at home. Daily treatment may be more effective than twice weekly treatment. Larger studies are needed to investigate this further. [ABSTRACT FROM AUTHOR]

Aim Although effective in faecal incontinence ( FI), sacral nerve stimulation ( SNS) is expensive and requires two procedures. It carries a small risk of infection and electrode migration. Transcutaneous SNS is noninvasive and cheap. Two small studies have reported the results when applied to segments S3 but there is no information on its effectiveness when applied to the whole sacral area. Method A pilot study was carried out of self-administered transcutaneous SNS given over a 4-week period for 12 h a day. A 2-week bowel diary was kept for the final 2 weeks and compared with baseline. Patients were assessed using the St Mark's Incontinence Score, a visual analogue scale assessing satisfaction with bowel habit, the Rockwood FI Quality of Life ( QOL) score and SF-36 QOL score. Results Of the 10 patients recruited, two achieved complete continence. There was a statistically significant reduction in the median (interquartile range) frequency of incontinent episodes per week from 9.5 (7.5) to 3 (7.38) ( P = 0.03), and in the median frequency of defaecation per week from 25.5 (19.5) to 14.5 (14.9) ( P = 0.007). There was a statistically significant improvement in the median ability to defer defaecation from 1 (1.25) to 4.5 (4.5) min ( P = 0.02). There was also a statistically significant improvement in the St Marks Incontinence Score from 20 (5.25) to 14.5 (8.0) ( P = 0.01) and in the bowel habit satisfaction visual analogue scale from 8.5 (20) to 45 (33) ( P = 0.008). There was no change in the Rockwood FI QOL or SF-36 QOL scores. No complications were reported. Conclusion Transcutaneous SNS appears to be an effective and safe treatment for FI. Larger controlled studies are needed to explore this further. [ABSTRACT FROM AUTHOR]

Aim The benefits of a laparoscopic approach to restorative proctocolectomy ( RPC) are controversial. The aim of this meta-analysis was to compare the outcome following laparoscopic and open RPC, with particular attention to adverse events and long-term function. Method A systematic search of the MEDLINE, EMBASE and Ovid databases was performed for studies published until March 2012. The primary end-point was long-term function. Secondary end-points were intra-operative details, short-term postoperative outcome and postoperative adverse events. Weighted mean difference ( WMD) and odds ratio ( OR) were calculated using fixed/random effect meta-analytic techniques. Results The final analysis included 27 comparative studies of 2428 patients, of whom 1097 (45.1%) underwent laparoscopic surgery. A laparoscopic approach was associated with a significantly longer operation time (WMD 70.1 min, P < 0.001), shorter length of hospital stay (WMD −1.00 day, P < 0.001), reduced intra-operative blood loss (WMD −89.10 ml, P < 0.001) and a lower incidence of wound infection (OR 0.60, P < 0.005). No significant differences were observed in the rate of pouch failure. Although there was no significant difference in the number of daily bowel movements (OR 0.04, P = 0.950), laparoscopic surgery led to fewer nocturnal bowel movements (WMD −1.14, P < 0.001) and reduced pad usage during the day (OR 0.22, P < 0.001) and night (OR 0.33, P < 0.001). The post hoc power to detect differences in adverse event rates ranged from 5% to 42%. Conclusion Laparoscopic and open approaches to RPC produced equivalent adverse event rates and long-term functional results. However, the present evidence is underpowered to detect true differences in adverse event rates. [ABSTRACT FROM AUTHOR]

Aim This review aimed to assess the published results of posterior tibial nerve stimulation ( PTNS) for faecal incontinence. Method A search was performed of PubMed, MEDLINE and Embase to identify studies describing the clinical outcome of PTNS for faecal incontinence. Results Thirteen studies were identified. These described the outcome of PTNS for faecal incontinence in 273 patients. Four described transcutaneous PTNS, eight percutaneous PTNS and one compared both methods of PTNS with a sham transcutaneous group. One investigated patients with faecal incontinence and spinal cord injury and another with inflammatory bowel disease. There was marked heterogeneity of the treatment regimens and of the end points used. All reported that PTNS improved faecal incontinence. A > 50% improvement was reported in episodes of faecal incontinence in 63-82% of patients. An improvement was seen in urgency (1-5 min). Improvement was also described in the Cleveland Clinic faecal incontinence score in eight studies. Patients with urge and mixed incontinence appear to benefit more than those with passive incontinence. Treatment regimens ranged in duration from 1-3 months. A residual therapeutic effect is seen after completion of treatment. Follow-up ranged from 1-30 months. Conclusion PTNS is effective for faecal incontinence. However, many of the published studies are of poor quality. Comparison between studies is difficult owing to differences in the outcome measures used, technique of PTNS and the timing and duration of treatment. [ABSTRACT FROM AUTHOR]

Aim Present quality of life instruments for inflammatory bowel disease do not evaluate many social aspects of patients' lives that are potentially important in clinical decision making. We have developed a new Social Impact of Chronic Conditions - Inflammatory Bowel Disease (SICC-IBD) questionnaire to assess these areas. Method A 34-item questionnaire was piloted to determine quality of life relating to education, personal relationships, employment, independence and finance. It was compared with the Short Form 36-Item version 2 (SF-36v2) and the Inflammatory Bowel Disease Questionnaire (IBDQ) in 150 patients with chronic ulcerative colitis on an endoscopic surveillance register who had never had surgery. Results Reliability and validity testing enabled the questionnaire to be shortened to only eight items. There was a high level of reliability (Cronbach's α = 0.72). The questionnaire correlated well with the social functioning domain of the SF-36 ( rs = 0.56) and was able to distinguish clinical severity of disease. Conclusion The SICC-IBD is a new tool for assessment of patients with ulcerative colitis, which has identified new aspects of social disability for further study and for potential use as an additional tool in therapy decisions. [ABSTRACT FROM AUTHOR]

