A observational study of the efficacy and safety of capecitabine versus bolus infusional 5-fluorouracil in pre-operative chemoradiotherapy for locally advanced rectal cancer

Background and objectives

This study is to evaluate the safety and efficacy of preoperative radiotherapy (RT) combined with bolus infusional 5-fluorouracil (5-FU) or oral capecitabine in patients with locally advanced rectal cancer (LARC).

Materials and methods

Seventy-four patients were retrospectively analyzed. Twenty-seven patients were treated with 5-FU (350?mg/m² IV bolus) and leucovorin (20?mg/m² IV bolus) for 5?days/week during week 1 and 5 of RT. Forty-seven patients were treated with capecitabine (850?mg/m², twice daily for 5?days/week). Both groups received the same RT course (45–50.4?Gy/25 fractions, 5?days/week, for 5?weeks). Patients underwent surgery in 6?weeks after completion of the chemoradiotherapy. Data of the observational study were collected.

Results

Grade 3 or 4 toxicities occurred in 40.7% (5-FU) and 19.1% (capecitabine) of the patients (P?=?0.044). Six patients in the 5-FU group (22.2%) and six patients in the capecitabine group (14%) achieved complete response. Primary tumor (T) downstaging were achieved in 51.9% (5-FU) and 69.8% (capecitabine) of the patients. The pathological ypT0-2 stage was 40.7% (5-FU) and 67.4% (capecitabine) (P?=?0.028).

Conclusions

In consideration of the better ypT0-2 downstaging rate, less severe toxicities, and no need for indwelling intravenous device on oral capecitabine regimen, the administration of oral capecitabine with RT may be a more favorable option in the neoadjuvant treatment for LARC.     

The treatment outcomes of synchronous and metachronous esophageal squamous cell carcinoma and head and neck squamous cell carcinoma

Background

The treatment outcomes of patients with esophageal squamous cell carcinoma (ESCC) and head and neck squamous cell carcinoma (HNSCC) have been poorly documented.

Patients and methods

We investigated 50 patients with synchronous and metachronous ESCC and HNSCC. We focused on the treatment results of 20 patients with synchronous ESCC and HNSCC who received simultaneous chemoradiotherapy (CRT).

Results

There were 34 patients (68.0?%) with stage 0?CI ESCC and 40 patients (80.0?%) with stage II?CIV HNSCC. A total of 13 (26.0?%) patients underwent endoscopic mucosal resection and 28 (56.0?%) underwent CRT for ESCC, and 35 (70.0?%) of the patients with HNSCC were treated with CRT. The 5-year overall survival rates of the 50 patients with synchronous and metachronous ESCC and HNSCC was 57.8?%. For the 20 patients with synchronous ESCC and HNSCC who received simultaneous CRT, the CRT was completed in 19 (95.0?%) patients. Although grade 3?C4 adverse events were observed in five (25.0?%) patients, there were no therapy-related deaths. Complete responses (CRs) of both ESCC and HNSCC were observed in ten (50.0?%) patients. The 5-year overall survival rate of the 20 patients was 60.0?%. CRs of both ESCC and HNSCC were obtained in seven (58.3?%) patients by using a cisplatin/5-FU regimen (n?=?12), and in the other three (37.5?%) patients by a platinum-based monotherapy regimen (n?=?8).

Conclusion

The surveillance of double cancer and the use of radical treatment contributed to the favorable outcome of the patients with ESCC and HNSCC. The optimal chemotherapy regimen for simultaneous CRT remains to be determined.     

Prone extralevator abdominoperineal excision of the rectum with porcine collagen perineal reconstruction (Permacol™): high primary perineal wound healing rates

Purpose

Extralevator abdominoperineal excision of the rectum (elAPER) is arguably the modern surgical approach to low rectal cancer and yet results in large defects that may necessitate plastic surgical reconstruction. This study aims to evaluate the quality of prone elAPER surgery with Permacol? repair of the perineum. The primary end point studied was the rate of primary perineal wound healing.

Methods

Data were prospectively collected for consecutive patients having prone elAPER at a single institution to assess surgical morbidity together with pathological and cancer-specific outcomes.

