Bowel Function Score Research Articles

Botulinum toxin type-A infiltration of the external anal sphincter to treat outlet constipation in motor incomplete spinal cord injury: pilot cohort study

Background Outlet constipation is a major problem in spinal cord injury (SCI) patients. We aimed to study the efficacy of external anal sphincter (EAS) infiltration with type-A botulinum toxin (BTX-A) in motor incomplete SCI patients with outlet constipation. Methods Double blind, randomized, placebo controlled, comparative study in 16 motor incomplete SCI subjects. Patients were randomly assigned toreceive100 UI of BTX-A (n = 9) or physiologic serum infiltration (n = 7) in the EAS under electromyographic guidance. Outcome measures included a questionnaire for clinical bowel function evaluation, colonic transit time and anorectal manometry. All assessments were done at baseline, 1 and 3 months after treatment. Results Fourteen patients completed the study. In the BTX-A group we observed an improvement of subjective perception of bowel function (p = 0.01), constipation (p = 0.02) and neurogenic bowel dysfunction score (p = 0.02). The anorectal manometry revealed are duction of EAS voluntary contraction pressure (p = 0.01). No changes were observed in the placebo group. No significant side effects were observed in none of the groups. Conclusion BTX-A infiltration of the EAS is a safe technique that in motor incomplete SCI, decreases the EAS contraction and the anal canal pressure during straining, and improves outlet constipation symptoms. Future studies in larger populations are needed.

Five-year outcomes from a prospective comparative effectiveness study evaluating external-beam radiotherapy with or without low-dose-rate brachytherapy boost for localized prostate cancer.

To inform patients who are in the process of selecting prostate cancer treatment, the authors compared disease-specific function after external-beam radiotherapy (EBRT) alone versus EBRT plus a low-dose-rate (LDR) brachytherapy boost (EBRT-LDR). For this prospective study, men who had localized prostate cancer in 2011 and 2012 were enrolled. Assessments at baseline, 0.5, 1, 3, and 5 years included the patient-reported Expanded Prostate Index Composite, the 36-item Medical Outcomes Study Short-Form Health Survey, and treatment-related regret. Regression models were adjusted for baseline function and for patient and treatment characteristics. The minimum clinically important difference in scores on the Expanded Prostate Index Composite 26-item instrument was from 5 to 7 for urinary irritation and from 4 to 6 for bowel function. Six-hundred ninety-five men met inclusion criteria and received either EBRT (n = 583) or EBRT-LDR (n = 112). Patients in the EBRT-LDR group were younger (median age, 66 years [interquartile range [IQR], 60-71 years] vs 69 years [IQR, 64-74 years]; P < .001), were less likely to receive pelvic radiotherapy (10% vs 18%; P = .040), and had higher baseline 36-item Medical Outcomes Study Short-Form Health Survey physical function scores (median score, 95 [IQR, 86-100] vs 90 [IQR, 70-100]; P < .001). Over a 3-year period, compared with EBRT, EBRT-LDR was associated with worse urinary irritative scores (adjusted mean difference at 3 years, -5.4; 95% CI, -9.3, -1.6) and bowel function scores (-4.1; 95% CI, -7.6, -0.5). The differences were no longer clinically meaningful at 5 years (difference in urinary irritative scores: -4.5; 95% CI, -8.4, -0.5; difference in bowel function scores: -2.1; 95% CI, -5.7, -1.4). However, men who received EBRT-LDR were more likely to report moderate or big problems with urinary function bother (adjusted odds ratio, 3.5; 95% CI, 1.5-8.2) and frequent urination (adjusted odds ratio, 2.6; 95% CI, 1.2-5.6) through 5 years. There were no differences in survival or treatment-related regret between treatment groups. Compared with EBRT alone, EBRT-LDR was associated with clinically meaningful worse urinary irritative and bowel function over 3 years after treatment and more urinary bother at 5 years. In men with prostate cancer who received external-beam radiation therapy (EBRT) with or without a brachytherapy boost (EBRT-LDR), EBRT-LDR was associated with clinically worse urinary irritation and bowel function through 3 years but resolved after 5 years. Men who received EBRT-LDR continued to report moderate-to-big problems with urinary function bother and frequent urination through 5 years. There was no difference in treatment-related regret or survival between patients who received EBRT and those who received EBRT-LDR. These intermediate-term estimates of function may facilitate counseling for men who are selecting treatment.