Aim Increasing life expectancy will increase the number of elderly patients with faecal incontinence. The study aimed to assess the safety and efficacy of sacral nerve stimulation (SNS) in patients over the age of 65 years. Method Patients aged over 65 years, who underwent temporary SNS from 1996 for faecal incontinence unresponsive to conservative treatment, were followed prospectively. Results Between January 1996 and December 2009, 30 patients [mean age 69.3 years (SD, 3.4)] underwent temporary SNS. Twenty-three (77%) had a >50% improvement in the St Mark's Continence Score and progressed to permanent SNS implantation. Their mean (±SD) score increased from 19 (3.2) at baseline to 8 (3.4) during temporary SNS and to 9 (3.4) 3 months after permanent SNS and 10 (3.7) at the latest median follow up (IQR) of 44 (20-150) months. The corresponding values at the same intervals for urgency [mean (±SD) min] were 1 (1.4), 8 (5.2), 8 (5) and 8 (5.4) and for incontinence episodes per 2 weeks [median (±IQR)] were 10 (7-14), 1 (0-5), 2 (0-5) and 0 (0-6). Conclusion SNS is an effective treatment for faecal incontinence in patients over 65 years. [ABSTRACT FROM AUTHOR]

Aliment Pharmacol Ther 2012; 35: 142-153 Summary Background Although population-based studies of patients with Crohn's disease (CD) suggest only a modestly increased mortality, recent data have raised concerns regarding the outcome of CD patients requiring hospitalisation. Aim To determine the mortality and contributory factors in 1595 patients hospitalised for CD in Scotland between 1998 and 2000. Methods The Scottish Morbidity Records database and linked datasets were used to assess longitudinal patient outcome, and to explore associations between 3-year mortality and age, sex, comorbidity, admission type and social deprivation. The standardised mortality ratio (SMR) at 3 years from admission was calculated with reference to the Scottish population. Results The SMR was 3.31 (95% confidence interval 2.80-3.89). This was increased in all patients, other than those <30 years at presentation, and was highest in patients aged 50-64 years (SMR 4.84 [3.44-6.63]). On multivariate analysis, age >50, admission type, comorbidity, social deprivation and length of admission were significantly associated with mortality. Other than age, admission type was the strongest factor predictive of death. Three-year crude mortality was 0.3% for elective surgical, 8.7% for emergency surgical, 8.3% for elective nonsurgical and 12.7% for emergency nonsurgical admission ( P < 0.001). Conclusions The study demonstrates high mortality rates in patients hospitalised during 1998-2000 for CD, especially in patients over 50. Elective surgery is associated with lower mortality than emergency surgery or medical therapy. Further study is needed to determine whether these patterns have changed following the introduction of biological treatment. [ABSTRACT FROM AUTHOR]

Aim Pudendal nerve stimulation (PNS), which is an alternative to sacral nerve stimulation, requires neurophysiological confirmation of correct siting of the electrode. We describe a modification of the existing technique where placement is assisted by guidance to the ischial spine by a finger introduced per anum. Method Cadaveric dissection was carried out to confirm the accuracy of this new approach. The surface marking of the ischial spine is marked. A stimulating needle electrode inserted through a skin incision at this point, is advanced towards the ischial spine using a finger introduced per anum as a guide. Once effective stimulation of the pudendal nerve is confirmed by observed and palpated contraction of the anal musculature, a permanent stimulating electrode is inserted and the position confirmed by radiological screening. Results Using cadaveric studies, the correct surface markings for needle placement were confirmed. This technique was then applied successfully for in vivo insertion of the needle electrode in 20 patients with bowel dysfunction, with only one lead displacement occurring over a mean follow-up period of 12 months. Conclusion Finger-guided assistance of PNS electrode insertion is simple and reproducible without requiring neurophysiological confirmation of nerve stimulation to ensure correct lead location. [ABSTRACT FROM AUTHOR]

Aim Females of child-bearing age have been reported to have a two to three-fold increase in infertility after restorative proctocolectomy (RPC). This study aimed to assess aspects of infertility and pregnancy. Method A postal questionnaire was sent to 790 females who had undergone primary RPC in two tertiary centres. Infertility, the number and outcome of pregnancies, delivery method and the use of fertility treatments were determined. Results Three hundred and six (38.5%) females responded (median age 47.9 years at follow up; 35.3 years at the time of RPC). Eighty-two per cent ( n = 250) had ulcerative colitis. Forty-five per cent ( n = 138) had conceived prior to RPC, 5.2% ( n = 16) conceived both before and after RPC, 5.5% ( n = 17) conceived after RPC only and 44.1% ( n = 135) had never conceived. Females delivering before RPC had significantly more vaginal deliveries than those conceiving after (pre-RPC 69.6%, n = 96 vs post-RPC 35.3%, n = 6; P = 0.001). Fifty-seven patients stated they had attempted to conceive after RPC, with 25 (45.5%) being successful. Eighteen females had been referred to a fertility specialist, of whom 16 received in vitro fertilization (IVF). Four (30.7%) females conceived using IVF. Conclusion While RPC is known to be associated with infertility, only a small proportion of patients are referred for fertility management. IVF outcomes and success rates after RPC are similar to the general population. Patients are more likely to have a Caesarean section following RPC. [ABSTRACT FROM AUTHOR]