Results

Between 2006 and 2012, 48 patients had prone elAPER with median age of 63 (40–86). Thirty-four patients (72.3 %) received neoadjuvant treatment. Median length of stay was 9 days (6–66). With a prone approach, three patients had specimen perforation (6.4 %) and seven patients had circumferential margin involvement (14.9 %). Complete perineal wound healing was achieved in 34 patients (73.9 %) at 4 weeks. Four patients (8.3 %) were unhealed at 6 months; one patient required a perineal sinus to be laid open, and another patient required plastic surgical reconstruction. No perineal wound herniae have been identified during follow-up.

Conclusions

Acceptable oncological outcomes are achieved with the prone extralevator approach. The technique achieves high rates of primary healing, making it an attractive option in centres without access to plastic reconstructive expertise.     

Novel postoperative adjuvant strategy prevents early hepatic recurrence after resection of pancreatic cancer

Background/Purpose

It has been reported recently that adjuvant gemcitabine prolonged postoperative disease-free survival in patients with resectable pancreatic cancer. However, the efficacy was limited and further studies are required to improve the prognosis. In particular, postoperative hepatic recurrence often occurs even after gemcitabine treatment.

Methods

We are currently trying to evaluate the efficacy of postoperative combination therapy of high-dose 5-fluorouracil (5-FU) arterial infusion with systemic gemcitabine. Patients received weekly high-dose 5-FU through the hepatic artery using a port-catheter system (1000?mg/m² for 5?h) plus concurrent systemic gemcitabine (1000?mg/m²).

Results

Thirty-one patients were enrolled and 29 patients (94%) completed the scheduled adjuvant chemotherapy. The toxicity was acceptable and this regimen was well feasible as an outpatient treatment. At the time of analysis, 21 patients (68%) had recurrence. Local recurrence was most frequently observed, in 43% of the patients with recurrence. On the other hand, hepatic recurrence developed in only 2 patients (10%). The 1-year disease-free rate and overall survival rate were 62.9 and 100%, respectively.

Conclusion

Our novel adjuvant strategy had a significant beneficial effect on early hepatic recurrence and may have the potential to prolong the overall survival of pancreatic cancer patients.     

Escalated radiation dose alone vs. concurrent chemoradiation for locally advanced and unresectable rectal cancers: results from phase II randomized study

Purpose

This trial was undertaken to compare the rates of resectability between patients treated with neoadjuvant concurrent chemoradiation vs. boosted radiotherapy alone.

Materials and methods

Patients with clinically unresectable rectal cancer were randomized to receive external beam radiation therapy (EBRT) to pelvis (45 Gy) with concurrent oral Capecitabine (CRT group; Arm 1) or EBRT to pelvis (45 Gy) alone followed by 20 Gy dose of localized radiotherapy boost to the primary tumor site (RT with boost group, Arm 2). All patients were assessed for resectability after 6 weeks by clinical examination and by CT scan and those deemed resectable underwent surgery.

Results

A total of 90 patients were randomized, 46 to Arm 1 and 44 to Arm 2. Eighty seven patients (44 in Arm 1 and 41 in Arm 2) completed the prescribed treatment protocol. Overall resectability rate was low in both the groups; R0 resection was achieved in 20 (43 %) patients in Arm 1 vs. 15 (34 %) in Arm 2. Adverse factors that significantly affected the resectability rate in both the groups were extension of tumor to pelvic bones and signet ring cell pathology. Complete pathological response was seen in 7 and 11 %, respectively. There was greater morbidity such as wound infection and delayed wound healing in Arm 2 (16 vs. 40 %; p = 0.03).

Conclusion

Escalated radiation dose without chemotherapy does not achieve higher complete (R0) tumor resectability in locally advanced inoperable rectal cancers, compared to concurrent chemoradiation.     

Clinicopathological differences of laterally spreading tumors arising in the colon and rectum

Purpose

Laterally spreading tumors (LST) have been recognized worldwide. The aim of our retrospective study was to evaluate the clinicopathological differences of LST arising in the colon and rectum.

Methods

We investigated the clinical records of consecutive patients with LST that were endoscopically or surgically resected at our hospital between February 2006 and March 2011. LST were classified into three types: granular-homogenous (LST-GH), granular-nodular mixed (LST-GM), and nongranular (LST-NG) types. We also defined the hardly elevated flat lesion with a dilated pit pattern that occurs at the margins of LST as the “skirt.” The clinicopathological characteristics of the LST arising in the colon and rectum, including the presence of the skirt, were compared.

