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Lahnaoui O, Essangri H, El Bahaoui N, Majbar MA, Benkabbou A, Mohsine R, Souadka A. From burden to relief: The economic and quality-of-life advantages of pseudo continent perineal colostomy in ultra-low rectal cancer patients. J Surg Oncol 2024; 129:297-307. [PMID: 37849420 DOI: 10.1002/jso.27484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023]
Abstract
BACKGROUND AND OBJECTIVE Pseudo Continent Perineal Colostomy (PCPC) is an alternative technique to left iliac colostomy (LIC) after abdominoperineal resection for ultra low rectal cancer (ULRC). It allows placing the stoma in the perineum to preserve patients' body image. However, concerns about its impact on quality of life and management costs have limited its adoption. We aimed to compare the early outcomes and financial burden of PCPC and LIC in ULRC patients in Morocco, a low-middle-income country. METHODS From January 2018 to December 2019, all patients who underwent abdomino-perineal resection (APR) with LIC or PCPC were prospectively enrolled. For each patient, baseline characteristics, and in hospital and 90 days morbidity with a focus on perineal complications were reported. Quality of life (QOL) was assessed using the validated EORTC-C30 and CR29 questionnaires. Financial burden to patients was reported using declarative out-of-pocket costs (OOPC) analysis. RESULTS Among 49 patients who underwent APR, 33 received PCPC and 16 received definitive LIC. Similar rates of early perineal complications were observed between the two groups (p = 0.49). Readmission rate at POD90 was higher in the LIC-group due to perineal sepsis (p = 0.09). QOL analysis at 6 months revealed that patients with PCPC had a higher global health status (p = 0.006), a better physical functioning and reported fewer symptoms of flatulence and fecal incontinence (p = 0.001). Patients with a LIC reported more financial difficulties with higher median OOPC of stoma management up to €23 versus €0 per month for PCPC (p = 0.0024). PCPC was the only predictive factor of improved patient reported outcomes. CONCLUSIONS PCPC is a cost-effective alternative to the standard definitive colostomy without alteration of the QOL or additional perineal complications during the first 6 months following the surgery. These findings may help convince surgeons to offer this option to patients refusing definitive LIC.
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Affiliation(s)
- Oumayma Lahnaoui
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
- Equipe de recherche en Oncologie Translationnelle (EROT), Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Hajar Essangri
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
| | - Nezha El Bahaoui
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
| | - Mohammed Anass Majbar
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
- Equipe de recherche en Oncologie Translationnelle (EROT), Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
- Equipe de recherche en Oncologie Translationnelle (EROT), Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Raouf Mohsine
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
- Equipe de recherche en Oncologie Translationnelle (EROT), Faculty of Medicine and Pharmacy, Rabat, Morocco
| | - Amine Souadka
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Mohammed Vth Unverisity, Rabat, Morocco
- Equipe de recherche en Oncologie Translationnelle (EROT), Faculty of Medicine and Pharmacy, Rabat, Morocco
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Essangri H, Majbar MA, Benkabbou A, Amrani L, Mohsine R, Souadka A. Transcultural adaptation and validation of the Moroccan Arabic dialect version of the Wexner incontinence score in patients with low anterior resection syndrome after rectal surgery. Surgery 2021; 170:47-52. [PMID: 33674127 DOI: 10.1016/j.surg.2021.01.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/17/2021] [Accepted: 01/21/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bowel dysfunction symptoms such as stool clustering, urgency, incomplete voiding, and fecal incontinence are frequent after colorectal surgery and known as the low anterior resection syndrome. The Wexner score is the most widely used tool for fecal incontinence assessment. We aimed to translate and test the psychometric properties of the Moroccan Arabic dialect version of the Wexner questionnaire in patients with low anterior resection syndrome after rectal surgery. METHODS The Wexner questionnaire was translated to Moroccan Arabic and administered to a group of 158 patients, among which a subgroup of 43 patients took the test for a second time to examine test-retest reliability. Cronbach alpha coefficient was used to determine internal consistency and correlation, and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 and the low anterior resection syndrome questionnaires were assessed for convergent validity. Discriminant validity was demonstrated through the Wexner score ability to detect differences based on the patients' different clinical and pathological characteristics. RESULTS One hundred and fifty-eight patients completed the Moroccan Arabic dialect version of the Wexner score, which showed an excellent internal consistency with a Cronbach alpha score of 0.91. Test-retest reliability was established by a Bland-Altman plot with 95% limits of agreement. The score showed positive correlation to the low anterior resection syndrome score (r = 0.748; P < .001) and the European Organisation for the Research and Treatment of Cancer Quality of Life C30 diarrhea symptom scale (r = 0.519; P < .001). A negative correlation was also demonstrated for each one of the 5 European Organisation for the Research and Treatment of Cancer quality of life C30 functional scales, namely physical functioning (r = -0.217 ; P = .006), role functioning (r = -0.267; P = .001), emotional functioning (r = -0.266; P = .001), cognitive functioning (r = -0.283; P < .001), and social functioning (r = -0,283; P < .001). The Wexner score differed between patients according to tumor location, chemoradiotherapy, type of mesorectal excision, and anastomosis. CONCLUSION The Moroccan Arabic dialect version of the Wexner score shows good psychometric properties and can be used for fecal incontinence assessment, particularly in colorectal cancer patients.
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Affiliation(s)
- Hajar Essangri
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Mohammed Anass Majbar
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Laila Amrani
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Raouf Mohsine
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco
| | - Amine Souadka
- Surgical Oncology Department, National Institute of Oncology, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University in Rabat, Morocco.
