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

Ostomy Care Nurses' Knowledge and Practice Related to Prevention and Management of Parastomal Hernias in Adults: A Nationwide Survey of UK Stoma Care Nurses

PURPOSE

The purpose of this study was to describe the knowledge and practices of ostomy care nurses related to the United Kingdom's Association of Stoma Care Nurses (ASCN) 2016 guidelines for prevention and management of parastomal hernia (PSH) in adults.

DESIGN

Cross-sectional descriptive study.

SUBJECTS AND SETTING

The target population was approximately 300 stoma care nurses; 120 useable responses to the survey were received, reflecting a response rate of approximately 40%.

METHODS

A 31-item questionnaire was developed for the purposes of this study, consisting of multiple choice and short answer questions grouped into 2 sections; demographics, and knowledge and practices. The questionnaire was distributed to members of the ASCN who work with adults via an online survey platform with the aim of reaching as many respondents as possible. The Chi-square test was used to determine relationships between the nominal demographic data and the nominal knowledge and practices data.

RESULTS

Almost two-thirds of respondents (65%, n = 78) rated their knowledge relating to prevention and management of PSH as good or excellent. Nevertheless, 79.8% (n = 95) indicated they needed additional education to improve their knowledge and practice related to prevention of PSH. Those who rated their knowledge as excellent or good were significantly more likely to be aware of the guidelines compared to those who ranked their knowledge as average or poor.

CONCLUSIONS

Study findings suggest variability in knowledge among UK stoma care nurses, along with a desire for additional education in this area of care.

Smooth Return to Work Through Early Rehabilitation and Interdisciplinary Collaboration After Ostomy: A Case Report of a Japanese Patient

A male patient in his 40s was diagnosed with rectal cancer and underwent abdominoperineal resection (APR) with permanent end colostomy as surgical treatment. He wanted to return to work as soon as possible after discharge. A physical therapist (PT) was involved in the preoperative consultation, and both the PT and occupational therapist started bed rest and activities of daily living (ADL) practice the day after surgery. On the third postoperative day, lightweight trunk exercises were initiated with a gradual increase in load. Stoma management was supervised by a nurse and progress was monitored. The patient's progress in ADLs, postoperative complications, and return to work were evaluated two weeks after discharge. Consequently, the patient was able to continue rehabilitation without early complications related to postoperative stoma. He could lift 20 kg and return to carpentry two weeks after discharge. The stoma quality of life improved from 61 points at two weeks after surgery to 74 points at two weeks after discharge. Early rehabilitation for social reintegration after ostomy creation can be safely performed under PT supervision, and a comprehensive interprofessional collaboration can contribute to smooth social reintegration.

Analysis of risk factors for the sigmoid stoma complications in patients after abdominoperineal resection surgery: An observational study

To analyze the risk factors for intraperitoneal sigmoid stoma complications after abdominoperineal resection (APR) surgery to guide clinical practice. Patients who were diagnosed with rectal cancer and underwent APR surgery from June 2013 to June 2021 were retrospectively enrolled. The characteristics of the stoma complication group and the no stoma complication group were compared, and univariate and multivariate logistic analyses were employed to identify risk factors for sigmoid stoma-related complications. A total of 379 patients who were diagnosed with rectal cancer and underwent APR surgery were enrolled in this study. The average age of the patients was 61.7 ± 12.1 years, and 226 (59.6%) patients were males. Patients in the short-term stoma complication group were younger (55.7 vs 62.0, P < .05) and had a more advanced tumor stage (P < .05). However, there was no significant difference between the long-term stoma complication group and the no stoma complication group. Multivariate logistic regression analysis revealed that operation time was an independent risk factor (P < .05, OR = 1.005, 95% CI = 1.000-1.010) for short-term stoma complications. Both the short-term and long-term stoma complication rates in our institution were low. A longer operation time was an independent risk factor for short-term stoma complications after APR surgery.

Quality of life in permanent ostomates - what really matters to them?

PURPOSE

The impact of a permanent stoma, such as post-abdominoperineal resection (APR), on quality of life (QoL) is well-documented. While stoma-related QoL tools exist, their relationship with stoma satisfaction is unclear. This study aimed to identify which aspects of QoL were most associated with stoma satisfaction.

