Quality of life in patients with a permanent stoma after rectal cancer surgery

Quality of life meta-analysis following coloanal anastomosis versus abdominoperineal resection for low rectal cancer

AIM

In low rectal cancers without sphincter involvement a permanent stoma can be avoided without compromising oncological safety. Functional outcomes following coloanal anastomosis (CAA) compared to abdominoperineal excision (APR) may be significantly different. This study examines all available comparative quality of life (QoL) data for patients undergoing CAA versus APR for low rectal cancer.

METHODS

Published studies with comparative data on QoL outcomes following CAA versus APR for low rectal cancer were extracted from electronic databases. The study was registered with PROSPERO and adhered to PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data was combined using random-effects models.

RESULTS

Seven comparative series examined QoL in 527 patients. There was no difference in the numbers receiving neoadjuvant radiotherapy in the APR and CAA groups (OR: 1.19, 95% CI: 0.78-1.81, p = 0.43). CAA was associated with higher mean scores for physical functioning(std mean diff -7.08, 95% CI: -11.92 to -2.25, p = 0.004) and body image (std. mean diff 11.11, 95% CI: 6.04-16.18, p < 0.0001). Male sexual problems were significantly increased in patients who had undergone APR compared to CAA (std. mean diff -16.20, 95% CI: -25.76 to -6.64, p = 0.0009). Patients who had an APR reported more fatigue, dyspnoea and appetite loss. Those who had a CAA reported higher scores for both constipation and diarrhoea.

DISCUSSION

It is reasonable to offer a CAA to motivated patients where oncological outcomes will not be threatened. QoL outcomes appear to be superior when intestinal continuity is maintained, and permanent stoma avoided.

Use of prophylactic stoma mesh is a risk factor for developing rectus abdominis muscle atrophy

Purpose

The aim of this study was to evaluate the possible risk factors for developing a parastomal hernia (PSH) in a cohort of rectal cancer patients with and without the application of a retro-muscular prophylactic mesh. The evaluated risk factors included the position of the stoma in the rectus abdominis muscle (RAM), RAM atrophy and shift of abdominal wall midline structures.

Methods

Rectal cancer patients treated with an abdominoperineal excision or Hartmann’s procedure between 2002 and 2015 at Västmanland Hospital, Sweden was included. Postoperative CT examinations were retrospectively reviewed regarding the presence of PSH and RAM atrophy and for measurements such as position of the stoma in the RAM.

Results

116 patients were included, with a median age of 71 years. 70 patients received a prophylactic stoma mesh. 55 patients (47%) had a parastomal hernia at three-year follow-up. Rectus abdominis muscle atrophy was significantly higher in the mesh group compared with the non-mesh group (37% vs 2%; P = 0.04). RAM atrophy was a significant independent protective factor for developing a PSH (P = 0.007; OR 0.15; 95% CI 0.03–0.55).

Conclusion

Placement of a prophylactic retro-muscular stoma mesh resulted in a high frequency of RAM atrophy distal to the stomal aperture and patients with such atrophy had a lower risk of developing a PSH.

Current Management and Treatment of Extramammary Paget's Disease

OPINION STATEMENT

Extramammary Paget's disease (EMPD) is a rare neoplastic disease affecting areas rich in apocrine glands in the elderly. EMPD clinically resembles a benign inflammatory skin disease, and ill-defined tumor borders can lead to misdiagnosis and incomplete excision. Several prognostic factors have been reported, including nodule formation, tumor thickness, tumor invasion, lymphovascular invasion, and a perianal location, which are characteristic of primary tumors. EMPD typically presents as an in situ tumor spreading horizontally within the epidermis and then invading into the dermis as it transitions to a vertical growth phase. For this reason, tumor thickness, rather than tumor size, is correlated with patient prognosis. The best treatment for resectable EMPD is complete surgical removal of the tumor. EMPD sometimes has unclear tumor borders, and it can unexpectedly spread beyond its clinical boundaries. Surgical resection in such cases is often associated with tumor-positive margins, which can result in recurrence. However, surgical excision with wide margins may deteriorate patients' organ functions and quality of life. Mohs micrographic surgery may be ideal for controlling the surgical margins and minimizing the sacrifice of normal tissue, but this technique is not always feasible because of constraints associated with the medical environment. No standard treatment for unresectable or metastatic EMPD has been established. Although conventional chemotherapy has been used as the first-line treatment, it frequently causes adverse events, and consequently, targeted therapy will become more valuable in the near future.

Body Image Issues in Patients With Colorectal Cancer: A Scoping Review

BACKGROUND

Stomas in colorectal cancer (CRC) survivors lead to body image problems. Advances in treatment help reduce the rate of stoma formation, but body image distress is still frequently experienced in CRC survivors.

OBJECTIVES

This review is aimed toward mapping and describing the state of knowledge regarding body image in patients with CRC.

METHODS

A systematic literature search complying with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted. Screening and data extraction were performed by 2 reviewers independently for all potentially eligible studies.

RESULTS

A total of 56 eligible articles were selected. The majority of these studies were quantitative studies (85%). The eligible studies were classified into 4 broad categories: instruments used to assess body image, prevalence of body image distress, factors related to body image, and impact of body image distress. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-CR38) colorectal questionnaire was the most common measurement tool found among the reviewed studies (70%), and body image distress was reported by 25.5% to 86% of participants. Excluding gender, age, type of surgery, adjuvant therapy, time from diagnosis, social support, and stoma status, changes in bowel habits was identified as affecting the body image of patients with CRC.

CONCLUSION

Changing bowel habits emerged as a significant factor causing body image distress for CRC survivors.

IMPLICATIONS FOR PRACTICE

Clinicians should raise awareness about body image distress in patients with CRC, focus on finding effective measures and interventions intended to help alleviate symptoms of bowel dysfunction, and prepare patients to adapt to altered bowel functions.

The efficacy and mechanism of positive psychological intervention on well-being for colostomy patients: a randomized controlled trial

AIMS

The positive psychology intervention (PPI) is an effective therapy designed to motivate individuals' positive quality and power, to help them survive in an adverse situation, and to establish a high-quality personal and social life. This study aims to evaluate the efficacy and mechanism of PPI on the psychological capital, psychological distress, and life satisfaction among colostomy patients.

METHODS

Patients (n = 120) with permanent stomas were recruited and randomly assigned into two groups. Patients in the experimental group (n = 60) received standard care and PPI, whereas patients in the control group (n = 60) only received standard care. The psychological capital, psychological distress, and life satisfaction were measured and compared between two groups before the intervention, the immediate post-intervention, and follow-up.

RESULTS

All 120 patients completed the study. The hope, optimism, resilience, psychological distress, and life satisfaction score of the experimental group were significantly higher than those of the control group at T1 and T2 (P < 0.05). Self-efficacy score of the experimental group had no significant difference at the two time points after the intervention than the control group (P > 0.05). Changes in hope and resilience which belong to psychological capital mediated the intervention's efficacy on changes in PPI on life satisfaction (β = 0.265, P = 0.005; β = 0.686, P = 0.002).

CONCLUSIONS

PPI could effectively improve psychological capital, psychological distress, and life satisfaction among patients with stomas. Besides, our findings add novel support that increased hope and resilience are the active ingredients that promote intervention change.

Adaptation and psychometric evaluation of the Stoma-QOL questionnaire among Chinese rectal cancer patients with colostomy

AIM

The purpose of this study was to translate the Stoma-quality of life into Chinese and evaluate its psychometric properties in Chinese patients.

BACKGROUND

Quality of life is an important issue for patients with colostomy, and its appropriate and precise measurement is beneficial to promoting better care. The Stoma-quality of life questionnaire has been widely used; however, the validity and reliability of its Chinese version has not been determined.

DESIGN

A cross-sectional validation study was conducted.

METHODS

We translated the Stoma-quality of life into Chinese using standardized methods. Then it was psychometrically tested on a convenience sample of 513 patients with colostomy. Construct validity was evaluated via exploratory factor analysis and confirmatory factor analysis. Reliability was measured with Cronbach's alpha and the split-half Spearman-Brown coefficient.

RESULTS

The content validity, the Cronbach's α coefficient and the Spearman-Brown split-half reliability coefficient indicated adequate validity and reliability. The exploratory factor analysis yielded four common factors, and the cumulative variance contribution rate was 67.5%. Moreover, the confirmatory factor analysis showed a good model fit.

CONCLUSION

This study confirmed that the Chinese version of Stoma-quality of life is an effective and reliable measurement for evaluating the quality of life of patients with colostomy.