Results

A total of 496 colorectal LST in 435 patients were examined. LST-GM was predominant in the rectum, whereas LST-NG was predominant in the colon (p?p?p?p?Conclusions A greater proportion of LST-GM, greater mean size, and lower incidence of low-grade dysplasia were found in rectal LST. The skirt was a novel and unique finding, primarily observed in rectal LST-GM cases.     

Can we predict pathologic complete response before surgery for locally advanced rectal cancer treated with preoperative chemoradiation therapy?

Background

Pathologic complete response has been proven to have oncological benefits for locally advanced rectal cancer treated with chemoradiation therapy. The aims of this study are to analyze and determine the factors to predict pathologic complete response for patients treated with preoperative neoadjuvant therapy.

Methods

Patients with biopsy-proven, locally advanced rectal cancer were treated neoadjuvantly followed by radical surgical resection. Tumors were re-assessed after completing chemoradiation, including pelvic magnetic resonance images, colonoscopic examination, and re-biopsy. The results of examination were compared with the final pathologic status.

Results

A retrospective chart review of 166 patients was conducted. Twenty-five patients (15.1%) had pathologic complete response after chemoradiation. The 5-year overall survival rates were better in the complete response group than the residual tumor group (91.1% vs. 70.8%; P?=?0.047), and there were also significant differences in the 5-year disease-free survival rates between these two groups (91.1% vs. 70.2%; P?=?0.027). The prediction rates for pathologic complete response by re-biopsy, magnetic resonance images, and colonoscopy were 21.4%, 33.3%, and 53.8%, respectively. In addition, when we further combine the results of colonoscopic findings and re-biopsy, the prediction rate for pathologic complete response reached 77.8% (P?=?0.009).

Conclusions

Combining the results of the re-biopsy and post-treatment colonoscopic findings, we can achieve a good prediction rate for pathologic complete response. Post-treatment magnetic resonance images are not useful tools in predicting tumor clearance following chemoradiation.     

Gefitinib enhances the effects of combined radiotherapy and 5-fluorouracil in a colorectal cancer cell line

Purpose

In a phase I/II trial, patients with locally advanced rectal cancer received preoperative radiotherapy (RT) and concurrent with 5-fluorouracil (5-FU) and gefitinib. Results were promising. To elucidate the molecular and biological effects, we replicated the schedule in the LoVo human colorectal adenocarcinoma cell line.

Methods

RT (2 Gy daily for 3 days), 5-FU (0.3, 0.6, 1.25, 2.5, 5, 10 μM) and gefitinib (0.2, 0.4, 0.8 μM) were administered alone, in double combinations and all together. We assessed viable cells, cell cycle, cyclin, p53 and p21 expression, signalling pathways by means of phosphorylated epidermal growth factor receptor (p-EGFR), p-AKT and p-ERK 1-2 and clonogenic capacity.

Results

RT and 5-FU were cytotoxic. Gefitinib was cytostatic. RT reduced clonogenic capacity more than 5-FU. 5-FU induced more cell death than RT, but surviving cells were proliferative (cyclins and p-EGFR increased). 5-FU?+?RT had a synergistic effect. Gefitinib, enhancing G1 accumulation, reduced proliferation of cells surviving 5-FU and 5-FU?+?RT. It slightly increased the cytotoxicity of RT and 5-FU.

Conclusions

As gefitinib limited the proliferation rate of cells surviving 5-FU and 5-FU?+?RT in the LoVo cell line, it may be a useful addition to chemotherapy and RT in rectal cancer patients.     

��-catenin and Her2/neu expression in rectal cancer: association with histomorphological response to neoadjuvant therapy and prognosis

Background

Neoadjuvant treatment strategies have been developed to improve survival of patients with advanced rectal cancer. Since mainly patients with major histopathological response benefit from this therapy, predictive and prognostic markers are needed. We examined the association of ??-catenin and Her2/neu protein expression with histopathologic response to neoadjuvant radiochemotherapy and prognosis in patients with locally advanced rectal cancer.