METHODOLOGY

A cross-sectional study of consecutive patients who had an APR for rectal cancer at an Australian tertiary hospital (2012-2021), identified from a prospectively maintained database, was conducted. The Stoma-QoL questionnaire was used. Overall patient satisfaction with stoma function, and whether healthcare advice was sought for stoma dysfunction, were explored. Linear regression assessed the association between individual issues examined in the Stoma-QoL questionnaire and overall patient satisfaction with stoma function.

RESULTS

Overall, 64 patients (62.5% male, mean 68.1 years) participated. Stoma-QoL score was associated with stoma satisfaction (P < 0.05). QoL items impacting satisfaction were: needing to know nearest toilet location (P = 0.04), pouch smell concerns (P = 0.008), needing daytime rest (P = 0.02), clothing limitations (P = 0.02), sexual attractiveness concerns (P < 0.05), embarrassment (P < 0.05), difficulty hiding the pouch (P = 0.02), concerns about being burdensome (P = 0.04) and difficulty with interpersonal interaction (P = 0.03). Only 11 (17.2%) patients sought healthcare advice for stoma dysfunction.

CONCLUSION

While stoma-specific QoL is associated with stoma satisfaction, individual QoL aspects impact differently on satisfaction in permanent colostomy patients. These findings may help identify focus areas for peri-operative counselling for clinicians and stomal therapists, highlight the importance of tailored multidisciplinary care in ostomates and suggests that a stoma type-specific Stoma-QoL questionnaire is required.

Clinical outcome and prognostic factors of T4N0M0 colon cancer after R0 resection: A retrospective study

BACKGROUND

Paradoxically, patients with T4N0M0 (stage II, no lymph node metastasis) colon cancer have a worse prognosis than those with T2N1-2M0 (stage III). However, no previous report has addressed this issue.

AIM

To screen prognostic risk factors for T4N0M0 colon cancer and construct a prognostic nomogram model for these patients.

METHODS

Two hundred patients with T4N0M0 colon cancer were treated at Tianjin Medical University General Hospital between January 2017 and December 2021, of which 112 patients were assigned to the training cohort, and the remaining 88 patients were assigned to the validation cohort. Differences between the training and validation groups were analyzed. The training cohort was subjected to multivariate analysis to select prognostic risk factors for T4N0M0 colon cancer, followed by the construction of a nomogram model.

RESULTS

The 3-year overall survival (OS) rates were 86.2% and 74.4% for the training and validation cohorts, respectively. Enterostomy (P = 0.000), T stage (P = 0.001), right hemicolon (P = 0.025), irregular review (P = 0.040), and carbohydrate antigen 199 (CA199) (P = 0.011) were independent risk factors of OS in patients with T4N0M0 colon cancer. A nomogram model with good concordance and accuracy was constructed.

CONCLUSION

Enterostomy, T stage, right hemicolon, irregular review, and CA199 were independent risk factors for OS in patients with T4N0M0 colon cancer. The nomogram model exhibited good agreement and accuracy.

Impact of parastomal hernia on colostomy costs at 1 year: Secondary analysis of a randomized clinical trial (STOMAMESH)

BACKGROUND AND AIMS

Parastomal hernia (PSH) is a common complication after the creation of a colostomy, with a prevalence of approximately 50%. Despite the high frequency, little is known how PSH affects the cost of colostomy care.The hypothesis in this study was that PSH increases the cost of colostomy care compared with not having a PSH.

METHODS

Two groups with (N = 61) and without (n = 147) PSH were compared regarding costs of stoma appliances and visits. The population from a large randomized trial comparing construction of colostomy with or without prophylactic mesh (STOMAMESH) was used and cross-matched with health economic data from the National Pharmaceutical Register, 1 year after initial surgery.

RESULTS

Patients with and without a PSH were similar in basic demographic data. No difference in cost of stoma appliances (with PSH 2668.3 EUR versus no PSH 2724.5 EUR, p = 0.938) or number of visits to a stoma therapist (p = 0.987) was seen, regardless of the presence or not of a PSH.

CONCLUSIONS

PSH appears not to affect costs due to colostomy appliances or the need to visit a stoma therapist, in the first year. The lesson to be learnt is that PSHs are not a driver for costs. Other factors may be determinants of the cost of a colostomy, including manufacturers' price and persuasion, means of procurement, and presence of guidelines.

From burden to relief: The economic and quality-of-life advantages of pseudo continent perineal colostomy in ultra-low rectal cancer patients

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.