Quality of life profiles and their association with clinical and demographic characteristics and physical activity in people with a stoma: a latent profile analysis

Purpose

Quality of life can be negatively impacted by the formation of a stoma and is influenced by a number of factors. Research to date treats people with a stoma as a homogenous group based on their quality of life. We attempted to identify subgroups based upon self-reported quality of life and explored variables associated with group membership.

Methods

The present study is a secondary analysis of a cross-sectional sample of 1419 people with a stoma. Participants completed validated questionnaires for quality of life, physical activity and clinical and demographic characteristics. Latent profile analysis was used to identify the optimal number of subgroups (profiles) and multinomial regression modelling was conducted to identify variables associated with profile membership.

Results

The analysis revealed 4 distinct profiles of people with a stoma: ‘consistently good quality of life’ [N = 891 (62.8%)], ‘some quality of life concerns’ [N = 184 (13.0%)], ‘low quality of life’ [N = 181 (12.8%)] and ‘financial concerns’ [N = 163 (11.5%)]. Modelling revealed that people with a recent stoma (formed < 2 years previously), who have a hernia and are less physically active were more likely to belong to the ‘low quality of life’ profile. Furthermore, those aged 16–55 were more likely to have financial concerns.

Conclusion

This study was the first to identify latent profiles within this population and assess whether certain variables are associated with membership. Future research should build upon this to identify additional variables associated with these profiles, which can help to provide the basis for targeting and tailoring future interventions to specific subgroups of people with a stoma.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03102-5.

Robot-Assisted Total Mesorectal Excision Versus Laparoscopic Total Mesorectal Excision: A Retrospective Propensity Score-Matched Cohort Analysis in Experienced Centers

BACKGROUND

The superiority of robot-assisted over laparoscopic total mesorectal excision has not been proven. Most studies do not consider the learning curve while comparing the surgical technique.

OBJECTIVE

This study aims to compare laparoscopic with robot-assisted total mesorectal excision performed by surgeons who completed the learning curve of the technique.

DESIGN

This is a multicenter retrospective propensity score-matched analysis.

SETTINGS

The study was performed in 2 large, dedicated robot-assisted hospitals and 5 large, dedicated laparoscopic hospitals.

PATIENTS

Patients were included if they underwent a robot-assisted or laparoscopic total mesorectal excision for rectal cancer with curative intent at a dedicated center for the minimally invasive technique between January 1, 2015, and December 31, 2017.

INTERVENTIONS

We compared robot-assisted with laparoscopic total mesorectal excision.

MAIN OUTCOME MEASURES

The main outcome was conversion to laparotomy during surgery. Secondary outcomes were postoperative morbidity and positive circumferential resection margin.

RESULTS

A total of 884 patients were included and, after matching, 315 patients per treatment group remained. Conversion was similar between laparoscopic and robot-assisted total mesorectal excision (4.4% vs 2.5% (p = 0.20)). Positive circumferential resection margin was equal (3.2% vs 4.4% (p = 0.41)). Overall morbidity was comparable as well, although a lower rate of wound infections was observed in the robot-assisted group (5.7% vs 1.9% (p = 0.01)). More primary anastomoses were constructed in the robot-assisted group (50.8% vs 68.3% (p < 0.001)). Finally, more open procedures were performed in dedicated laparoscopic centers, with an overrepresentation of cT4N+ tumors in this group.

LIMITATIONS

This is a retrospective multicenter cohort; however, propensity score matching was applied to control for confounding by indication.

CONCLUSIONS

Robot-assisted and laparoscopic total mesorectal excision are equally safe in terms of short-term outcomes. However, with the robot-assisted approach, more primary anastomoses were constructed, and a lower wound infection rate was observed. See Video Abstract at http://links.lww.com/DCR/B677.ESCISIÓN MESORRECTAL TOTAL ASISTIDA POR ROBOT VERSUS ESCISIÓN MESORRECTAL TOTAL LAPAROSCÓPICA: UNA PUNTUACIÓN DE PROPENSIÓN RETROSPECTIVA ANÁLISIS DE COHORTES EMPAREJADAS EN CENTROS EXPERIMENTADOS.

ANTECEDENTES

No se ha demostrado la superioridad de la escisión mesorrectal total asistida por robot sobre la laparoscópica. La mayoría de los estudios no tienen en cuenta la curva de aprendizaje al comparar la técnica quirúrgica.

OBJETIVO

Este estudio tiene como objetivo comparar la escisión mesorrectal total laparoscópica con la asistida por robot realizada por cirujanos que completaron la curva de aprendizaje de la técnica.

DISEO

Este es un análisis multicéntrico retrospectivo emparejado por puntuación de propensión.

AJUSTES

El estudio se realizó en dos grandes hospitales dedicados asistidos por robots y cinco grandes hospitales laparoscópicos dedicados.

PACIENTES

Se incluyeron pacientes que se sometieron a escisión mesorrectal total asistida por robot o laparoscópica para cáncer de recto con intención curativa, en un centro dedicado a la técnica mínimamente invasiva entre el 1 de enero de 2015 y el 31 de diciembre de 2017.

INTERVENCIONES

Comparamos la escisión mesorrectal total asistida por robot con la laparoscópica.

PRINCIPALES MEDIDAS DE RESULTADO

El principal resultado fue la conversión a laparotomía durante la cirugía. Los resultados secundarios fueron la morbilidad posoperatoria y el margen circunferencial positivo.

RESULTADOS

Se incluyó a un total de 884 pacientes y, después de emparejar, quedaron 315 pacientes por grupo de tratamiento. La conversión fue similar entre la escisión mesorrectal total laparoscópica y asistida por robot (4,4% frente a 2,5% [p = 0,20]). El margen de resección circunferencial positivo fue igual (3,2% vs 4,4% [p = 0,41]). La morbilidad general también fue comparable, aunque se observó una menor tasa de infecciones de heridas en el grupo asistido por robot (5,7% frente a 1,9% [p = 0,01]). Se construyeron más anastomosis primarias en el grupo asistido por robot (50,8% frente a 68,3% [p < 0,001]). Finalmente, se realizaron procedimientos más abiertos en centros laparoscópicos dedicados, con una sobrerrepresentación de tumores cT4N + en este grupo.

LIMITACIONES

Ésta es una cohorte multicéntrica retrospectiva; sin embargo, se aplicó el emparejamiento por puntuación de propensión para controlar los factores de confusión por indicación.

CONCLUSIONES

La escisión mesorrectal total asistida por robot y laparoscópica son igualmente seguras en términos de resultados a corto plazo. Sin embargo, con el abordaje asistido por robot, se construyeron más anastomosis primarias y se observó una menor tasa de infección de la herida. Consulte Video Resumen en http://links.lww.com/DCR/B677. (Traducción-Dr. Gonzalo Hagerman).

Stoma versus anastomosis after sphincter-sparing rectal cancer resection; the impact on health-related quality of life

BACKGROUND

Surgical resection is the mainstay of curative treatment for rectal cancer. Post-operative complications, low anterior resection syndrome (LARS), and the presence of a stoma may influence the quality of life after surgery. This study aimed to gain more insights into the long-term trade-off between stoma and anastomosis.

METHODS

All patients who underwent sphincter-sparing surgical resection for rectal cancer in the Leiden University Medical Center and the Reinier de Graaf Gasthuis between January 2012 and January 2016 were included. Patients received the following questionnaires: EORTC-QLQ-CR29, EORTC-QLQ-C30, EQ-5D-5L, and the LARS score. A comparison was made between patients with a stoma and without a stoma after follow-up.

RESULTS

Some 210 patients were included of which 149 returned the questionnaires (70.9%), after a mean follow-up of 3.69 years. Overall quality of life was not significantly different in patients with and without stoma after follow-up using the EORTC-QLQ-C30 (p = 0.15) or EQ-5D-5L (p = 0.28). However, after multivariate analysis, a significant difference was found for the presence of a stoma on global health status (p = 0.01) and physical functioning (p < 0.01). Additionally, there was no difference detected in the quality of life between patients with major LARS or a stoma.

CONCLUSION

This study shows that after correction for possible confounders, a stoma is associated with lower global health status and physical functioning. However, no differences were found in health-related quality of life between patients with major LARS and patients with a stoma. This suggests that the choice between stoma and anastomosis is mainly preferential and that shared decision-making is required.

An evaluation of short-term outcomes after reoperations for anastomotic leakage in colon cancer patients

PURPOSE

Scarce data are available on differences among index colectomies for colon cancer regarding reoperation for anastomotic leakage (AL) and clinical consequences. Therefore, this nationwide observational study aimed to evaluate reoperations for AL after colon cancer surgery and short-term postoperative outcomes for the different index colectomies.