Anorectal malformation with long perineal fistula: one of a special type

The anorectal malformation with long perineal fistula is a rare anomaly in the spectrum of anorectal malformations. Aim of the study is to describe the series of patients with anorectal malformation with long perineal fistula and compare the outcome with patient with standard perineal fistula. From March 2012 to January 2019, 7 patients who suffered from anorectal malformation with long perineal fistula were retrospectively reviewed. Three were operated on primarily by our department, and 4 cases were re-operated after a perineal anoplasty repair performed elsewhere. Four were operated by laparoscopy assisted anorectoplasty, and 3 cases were repaired by posterior sagittal anorectoplasty. The follow-up outcomes were compared with 71 cases of normal perineal fistula (NPF) in the same period. 7 cases have been followed up for 0.5–4 years (M = 2.57 ± 1.26) after definitive surgery. Their bowel function score was lower than normal perineal fistula (SPF = 12, range: 5–18; NPF = 18.5, range: 18–20). Four cases underwent anorectomanometry. The incidence of rectoanal inhibitory reflex was lower in the special type group. (p = 0.14). Three cases of contrast enema using barium: 2 cases of colorectal dilatation and thickening changes, 1 case showed no obvious abnormalities. Anorectal perineal fistula should be examined by distal colostogram at preoperation. This should be altered in: When suspecting a case of anorectal malformation type long perineal fistula a preoperative contrast enema could give insight of the anatomy befor performing a anoplasty.

Assessment of defecation function beyond infantile period for transanal single-stage endorectal pull-through in Hirschsprung disease.

PurposeTransanal single-stage endorectal pull-through (TERPT) procedure for patients with Hirschsprung disease (HD) has favorable outcomes, with a lower complication rate. Nevertheless, various degrees of bowel dysfunction and fecal incontinence can persist for a long time in some patients. The aim of this study was to assess the mid- and long-term outcomes of TERPT performed during the infantile period after the completion of toilet training.MethodsWe retrospectively reviewed 82 patients aged ≥4 years who underwent TERPT during the infantile period after the pathological diagnosis of HD between 2001 and 2013. Functional outcomes were investigated according to the answers of the Bowel Function Score (BFS) questionnaire, a previously validated 7-item questionnaire about bowel habits. Normal values were obtained in a previous study on BFS for children in Western countries, and a one-sample t-test was used for statistical analysis.ResultsOverall, BFS was similar in all investigated age groups. On comparing fecal soiling and social problems between the HD and normal populations, a lower score at an early age in patients with HD was noted; however, the scores became similar when the patients were 7 years of age. Stool frequency decreased continuously but was not significantly different between the 2 groups.ConclusionThe functional outcomes of TERPT performed during the infantile period, after completing toilet training, were similar to that of the normal population. In most cases, uncomfortable symptoms were diminished and functions improved with age.

Redo pull-through in total colonic aganglionosis due to residual aganglionosis: a single center's experience.

BackgroundReoperation for total colonic aganglionosis (TCA) may be required for residual aganglionosis after an initial radical operation. We aimed to investigate the symptoms, management, and outcomes of patients who required a redo pull-through (Redo PT).MethodsNine TCA patients underwent Redo PT at our center between 2007 and 2017. Their medical records were reviewed. Parental telephone interviews that included disease-specific clinical outcomes were conducted, and post-operative complications and long-term outcomes (including height-for-age/weight-for-age and bowel-function score) were compared to those of single-pull-through (Single PT) patients (n = 21).ResultsAll the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment. All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation, indicating residual aganglionosis. The median ages at the initial operation and Redo PT were 200 and 509 days, respectively. Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients. Post-operative complications included perianal excoriation (n = 3), intestinal obstruction (n = 2), enterocolitis (n = 2), and rectovestibular fistula (n = 1). Seven Redo PT patients were followed up for a mean time of 7.1 ± 2.3 years; six (85.7%) had good growth and four (57.1%) had good bowel-function recovery. Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups (all P > 0.05).ConclusionTCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation. Redo PT is effective and provides good long-term outcomes comparable to those of patients who benefited from Single PT.

