Long-term Bowel Research Articles

The risk of long‐term bowel dysfunction after resection for sigmoid adenocarcinoma: a cross‐sectional survey comparing complete mesocolic excision with conventional surgery

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

Hostile pelvis: how to avoid permanent stoma.

The aim was to report our experience with delayed colo-anal anastomosis (DCA) to avoid permanent stoma for complex rectal cases evaluating short- and long-term outcomes. Nine patients who underwent DCA from 2011 to 2016 were collected and analysed case by case. We considered medical history and surgical outcomes. Long-term bowel function was evaluated using the Wexner and low anterior resection syndrome (LARS) score at 6, 12 and 24months. The range from previous surgery and salvage procedure was 337days. All cases were performed with a full laparoscopic approach. The median length of hospital stay was 15days. The median follow-up was 970.5days. There was no peri-operative mortality. Two patients developed a post-operative pelvic abscess that required redo surgery. Long-term post-operative complications were mucosal prolapsed, anastomosis retraction and anastomotic stricture. The average values of LARS and Wexner scores were, respectively, at 6months 33.7 and 16.2, at 12months 28.5 and 11.7, at 24months 21.1 and 6.7. Colo-anal sleeve delayed anastomosis appears a real answer to avoid permanent stoma in selected patients. The laparoscopic procedure is safe and feasible for skilful mini-invasive surgeons. Our experience describes the complexity of clinical history of these patients underlying a slow, but progressive improvement in continence after restoration of bowel continuity.

Risk factors for late bowel and bladder toxicities in NRG Oncology prostate cancer trials of high-risk patients: A meta-analysis of physician-rated toxicities

PurposeA meta-analysis of sociodemographic variables and their association with late (>180 days from start of radiation therapy[RT]) bowel, bladder, and clustered bowel and bladder toxicities was conducted in patients with high-risk (clinical stages T2c-T4b or Gleason score 8-10 or prostate-specific antigen level >20) prostate cancer. Methods and materialsThree NRG trials (RTOG 9202, RTOG 9413, and RTOG 9406) that accrued from 1992 to 2000 were used. Late toxicities were measured with the Radiation Therapy Oncology Group Late Radiation Morbidity Scale. After controlling for study, age, Karnofsky Performance Status, and year of accrual, sociodemographic variables were added to the model for each outcome variable of interest in a stepwise fashion using the Fine-Gray regression models with an entry criterion of 0.05. ResultsA total of 2432 patients were analyzed of whom most were Caucasian (76%), had a KPS score of 90 to 100 (92%), and received whole-pelvic RT+HT (67%). Of these patients, 13 % and 16% experienced late grade ≥2 bowel and bladder toxicities, respectively, and 2% and 3% experienced late grade ≥3 bowel and bladder toxicities, respectively. Late grade ≥2 clustered bowel and bladder toxicities were seen in approximately 1% of patients and late grade ≥3 clustered toxicities were seen in 2 patients (<1%). The multivariate analysis showed that patients who received prostate-only RT+HT had a lower risk of experiencing grade ≥2 bowel toxicities than those who received whole-pelvic RT+long-term (LT) HT (hazard ratio: 0.36; 95% confidence interval, 0.18-0.73; P = .0046 and hazard ratio: 0.43; 95% confidence interval, 0.23-0.80; P = .008, respectively). Patients who received whole-pelvic RT had similar chances of having grade ≥2 bowel or bladder toxicities no matter whether they received LT or short-term HT. ConclusionsPatients with high-risk prostate cancer who receive whole-pelvic RT+LT HT are more likely to have a grade ≥2 bowel toxicity than those who receive prostate-only RT. LT bowel and bladder toxicities were infrequent. Future studies will need to confirm these findings utilizing current radiation technology and patient-reported outcomes.