METHODS

Patients who underwent resection with anastomosis for a first primary colon carcinoma between 2013 and 2019 and were registered in the Dutch ColoRectal Audit were included. Primary outcomes were mortality, ICU admission, and stoma creation.

RESULTS

Among 39,565 patients, the overall AL rate was 4.8% and ranged between 4.0% (right hemicolectomy) and 15.4% (subtotal colectomy). AL was predominantly managed with reoperation, ranging from 81.2% after transversectomy to 92.4% after sigmoid resection (p < 0.001). Median time to reoperation differed significantly between index colectomies (range 4-8 days, p < 0.001), with longer and comparable intervals for non-surgical reinterventions (range 13-18 days, p = 0.747). After reoperation, the highest mortality rates were observed for index transversectomy (15.4%) and right hemicolectomy (14.4%) and lowest for index sigmoid resection (5.6%) and subtotal colectomy (5.9%) (p < 0.001). Reoperation with stoma construction was associated with a higher mortality risk than without stoma construction after index right hemicolectomy (17.7% vs. 8.5%, p = 0.001). ICU admission rate was 62.6% overall (range 56.7-69.2%), and stoma construction rate ranged between 65.5% (right hemicolectomy) and 93.0% (sigmoid resection).

CONCLUSION

Significant differences in AL rate, reoperation rate, time to reoperation, postoperative mortality after reoperation, and stoma construction for AL were found among the different index colectomies for colon cancer, with relevance for patient counseling and perioperative management.

Long-term stoma-related reinterventions after anterior resection for rectal cancer with or without anastomosis: population data from the Dutch snapshot study

BACKGROUND

The aim of this study was to analyze the stoma-related reinterventions, complications and readmissions after an anterior resection for rectal cancer, based on a cross-sectional nationwide cohort study with 3-year follow-up.

METHODS

Rectal cancer patients who underwent a resection with either a functional anastomosis, a defunctioned anastomosis, or Hartmann's procedure (HP) with an end colostomy in 2011 in 71 Dutch hospitals were included. The primary outcome was number of stoma-related reinterventions.

RESULTS

Of the 2095 patients with rectal cancer, 1400 patients received an anterior resection and were included in this study; 257 received an initially functional anastomosis, 741 a defunctioned anastomosis, and 402 patients a HP. Of the 1400 included patients, 62% were males, 38% were females and the mean age was 67 years (SD 11.1). Following a primary functional anastomosis, 48 (19%) patients received a secondary stoma. Stoma-related complications occurred in six (2%) patients, requiring reintervention in one (0.4%) case. In the defunctioned anastomosis group, stoma-related complications were present in 92 (12%) patients, and required reintervention in 23 (3%) patients, in 10 (1%) of these more than 1 year after initial resection. Stoma-related complications occurred in 92 (23%) patients after a HP, and required reintervention in 39 (10%) patients in 17 (4%) of cases more than 1 year after initial resection. The permanent stoma rate was 11% and 20%, in the functional anastomosis and the defuctioned anastomosis group, respectively. The end colostomy in the HP group was reversed in 4% of cases.

CONCLUSIONS

Construction of a stoma after resection for rectal cancer with preservation of the sphincter is accompanied with long-term stoma-related morbidity. Stoma complications are more frequent after a HP. Even after 1 year, a significant number of reinterventions are required.

Anal preservation on the psychology and quality of life of low rectal cancer

INTRODUCTION

The aims of this study are to evaluate depression and quality of life (QOL) after laparoscopic abdominoperineal resection (LAPR) or transanal total mesorectal excision (TaTME) surgery in low rectal cancer (RC) patients.

METHODS

This is a prospective observational cohort study. Patients were divided into two groups: either TaTME surgery or LAPR. Psychosocial distress and QOL were assessed using a questionnaire before surgery, at 6 months postsurgery, and 12 months postsurgery. The Hospital Anxiety and Depression Scale was used to assess symptoms of anxiety and depression. The European Organization for Research and Treatment of Cancer-QOL questionnaire core was used to estimate the QOL.

RESULTS

In the TaTME group, the scores of psychosocial distress and QOL showed an obvious tendency to decrease and then recover. Meanwhile, in the LAPR group, these scores deteriorated significantly at 6 and 12 months, and the recovery was less pronounced. Multivariable analysis suggested that surgical options and tumor stage were significantly associated with psychosocial distress and QOL.

CONCLUSION

For low RC, TaTME could significantly improve patients' QOL and reduce psychological distress as compared to patients with LAPR at 12 months after surgery.

Surgical treatment of stoma-related hernias: retrospective cohort study of damage claims to the Swedish National Patient Insurance Company 2010-2016

Background

Parastomal hernia and stoma-site hernia are common stoma complications. Parastomal hernia repair is associated with high complication and recurrence rates. Insurance data can provide novel information on the consequences of perioperative complications from the patient’s point of view. The aim was to investigate what types of complications associated with stoma-related hernia surgery that cause patients to apply for economic compensation through the patient insurance system and to investigate demographic and clinical differences among cases based on gender and type of center at which the surgery was performed.

Methods

A national patient damage claim database was searched for ICD-10 codes related to parastomal and stoma-site hernia surgery over a seven-year period. Medical records were screened for claims associated with parastomal hernia repair, relocation or reversal due to parastomal hernia, or stoma-site hernia repair. Claims were classified according to one of four primary complaints: surgical, anesthetic, medical or other. Clinical and demographic differences between genders and hospital types were investigated. Reasons for non-compensation were analyzed.

Results

Thirty claims met the inclusion criteria. Eighteen were related to parastomal hernia repair, seven to stoma-site hernia repair, three to stoma reversal and two to relocation due to parastomal hernia. Twenty-five claims were primarily surgical, two related to anesthesia and three classified as other. Seven claims were granted compensation. No demographic or clinical differences were found apart from female gender being associated with previous parastomal hernia repair [6 women and 0 men (p = 0.02)].

Conclusion

Surgical complaints predominated. Few claims were compensated, reflecting the complexity and unsatisfactory outcomes of these procedures. Many claims were identified in relation to the incidence of stoma-related hernia surgery.

Trial registration

Due to its retrospective and descriptive nature, the study was not registered in any registry.

A semi-Markov model comparing the lifetime cost-effectiveness of mesh prophylaxis to prevent parastomal hernia in patients undergoing end colostomy creation for rectal cancer

AIM

Parastomal hernia (PSH) is a common problem following colostomy. Using prophylactic mesh during end colostomy creation may reduce PSH incidence, but concerns exist regarding the optimal type of mesh, potential long-term complications, and cost-effectiveness of its use. We evaluated the cost-effectiveness of mesh prophylaxis to prevent PSH in patients undergoing end colostomy creation for rectal cancer.

METHODS

We developed a decision-analytical model, stratified by rectal cancer stages I-IV, to estimate the lifetime costs, quality-adjusted life-years (QALYs) and net monetary benefits (NMBs) of synthetic, biologic and no mesh from a UK NHS perspective. We pooled the mesh-related relative risks of PSH from 13 randomised controlled trials (RCTs) and superimposed these on the baseline (no mesh) risk from a population-based cohort. Uncertainty was assessed in sensitivity analyses.

RESULTS

Synthetic mesh was less costly and more effective than biologic and no mesh to prevent PSH for all rectal cancer stages. At the willingness-to-pay threshold of £20,000/QALY, the incremental NMBs (95% CI) ranged between £1,706 (£1,692 to £1,720) (stage I) and £684 (£678 to £690) (stage IV) for synthetic versus no mesh, and £2,038 (£1,997 to £2,079) (stage I) and £1,671 (£1,653 to £1,689) (stage IV) for synthetic versus biologic mesh. Synthetic mesh was more cost-effective than no mesh unless the relative risk of PSH was ≥0.95 for stages I-III and ≥0.93 for stage IV. [Correction added on 05 October 2021 after first online publication: The estimation of health outcomes (QALYs) for all three interventions evaluated (synthetic mesh; biologic mesh; no mesh) have been corrected in this version.] CONCLUSIONS: Synthetic mesh was the most cost-effective strategy to prevent the formation of PSH in patients after end colostomy for any rectal cancer stage; however, conclusions are dependent on which subset of RCTs are considered to provide the most robust evidence.

Time interval between rectal cancer resection and reintervention for anastomotic leakage and the impact of a defunctioning stoma: A Dutch population-based study

AIM

In the Netherlands, a selective policy of faecal diversion after rectal cancer surgery is generally applied. This study aimed to evaluate the timing, type, and short-term outcomes of reoperation for anastomotic leakage after primary rectal cancer resection stratified for a defunctioning stoma.