Impact of High-Dose-Rate and Low-Dose-Rate Brachytherapy Boost on Toxicity, Functional and Cancer Outcomes in Patients Receiving External Beam Radiation Therapy for Prostate Cancer: A National Population-Based Study

External beam radiation therapy (EBRT) with brachytherapy boost reduces cancer recurrence in patients with prostate cancer compared with EBRT monotherapy. However, randomized controlled trials or large-scale observational studies have not compared brachytherapy boost types directly. This observational cohort study used linked national cancer registry data, radiation therapy data, administrative hospital data, and mortality records of 54,642 patients with intermediate-risk, high-risk, and locally advanced prostate cancer in England. The records of 11,676 patients were also linked to results from a national patient survey collected at least 18 months after diagnosis. Competing risk regression analyses were used to compare gastrointestinal (GI) toxicity, genitourinary (GU) toxicity, skeletal-related events (SRE), and prostate cancer-specific mortality (PCSM) at 5 years with adjustment for patient and tumor characteristics. Linear regression was used to compare Expanded Prostate Cancer Index Composite 26-item version domain scores (scale, 0-100, with higher scores indicating better function). Five-year GI toxicity was significantly increased after low-dose-rate brachytherapy boost (LDR-BB) (32.3%) compared with high-dose-rate brachytherapy boost (HDR-BB) (16.7%) or EBRT monotherapy (18.7%). Five-year GU toxicity was significantly increased after both LDR-BB (15.8%) and HDR-BB (16.6%), compared with EBRT monotherapy (10.4%). These toxicity patterns were matched by the mean patient-reported bowel function scores (LDR-BB, 77.3; HDR-BB, 85.8; EBRT monotherapy, 84.4) and the mean patient-reported urinary obstruction/irritation function scores (LDR-BB, 72.2; HDR-BB, 78.9; EBRT monotherapy, 83.8). Five-year incidences of SREs and PCSM were significantly lower after HDR-BB (2.4% and 2.7%, respectively) compared with EBRT monotherapy (2.8% and 3.5%, respectively). Compared with EBRT monotherapy, LDR-BB has worse GI and GU toxicity and HDR-BB has worse GU toxicity. HDR-BB has a lower incidence of SREs and PCSM than EBRT monotherapy.

What should be the treatment for intestinal neuronal dysplasia type B? A comparative long-term follow-up study

PurposeTo present the long-term follow-up outcomes of patients with intestinal neuronal dysplasia type B (IND-B) managed either conservatively or surgically. MethodsWe conducted an ambispective, observational, longitudinal, and comparative study. Clinical data were reviewed at the start of treatment. After a minimum period of five years, the patients participated in semi-structured interviews in which the bowel function score (BFS) was applied to assess intestinal function, a proposed intestinal symptom index (ISI) to assess clinical symptoms, and a classification of clinical prognosis to assess treatment success. Comparisons between the two types of treatment were performed by evaluating pre- and post-treatment criteria. ResultsFifty patients diagnosed with IND-B were included in the study. Thirty-eight patients underwent surgical treatment (26 elective surgical treatment for primary colorectal resection and 12 emergency colostomies for intestinal obstruction or enterocolitis). Twelve patients were managed conservatively. With the exception of the patients who required an emergency operation (n = 12), the two groups were composed of patients with severe constipation who had similar clinical and functional characteristics at the time of IND-B diagnosis. A better clinical response was observed in patients submitted to conservative treatment, with a greater increase in the BFS (16.5 [-4/+18] versus 4 [-15/+17]; p = 0.001), indicating better bowel function and a more pronounced drop in ISI (-6 [-7/-4] versus -4 [-6/+1]; p = 0.015), suggesting fewer symptoms. The percentage of patients who had a successful treatment was higher in the group treated conservatively (72.7% versus 42.3%; p = 0.03). ConclusionConservative management showed better long-term outcomes than surgical management in children with IND-B.

Phase I Trial of Stereotactic Radiotherapy Prior to Robotic Prostatectomy in High Risk Prostate Cancer