Aliment Pharmacol Ther 2011; 34: 409-415 Summary Background Evidence is emerging regarding the relationship between a dysbiosis of the human gut microbiota and a number of gastrointestinal diseases as well as diseases beyond the gut. Probiotics have been investigated in many gastrointestinal disease states, with variable and often modest outcomes. Faecal transplantation is an alternative approach to manipulate the gut microbiota. Aim To review the use of faecal transplantation therapy for the management of gastrointestinal disorders. Methods Available articles on faecal transplantation in the management of gastrointestinal disorders were identified using a Pubmed search and bibliographies of review articles on the subject were collated. Results A total of 239 patients who had undergone faecal transplantation were reported. Seventeen of 22 studies of faecal transplantation were in fulminant or refractory Clostridium difficile. Studies of faecal transplantation are heterogeneous regarding the patients, donors, screening, methods of administration and definition of response. Faecal transplantation for C. difficile has been demonstrated to be effective in 145/166 (87%) patients. Small numbers of patients are reported to have undergone successful faecal transplantation for irritable bowel syndrome and inflammatory bowel disease. Conclusions Faecal transplantation has been reported with good outcomes for fulminant and refractory C. difficile. No adverse effects of faecal transplantation have been reported. However, there are no level 1 data of faecal transplantation and reports to date may suffer from reporting bias of positive outcomes and under-reporting of adverse effects. This therapy holds great promise, where a dysbiosis of the gut microbiota is responsible for disease and further studies are necessary to explore this potential. [ABSTRACT FROM AUTHOR]

Aim: Faecal incontinence is estimated to affect between 2 and 3% of Western adult populations. In recent years sacral nerve stimulation has become an important treatment modality, often as the first-line surgical therapy. The aim of this article was to review the current evidence regarding patient selection and surgical technique and to evaluate the logistics of providing a neurostimulation service. Method: A Medline search was performed including the keywords and ⁄ or MeSH headings of sacral nerve stimulation, neuromodulation, artificial pacemaker, faecal incontinence, patient selection, predictive factors and anal canal. Further studies were identified by cross referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings. Results: Despite the success of sacral nerve stimulation for several pathophysiological causes of incontinence, case selection is of paramount importance. Sacral nerve stimulation should not be offered outside a multidisciplinary pelvic floor unit. Temporary evaluation using diary cards can lead to false positive and negative results. Adherence to a meticulous surgical technique, using lowamplitude stimulation to guide lead placement, provides optimal clinical outcome. Conclusion: The short-term outcome of sacral nerve stimulation is dependent on patient factors and operative technique. Despite this, specific preoperative predictive factors of treatment success have yet to be identified. [ABSTRACT FROM AUTHOR]

Aim: A knowledge of the principles of neuro stimulation is essential to achieve optimal efficacy and minimize adverse effects. The aim of this article was to review the current evidence regarding device programming in the management of patients having sacral nerve stimulation (SNS) for faecal incontinence. Method: A Medline search was performed including the keywords and ⁄ or MeSH headings of sacral nerve stimulation, neuromodulation, artificial pacemaker, faecal incontinence, programming, adverse effects and complications. Further studies were identified by cross-referencing from relevant articles and by appraisal of recent peer-reviewed conference abstracts and proceedings. Results: Neurostimulator programming is an important component of SNS. Efficacy can be improved or restored with reprogramming. Adverse stimulation is often reversible, and non-stimulation-related complications are correctable. A total loss of efficacy can be explained in over one-half of patients. Conclusion: An improved outcome of SNS can be achieved by selecting the best possible stimulation parameters individualized to each patient. Further research into the optimal settings is needed. [ABSTRACT FROM AUTHOR]

About 5% of restorative proctocolectomy (RPC) patients develop chronic antibiotic-dependent pouchitis. These require antibiotic maintenance therapy. We report our experience in managing this patient group. Patients with RPC that was treated with antibiotic maintenance therapy were identified from the hospital pouch database. Data including faecal antibiotic sensitivity, functional outcome, side effects and Cleveland Global Quality of Life (CGQOL) score were recorded. Twenty-five patients were identified. The median length of treatment was 15.8 (range 3-62) months. Ten (40%) patients had pouchitis with co-existing prepouch ileitis. The median frequency of defecation was 7 (range 4-11)/24 h, the median clinical Pouch Disease Activity Index (PDAI) was 0 (range 0-1) and the CQGOL score was 0.7 (range 0.5-1.0). Of those who relapsed, three (50%) patients had achieved mucosal healing following the induction of remission. Failure of mucosal healing did not predict a reduced time to relapse ( P = 0.18). Prepouch ileitis was associated with an increased risk of developing antibiotic resistance ( P = 0.023). Treatment of this with alternating antibiotic combination therapy was successful in all cases. Antibiotic maintenance therapy appears safe, well-tolerated and effective for the treatment of chronic antibiotic-dependent pouchitis. It results in an improved quality of life and function. Prepouch ileitis, but not failure of mucosal healing, is associated with an increased risk of developing antibiotic resistance. [ABSTRACT FROM AUTHOR]