METHOD

Data of all patients who underwent primary rectal cancer surgery with primary anastomosis from 2013-2019 were extracted from the Dutch ColoRectal Audit. Primary outcomes were new stoma construction, mortality, ICU admission, prolonged hospital stay, and readmission.

RESULTS

In total, 10,772 rectal cancer patients who underwent surgery with primary anastomosis were included, of whom 46.6% received a primary defunctioning stoma. The reintervention rate for anastomotic leakage was 8.2% and 11.6% for patients with and without a defunctioning stoma (p < 0.001). Reintervention consisted of reoperation in 44.0% and 85.3% (p < 0.001), with a median time interval from primary resection to reoperation of seven days (IQR 4-14) vs. five days (IQR 3-13), respectively. In the presence of a defunctioning stoma, early reoperation (<5 days; n = 47) was associated with significantly more end-colostomy construction (51% vs. 33%) and ICU admission (66% vs. 38%) than late reoperation (≥5 days; n = 127). Without defunctioning stoma, early reoperation (n = 252) was associated with significantly higher mortality (4% vs. 1%), and more ICU admissions (52% vs.34%) than late reoperation (n = 302).

CONCLUSIONS

Early reoperations after rectal cancer resection are associated with worse outcomes reflected by a more frequent ICU admission in general, more colostomy construction, and higher mortality in patients with primary defunctioned and nondefunctioned anastomosis.

Use of prophylactic mesh during initial stoma creation to prevent parastomal herniation: a systematic review and meta-analysis of randomised controlled trials

AIM

Parastomal hernia (PSH) is a common complication following stoma creation. Previous reviews found mesh reinforcement during initial stoma creation beneficial in reducing PSH incidence. Since then, several multicentre randomised controlled trials (RCTs) produced widely ranging results rendering previous findings debatable. This current review assessed whether combining the latest larger multicentre RCTs would alter the previous findings.

METHODS

The Cochrane Library, MEDLINE and Embase were searched from the respective dates of inception until 15 January 2021. RCTs were included if they compared mesh with no mesh during initial stoma creation in adult patients to prevent PSH. Included RCTs were summarised narratively and meta-analysed to estimate the relative risk (RR) of PSH incidence (primary analysis), peristomal complications and PSH repair (secondary analyses). Several subgroup analyses were performed, including mesh type (synthetic/biologic), surgical technique (open/laparoscopic) and mesh position (sublay/intraperitoneal).

RESULTS

Thirteen RCTs were included in the primary meta-analysis (1070 patients); PSH incidence was reduced in patients with mesh compared with patients without mesh at maximal follow-up (RR = 0.54; 95% CI 0.39-0.77; I²  = 67%; P < 0.01). The number of PSH repairs was fewer in patients who had mesh (RR = 0.63; 0.35-1.14; I²  = 6%; P = 0.39), with no difference in peristomal complications (RR = 0.96; 0.55-1.70; I²  = 0%; P = 0.71), comparing with no mesh. Subgroup analyses suggested that placing synthetic mesh using an open sublay technique might be more beneficial.

CONCLUSIONS

Prophylactic mesh reinforcement during initial stoma creation reduces PSH incidence and potentially its repair, without an increase in peristomal complications. However, substantial heterogeneity among included RCTs limits confidence in the results.

Predicting life with a permanent end colostomy: A prospective study on function, bother and acceptance

AIM

The factors that influence a patient's experience of a colostomy are not known. The aim of this study was to characterise stoma function, stoma-related bother and acceptance among patients operated for rectal cancer and to investigate if there were any preoperative personal factors with predictive impact on long-term stoma-related bother.

METHODS

The QoLiRECT (Quality of Life in RECTal cancer) study is a prospective multicentre study of patients with rectal cancer. This was a subgroup analysis of patients with a permanent colostomy with a 2-year follow-up. Penalised regression models with shrinkage estimation were used to predict the 1-and 2-year bother using baseline data. The predictive value and the importance of the included variables were evaluated using bootstrap resampling techniques.

RESULTS

A total of 379 patients were included. Overall stoma acceptance was high and a majority of patients were not bothered by their stoma; 77% and 83% at 1 and 2 years, respectively. The subgroup of patients with stoma-related bother had a high prevalence of difficulties, especially fear of leakage, and a low stoma acceptance in daily life. Both clinical and personal factors were associated with stoma-related bother. The most important factors were quality of life and physical health, but the prediction accuracy was low.

CONCLUSIONS

Stoma-related bother was associated with overall stoma dysfunction. As stoma-related bother is a multifactorial problem, it was not possible to predict which patients will experience stoma-related bother. It is therefore of importance to prevent stoma-related symptoms and optimise stoma function to reduce long-term bother and increase stoma acceptance.

Prophylactic funnel mesh to prevent parastomal hernia in permanent end colostomy: A retrospective cohort study

AIM

This study assessed the impact of a prophylactic, 3D funnel-shaped intraperitoneal mesh on the rate of parastomal hernia after abdominoperineal rectum resection with permanent end colostomy.

METHODS

Data from 76 patients receiving permanent end colostomy after abdominoperineal rectum resection between 2013 and 2018 were collected retrospectively. Occurrences of parastomal hernia and reoperation rate due to parastomal hernia in patients with and without a prophylactic mesh were compared by univariate, multivariate, and propensity score-adjusted analyses.

RESULTS

Twenty-two (28.9%) of the 76 included patients received a prophylactic mesh. The mean follow-up was 39.3 ± 23.8 months. Mesh implantation reduced the incidence of parastomal hernia to 9.1% (n = 2) compared to 42.6% (n = 23) in patients without a prophylactic mesh. The propensity score-adjusted hazard ratio (HR) was 0.14 (95% confidence interval (CI): 0.04-0.48, p = 0.001). No reoperations due to parastomal hernia were needed in patients who received a prophylactic mesh, while nine patients without mesh (16.7%) required parastomal hernia repair (HR = 0.09, 95% CI: 0.00-1.76, p = 0.015). Mesh implantation was not associated with increased short-term morbidity (Clavien-Dindo grade > 2, 31.8% vs. 40.7%, p = 0.468) or 30-day mortality (4.5% vs. 3.8%, p = 1.000).

CONCLUSIONS

Prophylactic implantation of a 3D funnel-shaped intraperitoneal mesh is a safe and effective method to prevent parastomal hernia in patients requiring permanent end colostomy. Mesh placement significantly reduces reoperations due to parastomal hernia.

Permanent stoma rates after anterior resection for rectal cancer: risk prediction scoring using preoperative variables

BACKGROUND

A permanent stoma after anterior resection for rectal cancer is common. Preoperative counselling could be improved by providing individualized accurate prediction modelling.

METHODS

Patients who underwent anterior resection between 2007 and 2015 were identified from the Swedish Colorectal Cancer Registry. National Patient Registry data were added to determine presence of a stoma 2 years after surgery. A training set based on the years 2007-2013 was employed in an ensemble of prediction models. Judged by the area under the receiving operating characteristic curve (AUROC), data from the years 2014-2015 were used to evaluate the predictive ability of all models. The best performing model was subsequently implemented in typical clinical scenarios and in an online calculator to predict the permanent stoma risk.

RESULTS

Patients in the training set (n = 3512) and the test set (n = 1136) had similar permanent stoma rates (13.6 and 15.2 per cent). The logistic regression model with a forward/backward procedure was the most parsimonious among several similarly performing models (AUROC 0.67, 95 per cent c.i. 0.63 to 0.72). Key predictors included co-morbidity, local tumour category, presence of metastasis, neoadjuvant therapy, defunctioning stoma use, tumour height, and hospital volume; the interaction between age and metastasis was also predictive.

CONCLUSION

Using routinely available preoperative data, the stoma outcome at 2 years after anterior resection for rectal cancer can be predicted fairly accurately.

Cancer survivors' greatest challenges of living with an ostomy: findings from the Ostomy Self-Management Telehealth (OSMT) randomized trial

OBJECTIVES

An ostomy results in lifelong quality of life changes for a cancer survivor. We describe the greatest challenges reported from a randomized trial of cancer survivors with stomas (ostomies).

METHODS

Cancer survivors with ostomies participating in a multi-site randomized prospective trial of an Ostomy Self-Management Telehealth (OSMT) program versus usual care (UC) were surveyed at six months post accrual. An open-ended question requested greatest challenges after ostomy surgery. Quantitative descriptive and qualitative analyses were used to examine greatest challenges reported.