Management after non-curative endoscopic resection of T1 rectal cancer

Since the introduction of population-based screening, increasing numbers of T1 rectal cancers are detected and removed by local endoscopic resection. Patients can be cured with endoscopic resection alone, but there is a possibility of residual tumor cells remaining after the initial resection. These can be located intraluminally at the resection site or extraluminally in the form of (lymph node) metastases. To decrease the risk of residual cells progressing towards more advanced disease, additional treatment is usually needed. However, with the currently available risk stratification models, it remains challenging to determine who should and should not be further treated after non-curative endoscopic resection. In this review, the different management strategies for patients with non-curatively treated T1 rectal cancers are discussed, along with the available evidence for each strategy and relevant considerations for clinical decision making. Furthermore, we provide practical guidance on the management and surveillance following non-curative endoscopic resection of T1 rectal cancer.

Anal Cancers in Previously Screened Versus Unscreened Patients: Tumor Stage and Treatment Outcomes

BACKGROUND

Targeted screening programs for patients at high risk for anal squamous-cell carcinoma have been proposed; however, the evidence in support of screening remains unclear.

OBJECTIVE

This study aimed to determine whether screening high-risk patients (predominantly those living with HIV) detected squamous-cell carcinoma at an earlier stage compared to the routine practice of not screening.

DESIGN

This is a cohort study.

SETTINGS

This study was conducted at a quaternary care center in Canada.

PATIENTS

Included patients were at least 18 years old with a pathologic diagnosis of invasive anal squamous-cell carcinoma between 2002 and 2022.

INTERVENTIONS

Patients diagnosed through a high-risk screening program were compared to those who did not undergo screening.

MAIN OUTCOME MEASURES

The primary outcome was clinical stage at presentation, categorized as T1N0M0 vs other. Secondary outcomes included treatments received, treatment failure, and overall survival.

RESULTS

A total of 612 patients with anal squamous-cell carcinoma were included, with 26 of those patients diagnosed through a screening program. Patients with screen-detected cancers had greater odds of presenting with T1N0M0 tumors compared to unscreened patients (18 [69.2%] vs 84 [14.3%]; adjusted OR 9.95; 95% CI, 3.95-25.08). A propensity score-matched sensitivity analysis found similar results (OR 11.13; 95% CI, 4.67-26.52). Screened patients had greater odds of treatment with wide local excision alone, as opposed to any combination of chemotherapy, radiation therapy, and surgery (3 [12.5%] vs 18 [3.2%]; OR 4.38; 95% CI, 1.20-16.04). There were no statistically significant differences in treatment failure or overall survival between groups.

LIMITATIONS

The small number of screened patients limits the power of the analysis.

CONCLUSIONS

Screening for anal squamous-cell carcinoma among high-risk populations detects cancers at an earlier stage. Patients with screen-detected cancers also had a greater likelihood of being candidates for wide local excision alone, which may have spared them the morbidity associated with chemoradiotherapy or abdominoperineal resection. See Video Abstract.

CNCERES DE ANO EN PACIENTES PREVIAMENTE DETECTADOS POR CRIBADO VERSUS NO DETECTADOS ESTADIO DEL TUMOR Y RESULTADOS DEL TRATAMIENTO