Standard therapies for patients with high risk prostate cancer (HR-CaP) include radiotherapy (RT) with hormonal therapy and radical prostatectomy (RP), usually followed by 6-7 weeks of local RT. Given recent data in the breast and pancreas cancer literature about the feasibility of preoperative stereotactic body RT (SBRT), we developed a prospective phase I trial investigating pre-operative SBRT dose escalation in patients with HR-CaP. Patients were eligible if they had HR-CaP, defined as a Gleason Score (GS) 8-10 on biopsy specimen. Patients received a total of 25 Gy or 30 Gy in 5 daily fractions of SBRT to the prostate and proximal seminal vesicles. Patients underwent robotic RP with pelvic lymph node dissection approximately 5 weeks after completion of RT. Primary outcomes were physician-reported genitourinary (GU) and gastrointestinal (GI) toxicities (CTCAE v4). Secondary outcomes were patient-reported quality of life (QoL) on AUA and EPIC questionnaires and biochemical recurrence (BcR), defined as PSA ≥0.2ng/mL. PSA was monitored every 3-6 months. Three patients received SBRT to 25 Gy in 5 fractions and four patients received 30 Gy in 5 fractions. Median time to RP after SBRT was 35 days (range 31-45). Median follow-up was 18 months. Patient characteristics are summarized in the accompanying table. Each patient experienced at least one Grade 2 GU event; most commonly erectile dysfunction (100%) and urinary incontinence (57%). One patient experienced Grade 3 urinary incontinence, but there were no Grade ≥4 GU toxicities. Two patients experienced GI toxicity which were one Grade 1 and one Grade 2 hemorrhoidal hemorrhage. On QoL surveys, acute GU complaints were common and peaked at 3 months (mean AUA total score 14.2, mean EPIC overall urinary function score 3). Acute bowel complaints were mild and uncommon, with only one patient reporting a score of ≥3 on EPIC overall bowel function score. Two patients experienced BcR; both had GS 4 + 5 with ypN1 disease at the time of RP, while one of the two was ypT3b and the other was ypT3a. Neither had evidence of distant metastasis on CT or bone scans. Both BcR were salvaged with leuprolide and bicalutamide with subsequent decrease in PSA. Pre-operative SBRT followed by RP in HR-CaP is feasible and safe. It is associated with moderate GU toxicity and rare GI toxicity. Phase II trials evaluating this treatment paradigm should exclude patients with GS 5, and those with clinically or radiographically T3b or node positive disease. A prospective trial is ongoing to determine the efficacy of pre-operative SBRT in selected patients with HR-CaP.Abstract 4112; TableCaseAge (y)SBRT Dose (Gy)GS (pre-op)PSA (pre-op)PSA (post-op)Stage (post-op)Surgical MarginsF/U (m)1**62254 + 525.330.59ypT3bN1+34254254 + 47.91<0.02ypT3aN0+26358254 + 48.40<0.02ypT2cN0-10464304 + 48.66<0.02ypT3aN0+24564304 + 45.93<0.02ypT2aN0-17658304 + 45.94<0.02ypT3aN0-187**66304 + 551.703.69ypT3aN1-12**Patient experienced biochemical recurrence Open table in a new tab

Clinical Results Of Proton Boost Combined With Pelvic IMRT For Node-Positive Prostate Cancer: Dosimetric Analysis And Patient-Reported Outcomes

Previous studies demonstrated the efficacy of radiation therapy for clinically node-positive prostate cancer. However, there are few reports on treatment strategies incorporating proton therapy. The purpose of this study was to evaluate the clinical outcome of pelvic IMRT combined with proton boost for node-positive prostate cancer, including toxicity and patient reported outcomes (PROs) of health-related quality of life (QOL), and to perform dosimetric comparison of boost plans between proton therapy and IMRT. From March 2013 to May 2016, 12 patients with node-positive prostate adenocarcinoma were treated by pelvic IMRT with 45 Gy/25 fr followed by proton boost with 34 GyE/17 fr to the prostate and seminal vesicles and 26 GyE/13 fr to positive lymph nodes. Biochemical failure was defined according to the Phoenix definition. Adverse effects were assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.0. Dosimetric comparisons were carried out between proton therapy and IMRT regarding boost plans. The same CTVs, dose fractionation and target volume coverage, and OAR dose constraints were used. All 12 patients completed the Expanded Prostate Cancer Index Composite (EPIC) health-related QOL questionnaire before and at 1-36 months after treatment. The median follow-up period was 59 months (range, 42-80 months). The Gleason score was 7 in 1 patient, 8 in 3 patients, and 9 in 8 patients. The median PSA level before treatment was 38.8 ng/ml (range, 11-230). All patients underwent androgen deprivation therapy for a median duration of 48.5 months. Three patients had biochemical failure. Two of them experienced extrapelvic recurrence. There was no grade 3 or higher acute or late GI and GU toxicity. Planning target volume coverage by the prescription dose was similar between the proton and IMRT plans. In the proton plan, mean rectum V40Gy was significantly lower than in the IMRT plan (44.4% vs 59.3%). The dose to the small intestine for 1 cc and to the colon for 1 cc was 45.1 and 52.3 Gy, respectively, in the proton plans, and 47.0 and 55.7 Gy, respectively, in the IMRT plans, but there were no significant differences. Mean bowel bother score and bowel function score at 6-36 months were similar to or greater than the scores before treatment. Mean urinary summary QOL score was 86.2 before treatment and 82.0, 92.0, 86.7, and 89.8 at 1, 6, 12, and 36 months, respectively. Proton boost combined with pelvic IMRT was feasible and offered reductions in radiation doses to gastrointestinal organs at risk in patients with node-positive prostate cancer. No grade 3 AEs were observed after IMRT plus proton boost and no change was noted in PROS scores. Further studies are warranted for a larger population.