Diarrhea and flatulence are major bowel disorders after radical cystectomy: Results from a cross-sectional study in bladder cancer patients

ObjectivesWe had previously demonstrated changes in defecation after radical cystectomy (RC). Reports addressing long-term bowel disorders following RC are rare. This cross-sectional study evaluates long-term bowel issues in a large cohort. Material and methodsA questionnaire assessing changes in bowel function (diarrhea, constipation, urge to defecate, sensation of incomplete defecation, and flatulence) and its effect on quality of life was developed based on the gastrointestinal quality of life index and distributed in collaboration with the German bladder cancer support group. There were 431 evaluable questionnaires. For the analyses, we focused on patients that had the RC>1 year ago (n = 324). ResultsCurrent bowel problems were reported by 42.6% of patients. The most frequent bowel problems were flatulence (48.8%), diarrhea (29.6%), and sensation of incomplete defecation (22.5%). In cases of bowel problems, 39.7% and 59.8% of the patients indicated life restriction and dissatisfaction, respectively. Prevalence of diarrhea and flatulence were significantly higher>12 (vs. ≤12) months following RC. Both symptoms significantly correlated with younger age at RC, life restriction, lower quality of life, lower health state, and lower energy level. Additionally, diarrhea significantly correlated with pouches as urinary diversion (vs. ileal conduit or ureterocutaneostomy) and higher dissatisfaction level. ConclusionsTo our knowledge this is the largest cohort evaluating long-term bowel symptoms after RC. Diarrhea is a prominent symptom after RC with a high impact on daily life that leads to dissatisfaction. A better understanding of long-term bowel symptoms could be translated into optimized surgical procedures, postoperative medication/nutrition, and patient education.

Functional and aesthetic evaluation of sacrococcygeal teratomas. Not everything ends with surgery

Abstract Introduction Sacrococcygeal teratoma is the most common solid neonatal tumour. The improvement in survival has meant that postoperative sequelae can be diagnosed and treated. The aim of this article is to evaluate the long-term outcomes of patients treated in our centre. Material and methods Records of patients treated for a sacrococcygeal teratoma in our hospital from 1977 to 2014 were retrospectively reviewed. Personal data was collected and a telephone questionnaire was used to assess long-term bowel and urinary habits, as well as an aesthetic and functional self-assessment. Results A total of 14 patients were treated during the study period, of whom 11 were females and 3 males, with a mean age at the time of the survey of 17 years (8 months to 37 years). Eight patients completed the questionnaire (57.1%). The mean age of the 8 patients was 23 years (4–37 years), of whom 37.5% were operated on due to a sacrococcygeal teratoma type I, 25% type II, 25% type III, and 12.5% type IV. Two of them (25%) had constipation, and one (12.5%) had faecal incontinence. Two (25%) patients suffered from recurrent urinary tract infections, and 3 (37.5%) patients had urinary incontinence. Five patients (62.5%) had a perception of being physically impaired, with limitation of their social life. Conclusions The incidence of constipation does not differ from that found in the literature. Faecal incontinence is slightly improved compared to what has been published. However, urinary tract infections and incontinence are more prevalent in our series. Five patients out of the eight that responded suffered from psychosocial problems, according to DAS-59 questionnaire. Patients with SCT require urological, bowel, and psychological counselling, until they have a complete functional and emotional development.

Adipose-Derived Mesenchymal Stromal Cells Improve the Healing of Colonic Anastomoses Following High Dose of Irradiation Through Anti-Inflammatory and Angiogenic Processes

Cancer patients treated with radiotherapy (RT) could develop severe late side effects that affect their quality of life. Long-term bowel complications after RT are mainly characterized by a transmural fibrosis that could lead to intestinal obstruction. Today, surgical resection is the only effective treatment. However, preoperative RT increases the risk of anastomotic leakage. In this study, we attempted to use mesenchymal stromal cells from adipose tissue (Ad-MSCs) to improve colonic anastomosis after high-dose irradiation. MSCs were isolated from the subcutaneous fat of rats, amplified in vitro, and characterized by flow cytometry. An animal model of late radiation side effects was induced by local irradiation of the colon. Colonic anastomosis was performed 4 wk after irradiation. It was analyzed another 4 wk later (i.e., 8 wk after irradiation). The Ad-MSC-treated group received injections several times before and after the surgical procedure. The therapeutic benefit of the Ad-MSC treatment was determined by colonoscopy and histology. The inflammatory process was investigated using Fluorine-182-Fluoro-2-Deoxy-d-Glucose Positron Emission Tomography and Computed Tomography (18F-FDG-PET/CT) imaging and macrophage infiltrate analyses. Vascular density was assessed using immunohistochemistry. Results show that Ad-MSC treatment reduces ulcer size, increases mucosal vascular density, and limits hemorrhage. We also determined that 1 Ad-MSC injection limits the inflammatory process, as evaluated through 18F-FDG-PET-CT (at 4 wk), with a greater proportion of type 2 macrophages after iterative cell injections (8 wk). In conclusion, Ad-MSC injections promote anastomotic healing in an irradiated colon through enhanced vessel formation and reduced inflammation. This study also determined parameters that could be improved in further investigations.