Aliment Pharmacol Ther 2010; 32: 664–669 Background Treatment with fluoroquinolones is associated with the development of Clostridium difficile and extended spectrum beta-lactamase-producing bacteria (ESBL). Clostridium difficile and ESBL are resistant to many antibiotics and each may cause pouchitis after restorative proctocolectomy (RPC) refractory to empirical antibiotic therapy. Aim To assess the prevalence and establish risk factors for the development of ESBL and Clostridium difficile toxins (CDT) in RPC patients with recurrent or refractory pouchitis under follow-up at our institution over a 1-year period. Method An enzyme-linked immunosorbent assay was used to detect CDT and a culture technique was used to identity ESBL in faecal samples. All patients had previously received fluoroquinolone treatment. Results Forty-eight patients (35 (74%) men; median age 42 years) underwent testing at a median interval from RPC of 8 (range 1–25) years. No patient had a positive CDT result, but ESBL bacteria were identified in 16 (33%) samples. ESBL positivity was significantly related to prepouch ileitis ( P = 0.035) and maintenance antibiotic therapy ( P = 0.039). Conclusions Extended spectrum beta-lactamase, but not CDT, is a common finding in faecal samples from patients with recurrent or refractory pouchitis. Treatment with maintenance antibiotics and prepouch ileitis are risk factors for developing ESBL-producing bacteria. [ABSTRACT FROM AUTHOR]

Aliment Pharmacol Ther 31, 1310–1321 Background Recent data associated higher mortality with medical rather than surgical intervention in patients with ulcerative colitis who require hospitalization. Aim To examine factors influencing UC-related mortality in Scotland. Method Using the national record linkage database 1998–2000, 3-year mortality was determined after four admission types: colectomy-elective or emergency; no colectomy-elective or emergency. Results Of 1078 patients, crude 3-year mortality rates were: colectomy elective 5.6% ( n = 177) and emergency 9.0% (100); no colectomy elective 9.8% (244) and emergency 16.0% (557). Using elective colectomy as reference, multivariate analysis [OR (95% CI)] showed that admission age >50 years [OR 5.46 (2.29–11.95)], male gender [OR 1.92 (1.23–3.02)], comorbidity [OR 2.2 (1.38–3.51)], length of stay >15 days [OR 2.04 (1.08–3.84)] and prior IBD admission [OR 1.66 (1.06–2.61)] were independently related to mortality. Age was the strongest determinant. No patient <30 years died. Mortality of patients aged <50 years [10/587 (1.7%)] was significantly lower than mortality of those aged 50–64 years [26/246 (10.6%)] (χ2 = 32.91; P < 0.0000001) and >65 [96/245 (39.2%)] (χ2 = 218.2; P < 0.0000001). For those patients aged more than 65 years, mortality in the four groups was 29.4%, 33.3%, 28.1% and 44.7%– all greater than expected in the Scottish population on assessment of standardized mortality ratios. Conclusion Hospital admission in UC patients >65 is associated with high mortality. Management strategies should consider this by treatment in specialist units, early investigation, focused medical treatment and earlier surgical referral. [ABSTRACT FROM AUTHOR]

Objective There is little information on the long-term failure and function after restorative proctocolectomy (RPC). The results of data submitted to a national registry were analysed. Method The UK National Pouch Registry was established in 2004. By 2006, it comprised data collected from ten centres between 1976 and 2006. The long-term failure and functional outcome were determined. Trends over time were assessed using the gamma statistic or the Kruskal–Wallis statistic wherever appropriate. Results In all, 2491 patients underwent primary RPC over a median of 54 months (range 1 month to 28.9 years). Of these, 127 (5.1%) underwent abdominal salvage surgery. The incidence of failure (excision or indefinite diversion) was 7.7% following primary and 27.5% following salvage RPC ( P < 0.001). The median frequency of defaecation/24 h was five including one at night. Nocturnal seepage occurred in 8% at 1 year, rising to 15.4% at 20 years ( P = 0.037). Urgency was experienced by 5.1% of patients at 1 year rising to 9.1% at 15 years ( P = 0.022). Stool frequency and the need for antidiarrhoeal medication were greater following salvage RPC. Conclusion In patients retaining anal function after RPC, frequency of defaecation was stable over 20 years. Faecal urgency and minor incontinence worsened with time. Function after salvage RPC was significantly worse. [ABSTRACT FROM AUTHOR]

Background Pre-pouch ileitis is a recently described condition which may occur following restorative proctocolectomy. Its aetiology remains unknown and only one study has reported the effect of treatment. We report a series of fourteen patients treated and followed up with repeat pouchoscopy. Aim To study the effectiveness of antibiotics for the treatment of pre-pouch ileitis following restorative proctocolectomy with ileal pouch–anal anastomosis. Methods Fourteen consecutive patients with symptomatic pre-pouch ileitis were treated with ciprofloxacin 500 mg b.d. and metronidazole 400 mg b.d. for 28 days. All had concurrent pouchitis. Symptomatic, endoscopic and histological assessment was performed before and following treatment using the pouchitis disease activity index (PDAI). Symptomatic remission was defined as a score of 0 in the clinical component of the PDAI. Results Twelve (86%) patients experienced symptomatic remission. Stool frequency fell from a median of 12 (range 8–20) to 6 (4–17) ( P = 0.002). There was a significant reduction in the anatomical length of pre-pouch ileitis with nine (64%) patients having either a resolution or a reduction in length of pre-pouch ileitis from a median of 10 cm (range 3–20 cm) to a median of 1 cm (range 0–10 cm) ( P = 0.007). Conclusion Combination antibiotic therapy in this uncontrolled study appears effective in reducing the length of pre-pouch ileitis and in inducing symptomatic remission in most patients whether or not its extent is reduced. [ABSTRACT FROM AUTHOR]