Effects of nerve-sparing procedures on bowel function after robot-assisted radical prostatectomy: A longitudinal study.

This study aimed to evaluate rectal pain and bowel function of the patients following robot-assisted radical prostatectomy (RARP). We divided 296 patients who underwent RARP into two groups depending on the intervention: NS (nerve-sparing) group (bilateral NS, unilateral NS and bilateral partial NS) and non-NS group (unilateral partial NS, bilateral non-NS). Bowel function was assessed using the Extended Prostate Cancer Index Composite for 24 months after RARP. The bowel function score and rectal urgency at 1-6 months after RARP were more significantly impaired in the non-NS group than in the NS group (p < 0.05). In a multivariate analysis of factors affecting the bowel function score at 6 months after RARP, only NS procedure had a significant effect. In the initial period after RARP, bowel symptoms were significantly impaired. This impairment was affected by the degree of NS. These results could guide patients in their decision to choose RARP.

Evaluation of Bowel Function, Urinary Tract Function, and Quality of Life after Transanal Endorectal Pull-Through Surgery for Hirschsprung's Disease.

The objective of this study is to determine short-term complications and evaluate long-term bowel function, lower urinary tract symptoms, and quality of life (QoL) in patients treated for Hirschsprung's disease (HSCR) with transanal endorectal pull-though (TERPT) compared with healthy controls. This cross-sectional case-control study included 30 HSCR patients treated with TERPT in 2006 to 2014 at Karolinska University Hospital, and 30 healthy controls matched for age and gender. Data on short-term complications were compiled from medical records and classified according to Clavien-Dindo. Bowel function and QoL were evaluated with the validated questionnaires bowel function score and KIDSCREEN-52. Lower urinary tract symptoms were evaluated through an 8-item lower urinary tract symptoms (LUTS) questionnaire. Six (20%) patients had a short-term postoperative complication according to Clavien-Dindo, with insufficient pain management being the most common complication. The median age at follow-up was 7 years (range = 4-11). Median bowel function score was significantly lower in HSCR patients than in controls, 14 versus 19 (p < 0.001). Twenty-one of the HSCR patients reported impaired bowel function compared with two of the controls (p < 0.001). The overall prevalence of LUTS was 11 (38%) in the HSCR patients compared with seven (23%) in the controls (p = 0.751). HSCR patients reported a slightly lower QoL in the KIDSCREEN domain "financial resources" compared with controls (p = 0.008). According to Clavien-Dindo, short-term postoperative complications occurred in 20% of the patients. Impaired bowel function persists throughout childhood for most HSCR patients. The prevalence of LUTS and QoL is not affected in HSCR patients compared with controls.

Rectourethral and rectovesical fistula as serious and rare complications after Hirschsprung disease operation: Experience in seven patients

AimTo present the features and treatment of rectourethral fistula (RUF) and rectovesical fistula (RVF) after Hirschsprung disease (HD) operation. MethodsA retrospective analysis was performed on patients with RUF and RVF after HD operation, who received repair surgery from a single surgeon between January 2005 and December 2019. Bowel function was assessed using the Rintala score. ResultsSeven patients were included. Six patients were referred to us after transanal endorectal pull-through (TEPT) in other centers; one RVF patient had fecal diversion at admission. Bladder-neck injury was detected during redo TEPT in our hospital in the remaining one patient and instant repair was given. 11 days later, RVF and sepsis were detected.Fecal and urine diversion was performed immediately. The fistula openings were prostatic urethra (3), membranous urethra (2), bladder triangle (1), and bladder-neck (1). Anastomotic stricture (4), bladder stone (3), hydronephrosis and ureterovesical junction obstruction (2), pelvic infection (2), distal colonic dilatation (1) and other fistulas (1) were identified before repair surgery. Fecal and urine diversion was performed before repair surgery in one RUF and one RVF patient respectively, to treat pelvic infection owing to fecal or urine leaks and accompanying problems. Five RUFs were repaired by transperineal approach, and two RVFs were repaired using the transabdominal and transanal approach respectively. Four patients with anastomotic stricture underwent redo TEPT with simultaneous fistula repair. Aside from one RUF patient, the fistula in all patients successfully resolved. Median follow up time was 81 months (range, 5–116 months). No recurrence was observed. Median bowel function score was 17.5 (range, 17–18). ConclusionThe location of fistula, presence of anastomotic stricture and the association of urinary complications have significant impacts on the treatment strategy in such rare complications after TEPT for HD. The type of studyTreatment study. Level of evidenceLevel IV.