Long-term bowel function, quality of life and sexual function in patients with anorectal malformations treated during the PSARP era

Anorectal malformations are an important group of congenital anomalies that vary widely in their anatomical characteristics and complexity. Understanding the long-term functional outcomes after modern treatments, and how these compare to the general population, are essential for ensuring that patients receive optimal, evidence-based care. With increasing appreciation of the wider impact of the illness on patients and their families, minimizing social disability from fecal incontinence and enabling normal social integration from the outset are key management concerns. This review summarizes the current knowledge on the functional outcomes by type of malformation, reflecting on the literature, and our institutional experience over a follow-up period of nearly 30 years.

Assessment of acute bowel function after radiotherapy for prostate cancer: Is it accurate enough?

Pelvic radiotherapy for prostate cancer can be associated with bowel toxicity, which may have a significant impact on quality of life. Our aim was to assess the adequacy of the tools currently used to assess bowel symptoms after radiotherapy, including physician and patient reported outcomes. This sub-study on acute toxicity was part of a prospective trial assessing long-term bowel dysfunction. Between February 2013 and July 2015, 75 patients with prostate cancer who received radiotherapy completed the LENT/SOMA and the EPIC questionnaires baseline and 2weeks after the treatment. The Bristol stool scale and two additional questions on faecal urgency were added. Physicians assessed toxicity using Common Terminology Criteria for Adverse Events v.4.0. Agreement between patients and clinicians was assessed using the Cohen's κ coefficient. Acute toxicity during radiotherapy was very low. The pattern of overall bowel bother was similar before and after treatment. Faecal urgency significantly increased after radiotherapy compared to baseline but was only detected by the additional questions and not by the physicians or the patient-reported outcomes (PRO) questionnaires. Correlation between physician and PRO was poor for most symptoms. Bowel symptoms such as urgency may remain undetected by usual tools to assess toxicity after radiotherapy. Assessment of bowel toxicity should be reappraised in order to identify those patients who may have symptoms with an impact on their quality of life.

Predictors of Bowel Function in Long-term Rectal Cancer Survivors with Anastomosis.

Bowel function in long-term rectal cancer survivors with anastomosis has not been characterized adequately. We hypothesized that bowel function is associated with patient, disease, and treatment characteristics. The cohort study included Kaiser Permanente members who were long-term (≥5years) rectal cancer survivors with anastomosis. Bowel function was scored using the self-administered, 14-item Memorial Sloan-Kettering Cancer Center Bowel Function Index. Patient, cancer, and treatment variables were collected from the electronic medical chart. We used multiple regression to assess the relationship of patient- and treatment-related variables with the bowel function score. The study included 381 anastomosis patients surveyed an average 12years after their rectal cancer surgeries. The total bowel function score averaged 53 (standard deviation, 9; range, 31-70, higher scores represent better function). Independent factors associated with worse total bowel function score included receipt of radiation therapy (yes vs. no: 5.3-unit decrement, p<0.0001), tumor distance from the anal verge (≤6cm vs.>6cm: 3.2-unit decrement, p<0.01), and history of a temporary ostomy (yes vs. no: 4.0-unit decrement, p<0.01). One factor measured at time of survey was also associated with worse total bowel function score: ever smoking (2.3-unit decrement, p<0.05). The regression model explained 20% of the variation in the total bowel function score. Low tumor location, radiation therapy, temporary ostomy during initial treatment, and history of smoking were linked with decreased long-term bowel function following an anastomosis. These results should improve decision-making about surgical options.

269 - Diarrhea as a limiting factor of quality of life after radical cystectomy: Results from a cross-sectional study evaluating long-term bowel issues in bladder cancer patients

269 - Diarrhea as a limiting factor of quality of life after radical cystectomy: Results from a cross-sectional study evaluating long-term bowel issues in bladder cancer patients

Cross-sectional evaluation of long-term bowel issues after radical cystectomy.