Methods

Fifty-four patients (33 male; 21 female; median age 60.4?years) with locally advanced rectal cancer were included in this study. All patients received a neoadjuvant radiochemotherapy (50.4?Gy, 5-FU) followed by surgical resection. Histomorphologic regression was evaluated by Dworak and Cologne staging system. Major response was defined by Dworak classification when resected specimens contained less than 50% vital tumor cells (n?=?14) and by Cologne grading system when resected specimens contained less than 10% vital tumor cells (n?=?15). Intratumoral ??-catenin (nuclear/membranous) and Her2/neu (cytoplasmatic/membranous) expression was determined by immunohistochemistry in pre- and post-therapeutic specimens and correlated with clinicopathologic parameters.

Results

A significant association was detected between pre-therapeutic membranous ??-catenin levels and response: patients with a lower ??-catenin protein expression showed significantly more often a major response compared with patients having high intratumoral protein levels (p?=?0.011). In addition, patients with a higher Her2/neu protein expression showed a significant survival benefit compared with patients having low intratumoral protein levels (5-year survival rate: 81% vs. low 41%; p?=?0.023).

Conclusions

The pre-therapeutic ??-catenin and Her2/neu protein expression seem to be valuable predictive and prognostic markers in the multimodality treatment of advanced rectal cancer.     

Management of synchronous rectal and prostate cancer

Purpose

Although well described, there is limited published data related to management on the coexistence of prostate and rectal cancer. The aim of this study was to describe a single institution’s experience with this and propose a treatment algorithm based on the best available evidence.

Methods

From 2000 to 2011, a retrospective review of institutional databases was performed to identify patients with synchronous prostate and rectal cancers where the rectal cancer lay in the lower two thirds of the rectum. Operative and non-operative outcomes were analysed and a management algorithm is proposed.

Results

Twelve patients with prostate and rectal cancer were identified. Three were metachronous diagnoses (>3-month time interval) and nine were synchronous diagnoses. In the synchronous group, four had metastatic disease at presentation and were treated symptomatically, while five were treated with curative intent. Treatment included pelvic radiotherapy (74?Gy) followed by pelvic exenteration (three) and watchful waiting for rectal cancer (one). The remaining patient had a prostatectomy, long-course chemoradiotherapy and anterior resection. There were no operative mortalities and acceptable morbidity. Three remain alive with two patients disease-free.

Conclusions

Synchronous detection of prostate cancer and cancer of the lower two thirds of the rectum is uncommon, but likely to increase with rigorous preoperative staging of rectal cancer and increased awareness of the potential for synchronous disease. Treatment must be individualized based on the stage of the individual cancers taking into account the options for both cancers including EBRT (both), surgery (both), hormonal therapy (prostate), surgery (both) and watchful waiting (both).     

Hemorrhoid management in patients with radiation proctitis

Purpose

Management of rectal bleeding in patients with radiation proctitis presents a conundrum for practitioners. Surgeons are appropriately concerned about using conventional methods of treatment in these patients, such as cautery for bleeding areas in the rectum, rubber band ligation, or excision of internal and/or external hemorrhoids, for fear of poor healing and possible exacerbation of the original problem. Few randomized controlled trials are available on the treatment of radiation proctitis alone, and no literature exists pertaining to the management of symptomatic hemorrhoids in the radiated patient.

Methods

In the absence of observational studies, the authors created an email survey to distribute to the membership of the American Society of Colon and Rectal Surgeons in order to try to identify current management practices for radiation proctitis and for the treatment of their symptomatic hemorrhoids.

Results

Of the 327 respondents, 85?% favored the use of topical formalin to treat radiation proctitis, while 42?% additionally used argon plasma coagulation. Only 25?% of practitioners report using sucralfate, though existing data on this therapy are promising. Regarding the management of hemorrhoids in patients with a history of rectal irradiation, 55?% of respondents hoped treatment of radiation proctitis alone would solve the problem. Forty-three percent reported using rubber band ligation, 30?% using hemorrhoidectomy, and 18?% using sclerotherapy.

Conclusions

While most respondents treated radiation proctitis alone in patients with symptomatic hemorrhoids, many also felt rubber band ligation, hemorrhoidectomy, and sclerotherapy are safe and effective alternative therapies in this population.     