ANTECEDENTES:Se han propuesto programas de cribado dirigidos a pacientes con alto riesgo de carcinoma anal de células escamosas; sin embargo, la evidencia a favor de la detección sigue sin estar clara.OBJETIVO:Este estudio tuvo como objetivo determinar si el cribado de pacientes de alto riesgo (predominantemente aquellos que viven con el VIH) detectó el carcinoma de células escamosas en una etapa más temprana en comparación con la práctica habitual de no cribado.DISEÑO:Este es un estudio de cohortes.CONFIGURACIÓN:Este estudio se realizó en un centro de atención cuaternaria en Canadá.PACIENTES:Los pacientes incluidos tenían al menos 18 años con un diagnóstico patológico de carcinoma de células escamosas anal invasivo entre 2002 y 2022.INTERVENCIONES:Los pacientes diagnosticados mediante un programa de cribado de alto riesgo se compararon con aquellos que no se sometieron a cribado.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue el estadio clínico en la presentación, categorizado como T1N0M0 versus otro. Los resultados secundarios incluyeron los tratamientos recibidos, el fracaso del tratamiento y la supervivencia general.RESULTADOS:Se incluyeron un total de 612 pacientes con carcinoma anal de células escamosas, con 26 de esos pacientes diagnosticados a través de un programa de cribado. Los pacientes con cánceres detectados mediante cribado tenían mayores probabilidades de presentar tumores T1N0M0 en comparación con los pacientes no cribados (18 [69.2%] frente a 84 [14.3%]; razón de probabilidad ajustada 9.95; intervalo de confianza del 95 % 3.95 -25.08). Un análisis de sensibilidad emparejado por puntaje de propensión encontró resultados similares (odds ratio 11.13; intervalo de confianza del 95% 4.67 -26.52; p < 0.001). Los pacientes examinados tenían mayores probabilidades de recibir tratamiento con escisión local amplia sola, en comparación con cualquier combinación de quimioterapia, radiación y cirugía (3 [12.5%] frente a 18 [3.2%]; razón de probabilidad 4.38; intervalo de confianza del 95 % 1.20 -16.04). No hubo diferencias estadísticamente significativas en el fracaso del tratamiento o la supervivencia global entre los grupos.LIMITACIONES:El pequeño número de pacientes evaluados limita el poder del análisis.CONCLUSIONES:La detección del carcinoma anal de células escamosas entre las poblaciones de alto riesgo detecta los cánceres en una etapa más temprana. Los pacientes con cánceres detectados mediante cribado también tenían una mayor probabilidad de ser candidatos para una escisión local amplia sola, lo que puede haberles evitado la morbilidad asociada con la quimiorradioterapia o la resección abdominoperineal. (Traducción --Dr. Aurian Garcia Gonzalez ).

Association of Frailty With Post-Operative Outcomes of Older Adults Undergoing Elective Ostomy Reversal

BACKGROUND

Ostomy reversal is a common surgical procedure; however, it is not without associated risks. Patient selection for this elective procedure is therefore critically important. Elderly patients represent a growing population and a substantial proportion of patients that present for evaluation after ostomy creation due to the most common etiologies. This study aims to assess the impact of frailty on the outcomes of ostomy reversal among older adults.

METHODS

Patients ≥65 years who underwent ostomy reversal from 2015 to 2019 were identified in the NSQIP database. Frailty was calculated using the 5-item Modified Frailty Index (MFI). Multivariate regression was performed to evaluate the association of frailty with post-operative 30-day mortality, 30-day serious complications, discharge to a facility, and 30-day readmission.

RESULTS

A total of 13,053 patients were included, of which 18.7% were frail (MFI ≥ 2). Patients who underwent colostomy reversal had higher rates of serious complications (P < .0001) and discharge to facility (P < .0001) compared to other reversals. In multivariate analysis, frailty was associated with increased odds of serious complications (OR 1.52, 95% CI 1.31-1.77), discharge to facility (OR 2.14, 95% CI 1.79-2.57), and readmission (OR 1.23, 95% CI 1.04-1.46), but not mortality. Frail patients had predicted probabilities 1.4 times higher for serious complications and 1.7-2.2 times greater for discharge to facility than non-frail patients.

CONCLUSIONS

Among older adults undergoing elective ostomy reversal, frailty is independently associated with increased odds of 30-day serious complications, discharge to facility, and 30-day readmission. As a potentially modifiable risk factor, identification of frailty offers the opportunity for shared decision-making and prehabilitation.

Permanent stoma rate and long-term stoma complications in laparoscopic, robot-assisted, and transanal total mesorectal excisions: a retrospective cohort study

BACKGROUND

The surgical resection of rectal carcinoma is associated with a high risk of permanent stoma rate. Primary anastomosis rate is suggested to be higher in robot-assisted and transanal total mesorectal excision, but permanent stoma rate is unknown.

METHODS

Patients undergoing total mesorectal excision for MRI-defined rectal cancer between 2015 and 2017 in 11 centers highly experienced in laparoscopic, robot-assisted or transanal total mesorectal excision were included in this retrospective study. Permanent stoma rate, stoma-related complications, readmissions, and reoperations were registered. A multivariable regression analysis was performed for permanent stoma rate, stoma-related complications, and stoma-related reoperations.