Objective One surgical option to treat failure after restorative proctocolectomy (RPC) is indefinite diversion (ID) without excision of the pouch. The study aimed to assess the mucosal morphology of the pouch and ileoanal anastomosis (IAA) over time after ID with particular reference to inflammation, dysplasia and carcinoma. Method Patients with ID were identified from the hospital’s Ileal Pouch Database. Individuals were invited by mail to attend for flexible pouchoscopy and biopsy from the ileal pouch and immediately distal to the IAA. Results Of 1822 patients on the database, 28 had undergone ID. Of these, 20 patients (18 ulcerative colitis, one familial adenomatous polyposis, one pseudo-obstruction) of median age 42 (18–67) years took part. There were eight males. The median (range) intervals from diagnosis of primary disease, pouch surgery and ID to the time of study were 221 (63–410), 146 (31–314) and 44 (10–159) months respectively. One patient had dysplasia in the original resection specimen. Five patients developed type C changes in the pouch. Of these three were identified between RPC and ID, one developed between ID and the present assessment and one was identified for the first time at the present assessment. No case of dysplasia or cancer was found in any of the biopsies. Rectal mucosa was found in biopsies from the IAA in four patients (three stapled; one handsewn); this was inflamed in three patients. Conclusion At a median follow-up of 12 years after RPC and 3.6 years after indefinite diversion no instance of dysplasia or carcinoma in the ileal reservoir or distal to the IAA was found in any of the 20 patients having ID. Type C changes occurred at some time in five (25%) patients, indicating the importance of continued follow up. [ABSTRACT FROM AUTHOR]

Background Restorative proctocolectomy with ileal pouch-anal anastomosis is the procedure of choice for the majority of patients with ulcerative colitis who require surgery. Over 2500 patients in the UK have undergone restorative proctocolectomy. It is now increasingly being performed in district general hospitals as well as in specialist inflammatory bowel disease units. Gastroenterologists are increasingly involved in the management of patients following restorative proctocolectomy. Aim To provide gastroenterologists with a clear understanding of the investigation and evidence-based management of complications and the aftercare required in patients who have undergone restorative proctocolectomy. Results Following restorative proctocolectomy, most patients have an excellent long-term functional outcome. Pouchitis, pelvic sepsis and poor function are the most common causes of failure. The development of cancer is rare; nevertheless, long-term follow-up is required. Conclusions The investigation and management of patients who develop complications require a multidisciplinary team approach to optimize the outcome. Protocols are suggested for investigation and management of patients with complications and for long-term cancer surveillance. [ABSTRACT FROM AUTHOR]

Objective The choice of ileal pouch reservoir has been a contentious subject with no consensus as to which technique provides better function. This study aimed to compare short- and long-term outcomes of three ileal reservoir designs. Method Comparative studies published between 1985 and 2000 of J, W and S ileal pouch reservoirs were included. Meta-analytical techniques were employed to compare postoperative complications, pouch failure, and functional and physiological outcomes. Quality of life following surgery was also assessed. Results Eighteen studies, comprising 1519 patients (689 J pouch, 306 W pouch and 524 S pouch) were included. There was no significant difference in the incidence of early postoperative complications between the three groups. The frequency of defecation over 24 h favoured the use of either a W or S pouch [J vs S: weighted mean difference (WMD) 1.48, P < 0.001; J vs W: WMD 0.97, P = 0.01]. The S pouch was associated with an increased need for pouch intubation (S vs J: OR 6.19, P = 0.04). The use of a J pouch was associated with a significantly higher prevalence of use of anti-diarrhoeal medication (J vs S: OR 2.80, P = 0.01; J vs W: OR 3.55, P < 0.001). Conclusion All three reservoirs had similar perioperative complication rates. The S pouch was associated with the need for anal intubation. There was less frequency and less need for antidiarrhoeal agents with the W rather than the J pouch. [ABSTRACT FROM AUTHOR]

Objective Restorative proctocolectomy (RPC) with or without mucosectomy is the treatment of choice for most patients with ulcerative colitis (UC) requiring surgery. The ileal mucosa in the reservoir and the anorectal columnar epithelium below the ileo-anal anastomosis are at risk of neoplastic transformation. Method The literature has been reviewed to identify patients developing this complication and an attempt has been made to develop a rational follow-up policy based on the data available. Results Dysplasia in the ileal reservoir is rare. It is associated with histological type C changes, sclerosing cholangitis and unremitting pouchitis in the ileal mucosa and to the presence of sclerosing cholangitis. Nine patients who have developed adenocarcinoma in the residual anorectal mucosa and seven in the reservoir have been reported in the literature. A further hitherto unreported patient treated by the authors brings the total to 17 patients. Twelve of these had histopathological data on either dysplasia or carcinoma in the original operative specimen. The time intervals from the onset of UC and from the RPC to the development of cancer were 120–528 (median 246) and 16–216 (median 60) months respectively. Cancer appeared to be related to the duration of disease rather than to the interval from RPC. In all the reported patients the interval from the onset of UC was 10 years. Conclusion Based on these data a surveillance programme should begin at 10 years from the onset of disease. Patients with dysplasia or carcinoma in the original specimen, those with type C ileal mucosal changes and patients with sclerosing cholangitis should be selected for surveillance. This will involve multiple biopsies of the ileal reservoir and the anorectal mucosa below the ileo-anal anastomosis. [ABSTRACT FROM AUTHOR]