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Souadka A, Majbar MA, Essangri H, Amrani L, Benkabbou A, Mohsine R, Souadka A. Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma. J Surg Oncol 2020; 122:753-759. [PMID: 32563198 DOI: 10.1002/jso.26074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 06/08/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Pseudocontinent-perineal colostomy (PCPC) following abdominoperineal resection (APR) is a promising technique associated with good quality of life. This study evaluates over time the functional results after PCPC using the Kirwan score. METHODS All PCPC patients operated on from January 2001 to January 2016 were followed with their functional results assessed at four checkpoints. A/B Kirwan scores and a 48 to 72 hours colonic irrigation rhythm were considered "good" and "convenient" and their overall variations over time were assessed by means of Cochran's Q test corrected by Bonferroni post hoc test. RESULTS Fifty-seven eligible patients were included in the study with 33 (58%) women. We noted a significant difference in both Kirwan score and colic irrigation rhythm during the four checkpoints in follow-up with Q(1) = 85.01 and Q(2) = 69. 86. By the fourth checkpoint, 86% of patients had a Kirwan score of A/B. Concerning the rhythm of colonic irrigation, there was a significant improvement between 6 months and other checkpoints. In the second year, 63% of patients reduced their colonic irrigation rhythm. CONCLUSIONS The functional results of PCPC after APR improve and stabilize from 6 months to 1 year after surgery thus making PCPC a good alternative that surgeons can present to their patients.
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Affiliation(s)
- Amine Souadka
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Mohammed Anass Majbar
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Hajar Essangri
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Laila Amrani
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Amine Benkabbou
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Raouf Mohsine
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
| | - Abdelilah Souadka
- Surgical Oncology Department, Medical School, National Institute of Oncology, Mohammed V University, Rabat, Morocco
- Surgical Department, Al Azhar Oncological Center, Rabat, Morocco
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A Systematic Review and Meta-analysis on Omentoplasty for the Management of Abdominoperineal Defects in Patients Treated for Cancer. Ann Surg 2020; 271:654-662. [DOI: 10.1097/sla.0000000000003266] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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What is the impact of neoadjuvant chemoradiation on outcomes in gastro-intestinal cancer? J Visc Surg 2017; 154:185-195. [DOI: 10.1016/j.jviscsurg.2017.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Combined NOTES total mesorectal excision and single-incision laparoscopy principles for conservative proctectomy: a single-centre study. Tech Coloproctol 2016; 21:43-51. [DOI: 10.1007/s10151-016-1568-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 10/15/2016] [Indexed: 01/17/2023]
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Perineal colostomy may be the solution of phantom rectum syndrome following abdominoperineal resection for rectal cancer. J Wound Ostomy Continence Nurs 2015; 41:15-6. [PMID: 24378688 DOI: 10.1097/01.won.0000437014.90808.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Inglin RA, Eberli D, Brügger LE, Sulser T, Williams NS, Candinas D. Current aspects and future prospects of total anorectal reconstruction--a critical and comprehensive review of the literature. Int J Colorectal Dis 2015; 30:293-302. [PMID: 25403563 DOI: 10.1007/s00384-014-2065-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed. METHODS A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis. RESULTS Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy. CONCLUSIONS Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.
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Affiliation(s)
- Roman A Inglin
- Department of Visceral Surgery and Medicine, Bern University Hospital, University of Bern, Freiburgstrasse 10, CH-3010, Bern, Switzerland,
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Risk factors of poor functional results at 1-year after pseudocontinent perineal colostomy for ultralow rectal adenocarcinoma. Dis Colon Rectum 2013; 56:1143-8. [PMID: 24022531 DOI: 10.1097/dcr.0b013e31829f8cd5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Pseudocontinent perineal colostomy is one of the techniques that helps recover the body image of patients undergoing abdominoperineal resection. This technique is rarely used internationally given its unknown functional results. OBJECTIVE The study aimed to evaluate 1-year functional outcomes of perineal pseudocontinent colostomy and to determine the risk factors for "poor" functional results. DESIGN This study is a retrospective interventional case series. SETTINGS This study was conducted at a tertiary care university hospital and oncological center in Morocco. PATIENTS From January 1993 to December 2007, 149 patients underwent pseudocontinent perineal colostomy after abdominoperineal resection for low rectal adenocarcinoma. INTERVENTION Pseudocontinent perineal colostomy was performed with the use of the Schmidt technique after abdominoperineal resection. MAIN OUTCOME MEASURES One-year functional results were assessed according to the Kirwan classification system. Functional results were considered "poor" when the Kirwan score was C, D, or E. Univariable and multivariable analyses were used to evaluate the impact of age, sex, type of surgery, irrigation frequency, palpable muscular ring, concomitant chemoradiotherapy, stage, and perineal complications on functional results. RESULTS One hundred forty-six patients were analyzed. According to the Kirwan system, the scores showed that 100 (68.5%) patients had "good" continence results (stage A-B) and 46 (31.5%) patients had altered functional results (stage C-D-E). With the exception of pelvic recurrences, no conversions from a perineal colostomy to an abdominal colostomy were performed for dissatisfactory functional results. In multivariate analysis, the only independent predictive factors of poor functional results were the occurrence of perineal complications (OR, 3.923; 95% CI, 1.461-10.35; p = 0.007) and extended resection (OR, 3.03; 95% CI, 1.183-7.750; p = 0.021) LIMITATION OF THE STUDY:: This study is an observational retrospective study on selected patients (mainly a young population). CONCLUSIONS This study showed that perineal complications and extended resection are associated with poor functional results after pseudocontinent perineal colostomy. These data can help clinicians to better inform patients about the outcomes of this technique and to assist them in choosing the right reconstruction technique after abdominoperineal resection.
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