Resection margin histology may predict intermediate-term outcomes in children with rectosigmoid Hirschsprung disease.

Recent studies suggest that some of the post-surgical morbidity in Hirschsprung disease (HSCR) is due to enteric nervous system structural defects in the proximal, ganglionated bowel that remains after surgery. We hypothesized that resection margin histology would predict intermediate-term outcomes in HSCR patients. Following IRB approval, HSCR patients with rectosigmoid disease born between 2009 and 2016 were reviewed and tissue blocks were obtained for new analyses. Proximal resection margins were analyzed for ganglion size, Hu + neurons/ganglion, and % nitric oxide synthase (NOS) neurons/ganglion as compared to control (non-HSCR) patient samples. Chart reviews were performed for 1- and 2-year outcomes. Patients were contacted for survey to determine Rintala bowel function score. 45 patients had recto-sigmoid disease and were further analyzed. HSCR patients had significantly smaller individual ganglion size (4533 μm2, range 1744-16,287 vs. 6492 μm2, range 1932-30,838, p = 0.0192) and fewer HuC/D + neurons per ganglion (15, range 5.2-34 vs. 21, range 5.2-6.7, p = 0.0214). HSCR patients demonstrated a markedly increased percentage of NOS (relaxation neurotransmitter) neurons (50, range 22-85 vs. 37, range 16-80, p = 0.0266). None of the histology measures correlated with presence/absence of constipation at 1-2year follow-up (p = NS). However, smaller ganglion size and higher percentage of NOS neurons correlated with decreased patient-reported quality of life (r = 0.3838, r = - 0.1809). 1-2year follow-up may be insufficient to determine if resection margin histology correlates with outcomes. Patient-reported quality of life surveys, although limited in number, suggest that neurotransmitter imbalance at the resection margin may predict poor outcomes in HSCR patients. This study supports the concept that the ganglionated portion of the remaining colon post-surgery may not sustain normal bowel function.

Acute patient-reported bowel quality of life and rectal bleeding with the combination of prostate external beam radiation, low-dose-rate brachytherapy boost, and SpaceOAR

PurposeThis study evaluates acute patient-reported bowel quality of life (QOL) and rectal bleeding in prostate cancer patients treated with combination external beam radiation (EBRT), low-dose-rate brachytherapy (LDR-BT), and SpaceOAR. Materials and MethodsA retrospective review of prostate cancer patients treated with EBRT (45 Gy), cesium-131 LDR-BT (85 Gy), and SpaceOAR was conducted. Patient-reported acute (≤3 months after LDR-BT) bowel QOL and rectal bleeding was analyzed from Expanded Prostate Cancer Index Composite (EPIC) questionnaires. Five-point changes in mean bowel QOL scores were considered clinically significant. Clinically significant rectal bleeding was bleeding occurring more than “rarely” (“about half the time,” “usually,” or “always”), and clinically significant bleeding bother was considering bleeding a “small, moderate, or big problem.” Outcomes were analyzed using descriptive statistics and paired t-tests. Results69 patients were identified. Bowel summary, function, and bother scores clinically and significantly decreased 2 weeks after LDR-BT (79.9 ± 15.6, 80.5 ± 15.4, and 79.4 ± 18.1, respectively) compared with pre-EBRT scores (92.3 ± 9.1, 93.3 ± 9.0, and 92.6 ± 11.9, respectively) and pre-LDR-BT scores (91.1 ± 11.0, 91.6 ± 9.8, and 90.6 ± 13.3, respectively), but returned to clinical and statistical baseline pre-EBRT values at 3 months (88.7 ± 12.4, 88.8 ± 11.1, and 88.7 ± 14.5, respectively). The 3-month cumulative incidence of clinically significant rectal bleeding and bleeding bother was 4.35% and 2.90%, respectively. ConclusionsWith combination EBRT, LDR-BT, and SpaceOAR, bowel QOL returned to the baseline 3 months after LDR-BT. Clinically significant rectal bleeding was <5%. Further followup will confirm if low acute rectal toxicity translates to reduced late toxicity.