318 Background: We had previously shown that a significant number of patients after radical cystectomy (RC) suffer from changes in bowel habits and defecation. Reports addressing long-term bowel disorders following RC are rare. This cross sectional study evaluates long-term bowel issues in a large cohort with the help of an issue-tailored questionnaire. Methods: For this purpose a questionnaire assessing changes in bowel function and its impact on daily life was developed and distributed among members of the German bladder cancer self-help group. A total of 431 patients after RC were evaluated. Symptoms such as diarrhea, constipation, urge to defecate, sensation of incomplete defecation, flatulence, and impact on quality of life (QoL) were assessed. Results: A total of 324 patients were followed ≥1 year, 43% patients of those reported current bowel disorders, 40% life restriction and 60% dissatisfaction. Most frequent bowel symptoms were flatulence (49%), followed by diarrhea (30%) and the sensation of incomplete defecation (23%). The highest prevalence rate of diarrhea is reported in year 3 after surgery: &lt;3 months after surgery 14%, 3-11 months 21%, 12-23 months 18%, 24-35 months 44%, 36-59 months 36%, ≥60 months 27% (p&lt;0.01). Also flatulence is a long-term bowel symptom with a prevalence of 50% ≥1 year vs 37% &lt;1 year after surgery (p=0.0334), while the prevalence of other bowel symptoms did not change over time. After 12 months, diarrhea significantly correlated with flatulence, uncontrolled stool loss, urge to defecate, younger age at time of surgery, and the size of bowel segment for urinary diversion (all p&lt;0.01). Patients suffering from diarrhea report a higher defecation frequency, a lower QoL, a higher dissatisfaction level, a lower energy level (all p&lt;0.01), and a lower health state (p=0.0488). Conclusions: Diarrhea is a prominent long-term bowel symptom after RC. A better understanding of long-term bowel symptoms might lead to optimized surgical procedures, post-operative medication and patient education.

Reply by Authors

No AccessJournal of UrologyLetter to the Editor/Errata1 May 2017Reply by Authors View All Author Informationhttps://doi.org/10.1016/j.juro.2016.12.123AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "Reply by Authors." The Journal of Urology, 197(5), pp. 1364–1365 References 1 : Bowel function and lower urinary tract symptoms in females with anterior anus treated conservatively: controlled outcomes into adulthood. J Pediatr Surg2015; 50: 1168. Google Scholar 2 : Bowel function and lower urinary tract symptoms in males with low anorectal malformations: an update of controlled, long-term outcomes. Int J Colorectal Dis2015; 30: 221. Google Scholar 3 : Bowel functional outcomes in females with perineal or vestibular fistula treated with anterior sagittal anorectoplasty: controlled results into adulthood. Dis Colon Rectum2015; 58: 97. Google Scholar 4 : Long-term bowel functional outcomes in rectourethral fistula treated with PSARP: controlled results after 4-29 years of follow-up: a single-institution, cross-sectional study. J Pediatr Surg2014; 49: 1635. Google Scholar 5 : Validation of the Erection Hardness Score. J Sex Med2007; 4: 1626. Google Scholar 6 : Bowel function and gastrointestinal quality of life among adults operated for Hirschsprung disease during childhood: a population-based study. Ann Surg2010; 252: 977. Google Scholar 7 : Bowel function and quality of life after transanal endorectal pull-through for Hirschsprung disease: controlled outcomes up to adulthood. Ann Surg2016; 10.1097/SLA.0000000000001695. Crossref, Google Scholar 8 : Health-related quality of life and parental stress in children with fecal incontinence: a normative comparison. J Pediatr Gastroenterol Nutr2016; 63: 633. Google Scholar 9 : Study of intestinal function in anorectal malformations: the role of bowel management in quality of life. Acta Biomed2016; 87: 197. Google Scholar 10 : Long-term disease-specific quality of life in children and adolescent patients with ARM. J Pediatr Surg2012; 47: 1317. Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 197Issue 5May 2017Page: 1364-1365 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Expand All Advertisement PDF downloadLoading ...