RESULTS

A total of 118 trial participants identified greatest challenges with 55 in the OSMT and 63 in the UC. Six conceptual domains were used to code comments-physical, psychological, social, and spiritual quality of life; ostomy-specific issues, and healthcare issues. The OSMT contributed 187 comments, and UC contributed 235 comments. Ostomy specific issues and social well-being had the most comments overall with UC contributing more comments in all domains except physical well-being. Word Clouds revealed post-operative and treatment-related issues and going out in public as the most common challenges in both groups. Word Clouds compared types of ostomies revealing bowel function challenges (colostomy group), difficulties going out in public (ileostomy group), and positive support (urostomy group).

CONCLUSIONS

Fewer challenges submitted by the OSMT group provide the beginning evidence of the OSMT program impact. Dominant challenges across both groups were social well-being and ostomy care. Challenges varied by type of ostomy. Findings support long-term care and support for all cancer survivors with ostomies.

TRIAL REGISTRATION

NCT02974634.

Sociodemographic characteristics and self-care management knowledge of patients with an ostomy

BACKGROUND

An increasing number of patients worldwide are living with an ostomy. Among them, self-care management skills and stoma self-care abilities are associated with better quality of life.

AIMS

To identify the sociodemographic and clinical characteristics of Italian ostomy patients and investigate their knowledge of stoma management.

METHODS

A questionnaire was used to gather the sociodemographic and clinical data of 433 adult patients. Participants responded to a nine-item survey assessing their knowledge of stoma management.

FINDINGS

Respondents reported having received extensive or adequate information in 64.4% of cases, and the remaining 35.6% reported receiving little or no information at any time. The health professional who imparted at least adequate information was a stoma nurse specialist in 32.1% of cases, usually during admission (24.0%) or before and during admission (19.6%).

CONCLUSION

This study demonstrated that most patients received adequate information regarding the ostomy.

Effects of a Self-Management Program for Patients With Colorectal Cancer and a Colostomy: A Nonrandomized Clinical Trial

PURPOSE

We constructed a self-management program for rectal cancer survivors with colostomies and evaluated the effect of the program on self-efficacy, self-management ability, and incidence of stomal and peristomal complications.

DESIGN

A prospective, nonrandomized clinical trial.

SUBJECTS AND SETTING

Participants were recruited from 4 proctology departments in a tertiary hospital in northeast China. Fifty-five were assigned to the intervention group and 56 were assigned to the control group; 26 were lost to follow-up. Therefore, data analysis was based on 43 participants in the intervention group and 42 in the control group.

METHODS

Control group patients received the standard care where guidance and stoma care manuals were given the day before hospital discharge, and regular telephone follow-up twice a month for 3 months. Participants in the experimental group received, in addition to standard care, a self-management program delivered via a multimedia messaging app initiated after discharge available over a 6-week period. Primary outcomes were self-efficacy and self-management ability; we also analyzed the incidence of stomal and peristomal complications as a secondary outcome. Between-groups outcomes were analyzed via a repeated-measures analysis of variance.

RESULTS

Analysis indicated intervention group participants had higher levels of self-efficacy and self-management of their colostomies than did control group participants. Analysis also revealed intervention group participants had a lower incidence of peristomal complications; no differences in the incidence of stomal complications were found.

CONCLUSIONS

Study findings suggest that use of the multimedia messaging app-based self-management program enhanced self-efficacy and self-management, while reducing the incidence of peristomal complications in rectal cancer survivors with colostomies.

Retroileal colorectal anastomosis after left-sided or transverse colectomy for advanced serous carcinoma of the ovary or uterus

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In advanced or recurrent ovarian and uterine cancer, the ability to achieve optimal cytoreduction is a prognostic factor.

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Colonic resections are commonly required to achieve minimal or no residual disease.

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The retroileal technique can be used to achieve complete gross resection in cytoreductive surgery for gynecologic malignancy.

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Lack of postoperative complications and acceptable time interval to return of bowel function suggest this technique is safe.

The ability to achieve complete or optimal cytoreduction in advanced or recurrent ovarian and uterine cancer is a well-established prognostic factor. Colonic resections are commonly required to achieve minimal or no residual disease. When multiple colonic resections are required there is a corresponding difficulty in obtaining sufficient colonic mobility to create tension-free anastomoses for restoration of gastrointestinal continuity; specifically, when a left hemicolectomy or a transverse colectomy is required in addition to a rectosigmoid resection, it may be difficult to achieve a tension-free colorectal anastomosis. We describe the use of retroileal routing of the colon to address this scenario in the context of gynecologic cancer debulking surgery. We report four cases in which the surgeon encountered limited colonic mobility after performing either a left hemicolectomy or a transverse colonic resection in addition to a rectosigmoid resection. In using a retroileal path to perform the colorectal anastomosis, we were able to achieve well-perfused and tension-free anastomoses. Complete gross resection was achieved in all four cases, with acceptable rates of perioperative complications.

Successful reversal of ostomy 13 years after Hartmann procedure in a patient with colon cancer: A case report

BACKGROUND

The Hartmann procedure is currently recognized as a common, safe, and feasible surgical procedure. However, its reversal rate is low, and the optimal timing for Hartmann reversal surgery is controversial.

CASE SUMMARY

A 65-year-old man came to our hospital with a complaint of an intestinal fistula next to the stoma. The patient had undergone a Hartmann procedure 13 years prior. We performed colonoscopy, computed tomography, and other diagnostics before successfully reversing the stoma.

CONCLUSION

Although the optimal time for Hartmann procedure reversal is controversial, time may ultimately not be a factor in the success of reversal.

Effect of FOCUS-PDCA procedure on improving self-care ability of patients undergoing colostomy for rectal câncer

OBJECTIVE

To investigate the effect of the FOCUS-PDCA procedure on the self-care ability of patients undergoing colostomy for rectal cancer.

METHOD

A nonrandomized controlled trial of 160 patients with rectal cancer undergoing colostomy. The control group received routine nursing intervention, and the observation group received the FOCUS-PDCA procedure. The self-care ability of the two groups was investigated 1 week and 1 month after surgery, and a comparative analysis was made between the groups.

RESULTS

One week after surgery, the self-care ability of rectal cancer patients with colostomy increased from 39.09 points before implementation of the FOCUS-PDCA procedure to 60.15 points after implementation; an increase of 21.06%. One month after surgery, the self-care ability increased from 61.50 points to 83.13 points after implementation of the FOCUS-PDCA procedure; an increase of 21.63%.

CONCLUSION

Application of the FOCUS-PDCA procedure improved the self-care ability of rectal cancer patients undergoing colostomy, improved their physical and mental health, reduced colostomy complications, and improved their quality of life. The results suggest that it is worth applying FOCUS-PDCA more widely.

Body image in colorectal cancer patients: A longitudinal study

OBJECTIVE

To assess changes in body image distress (BID) over time, identify factors associated with BID, and explore the mediating role of body image on the longitudinal association between stoma status (permanent stoma, temporary stoma, or nonstoma) and psychological distress in postoperative colorectal cancer (CRC) patients in China.

METHODS

Participants (N = 255) 1-2 weeks postsurgery completed self-report questionnaires assessing BID (Body Image Scale) and psychosocial distress (Distress Thermometer, Hospital Anxiety and Depression Scale); 212 (83%) completed 6-month follow-up surveys. Generalized estimating equations were used to identify factors associated with BID for longitudinal data analysis.

RESULTS

A total of 46.7% of participants reported BID at follow-up. Prevalence of BID and BID scores did not significantly change over time in the total sample. Body image scores decreased in patients whose temporary stoma was removed during follow-up (p < 0.05). Prevalence of BID decreased in nonstoma patients at follow-up (p < 0.05). There were significant decreases in the prevalence and scores of distress, anxiety, and depression between baseline and follow-up (p < 0.001). Stoma presence, later clinical stages, greater distress, anxiety, and depression were risk factors for poorer body image. Body image had partial mediating effects on the longitudinal association between stoma status and distress.

CONCLUSIONS

Our findings indicate that BID remains stable even as psychological distress decreases. BID should be addressed early postoperation to avoid persistent impairment in CRC patients.

Stoma-related complications: a report from the Stoma-Const randomized controlled trial

AIM

The impact of construction techniques on the development of stoma complications is partly undiscovered. The aim of this paper was to report and analyse the impact of the three surgical techniques in a randomized controlled trial Stoma-Const on stoma-related complications as well as identifying risk factors and patient-reported stoma function as a planned secondary analysis.

METHODS

This was a randomized, multicenter trial where all patients scheduled to receive an end colostomy were invited to participate. Patients were randomized to one of three techniques for stoma construction; cruciate fascial incision, circular incision or prophylactic mesh. Stoma complications were assessed by a surgeon and stoma care nurses within 1 year postoperatively.