Long-term outcomes and quality of life of patients with Hirschsprung disease: a systematic review and meta-analysis

BackgroundAdvances in surgical techniques and perioperative care have improved the short- and mid-term postoperative outcomes of patients with Hirschsprung disease (HD). However, the long-term outcomes of these patients (older than 10 years) have not been fully investigated. The aim of this systematic review is to clarify the prevalence of long-term outcomes and the quality of life of these patients.MethodsPubMed, AMED, Cochrane Library, CINAHL and PsycINFO databases were searched from inception to October 2018, following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guideline. Original studies reporting the outcomes of patients older than ten years with HD were selected and reviewed. The overall prevalence of fecal incontinence, constipation, bowel function score, bladder dysfunction symptoms, and patients’ quality of life were extracted from the included studies and pooled through the random-effects meta-analysis model. The heterogeneity and variation in the pooled estimations were evaluated by Cochrane’s Q test and the I2 test. The sensitivity analysis was conducted by the sequential omission of individual studies. Publication bias was evaluated by Egger’s linear regression test. The whole procedure was conducted with Stata (version 14).ResultsIn total, 3406 articles were identified from the literature search, among which twelve studies, including 625 patients, were included for analysis. The pooled prevalences of fecal incontinence, constipation, and bladder dysfunction symptoms and good to excellent bowel function scores were 0.20 (95% CI 0.13–0.28), 0.14 (95% CI 0.06–0.25), 0.07 (95% CI 0.04–0.12), and 0.95 (95% CI: 0.91–0.97), respectively; the pooled mean score of gastrointestinal-related quality of life was 118 (95% CI: 112.56–123.44).ConclusionsHD patients older than ten years old have an overall high prevalence of fecal incontinence and a low quality of life. Targeted and evidence-based follow-up procedures and transitional care are essential to meet these patients’ long-term care needs. Prospective and multicenter research that focuses on the attributes and predictors of the long-term prognosis of patients with HD are necessary.

Microbial Diversity and Composition Is Associated with Patient-Reported Toxicity during Chemoradiation Therapy for Cervical Cancer

Patients receiving pelvic radiation for cervical cancer experience high rates of acute gastrointestinal (GI) toxicity. The association of changes in the gut microbiome with bowel toxicity from radiation is not well characterized. Thirty-five patients undergoing definitive chemoradiation therapy (CRT) underwent longitudinal sampling (baseline and weeks 1, 3, and 5) of the gut microbiome and prospective assessment of patient-reported GI toxicity. DNA was isolated from stool obtained at rectal examination and analyzed with 16S rRNA sequencing. GI toxicity was assessed with the Expanded Prostate Cancer Index Composite instrument to evaluate frequency, urgency, and discomfort associated with bowel function. Shannon diversity index was used to characterize alpha (within sample) diversity. Weighted UniFrac principle coordinates analysis was used to compare beta (between sample) diversity between samples using permutational multivariate analysis of variance. Linear discriminant analysis effect size highlighted microbial features that best distinguish categorized patient samples. Gut microbiome diversity continuously decreased over the course of CRT, with the largest decrease at week 5. Expanded Prostate Cancer Index Composite bowel function scores also declined over the course of treatment, reflecting increased symptom burden. At all individual time points, higher diversity of the gut microbiome was linearly correlated with better patient-reported GI function, but baseline diversity was not predictive of eventual outcome. Patients with high toxicity demonstrated different compositional changes during CRT in addition to compositional differences in Clostridia species. Over time, increased radiation toxicity is associated with decreased gut microbiome diversity. Baseline diversity is not predictive of end-of-treatment bowel toxicity, but composition may identify patients at risk for developing high toxicity.

Functional outcome, quality of life, and ‘failures’ following pull-through surgery for hirschsprung's disease: A review of practice at a single-center

AimsThe purpose of this study was to assess bowel function and quality of life (QoL) in patients with Hirschsprung's disease (HD) and identify patients who have ‘failed’ treatment. MethodsA review of a single-center HD cohort treated with pull-through surgery from 2004 to 2017 was completed. Bowel function of patients five years and above and QoL of all patients were assessed using validated questionnaires. Patients who ‘failed’ treatment were defined as above five years with one or more of: a) long-term stoma, b) needing an antegrade continence enema or transanal irrigation, c) severe soiling, or d) severe constipation. Statistical analysis was performed with P < 0.05 deemed significant. Data are given as mean [range]. ResultsSeventy-one patients presented with HD within the study period. Mean follow-up was 5.4 years [0.7–13.3]. Of 38 eligible patients, bowel function was assessed in 24 patients (nine had a stoma, five lost to follow-up). The mean incontinence score was 17 [0–28)], and the mean constipation score was 17 [5–25]. Incontinence and constipation scores were worse than healthy controls (P < 0.001 and P = 0.001, respectively) and did not improve with age. Fifty-six patients had QoL assessed with no difference between our cohort (81 [25–100]) and healthy controls (81 [unknown]); (P = 0.85). Thirty-three patients were assessed for ‘failure’ (bowel function score n = 24; stoma n = 9). Thirty of 33 (91%) children older than five years can be considered to have ‘failed’ treatment. ConclusionsPatients have worse bowel function than healthy children, which does not improve with age. QoL is comparable to healthy controls. A significant proportion of patients have poor outcomes and have ‘failed’ treatment. Level of evidenceLevel III.