Objective Ileal inflammation in ulcerative colitis can occur as backwash ileitis or prestomal ileitis. After restorative proctocolectomy (RPC), ileal inflammation may be present in the pouch (pouchitis) but inflammation proximal to the pouch in the neo-terminal ileum, so called pre-pouch ileitis (PI), has also been observed. As pouchitis is increasingly common and PI can mimic it, our aim was to characterize this condition. Subjects and methods A review of prospectively collected data on 571 inflammatory bowel disease patients undergoing follow-up after RPC in a single centre over 22 years was performed. The histology of biopsy material was reviewed and staining for colonic mucosal phenotypic changes was undertaken. It was not routine practice to prospectively assess all patients for pre-pouch ileitis when the database was constructed. Results Of 19 patients with inflammation of the pre-pouch neo-terminal ileum (NTI) identified three had Crohn's disease and one a NSAID stricture. The remaining 15 had a characteristic diffuse inflammation extending from the NTI-pouch junction proximally: pre-pouch ileitis. The inflammation extended proximally for up to 50 cm. Fistula formation was seen in only one. Seven (47%) of 15 had pouchitis but only two had suffered backwash ileitis pre-operatively. Seven responded to medical therapy and four to surgery. The histological appearances including staining for colonic phenotypic change were similar in PI and pouchitis. Conclusion Pre-pouch ileitis is uncommon. As the patients' previous diagnosis of UC was confirmed and there was no radiological or histological evidence of Crohn's disease, PI appears to have a distinct pathogenesis from Crohn's disease. [ABSTRACT FROM AUTHOR]

Objective Using meta-analytical techniques the present study evaluated differences in short-term and long-term outcomes of adult patients with colonic Crohn's disease who underwent either colectomy with ileorectal anastomosis (IRA) or segmental colectomy (SC). Methods Comparative studies published between 1988 and 2002, of subtotal/total colectomy and ileorectal anastomosis vs segmental colectomy, were used. The study end points included were surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Random and fixed-effect meta-analytical models were used to evaluate the study outcomes. Sensitivity analysis, funnel plot and meta-regressive techniques were carried out to explain the heterogeneity and selection bias between the studies. Results Six studies, consisting of a total of 488 patients (223 IRA and 265 SC) were included. Analysis of the data suggested that there was no significant difference between IRA and SC in recurrence of Crohn's disease. Time to recurrence was longer in the IRA group by 4.4 years (95% CI: 3.1–5.8), P < 0.001. There was no difference between the incidence of postoperative complications (OR = 1.4., 95% CI 0.16–12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95% CI 0.78–9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance ( P = 0.177). Conclusions Both procedures were equally effective as treatment options for colonic Crohn's disease however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. Since no prospective randomised study has been undertaken, a clear view about which approach is more suitable for localised colonic Crohn's disease cannot be obtained. [ABSTRACT FROM AUTHOR]

The present study aims to evaluate the short-term and long-term outcomes of patients undergoing restorative proctocolectomy (RPC) for Crohn's disease (CD) and Indeterminate colitis (IC) and to identify factors associated with adverse outcomes.A descriptive study of 52 patients with CD or IC from a total of 1652 patients undergoing primary or salvage RPC in a single tertiary referral centre between 1978 and 2003. Primary outcomes were ileal pouch failure (excision or indefinite diversion), adverse events and functional outcomes (bowel frequency, urgency and continence).Patients with IC or IC favouring ulcerative colitis (Group 1,n = 26) had a pouch failure rate of 11.5%vs57.5% for patients with CD or IC favouring CD (Group 2,n = 26). Pouch salvage surgery was undertaken in 15 patients with a 13.3% failure rate. Patients in Group 2 were 2.6 times more likely (95% CI: 0.96–7. No significant differences were evident between CD and IC patients with regards to pelvic sepsis (19.2%vs15.4%), anastomotic stricture (23.1%vs21.7%), small bowel obstruction (26.9%vs26.9%) or pouchitis (15.4%vs11.5%). The 24-h bowel frequency (7.5vs8), faecal urgency, daytime or night time incontinence were similar between patients with CD or IC..17) to develop a pouch-related fistula than patients in Group 1.Crohn's disease and to a great extent indeterminate colitis favouring CD were both associated with high failure rates and postoperative pouch-related fistula rates. Despite these problems, functional outcomes for patients with CD or IC were similar. Patients with IC should remain candidates for RPC but careful pre-operative assessment is advised to exclude clinical signs favouring the diagnosis of CD. The complications associated with failure are extensive and the option of reconstructive surgery in patients with CD should be questioned. [ABSTRACT FROM AUTHOR]