RESULTS

Two hundred and nine patients were randomized. Patient demographics were similar in all three groups. Data on stoma-related complications were available for analysis in 201 patients. A total of 127 patients (63%) developed some type of stoma complication within 1 year after surgery. The risk ratio (95% CI) for stoma complications was 0.93 (0.73; 1.2) between cruciate vs. circular incision groups and 1.02 (0.78; 1.34) between cruciate vs. mesh groups. There were no statistically significant differences between the groups regarding parastomal hernia rate and no risk factors could be identified.

CONCLUSION

This randomized trial confirmed a high prevalence of stoma-related complications but could not identify an impact of surgical technique or identify modifiable risk factors for stoma-related complications.

Moderating Effect of Posttraumatic Growth on the Relationship Between Social Support and Quality of Life in Colorectal Cancer Patients With Ostomies

BACKGROUND

Little research has examined the moderating influence of posttraumatic growth (PTG) on the relationship between social support and quality of life.

OBJECTIVES

This study examined the relationship between social support and quality of life by the level of PTG in colorectal cancer patients with ostomies.

METHODS

Using a cross-sectional design, colorectal cancer patients with ostomies (n = 140) were recruited using convenience sampling. The City of Hope Quality of Life-Ostomy, the Multidimensional Scale of Social Support, and the Posttraumatic Growth Inventory measured quality of life, social support, and PTG, respectively.

RESULTS

Social support and PTG were positively related to psychological and social well-being. Higher social support was associated with better psychological and social well-being. Posttraumatic growth moderated the relationship between psychological and social well-being. At a low and moderate level of PTG, social support was more strongly associated with psychological and social well-being, whereas at high levels, this association was not significant.

CONCLUSIONS

Findings highlight the significance of social support to improve the quality of life for colorectal cancer patients with an ostomy, particularly those with low levels of PTG.

IMPLICATIONS FOR PRACTICE

Screening for patients' positive cognitive adaptations while living with an ostomy could identify those who might need further social support to improve their quality of life. Further, intensive social support programs might promote the quality of life for colorectal patients with an ostomy, which was found to be effective for those with low levels of PTG.

Mucosal Invasion, but Not Incomplete Excision, Has Negative Impact on Long-Term Survival in Patients With Extramammary Paget's Disease

Background

Extramammary Paget’s disease (EMPD) sometimes spreads from the skin to mucosal areas, and curative surgical excision of these areas is challenging. The aim of this study is to analyze the impact of mucosal involvement and surgical treatment on the survival of patients with EMPD.

Methods

We conducted a retrospective review of 217 patients with EMPD. We also assessed the associations between tumor involvement in boundary areas (anal canal, external urethral meatus, vaginal introitus), prognostic factors, and survival in 198 patients treated with curative surgery.

Results

Of 217 patients, 75 (34.6%) had mucosal boundary area involvement. Lesions in these areas were associated with frequent lymphovascular invasion (p = 0.042), lymph node metastasis (p = 0.0002), incomplete excision (p < 0.0001), and locoregional recurrence (p < 0.0001). Boundary area involvement was an independent prognostic factor associated with disease-specific survival, per multivariate analysis (HR: 11.87, p = 0.027). Incomplete excision was not significantly correlated with disease-specific survival (HR: 1.05, p = 0.96).

Conclusion

Boundary area tumor involvement was a major risk factor for incomplete excision, local recurrence, and poor survival outcomes. However, incomplete removal of primary tumors was not significantly associated with poor prognosis. A less invasive surgical approach for preserving anogenital and urinary functions may be acceptable as the first-line treatment for resectable EMPD.

Can transanal endoscopic microsurgery effectively treat T1 or T2 rectal cancer?A systematic review and meta-analysis

AIM

We aimed to compare the safety and oncological outcomes of transanal endoscopic microsurgery (TEM) and radical surgery (RS) for patients with T1 or T2 rectal cancer.

METHOD

We searched Pubmed, Embase, Cochrane Library databases for relevant studies comparing TEM with RS in rectal cancer published until April 2020. We focused on safety and oncological outcomes.

RESULTS

This meta-analysis included 3526 patients from 12 studies. Compared with RS, TEM had a shorter operative time (weighted mean difference [WMD] -110.02, 95% confidence interval [CI]: 143.98, -76.06), less intraoperative blood loss (WMD -493.63, 95% CI: 772.66, -214.59), lower perioperative morality (risk ratio [RR] 0.25, 95% CI: 0.06, 0.99), and fewer postoperative surgical complications (RR 0.23, 95% CI: 0.11,0.45). TEM was associated with more patients with a positive margin or a doubtfully complete margin than RS (RR 7.36, 95% CI: 3.66, 14.78). TEM was associated with higher local recurrence (RR 2.63, 95% CI: 1.60, 4.31) and overall recurrence (RR 1.60, 95% CI: 1.09, 2.36). TEM had a negative effect on 5-year overall survival (hazard ratio [HR] 1.51, 95% CI: 1.16, 1.96), especially in the T2 without neoadjuvant therapy (NAT) subgroup (HR 2.02, 95% CI: 1.32, 3.09), but in the subgroups of T1 or T2 with NAT before TEM, TEM did not yield a significantly lower overall survival than RS.

CONCLUSION

TEM seems appropriate for T1 rectal cancer with favourable histopathology. For patients with T2 rectal cancer, NAT before TEM may contribute to achieving oncological outcomes equivalent to that achieved with RS.

How is quality of life defined and assessed in published research?

PURPOSE

To ensure clarity in communication in the field of quality of life research, and meaningful use of 'quality of life' as a research outcome, requires two things: awareness that there is a range of conceptualisations and definitions of 'quality of life', and for any particular study, consistency between the way the term is defined and operationalised in that setting. We aimed to identify how frequently research articles described (HR)QOL as a construct of interest, how frequently they referred to "patient-reported outcome (measures)", which patient-reported outcome measures were used, and how (HR)QOL was defined.

METHODS

We reviewed all Quality of Life Research articles published in 2017 and recorded whether they described health-related quality of life or quality of life as constructs of interest, and/or mentioned the term(s) patient-reported outcome (measures). We recorded definitions of (HR)QOL stated and questionnaires used. We classified articles according to constructs assessed and instruments used, and examined whether articles citing the same definition used the same questionnaires.

RESULTS

We reviewed 300 articles; 65% stated that (HR)QOL was a construct of interest, 27% mentioned patient-reported outcome (measures), and 20% mentioned neither. Fifty-one articles provided definitions of (HR)QOL, citing 66 sources, with 11 definitions cited more than once. PROMIS, SF, EQ-5D, and EORTC instruments were the most commonly used. The only definition and questionnaire consistently used together were the WHO definitions/instruments.

CONCLUSION

These results demonstrate considerable heterogeneity in the definition and operationalisation of (HR)QOL, between and within studies. This limits meaningful interpretation of (HR)QOL scores and complicates literature searches. Investigators should define constructs and select instruments aligned with their definitions.

Permanent stoma: a quality outcome in treatment of rectal cancer and its impact on length of stay

BACKGROUND

This study aimed to identify socioeconomic predictors of permanent stoma in rectal cancer treatment and examine its association with length of stay at the treatment facility.

METHODS

Rectal cancer patients who underwent elective surgery between January 2015 and December 2018 were identified from the Agency for Health Care Administration Florida Hospital Inpatient Discharge Dataset. Multivariate regression models were utilized to identify demographic and socioeconomic factors associated with receiving a permanent stoma as well as the associated length of stay of these patients.

RESULTS

Of 2630 rectal cancer patients who underwent surgery for rectal cancer, 21% had a permanent stoma. The odds of receiving permanent stoma increased with higher Elixhauser score, metastatic disease, advanced age, having open surgery, residence in Southwest Florida, and having Medicaid insurance or no insurance/self-payers (p < 0.05). Patients with a permanent stoma had a significantly extended stay after surgery (p < 0.001).

CONCLUSIONS

Patients with a permanent stoma following cancer resection were more likely to have open surgery, had more comorbidities, and had a longer length of stay. Having permanent stoma was higher in patients living in South West Florida, patients with Medicaid insurance, and in the uninsured. Additionally, the payer type significantly affected the length of stay.

Psychometric Properties of New Subscales of the Ostomy Adjustment Scale: A Cross-Sectional Study

BACKGROUND

The Ostomy Adjustment Scale (OAS), which consists of an overall sum score along with 34 single-item scores, has been frequently used to measure self-reported adjustment to life with an ostomy. However, it is unknown whether the OAS can be divided into meaningful thematic subscales that may make it easier to administer and to apply in a clinical feedback system.