Clinical Outcomes After Staged and Primary Laparotomy Soave Procedure for Total Colonic Aganglionosis: a Single-Center Experience from 2007 to 2017

PurposeTo compare the clinical outcomes of the staged laparotomy Soave procedure (SLSP) and primary laparotomy Soave procedure (PLSP) for patients with total colonic aganglionosis (TCA), including some patients who underwent surgical treatment after the age of 1 year. MethodsA retrospective, comparative study of TCA patients who underwent SLSP or PLSP at Beijing Children Hospital from 2007 to 2017 was conducted. The primary outcomes were height-for-age (HFA), weight-for-age (WFA), and bowel function score (BFS); the major types of postoperative complications were also analyzed. ResultsThirty-five patients (SLSP = 14, PLSP = 21) were included. The patients in the SLSP group underwent an enterostomy at a median age of 47 (14, 104) days. The median age at the time of the Soave procedure showed no significant difference between the two groups ([181 (131,346) vs 55 (29, 343)] days, p = 0.072). No significant differences between groups were noted in terms of presenting symptoms, perioperative results, and postoperative outcomes. Twenty-three patients (SLSP = 8, PLSP = 15) were followed for more than 1 year. Both the SLSP and PLSP groups showed similar operative mortality ([1/14, 7.1%] vs [3/21, 14.3%], p = 0.635) and complication rates ([postoperative enterocolitis, (5/8, 62.5%) vs (5/15, 33.3%), p = 0.221] [perianal excoriation, (7/8, 87.5%) vs (10/15, 66.6%), p = 0.369]). Nineteen patients (19/23, 82.6%) had normal growth according to the median percentage of HFA or WFA. Mean BFS was 15.9±3.3 in the 15 patients aged older than 4 years who were followed up. Six patients (SLSP = 1, PLSP = 5) who underwent surgical treatment aged older than 1 year were all alive with good outcomes. ConclusionPLSP and SLSP had equivalent clinical outcomes, but enterocolitis and perianal excoriation after the Soave procedure need to be managed carefully. PLSP is a feasible option for older TCA patients after conservative treatment.

Quality of life and functional outcome in Swedish children with low anorectal malformations: a follow-up study

PurposeThe aim was to investigate the quality of life and bowel function in children with low anorectal malformations (ARM).Additional aimTo evaluate the Swedish version the Hirschsprung’s Disease/Anorectal Malformation Quality of life Questionnaire (HAQL).MethodsForty-four children and their parents were invited to complete the HAQL and the Bowel Function Score (BFS). Healthy children participated as controls and completed the HAQL.ResultsSeventeen children and 18 mothers completed the HAQL. The children reported impaired function in the physical symptom (PH) fecal continence (FC) and laxative diet (LD) domains compared to controls. Compared with their mothers, they reported impaired physical function and more symptoms in the emotional functioning (EMF) and PH domains. 27 families completed the BFS; 63% reported normal bowel function, 33% moderate outcome and one patient, comprising 4%, poor outcome. Evaluation of the HAQL, FC, EMF and PH domains showed no obvious conflicts.ConclusionsThe children did not differ much regarding their QoL, even though they appeared to have impaired bowel function and worse emotional functioning compared to controls. The mothers underestimated their children’s physical symptoms and overestimated their emotional functioning. Evaluated domains in the HAQL appear to work as intended, but the questionnaire needs further development.

COMPLICATIONS AFTER TRANSABDOMINAL SOAVE'S PROCEDURE IN CHILDREN WITH HIRSCHSPRUNG'S DISEASE.

ABSTRACTBackground:Hirschsprung’s disease is a congenital disorder that causes functional obstruction of large bowel. Aim: To evaluate complication and bowel function score of children with Hirschsprung’s disease who underwent transabdominal Soave’s procedure. Methods: In this study all the children with Hirschsprung’s disease who underwent transabdominal Soave procedure were evaluated regarding bowel function and complication of trans-abdominal Soave’s procedure. Results: Were enrolled 160 children. Enterocolitis and constipation were seen in 15% of the cases. Fecal incontinency was the least frequent study which was seen in 1% of the children. Conclusion: Constipation and enterocolitis was the most frequent complication following transabdominal Soave technique.