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Anal incontinence describes the uncontrolled transanal passage of gaseous, solid or liquid intestinal contents. It can be a considerable psychosocial burden and impairment of the quality of life for those affected. The cause can be primary damage to the continence organ or incontinence can be a secondary symptom of other diseases. The detailed patient history and clinical examination document the severity of incontinence, impairment of quality of life and pathomorphological changes. The treatment is primarily conservative. A combination of conservative therapeutic approaches can often achieve satisfactory symptom relief. If conservative treatment remains insufficient, surgical measures can be considered. Sphincteroplasty and sacral neuromodulation are the preferred surgical interventions.

Anal incontinence describes the uncontrolled transanal passage of gaseous, solid or liquid intestinal contents. It can be a considerable psychosocial burden and impairment of the quality of life for those affected. The cause can be primary damage to the continence organ or incontinence can be a secondary symptom of other diseases. The detailed patient history and clinical examination document the severity of incontinence, impairment of quality of life and pathomorphological changes. The treatment is primarily conservative. A combination of conservative therapeutic approaches can often achieve satisfactory symptom relief. If conservative treatment remains insufficient, surgical measures can be considered. Sphincteroplasty and sacral neuromodulation are the preferred surgical interventions.Anale Inkontinenz bezeichnet den unkontrollierten transanalen Abgang gasförmigen, festen oder flüssigen Darminhalts. Sie kann eine erhebliche psychosoziale Belastung und Einschränkung der Lebensqualität für die Betroffenen bedeuten. Ursächlich können primär Schädigungen des Kontinenzorgans sein oder die Inkontinenz kann sekundär ein Symptom anderer Erkrankungen sein. Die sorgfältige Anamnese und klinische Untersuchung erfassen den Schwergrad der Inkontinenz, Einschränkungen der Lebensqualität und pathomorphologische Veränderungen. Die Therapie ist primär konservativ. Häufig kann durch Kombination konservativer Therapieansätze eine zufriedenstellende Symptomlinderung erzielt werden. Ist die konservative Therapie ausgereizt, können operative Maßnahmen erwogen werden. Von den operativen Möglichkeiten kommen insbesondere die Sphinkteroplastik und sakrale Neuromodulation zum Einsatz.

The distal resection margin (DRM) plays a pivotal role in rectal cancer surgery. Colorectal surgeons are often torn between keeping an oncologically safe margin versus aiming at sphincter preserving surgery. This study was performed to assess the oncological safety of a minimal DRM of1 cm.From a prospectively maintained database for rectal cancer 405 patients were identified. Out of 405 patients 88 patients were eligible for the study characterized by UICC tumor stage of II or III, cancer less than 12 cm from the anal verge and a complete course of preoperative chemoradiotherapy (CRT) before undergoing low anterior rectal resection between 2004 and 2012. Preoperative staging included rigid rectoscopy, endo-rectal ultrasound as well as pelvic MRI. Primary endpoints were overall survival (OS) and local recurrence-free survival (LRFS).The incidence of local recurrence was 5.7% (n = 5). In DRM1 cm (n = 33) local recurrence was seen in two patients (6.1%) and with DRM ≥ 1 cm (n = 55) in three patients (5.5%). The 5-year OS rate was 94.5% (93.2% DRM1 cm, 95.7% DRM ≥1 cm; P = 0.642). 5-year LRFS was 93.2% in DRM1 cm and 95.7% in DRM ≥1 cm (P = 0.936).R0 resection of stage II and II rectal cancer of the mid and lower third after preoperative CRT yields excellent results even with DRM1 cm. Minimizing the distal resection margin may allow surgeons to offer sphincter sparing surgery without compromising local recurrence-free and overall survival in individual patients.

Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Introduction: Resection of anorectal malignancies may result in extensive perineal/pelvic defects that require an interdisciplinary surgical approach involving reconstructive surgery. The myocutaneous gracilis flap (MGF) and the gluteal fold flap (GFF) are common options for defect coverage in this area. Here we report our experience with the MGF/GFF and compare the outcome regarding clinical key parameters. Methods: In a retrospective chart review, we collected data from the Department of Plastic Surgery of the University of Freiburg from December 2008-18 focusing on epidemiological, oncological, and therapy-related data including comorbidities (ASA Classification) and peri-/postoperative complications (Clavien-Dindo-System). Results: Twenty-nine patients were included with a mean follow-up of 17 months. Of the cases, 19 (65.5%) presented with recurrent disease, 21 (72.4%) received radiochemotherapy preoperatively, 2 (6.9%) received chemotherapy alone. Microscopic tumor free margins were achieved in 25 cases (86.2%). 17 patients (7 men, 10 women, rectal adenocarcinoma n = 11; anal squamous cell carcinoma n = 6; mean age 58.5 ± 10.68, mean BMI 23.1, mean ASA score 2.8) received a MGF (unilateral n = 10; bilateral n = 7). Twelve patients (7 men, 5 women, rectal adenocarcinoma n = 7; anal squamous cell carcinoma n = 4, proctodeal gland carcinoma n = 1, mean age 66.2 ± 9.2, mean BMI 23.6, mean ASA score 2.6) received coverage with a GFF (unilateral n = 4; bilateral n = 8). Mean operation time of coverage was 105 ± 9 min for unilateral and 163 ± 11 for bilateral MGFs, 70 ± 13 min for unilateral and 107 ± 14 for bilateral GFFs. Complications affected 62%. There was no significant difference in the complication rate between the MGF- and GFF-group. Complications were mainly wound healing disorders that did not extend the hospital stay. No flap loss and no complication that lead to long-lasting disability was documented (both groups). Pain-free sitting took more time in the GFF-group due to the location of the donor site. Conclusion: MG-flaps and GF-flaps prove to be reliable and robust techniques for perineal/pelvic reconstruction. Though flap elevation is significantly faster for GF-flaps, preoperative planning and intraoperative Doppler confirmation are advisable. With comparable complication rates, we suggest a decision-making based on distribution of adipose tissue for dead space obliteration, intraoperative patient positioning, and perforator vessel quality/distribution.

Importance Total neoadjuvant therapy has been increasingly adopted for multimodal rectal cancer treatment. The optimal sequence of chemoradiotherapy (CRT) and chemotherapy needs to be established. Objective To report the long-term results of the secondary end points prespecified in the Randomized Phase 2 Trial of Chemoradiotherapy Plus Induction or Consolidation Chemotherapy as Total Neoadjuvant Therapy (CAO/ARO/AIO-12 trial) for Locally Advanced Rectal Cancer. Design, Setting, and Participants This secondary analysis of a randomized clinical trial included 311 patients who were recruited from the accrued CAO/ARO/AIO-12 trial population from June 15, 2015, to January 31, 2018, from 18 centers in Germany. Patients with cT3-4 and/or node-positive rectal adenocarcinoma were included in the analysis. Data were analyzed from June 15, 2015, to January 31, 2018. The follow-up analysis was conducted between January 31, 2018, and November 30, 2020. Interventions Patients were randomly assigned to group A for 3 cycles of fluorouracil, leucovorin, and oxaliplatin before fluorouracil/oxaliplatin CRT (50.4 Gy), or to group B for CRT before chemotherapy. Total mesorectal excision was scheduled on day 123 after the start of total neoadjuvant therapy in both groups. Main Outcomes and Measures The end points assessed in this secondary analysis included long-term oncologic outcomes, chronic toxicity, patient-reported outcome measures for global health status (GHS) and quality of life (QoL), and the Wexner stool incontinence score. Results Of the 311 patients enrolled, 306 were evaluable, including 156 in group A (mean [SD] age, 60 [11] years; 106 men [68%]) and 150 in group B (mean [SD] age, 62 [10] years; 100 men [67%]). After a median follow-up of 43 months (range, 35-60 months), the 3-year disease-free survival was 73% in both groups (hazard ratio, 0.95; 95% CI, 0.63-1.45,P = .82); the 3-year cumulative incidence of locoregional recurrence (6% vs 5%,P = .67) and distant metastases (18% vs 16%,P = .52) were not significantly different. Chronic toxicity grade 3 to 4 occurred in 10 of 85 patients (11.8%) in group A and 8 of 66 patients (9.9%) in group B at 3 years. The GHS/QoL score decreased after total mesorectal excision but returned to pretreatment levels 1 year after randomization with no difference between the groups. Stool incontinence deteriorated 1 year after randomization in both groups and only improved slightly at 3 years, but never reached baseline levels. Conclusions and Relevance This secondary analysis of a randomized clinical trial showed that CRT followed by chemotherapy resulted in higher pathological complete response without compromising disease-free survival, toxicity, QoL, or stool incontinence and is thus proposed as the preferred total neoadjuvant therapy sequence if organ preservation is a priority. Trial Registration ClinicalTrials.gov identifier:NCT02363374