PURPOSE

The purpose of this study was to specify thematic OAS subscales and evaluate their psychometric properties.

PATIENTS AND METHODS

A cross-sectional study was conducted with 302 patients across Norway having colostomy, ileostomy, or urostomy. The OAS items were divided into different subscales by expert nurses and patients based on clinical and theoretical considerations. The overall structural validity of this analysis of the OAS was examined using robust confirmatory factor analysis. We evaluated the overall goodness of fit using the root mean square error of approximation (RMSEA), the comparative fit index (CFI) and the Tucker-Lewis index (TLI). Factor loadings from the confirmatory factor analysis were used to calculate composite reliability values for the new OAS scales.

RESULTS

The OAS was divided into seven subscales. The overall structure validity was acceptable with RMSEA = 0.053 (90% CI, 0.045-0.060), CFI = 0.913 and TLI = 0.904. The composite reliability values of all scales were >0.70.

CONCLUSIONS

The OAS can be divided into seven clinically meaningful subscales with acceptable psychometric properties.

TRIAL REGISTER

ClinicalTrials.gov Registration Number: NCT03841071. Date 18. February 2019 retrospectively registered.

A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival

PURPOSE

Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach.

METHODS

This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures.

RESULTS

A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively.

CONCLUSION

Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Immediate postoperative experiences before discharge among patients with rectal cancer and a permanent colostomy: A qualitative study

PURPOSE

Patients with rectal cancer with a permanent colostomy often have issues in physical, psychological and social domains. Since discharge is an important transition period, the patient experience at that time is worthy of attention. The aim of this study was to explore the immediate postoperative experiences before discharge among patients with rectal cancer and a permanent colostomy in China.

METHODS

A qualitative design was used. Semi-structured interviews were conducted with 18 patients newly living with colostomy in China, who were asked open-ended questions about their postoperative experience. The thematic analysis approach was used to analyze the data.

RESULTS

Four themes and twelve sub-themes were identified from the interviews: (1) psychological reactions (stoma self-acceptance, negative emotion and social isolation), (2) daily life concern (daily life misunderstandings, sexual life compromise and work restriction), (3) stoma care consideration (strong stoma self-care willingness, decreased stoma self-care confidence and access to high-quality stoma care), and (4) support from others (enterostomal nurses, family members and stoma friends).

CONCLUSION

Colostomy patients experience various obstacles in physiological, psychological, and societal aspect. Nurses should provide effective discharge guidance to correct misunderstandings about the stoma, refer patients to psychological care, and promote transitional care.

Delayed Surgery after Neoadjuvant Treatment for Rectal Cancer Does Not Lead to Impaired Quality of Life, Worry for Cancer, or Regret

Non operative management of complete clinical responders after neoadjuvant treatment for rectal cancer enjoys an increasing popularity because of the increased functional outcome results. Even a near complete response can evolve in a cCR, and therefore further delaying response assessment is accepted. However, up to 40% of patients will develop a regrowth and will eventually require delayed surgery. It is presently unknown if and to what extent quality of life of these patients is affected, compared to patients who undergo immediate surgery. Between January 2015-May 2020, 200 patients were treated with neoadjuvant therapy of whom 94 received TME surgery. Fifty-one (59%) of 87 alive patients returned the questionnaires: 33 patients who underwent immediate and 18 patients who underwent delayed surgery. Quality of life was measured through the QLQ-C30, QLQ-CR29, and Cancer Worry Scale questionnaires. Regret to participate in repeated response assessment protocol was assessed through the Decision Regret Scale. Exploratory factor analysis (EFA) and a 'known groups comparison' was performed to assess QLQ questionnaires validity in this sample. Higher mean physical function scores (89.2 vs. 77.6, p = 0.03) were observed in the immediate surgery group, which lost significance after correction for operation type (p = 0.25). Arousal for men was higher in the delayed surgery group (20.0 vs. 57.1, p = 0.02). There were no differences between surgical groups for the other questionnaire items. Worry for cancer was lower in the delayed surgery group (10.8 vs. 14.0, p = 0.21). Regret was very low (12-16%). EFA reproduced most QLQ C-30 and CR29 subscales with good internal consistency. Quality of life is not impaired in patients undergoing delayed TME surgery after neoadjuvant treatment for rectal cancer. Moreover, there is very low regret and no increase in worry for cancer. Therefore, from a quality of life perspective, this study supports a repeated response assessment strategy after CRTx for rectal carcinoma to identify all complete responders.

Complete intersphincteric longitudinal muscle excision May Be key to reducing local recurrence during intersphincteric resection

BACKGROUND

Although total mesorectal excision (TME) is regarded as a standard procedure for rectal cancer, technical definition and evaluation method have not yet been investigated for intersphincteric resection (ISR). This study was performed to introduce a complete ISR procedure, and to assess whether total intersphincteric longitudinal muscle excision (TILME) facilitated the completeness of ISR and reduced recurrence.

METHODS

A total of 1080 patients with rectal adenocarcinoma who underwent robot-assisted low anterior resection (LAR) over 10 years were consecutively enrolled. Propensity-score matching of the two LAR groups (ISR vs LAR group, 1:1) and three ISR subgroups (partial vs subtotal vs total ISR subgroup, 2:2:1) was performed by strict adjustment of baseline characteristics. Archived specimens and video-/photo-records were reevaluated to examine completeness of TILME.

RESULTS

Complete-TILME was performed in 84.5% of patients who underwent ISR. Multivariate analysis showed that incomplete-TILME was the only parameter independently associated with increased 5-year cumulative local recurrence (odds ratio = 23.385; 95% confidence interval = 1.492-366.421; p = 0.03), and that incomplete-TILME was independently associated with adipose tissue surrounding the intersphincteric longitudinal muscle, coloanal anastomosis, and total ISR (p < 0.001-0.05). Although mean incontinence scores and anorectal manometry deteriorated to some degree 12-24 months after surgery in all patients, they remained acceptable. The 5-year cumulative DFS (74.1% vs 60%, p = 0.18) and OS (85.9% vs 70%, p = 0.10) rates tended to be higher in patients with complete than incomplete-TILME.

CONCLUSIONS

The completeness of TILME appears to be an independent indicator of complete ISR, reducing local recurrence following lower rectal cancer surgery.

Coping Processes of Patients with Ostomies in South Korea: A Focus Group Study

Despite the adverse effects of negative coping after receiving a stoma, there is a lack of information on how patients cope with ostomies and on their families' experiences throughout the coping process. We aimed to explore the coping experiences of individuals with ostomies throughout their illness, applying the Corbin and Strauss Chronic Illness Trajectory Framework, using exploratory qualitative methods involving focus group interviews. Purposive sampling was utilized to recruit 19 participants (split across three groups) through an ostomy association in South Korea. Two focus group interviews were separately conducted from March through to May 2017 until data saturation was achieved. Using qualitative content analysis, we analyzed the transcribed interviews and identified words and themes to interpret the results. The coping experiences of patients with ostomies were expressed through three interrelated themes: struggling and suffering, learning how to live with ostomy, and living with ostomy. We found gender differences in spousal support and a struggle among older patients regarding social coping. The themes identified suggest that gender should be considered when designing interventions to help patients cope with ostomies.

Quality of life in patients with resectable rectal cancer during the first 24 months following diagnosis

AIM

An increasing number of patients survive rectal cancer, resulting in more patients living with the side-effects of the treatment. Exploring quality of life before and after treatment enables follow-up and additional treatment to be adjusted to the patient's needs. The aim of the study was to describe the quality of life during the 24 months following diagnosis and to identify risk factors for poor quality of life.

METHOD

This is a prospective cohort study of patients with rectal cancer followed up by extensive questionnaires. Patients from 16 surgical departments in Denmark and Sweden from 2012 to 2015 were included. The self-assessed quality of life was measured with a seven-point Likert scale.

RESULTS

A total of 1110 patients treated with curative intent were included, and the response rate at the 24-month follow-up was 71%. Patients with rectal cancer assessed their quality of life before start of treatment as poorer than that of a reference population. At the 12- and 24-month follow-up, the quality of life on group level had recovered to the same level as for the reference population. Risk factors for poor quality of life included bother with urinary, bowel and stoma function. A reference population was used for comparison.

CONCLUSION

The quality of life of patients with resectable rectal cancer recovered to levels comparable to a reference population 12 and 24 months after diagnosis. Our results indicate that the urinary, bowel and stoma function has an impact on quality of life.