A Nordic multicenter survey of long-term bowel function after transanal endorectal pull-through in 200 patients with rectosigmoid Hirschsprung disease

ObjectiveTransanal endorectal pull-through (ERPT) is the most popular technique to treat Hirschsprung disease (HD). Still, there is limited knowledge on long-term bowel function. This cross-sectional, multicenter study assessed long-term bowel function in a large HD population and examined predictors of poor outcome. MethodsPatients older than four years or their parents filled out a validated questionnaire on bowel function. Clinical details were recorded retrospectively from medical records. Results73/200 (37%) patients reported absolutely no impaired bowel function, meaning no constipation, fecal accidents, stoma, appendicostomy or need for enemas. Seven (4%) had a stoma, and 33 (17%) used antegrade or rectal colonic enemas. Most disarrangements of fecal control and constipation were significantly less common in older age group, but abnormal defecation frequency and social problems remained unchanged. Syndromic patients (n=31) experienced frequent fecal accidents (46%) more often than nonsyndromic (14%, P<0.001). Having a syndrome (adjusted OR 5.6, 95% CI 2.1–15, P=0.001) or a complete transanal ERPT (adjusted OR 2.4, 95% CI 1.1–5.7, P=0.038) was significantly associated with poor outcome defined as having a stoma, an appendicostomy, daily fecal accidents or need of regular rectal wash outs. ConclusionA significant number of HD patients experience bowel problems many years after definite surgery. Fecal control was significantly better in older than younger HD patients, but some continued to have considerable bowel problems also as adults. A total transanal ERPT was associated with poorer outcome. Long-term follow-up of HD patients is warranted.Prognosis Study: Level II.

Oncological and functional outcomes of postoperative total parenteral nutrition after radical cystectomy in bladder cancer patients: A single-center randomized trial.

To prospectively evaluate the long-term oncological and functional outcomes of postoperative total parenteral nutrition after radical cystectomy. A total of 157 consecutive patients (≤cT3, cN0, cM0) who underwent extended pelvic lymph node dissection, radical cystectomy and ileal urinary diversion from September 2008 to March 2011 at a single center were randomized to receive either postoperative total parenteral nutrition (group A; n = 74) or oral nutrition alone (group B; n = 83). All but two patients in group B (who were thus excluded from further analysis) had regular postoperative follow up at the Department of Urology, University of Bern, Switzerland. Computed tomography and bone scan were carried out to assess local recurrences and distal metastases. We used validated questionnaires to evaluate bowel function, sexual function and quality of life, and an institutional questionnaire to evaluate neobladder function. The median follow up was 50 months (IQR 21-62). The rate of local recurrences (4/74 [5.4%] in group A; 4/81 [4.9%] in group B; P = 0.9) and the rate of distant metastases (23/74 [31%] in group A; 23/81 [28%] in group B; P = 0.72) did not differ between the two groups. There was no difference in cancer-specific (P = 0.86) and overall survival (P = 0.85). Group B patients had significantly better bowel function at 3 months (P = 0.03) and 12 months (P = 0.01). There was no difference in terms of quality of life, and sexual and neobladder function. The administration of total parenteral nutrition after radical cystectomy does not impair long-term oncological outcomes. It does, however, negatively influence long-term bowel function.

Laparoscopic-assisted pull-through operation for Hirschsprung's disease: a systematic review and meta-analysis.

In the last two decades, laparoscopic-assisted pull-through (LAPT) has gained much popularity in the treatment of Hirschsprung's disease. The aim of this meta-analysis was to determine the long-term outcome of patients treated laparoscopically. A systematic literature-based search for relevant cohorts was performed using the terms "Hirschsprung's disease and Laparoscopy", "Laparoscopic-assisted pull-through outcome", "Laparoscopic-assisted Soave pull-through" "Laparoscopic-assisted Swenson pull-through" and Laparoscopic-assisted Duhamel pull-through. The relevant cohorts of laparoscopic operated HD were systematically searched for outcome regarding continence, constipation, secondary surgery related to the laparoscopic approach and enterocolitis. Pooled incidence rates and odds ratios (ORs) with 95% confidence intervals (CI) were calculated using standardized statistical methodology. Sixteen studies met defined inclusion criteria, reporting a total of 820 patients. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. The median cohort size consisted of 28 patients (range 15-218). In the long-term follow-up, 97 patients (11.14%) experienced constipation (OR 0.06, 95% CI 0.05-0.08, p<0.00001), 53 (6.46%) incontinence/soiling (OR 0.01 95% CI 0.01-0.01, p<0.00001), 75 (9.14%) recurrent enterocolitis (OR 0.02 95% CI 0.01-0.02, p<0.00001) and 69 (8.4%) developed complications requiring secondary surgery (OR 0.01 95% CI 0.01-0.02, p<0.00001). Overall events in long-term follow-up occurred in 225 (27.5%) patients (OR 0.24 95% CI 0.20-0.30, p<0.00001). This meta-analysis shows that nearly one-third of the patients continue to have long-term bowel problems, such as constipation, soiling and recurrent enterocolitis following LAPT. Many patients treated by LAPT require secondary surgery. Large randomized studies with long-term follow-up are necessary to determine the difference in outcome between LAPT and completely transanal pull-through operation.