Adjuvant arterial infusion chemotherapy after resection of hepatocellular carcinoma with portal thrombosis: a pilot study

Background/Purpose

The prognosis of hepatocellular carcinoma (HCC) with tumor thrombosis of the main trunk or major branches of the portal vein (mPVTT) is extremely poor, even if it is curatively resected. Uncontrollable multiple metastases to the residual liver are often observed within several months after the operation. We report here the results of a pilot study, showing the efficacy of adjuvant arterial infusion chemotherapy after the resection of HCC with mPVTT.

Methods

Twelve patients had curative resection of HCC with mPVTT. Six of the patients were treated by the arterial infusion of a chemotherapeutic agent via a subcutaneously implanted injection port after curative resection of HCC with mPVTT. The initial course consisted of the daily administration of cisplatin (CDDP) and continuous infusion of 5-fluorouracil (5-FU). This was followed by the weekly or biweekly administration of CDDP and subsequent infusion of 5-FU until the cumulative dose of 5-FU reached 15?g.

Results

The median overall survival time was 58.0 months with adjuvant chemotherapy and 8.0 months without adjuvant chemotherapy. The median disease-free interval was 15.0 months with adjuvant chemotherapy and 4.0 months without adjuvant chemotherapy. Adverse reactions were tolerable nausea and loss of appetite.

Conclusions

This chemotherapeutic regimen achieved favorable results and may be useful as adjuvant chemotherapy in treating patients after curative resection of HCC with mPVTT.     

Low-dose rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized controlled trial

Background

Acute pancreatitis is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Rectal nonsteroidal anti-inflammatory drugs (specifically, 100?mg of diclofenac or indomethacin) have shown promising prophylactic activity in post-ERCP pancreatitis (PEP). However, the 100-mg dose is higher than that ordinarily used in Japan.

Methods

We performed a prospective randomized controlled study to evaluate the efficacy of low-dose rectal diclofenac for the prevention of PEP. Patients who were scheduled to undergo ERCP were randomized to receive a saline infusion either with 50?mg of rectal diclofenac (diclofenac group) or without (control group) 30?min before ERCP. The dose of diclofenac was reduced to 25?mg in patients weighing <50?kg. The primary outcome measure was the occurrence of PEP.

Results

Enrollment was terminated early because the planned interim analysis found a statistically significant intergroup difference in the occurrence of PEP. A total of 104 patients were eligible for this study; 51 patients received rectal diclofenac. Twelve patients (11.5%) developed PEP: 3.9% (2/51) in the diclofenac group and 18.9% (10/53) in the control group (p?=?0.017). After ERCP, the incidence of hyperamylasemia was not significantly different between the two groups. Post-ERCP pain was significantly more frequent in the control group than in the diclofenac group (37.7 vs. 7.8%, respectively; p?Conclusions Low-dose rectal diclofenac can prevent PEP.     

Endorectal ultrasound does not reliably identify patients with uT3 rectal cancer who can avoid neoadjuvant chemoradiotherapy

Purpose

Neoadjuvant chemoradiation (NCRT) may be avoided in some patients with T3-staged rectal cancer undergoing radical resection. We aimed to evaluate the accuracy of endorectal ultrasound (ERUS) in the nodal staging of uT3 tumors and hence the decision for administration of NCRT.

Methods

Patients with uT3-staged rectal cancer who underwent proctectomy were retrospectively identified. The accuracy of ERUS for detecting nodal involvement was determined for patients who did not undergo NCRT. In order to evaluate the impact of use of NCRT, oncologic outcomes, functional outcomes, and quality of life (QOL) were compared for patients who received NCRT (group A) and those who did not (group B).

Results

For 384 patients who were included, ERUS overstaging rate for nodal involvement was 6.3 % while understaging rate was 23.2 %. For the 289 patients in group A and 95 in group B, Kaplan–Meier analysis showed similar 5-year local recurrence rates (3.5 %), overall survival (76.9 vs 75.6 %), and disease-free survival (87.9 vs 88.1 %). Node positivity on final pathology was however associated with worse 5-year local recurrence (9.3 vs 4.3 %). For patients undergoing restorative resection, NCRT was associated with worse functional outcomes but QOL was similar.

Conclusions

ERUS identification of nodal involvement used as a criterion for NCRT carries a greater risk for undertreatment than overtreatment. Undertreatment adversely affects oncologic outcomes. While there is functional impairment related to NCRT, its effect on QOL is non-significant. The decision for omitting neoadjuvant chemoradiation for uT3 rectal cancer should hence not be based on ERUS nodal staging alone.     