Recto-vaginal fistula is a rare complication of ulcerative colitis. There are few reports of restorative proctocolectomy carried out in patients with ulcerative colitis having a rectovaginal fistula. We report our experience with this condition. Between 1 January 1976 and 31 December 2001, 838 patients underwent restorative proctocolectomy for ulcerative colitis at one hospital. These included 400 women of whom 4 (1%) had an already present rectovaginal fistula. We reviewed all patients who presented with a rectovaginal fistula. These patients were contacted by telephone to establish function and satisfaction. The mean age was 30.0 years (range 19–39 years). The mean age at onset of ulcerative colitis was 21.5 years (range 13–34 years). One patient was asymptomatic, the fistula being discovered at operation. In the other three patients the recto-vaginal fistula had occurred at a mean of 108 months (range 72–192 months) after the onset of ulcerative colitis. Three of four patients had had previous episodes of acute severe disease. Three patients had a narrow rectum with deep ulceration. The mean distance between the anorectal junction and the site of fistulation was 2.7 cm (range 0–7 cm). Three patients had a three-stage and one patient a two-stage procedure. Mean follow-up after closure of the loop ileostomy was 107 months (range17–276 months). All patients were treated successfully but 2 (50%) had a recurrence at 156 and 40 months after the closure of the loop ileostomy. One patient was diverted and the fistula was closed by a subsequent transanal repair and the other patient was treated with success by temporary loose seton technique. Two patients had excellent functional results whereas two other had some difficulties in continence. Nevertheless all patients were satisfied with the outcome. Patients with ulcerative colitis and a recto-vaginal fistula can be successfully treated by restorative proctocolectomy, nevertheless they are at risk of late recurrence of the fistula. [ABSTRACT FROM AUTHOR]

Summary The indication for surgery is a balance between the severity of the disease despite full medical treatment and the potential disadvantages of surgery. The decision requires cooperation between gastroenterologist and surgeon. Colectomy with ileostomy and preservation of the rectum in the emergency setting is the accepted procedure and can rapidly restore the patient to normal health allowing withdrawal of anti-inflammatory medication. After recovery all surgical possibilities are then open for the future. The elective indications for surgery include failure of medical treatment, retardation of growth in a child or adolescent and neoplastic transformation. The choice of operation includes conventional proctocolectomy, restorative proctocolectomy (RPC) and colectomy with ileo-rectal anastomosis. Each has relative advantages and disadvantages. RPC is the commonest procedure. It offers a satisfactory outcome in 70–90% of patients with a cumulative failure rate of 10–15% over a 10 year period. Causes of failure include sepsis (50%), dysfunction (30%) and pouchitis (10%). In selected cases salvage surgery to avoid failure can be successful with rates of around 70% for outlet obstruction and fistulation and 50% for pelvic sepsis. [ABSTRACT FROM AUTHOR]

Background: Preliminary data suggest that short-term antibiotic therapy with a single drug is effective for the treatment of patients with pouchitis. However, some patients are resistant to treatment. Aim: To evaluate the therapeutic efficacy of a prolonged course of a combination of two antibiotics in patients with refractory or recurrent pouchitis, as well as its impact on their quality of life. Methods: Patients with active refractory or recurrent pouchitis were recruited. This was defined as both: (i) a history of pouchitis at least twice in the last 12 months or persistent pouchitis requiring continual intake of antibiotics; and (ii) a Pouchitis Disease Activity Index score 3 7 (best to worst pouchitis=0–18) at the beginning of therapy. Treatment consisted of a combination of metronidazole, 400 or 500 mg twice daily, and ciprofloxacin, 500 mg twice daily, for 28 days. Symptomatic, endoscopic and histological evaluations were undertaken before and after antibiotic therapy using the Pouchitis Disease Activity Index score. Remission was defined as a combination of a Pouchitis Disease Activity Index clinical score of <= 2, endoscopic score of <= 1 and total score of <= 4. The quality of life was assessed with the Inflammatory Bowel Disease Questionnaire, which encompasses bowel, systemic and emotional symptoms as well as social function (worst to best=32–224). Results: Forty-four patients (24 male, 20 female; median age, 37.5 years) entered the trial and completed treatment. Thirty-six (82%) went into remission. The median Pouchitis Disease Activity Index scores before and after therapy were 12 (range, 8–17) and 3 (range, 1–10), respectively (P < 0.0001). The median Inflammatory Bowel Disease Questionnaire score also significantly improved from 96.5 (range, 74–183) to 175 (range, 76–215) with this therapy (P < 0.0001). The eight patients (five male, three female) who did not go into remission were... [ABSTRACT FROM AUTHOR]

Introduction Volume acquisition during anal ultrasound enables multiplanar imaging of the anal canal. The normal ultrasonic multiplanar appearance of the anal canal is described and gender differences in canal anatomy are highlighted. Methods Ten male and 12 female normal volunteers (mean ages 31.5 years (s.d. 5.9) and 31.2 (s.d. 6.7)) had three-dimensional anal endosonography (3-D AES). Each volume dataset was seeded in the axial plane facilitating multiplanar identification of known anatomical structures. Results The anterior external anal sphincter (EAS) was significantly longer in men than women 30.1 mm (3.9) vs 16.9 mm (7.4) (P < 0.001). There was no difference in the length of the puborectalis 24.7 mm (6.4) vs 24 mm (5) (P=0.78) in men compared with women. The cranial extent of the anterior EAS was tilted forward in both sexes. The angle formed by the anterior EAS and the longitudinal axis of the anal canal was more acute in men than in women (11.1° vs 18.6°; P=0.007). Dataset volume seeding of familiar structures in the axial plane allowed the multiplanar endosonographic anatomy to be described. Conclusions Multiplanar AES has enabled detailed longitudinal measurement of the components of the anal canal and has revealed important gender differences. The multiplanar ultrasonic appearance of the normal anal canal has been described for the first time. [ABSTRACT FROM AUTHOR]