The holistic management of consequences of cancer treatment by a gastrointestinal and nutrition team: a financially viable approach to an enormous problem?

There is no national NHS tariff to fund services for patients experiencing long-term bowel and nutritional problems after cancer treatment. In this paper, we report the clinical characteristics and outcomes of patients referred to our service and the estimated cost of a completed episode of care. Patient characteristics, symptom severity, investigations, diagnoses, number of clinic visits and referrals elsewhere were recorded in a prospective cohort study. During 2013-14, 325 patients completed assessment and treatment. The majority of original cancer diagnoses were urological (43%) and gynaecological (21%). A median of six investigations were requested. 62% were found to have three or more new diagnoses including small intestinal bacterial overgrowth (46%), vitamin D deficiency (38%), bile acid malabsorption (28%), gastritis (22%), radiation-induced bleeding (20%), vitamin B12 deficiency (17%), pelvic floor weakness (17%), colorectal polyps (13%) and pancreatic insufficiency (5%). A median of three visits were required and all commonly reported gastrointestinal symptoms improved by discharge. The mean episode of care per patient was costed at £1,563. Effective amelioration of chronic gastrointestinal toxicity after cancer treatment costs substantially less than treating the cancer in the first place and requires an NHS tariff.

Assessment of Long-Term Bowel Symptoms After Segmental Resection of Deeply Infiltrating Endometriosis: A Matched Cohort Study

Study ObjectiveTo assess long-term bowel symptoms in women who underwent segmental bowel resection for deep-infiltrating endometriosis (DIE) compared with women who underwent resection of severe endometriosis without bowel resection. DesignCohort study with matched controls (Canadian Task Force classification II-2). SettingCleveland Clinic. Patients71 patients (36 cases and 35 controls). InterventionsPatients who were at least 4 years out from undergoing segmental bowel resection due to DIE were matched with patients who had undergone resection of stage III/IV endometriosis without bowel resection. The patients completed validated questionnaires, and data were analyzed using the Wilcoxon rank-sum, χ2, and Fisher exact tests. Measurements and Main ResultsThe Bristol Stool Form Scale, Patient Assessment of Constipation Symptoms Questionnaire (PAC-SYM), and St Mark's Vaizey Fecal Incontinence Grading System were used to elicit information. The median duration of follow-up was 10.1 years (range, 4–18 years). The mean patient age and body mass index were comparable in the cases and the controls. A larger proportion of cases than controls reported new bowel symptoms (58% [21 of 36] vs 14% [5 of 35]; p = .001), as well as abdominal pain, incomplete bowel movements, and false alarms on the PAC-SYM questionnaire; however, total PAC-SYM and Vaizey Fecal Incontinence Grading System scores were similar in the 2 groups (median, 8 [interquartile range, 8–10] vs 8 [8–10]; p = .86). Similarly, the proportion of patients with normal stool consistency (Bristol Stool Form Scale score 2–6) was similar in the 2 groups (80.6% [29 of 36] vs 94.3% [33 of 35]; p = .59). ConclusionSegmental bowel resection for DIE may be associated with a higher incidence of new bowel symptoms (possibly due to abdominal pain, incomplete bowel movements, and/or false alarms), but not with worse constipation or fecal incontinence, compared with surgery without bowel resection.

Stereotactic Body Radiotherapy (SBRT) Reirradiation for Recurrent Pancreas Cancer.