Late entry into HIV care: lessons from Brazil, 2003 to 2006

Background

Treatment of shigellosis in rabbits with butyrate reduces clinical severity and counteracts the downregulation of cathelicidin (CAP-18) in the large intestinal epithelia. Here, we aimed to evaluate whether butyrate can be used as an adjunct to antibiotics in the treatment of shigellosis in patients.

Methods

A randomized, double-blind, placebo-controlled, parallel-group designed clinical trial was conducted. Eighty adult patients with shigellosis were randomized to either the Intervention group (butyrate, n?=?40) or the Placebo group (normal saline, n?=?40). The Intervention group was given an enema containing sodium butyrate (80?mM), twice daily for 3?days, while the Placebo group received the same dose of normal saline. The primary endpoint of the trial was to assess the efficacy of butyrate in improving clinical, endoscopic and histological features of shigellosis. The secondary endpoint was to study the effect of butyrate on the induction of antimicrobial peptides in the rectum. Clinical outcomes were assessed and concentrations of antimicrobial peptides (LL-37, human beta defensin1 [HBD-1] and human beta defensin 3 [HBD-3]) and pro-inflammatory cytokines (interleukin-1?? [IL-1??] and interleukin-8 [IL-8]) were measured in the stool. Sigmoidoscopic and histopathological analyses, and immunostaining of LL-37 in the rectal mucosa were performed in a subgroup of patients.

Results

Compared with placebo, butyrate therapy led to the early reduction of macrophages, pus cells, IL-8 and IL-1?? in the stool and improvement in rectal histopathology. Butyrate treatment induced LL-37 expression in the rectal epithelia. Stool concentration of LL-37 remained significantly higher in the Intervention group on days 4 and 7.

Conclusion

Adjunct therapy with butyrate during shigellosis led to early reduction of inflammation and enhanced LL-37 expression in the rectal epithelia with prolonged release of LL-37 in the stool.

Trial Registration

ClinicalTrials.gov, NCT00800930.     

Colorectal motor and sensory function after hysterectomy

Purpose

Women may develop constipation after hysterectomy. The pathophysiology and underlying mechanisms are poorly understood. They may originate from either neural damage of rectum and colon or changes in anatomical constellation of the remaining pelvic organs. The aim of this study is to evaluate sensory and motor functions of rectum and colon in women with newly developed constipation after hysterectomy in comparison with women without constipation and healthy controls after hysterectomy .

Methods

Barostat measurements were performed in posthysterectomy women with constipation (PH-C), without constipation (PH-NC), and healthy controls (n?=?10, every group). Outcome measures were rectal and colonic compliance (millilitre per millimetre of mercury), rectocolonic perception in reaction to mechanical distension (millimetre; VAS scores) and rectocolonic reflex (millilitre per millimetre of mercury).

Results

No differences in rectal or colonic compliance were observed. Urge perception due to rectal distension increased significantly in controls (from 7?±?5 to 41?±?10 mm; p?<?0.05) and PH-NC group (from 3?±?1 to 24?±?9 mm; p?<?0.05), but not in PH-C patients (1?±?1 to 11?±?5 mm; ns). In healthy controls and the PN-NC group, respectively, 100 and 70 % of subjects reached the minimal threshold value for urge of 10 mm during the isobaric distension sequence. In the PH-C group, only two subjects (20 %) reached this threshold (p?<?0.05). Rectal pain perception, phasic colonic motility and the rectocolonic reflex were intact in all three groups.

Conclusions

Colorectal motor and sensory function is generally well preserved in women with constipation after hysterectomy. It is unlikely that the symptom of constipation after hysterectomy has been caused by iatrogenic neuronal damage in these patients.     

Anastomotic leak after restorative proctosigmoidectomy for cancer: what are the chances of a permanent ostomy?

Objective

The objective of this study is to identify rates and factors associated with permanent diversion following restorative proctosigmoidectomy for rectal cancer when complicated by an anastomotic leak.

Design

This study is a retrospective review.

Setting

The setting of this study is a tertiary referral hospital

Patients

Patients involved in this study were those who underwent restorative rectal cancer surgery from 1997 through 2008 identified from an institutional cancer database.

Interventions

No interventions were performed in this study.