Objective Sacral nerve stimulation improves faecal continence. Preliminary evidence suggests that the effect may be mediated via altered rectal and anal smooth muscle activity, as well as facilitation of external sphincter contraction. Clinical benefit however, appears unrelated to whether stimulation amplitude is above or below that required to produce threshold perineal sensation. Formal evaluation of the effect of different levels of stimulation has not been undertaken. This study aimed to assess the effect of varying stimulation amplitude on pelvic floor motor and sensory function in patients permanently implanted for faecal incontinence. Patients and methods Three female patients with passive faecal incontinence secondary to internal sphincter weakness, rendered continent with a permanently implanted sacral nerve stimulating electrode and pulse generator a mean of 19 months previously, were assessed. Patients underwent a series of anorectal physiological tests whilst stimulating amplitude was altered but all other stimulation parameters were kept constant. Baseline studies were initially performed at the stimulation amplitude providing continence over recent months for individual patients. Amplitude was then initially reduced, and then increased, in increments of 0.2 V, initially down to zero, and then to the maximal tolerated stimulation amplitude, at which pain was felt. Anorectal physiological testing was repeated 10 min after adjustment to each new amplitude of stimulation. Results Procedures were well tolerated by all patients. There were no significant differences in any of the physiological variables measured dependent upon intensity of stimulation between zero and the maximum tolerated stimulation. The recto-anal inhibitory reflex was unaltered in the one patient in whom it was demonstrable prior to stimulation. Conclusion Acute changes in stimulation amplitude alone do not produce acute measurable differences in standard anorectal physiological... [ABSTRACT FROM AUTHOR]

Faecal incontinence affects a percentage of the population and can have a significant effect on their ability to establish and maintain sexual relations. Sixteen consecutive patients with permanent sacral neuromodulation (SNM) for faecal incontinence completed a ‘Sex Life Questionnaire’ at their follow up visit to ascertain whether there was any improvement in this aspect of their life. Nine of the sixteen patients was sexually active. These nine patients (median age 56 (35–61) years) had a significant reduction in faecal incontinence episodes per week from a median of 12 (1–55) to 1.5 (0–8.5) ( P = 0.008). All nine patients reported that their sex life had been affected by feacal incontinence prior to SNM and seven had felt benefit from implantation. The median improvement in their sex life was 40% (1–100) and the percentage improvement was inversely correlated to age ( r = −0.834, P = 0.005). SNM improves the quality of sexual activity in 78% of patients. More improvement seems to be gained the younger the patients. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Orlistat as a potential treatment for chronic idiopathic constipation" by A. Dudekula and colleagues that was published in a previous issue of the periodical.

The above article, published online on 15 July 2016 in Wiley Online Library (), has been retracted by agreement between the authors, the journal Editor-in-Chief, Neil Mortensen, and John Wiley & Sons Limited. After acceptance the authors were made aware of a contribution to a prior publication of the UICC, TNM Supplement: A commentary on uniform use, 4th Edition, ed. C. Wittekind (Wiley, 2012), p. 195, which renders the central argument of their article invalid. They have therefore asked for it to be withdrawn. A modified version of the paper was published in the January 2017 issue (volume 19; issue 1) with the title 'The degree of extramural spread of T3 rectal cancer: an appeal to the American Joint Committee on Cancer'. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented about transcutaneous sacral nerve stimulation (tSNS) as an effective treatment for faecal incontinence.

A letter to the editor is presented in response to the article "Pre-Pouch Ileitis: A Disease of the Ileum in Ulcerative Colitis After Restorative Proctocolectomy," which was published in a 2006 issue.

Purpose: To evaluate differences in short- and long-term outcomes of patients with colonic Crohn's disease (CD) undergoing either subtotal/total colectomy with ileorectal anastomosis (IRA) or segmental colectomy(SC). Method: Comparative studies from 1988 to 2002, of subtotal/total colectomy and IRA vs SC, were used. The study end points included surgical and overall recurrence, time to recurrence, postoperative morbidity and incidence of permanent stoma. Meta-analytical tools were used to evaluate the study outcomes. Results: Six studies, consisting of a total of 488 patients (223-IRA and 265-SC) were included. Meta-analysis suggested no significant difference between IRA and SC in recurrence of CD. Time to recurrence was longer in the IRA group by 4.4 years (95%CI, 3.1–5.8), P < 0.001. There was no difference in postoperative complications (OR = 1.4, 95%CI, 0.16–12.74) or the need for a permanent stoma between the two groups (OR = 2.75, 95%CI, 0.78–9.71). Patients with two or more colonic segments involved were associated with lower re-operation rate in the IRA group, a difference which did not reach statistical significance ( P = 0.177). Conclusions: Both procedures were equally effective as treatment options for colonic CD, however, patients in the SC group exhibited recurrence earlier than those in the IRA group. The choice of operation is dependent on the extent of colonic disease, with a trend towards better outcomes with IRA for two or more colonic segments involved. [ABSTRACT FROM AUTHOR]