Background and Aims Dysregulated T cell responses contribute to the pathogenesis of inflammatory bowel disease [IBD]. Because vitamin D [vitD] deficiency is a risk factor for adverse disease outcomes, we aimed to characterize the impact of vitD on intestinal and peripheral T cell profiles. Methods T cells were isolated from peripheral blood and intestinal biopsies of IBD patients, incubated with vitD and characterized by flow cytometry. To translate these in vitro findings to the clinic, serum vitD concentrations and clinical outcomes were correlated with T cell phenotype and function in a prospective patient cohort. Results Incubation of peripheral and intestinal T cells with 1,25(OH)2-vitD resulted in strongly reduced frequencies of pro-inflammatory CD4+ and CD8+ T cells producing interferon γ [IFNγ], interleukin-17 [IL-17], IL-22, IL-9 and tumour necrosis factor [TNF]. Univariable analysis of 200 IBD patients revealed associations of vitD deficiency with non-compliant vitD intake, season of the year and anaemia in Crohn’s disease [CD] as well as disease activity in ulcerative colitis [UC]. Ex vivo immunophenotyping revealed that CD4+ and CD8+ T cell subsets were not substantially altered in vitD-deficient vs vitD-sufficient patients while regulatory T cell frequencies were reduced in UC and non-smoking CD patients with vitD deficiency. However, normalization of serum vitD concentrations in previously deficient CD patients resulted in significantly reduced frequencies of CD4+ T cells producing IFNγ, IL-17 and IL-22. Conclusion vitD exerts profound anti-inflammatory effects on peripheral and intestinal CD4+ and CD8+ T cells of IBD patients in vitro and inhibits TH1 and TH17 cytokine production in CD patients in vivo.

Objectives To determine a cut-off apparent diffusion coefficient (ADC) value distinguishing local recurrence from scar tissue in patients with rectal cancer treated with complete surgical tumour removal. Methods 72 patients were retrospectively included. Patients underwent 1.5T MRI including multiplanar T2-weighted turbo-spin-echo sequences (TSE) and axial single-shot epi-diffusion-weighted sequences (EPSE). Two independent observers measured mean tumour and scar tissue ADCs by manually drawing regions of interest (ROIs). The t -test and ROC analysis were used for comparison and determining an optimal discrimination threshold. As reference standard histopathological results were used in 23 patients (32%) and clinical follow-up in 49 patients (68%). Results Recurrent rectal cancer was found in 30 patients (4 female, 26 male, median age 63.13 years) and treatment related changes such as scar tissue in 42 patients (11 female, 31 male, median age 63.67 years). The mean ADC value of tumour recurrence was 1.02×10 −3 mm 2 /s (0.63–1.44×10 −3 mm 2 /s) and of scar tissue 1.77×10 −3 mm 2 /s (1.11–2.41×10 −3 mm 2 /s) showing a statistically significant difference (p −3 mm 2 /s with a sensitivity, specificity, and accuracy of 93%, 91%, and 92% respectively. Conclusions Diffusion weighted MRI allows for the differentiation of tumour recurrence from scar tissue after surgical resection of rectal cancer.

Purpose: The purpose of this study was to assess primary healing, recurrence and continence after endoanal advancement flap repair in patients with IBD compared to those with cryptoglandular disorders. Patients and Methods: 71 patients with fistulas-in-ano received endoanal advancement flap repair between 1997 and 2009. This is a prospective, non-randomized, single-centre study. Results: Follow up data was available for 63 patients. In 46% the fistulas were due to chronic inflammatory bowel disease. 54 % had cryptoglandular fistulas. Primary healing was observed in 37 cases (58.7 %). The median time to recurrence was 27 months (mean: 45 ± 50.31) and differed significantly across the patient groups: Inflammatory bowel disease 11 months (mean: 23.65 ± 32.47), cryptoglandular origin 51 months (mean: 63.20 ± 55.84) (P < 0.01). Preoperatively, 31 (49.2 %) of the patients had impaired continence versus 30 (47.6%) postoperatively. In IBD there was no significant difference between pre- and postoperative CCIS values (pre 4.05 ± 4.12 vs 3.61 ± 4.78, P = 0.4) Conclusions: Full-thickness endoanal advancement flap repair is a successful treatment option for IBD patients with transsphincteric fistulas. Fistulas associated with chronic inflammatory bowel disease were found to have a significantly higher rate of recurrence and a shorter time to recurrence at long-term follow-up. Repeat interventions do not negatively impact postoperative continence.