Main outcome measures

Factors associated with time to ostomy closure and rates of permanent diversion following anastomotic leaks

Results

One hundred and thirty patients (mean age 59.7?years) were identified, 111 (85%) of whom had stoma diversion at the index surgery. Asymptomatic occult radiological leaks occurred in 52 patients (40%). Seventy-eight patients (60%) underwent ultimate ostomy closure at a median time of 6.3?months after the index surgery, which was not significantly affected by previous radiotherapy (p?=?0.08). Twelve patients (9%) underwent anastomotic reconstruction. Pathologic stage II or greater (OR 4.42; 1.95–10.04), symptomatic presentation (OR 4.13; 1.86–9.19) and anastomotic disruption >5?mm (OR 4.42; 2.01–9.74) were independently associated with permanent diversion. Among all survivors, 33% did not have their ostomy reversed. Stoma diversion constructed after leak detection in 19 patients (15%) did not affect permanent stoma rate (OR 0.86; 0.31–2.34) or time to stoma closure (p?=?0.29).

Conclusions

The majority of anastomotic leaks after restorative rectal cancer surgery can be salvaged without anastomotic reconstruction. However, in one third of the patients, an anastomotic leak results in a permanent stoma.     

Defecation 1: Testing a hypothesis for pelvic striated muscle action to open the anorectum

Background

We conducted an observational study to assess the hypothesis that the pelvic muscles actively open the anorectal lumen during defecation.

Methods

Three groups of female patients were evaluated with video imaging studies of defecation using a grid or bony reference points. Eight patients with idiopathic fecal incontinence had video myogram defecography; eight with obstructive defecation had magnetic resonance imaging (MRI) defecating proctograms; and four normal patients had video X-ray or MRI defecating proctogram studies.

Results

In all three groups, the anorectum was stretched bidirectionally by three directional muscle force vectors acting on the walls of the rectum, effectively doubling the diameter of the rectum during defecation. The anterior rectal wall was pulled forwards, and the posterior wall backwards and downwards opening the anorectal angle, associated with angulation of the anterior tip of the levator plate (LP). These observations are consistent with a staged relaxation of some parts of the pelvic floor during defecation, and contraction of others. First, the puborectalis muscle relaxes. Puborectalis muscle relaxation frees the posterior rectal wall so that it can be stretched and opened by contraction of the LP and conjoint longitudinal muscle of the anus. Second, contraction of the pubococcygeus muscle pulls forward the anterior rectal wall, further increasing the diameter of the rectum. Third, when the bolus has entered the rectum, the external anal sphincter relaxes, and the rectum contracts to expel the fecal bolus.

Conclusions

Our results are consistent with the hypothesis that pelvic striated muscle actively opens the rectal lumen, thereby reducing internal anorectal resistance to expulsion of feces. Controlled studies of electromyographic activity would be useful to further test this hypothesis.     

Ostomy function after abdominoperineal resection—a clinical and patient evaluation

Purpose

Abdominoperineal resection (APR) for rectal cancer results in a permanent colostomy. As a consequence of a recent change in operative technique from standard (S-APR) to extralevator resection (E-APR), the perineal part of the procedure is now performed with the patient in a prone jackknife position. The impact of this change on stoma function is unknown. The aim was to determine stoma-related complications and the individual patient experience of a stoma.

Methods

Consecutive patients with rectal cancer operated on with APR in one institution in 2004 to 2009 were included. Recurrent cancer, palliative procedures, pre-existing stoma and patients not alive at the start of the study were excluded. Data were collected from hospital records and the national colorectal cancer registry. A questionnaire was sent out to patients. The median follow-up was 44?months (13–84) after primary surgery.

Results

Ninety-six patients were alive in February 2011. Seventy seven agreed to participate. Sixty-nine patients (90?%) returned the questionnaire. Stoma necrosis was more common for E-APR, 34?% vs. 10?%, but bandaging problems and low stoma height were more common for S-APR. There were no differences in the patients' experience of stoma function. In all, 35?% of the patients felt dirty and unclean, but 90?% felt that they had a full life and could engage in leisure activities of their choice.

Conclusions

This exploratory study indicates no difference in stoma function after 1?year between S-APR and E-APR. Over 90?% of the patients accept their stoma, but our study indicates that more information and support for patients are warranted.