Objectives: After adjuvant or definitive radiation for pancreas cancer, there are limited conventional treatment options for recurrent pancreas cancer. We explored the role of (Stereotactic Body Radiotherapy) SBRT for reirradiation of recurrent pancreas Cancer.Methods: This is a retrospective study of patients reirradiated with SBRT for recurrent pancreas cancer. All patients were deemed unresectable and treated with systemic therapy. Fiducial gold markers were used. CT simulation was performed with oral and IV contrast and patients were treated with respiratory motion tracking in the CyberknifeTM system.Results: 30 patients (17 men and 13 women) with a median age of 67 years were included in the study. The median target volume was 41.29cc. The median prescription dose was 25Gy (24-36Gy) in a median of 5 fractions prescribed to a mean 78% isodose line. The median overall survival was 14 months. The 1 and 2 year local control was 78%. The worst toxicity included 3/30(10%) Grade III acute toxicity for pain, bleeding and vomiting. There was 2/30 (7%) Grade III long-term bowel obstructions.Conclusions: SBRT can be a useful and tolerable option for patients with recurrent pancreas cancer after prior radiation.

Mass Surgical Treatment of Obesity and Type-2 Diabetes: Now is the Right Time

Copyright © 2015, Minimally Invasive Surgery Research Center and Mediterranean & Middle Eastern Endoscopic Surgery Association. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. I recently wrote a provocative commentary (1) following the article written by Anita Courcoulas on in JAMA surgery (2). After the Second World War, with the raise of tobacco usage, high alcohol concentrations intake, urban pollution, high fat diets and sedentary lifestyle, coronary atherosclerotic disease became one of the most important public enemy. The response came in 1950, at McGill University in Montreal, where Vineberg and Buller were the first to implant an internal mammary artery into the myocardium to treat cardiac ischemia and angina (3). Indeed, coronary disease peaked in the sixties and seventies, and saphenous vein graft coronary bypasses popularized by the Argentinian Rene Favaloro, while he worked at the Cleveland Clinic, increased exponentially (4). Mass surgical treatment took its course, with cardiac surgical institutes growing like mushrooms everywhere in the world. Hospitals were built solely on this pathology, with cardiologists, coronarographers, perfusionnists and dedicated cardiac surgeons doing more than half a million procedures a year in USA, and an estimated > 1 million per year worldwide (4). That volume has recently gone down by almost half these numbers, from interventional cardiology, but mostly from a decrease in tobacco and alcohol usage, a better lesser fat diet, statins and increased regular exercises (in lesser local atmospheric pollution). Is it possible that in order to target obesity and type2 diabetes, we have to go the same path? That is, mass surgical treatment, is again ahead of lifestyle changes and medical treatment. We should be building obesity/ diabetes institutes, entire hospitals with multidisciplinary teams, complete with internists, endocrinologists, bariatric and metabolic surgeons, psychologists and nutritionists, as well as public health stakeholders. We could operate millions of affected patients in the World and really have an impact on those 2 chronic diseases, as there is an estimate of 350 million affected (5). We should be operating fast enough, so that the new pool of patients would not overlap on the ones we are treating annually. Already, with the rapid rise of sleeve gastrectomy, the number one choice in USA, 200,000 patients are operated annually, and perhaps a projected < 500000 operations per year in the globe for 2015. That is not enough; we should be doing 10 times these numbers, at the very least. Even at 5 million patients per year, it would take us 70 years to operate everybody. But that is a reasonable goal in the short-term. It would take a procedure that is relatively brief, with few complications, a very low mortality rate, reproducible and has acceptable long-term results. At this time, laparoscopic sleeve gastrectomy would fit this profile (GERD can be treated medically), better that Roux-en-Y gastric bypass, as it may have longterm bowel obstruction risks, ulcer risks, micronutrients severe deficiency, bone disease, and 10% hypoglycemia/ dumping syndromes (6, 7). Sleeves gastrectomies can be revised more easily with numerous options. Also, I can do 3 sleeves while one gastric bypass is being done in the same time interval, as we have a surgical manpower problems, the former is preferable. Is it time for mass surgical treatment of obesity and type-2 diabetes? Yes, now is the right time.

Validation of the English translation of the low anterior resection syndrome score.

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