Efficacy of pelvic floor rehabilitation for bowel dysfunction after anterior resection for colorectal cancer: a systematic review

PURPOSE

Bowel dysfunction is common after anterior resection for colorectal cancer (CRC). Pelvic floor rehabilitation (PFR) may improve functional outcomes after surgery. This review aimed to evaluate the efficacy of PFR for patients with bowel symptoms after anterior resection.

METHODS

MEDLINE, CINHAL, PUBMED, EMBASE, Scopus, PsycINFO, Web of Science, PEDRO and Cochrane Library were searched from inception to June 2019. A final search was performed on 11 July 2020. Randomised controlled trials (RCTs), cohort studies, case-control studies and case series of bowel dysfunction after CRC surgery and PFR were eligible for review. Outcome measures were bowel function changes measured by patient-reported outcomes and manometric measurement. Risk of bias assessments using Methodological Index for Non-Randomized Studies (MINORS) tool and Newcastle Ottawa Scale (NOS) were conducted.

RESULTS

Eleven trials met eligibility criteria: four retrospective studies and seven prospective, non-randomised controlled studies. A total of 516 participants were included, of which 455 received PFR. Functional outcomes were measured by bowel functional outcome questionnaires, patient diary, anorectal manometry and three studies measured quality of life. Faecal incontinence was improved in seven studies, and bowel frequency also decreased in five studies. The mean MINORS score was 10 (8-13) out of 16 in non-comparative groups and 18 (16-22) out of 24 in comparative groups; the NOS was 4.2 (3-7) out of 9. The overall risk of bias was high in most studies.

CONCLUSIONS

PFR appears to be beneficial for improving bowel function after anterior resection for CRC. However, the studies included had methodological limitations, so further investigation on the effectiveness of PFR is warranted.

Quality of Life and Its Influencing Factors Among Chinese Patients With Permanent Colostomy in the Early Postoperative Stage: A Longitudinal Study

BACKGROUND

Colorectal cancer is one of the most common cancers worldwide. Although colostomies are necessary for disease treatment, they unavoidably affect patient quality of life (QOL), especially in the early postoperative stage.

OBJECTIVE

The aim of this study was to investigate the dynamic changes and factors influencing QOL among Chinese patients with permanent colostomy.

METHODS

We investigated 74 patients before discharge and at 1 and 3 months after discharge. Instruments included the Quality of Life Questionnaire for People With Ostomy-Chinese version, Stoma Self-efficacy Scale, Stoma Self-care Scale-Early Stage Version, and a demographic and stoma-related information questionnaire.

RESULTS

The average QOL increased significantly after discharge (P < .01). Multivariate linear regression showed that the influencing factor of QOL was self-efficacy (before discharge, explained 22.9% of the variance); self-efficacy, truth-telling, average time of stoma care, communicating with friends with colostomy, and family relationship (1 month after discharge, explained 48.8% of the variance); and self-efficacy, body image loss, and participating in activities of patients with colostomy (3 months after discharge, explained 85.2% of the variance).

CONCLUSIONS

Clinicians need to give attention to improving the QOL of colostomy patients especially 1 month after discharge. Interventions aimed at improving self-efficacy, preoperative education regarding the surgery, colostomy care ability, family relationship, stoma self-acceptance, and involvement in activities of friends with colostomy should be considered to improve QOL among Chinese patients in this setting.

IMPLICATIONS FOR PRACTICE

Transitional care should be provided for colostomy patients especially 1 month after discharge. Interventions should focus on enhancing self-efficacy, stoma self-management, and social-environmental support.

HALT (Hernia Active Living Trial): protocol for a feasibility study of a randomised controlled trial of a physical activity intervention to improve quality of life in people with bowel stoma with a bulge/parastomal hernia

BACKGROUND

Parastomal hernia (PSH) can be repaired surgically, but results to date have been disappointing, with reported recurrence rates of 30 to 76%. Other types of intervention are therefore needed to improve the quality of life of people with PSH. One potential intervention is physical activity. We hypothesise that the intervention will increase core activation and control across the abdominal wall at a site of potential weakness and thus reduce the risk of PSH progression. Increases in physical activity will improve body image and quality of life (QoL).

METHODS

Subjects and sampleThere were approximately 20 adults with a bowel stoma and PSH. People with previous PSH repair will be excluded as well as people who already do core training.Study designThis is a feasibility study of a randomised controlled trial with 2 months follow-up, in 2 sites using mixed methods. Stage 1 involves intervention development and in stage 2, intervention and trial parameters will be assessed.InterventionA theoretically informed physical activity intervention was done, targeting people with PSH.Main outcome of feasibility studyThe main outcome is the decision by an independent Study Steering Committee whether to proceed to a full randomised controlled trial of the intervention.Other outcomesWe will evaluate 4 intervention parameters-fidelity, adherence, acceptability and safety and 3 trial parameters (eligible patients' consent rate, acceptability of study design and data availability rates for following endpoints): I.Diagnosis and classification of PSHII.Muscle activationIII.Body composition (BMI, waist circumference)IV.Patient reported outcomes: QoL, body image and physical functioningV.Physical activity;VI.Psychological determinants of physical activityOther dataIncluded are other data such as interviews with all participants about the intervention and trial procedures.Data analysis and statistical powerAs this is a feasibility study, the quantitative data will be analysed using descriptive statistics. Audio-recorded qualitative data from interviews will be transcribed verbatim and analysed thematically.

DISCUSSION

The feasibility and acceptability of key intervention and trial parameters will be used to decide whether to proceed to a full trial of the intervention, which aims to improve body image, quality of life and PSH progression.

TRIAL REGISTRATION

ISRCTN15207595.

Prevalence and severity of long-term physical, emotional, and cognitive fatigue across 15 different cancer entities

Background

Fatigue prevalence and severity have been assessed in a variety of studies, yet, not in a standardized way, and predominantly in breast cancer patients. Systematic, comparative investigations across a broad range of cancer entities are lacking.

Methods

The FiX study systematically enrolled 2244 cancer patients across 15 entities approximately 2 years after diagnosis. Fatigue was assessed with the multidimensional EORTC QLQ‐FA12 questionnaire. Physical, emotional, cognitive, and total fatigue were compared across entities and with normative values of the general population. Differences in patients' characteristics and cancer therapy between entities were taken into account using analyses of covariance models.

Results

Across all entities, mean physical fatigue levels were significantly higher than age‐ and sex‐matched means of the general population for all cancer entities (all Bonferroni‐Holm adjusted P < .01). For most entities also emotional and cognitive fatigue levels were significantly higher than normative values. Age‐ and sex‐standardized physical fatigue prevalence ranged from 31.8% among prostate to 51.7% among liver cancer patients. Differences between entities could not be fully explained by sex, age, BMI, or cancer therapy. Adjusted for these factors, mean physical fatigue was higher for stomach (P = .0004), lung (P = .034), kidney (P = .0011), pancreas (P = .081), and endometrium (P = .022) compared to breast cancer patients. Adjusted means of emotional fatigue were also lowest in breast cancer patients and significantly higher in stomach (P = .0047), bladder (P = .0036), and rectal (P = .0020) cancer patients.

Conclusions

Physical, emotional, and cognitive fatigue is prevalent in all 15 investigated cancer entities even 2 years after diagnosis. Fatigue in breast cancer patients, the so‐far most studied group, is in the lowest range among all entities, suggesting that the extent of fatigue is still insufficiently determined. Entity‐specific problems might need to be considered in the treatment of fatigue.

Quality of life in colostomy patients practicing colonic irrigation: An observational study

AIMS OF THE STUDY

The presence of colostomy has a major impact on quality of life that could potentially be improved by performing colonic irrigation (CI), yet few studies have assessed the impact of this technique on quality of life. The aim of this study was to assess the quality of life between two groups of patients having a colostomy; those practicing CI vs those not practicing CI.

PATIENTS AND METHODS

The French Federation of Ostomy (FFO) members were evaluated by a self-questionnaire assessing their experience of CI. Quality of life as assessed by the Stoma-QOL questionnaire was compared between patients practicing CI or not.

RESULTS

In total 752 patients were eligible for the study. The median age was 75 years, and 47.26% were men. The median duration between stoma surgery and questionnaire completion was 12.3 years. Forty-one percent of the patients practiced CI. The median quality of life score was significantly higher for the patients practicing the CI: (69.26 vs 58.33, P<0.001). In multivariable analysis, the risk factors for not performing CI were age, obesity, the presence of colostomy for less than six years, and a non-oncologic indication for operation.

CONCLUSIONS

CI appeared to improve the quality of life of patients with colostomy. This care is a therapeutic education issue and should be proposed to all patients. Supervision by the enterostomal therapy nurse is recommended especially for patients with a high risk of failure.