RESULTS

In total, 1198 patients were included. Permanent stoma rate after low anterior resection (with anastomosis or with an end colostomy) was 40.1% in patients undergoing laparoscopic surgery, 21.3% in patients undergoing robot-assisted surgery, and 25.6% in patients undergoing transanal surgery (P < 0.001). Permanent stoma rate after low anterior resection with an anastomosis was 17.3%, 11.8%, and 15.1%, respectively. The robot-assisted and transanal techniques were independently associated with a reduction in permanent stoma rate in patients who underwent a low anterior resection (with anastomosis or with an end colostomy) (OR 0.39 [95% CI 0.25, 0.59] and OR 0.35 [95% CI 0.22, 0.55]), while this was not seen in patients who underwent a restorative low anterior resection. 45.4% of the patients who had a stoma experienced stoma-related complications, 4.0% were at least once readmitted, and 8.9% underwent at least one reoperation.

CONCLUSIONS

The robot-assisted and transanal techniques are associated with a lower permanent stoma rate in patients who underwent a low anterior resection.

Patient-Reported Sexual Function, Bladder Function and Quality of Life for Patients with Low Rectal Cancers with or without a Permanent Ostomy

BACKGROUND

Despite the increasing utilization of sphincter and/or organ-preservation treatment strategies, many patients with low-lying rectal cancers require abdominoperineal resection (APR), leading to permanent ostomy. Here, we aimed to characterize overall, sexual-, and bladder-related patient-reported quality of life (QOL) for individuals with low rectal cancers. We additionally aimed to explore potential differences in patient-reported outcomes between patients with and without a permanent ostomy.

METHODS

We distributed a comprehensive survey consisting of various patient-reported outcome measures, including the FACT-G7 survey, ICIQ MLUTS/FLUTS, IIEF-5/FSFI, and a specific questionnaire for ostomy patients. Descriptive statistics and univariate comparisons were used to compared demographics, treatments, and QOL scores between patients with and without a permanent ostomy.

RESULTS

Of the 204 patients contacted, 124 (60.8%) returned completed surveys; 22 (18%) of these had a permanent ostomy at the time of survey completion. There were 25 patients with low rectal tumors (≤5 cm from the anal verge) who did not have an ostomy at the time of survey completion, of whom 13 (52%) were managed with a non-operative approach. FACTG7 scores were numerically lower (median 20.5 vs. 22, p = 0.12) for individuals with an ostomy. Sexual function measures IIEF and FSFI were also lower (worse) for individuals with ostomies, but the results were not significantly different. MLUTS and FLUTS scores were both higher in individuals with ostomies (median 11 vs. 5, p = 0.06 and median 17 vs. 5.5, p = 0.01, respectively), suggesting worse urinary function. Patient-reported ostomy-specific challenges included gastrointestinal concerns (e.g., gas, odor, diarrhea) that may affect social activities and personal relationships.

CONCLUSIONS

Despite a limited sample size, this study provides patient-centered, patient-derived data regarding long-term QOL in validated measures following treatment of low rectal cancers. Ostomies may have multidimensional negative impacts on QOL, and these findings warrant continued investigation in a prospective setting. These results may be used to inform shared decision making for individuals with low rectal cancers in both the settings of organ preservation and permanent ostomy.

Autologous full-thickness skin in the repair of complex ventral hernias: an innovative step into the future of complex hernia repair?

The repair of complex ventral hernias, such as giant incisional or parastomal hernia, is associated with a high risk for complications and recurrence. Some serious complications are related to implantation of synthetic mesh as reinforcement material. Autologous full-thickness skin graft (FTSG) as reinforcement material in the repair of these complex hernias may offer a safe alternative. This is a review of the history of FTSG use in hernia surgery and the experiences of our research group regarding its application over the last decade. The results of FTSG used in the repair of giant ventral hernias are promising, and this method may already be recommended in selected cases. We have also conducted a translational chain of preclinical studies, based on a murine model, to gain a greater understanding of the behaviour of FTSG implanted in various positions in the abdominal wall. The use of intraperitoneal FTSG as reinforcement material in parastomal hernia repair is currently being evaluated in a randomised, controlled, multicentre study.

Survivorship in Early-Stage Rectal Cancer Patients Who Have Received Combined Modality Therapy

Survival rates in early-stage rectal cancer patients have increased over the past few decades. Societies such as the National Comprehensive Cancer Network (NCCN), American Cancer Society (ACS), American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO) have proposed guidelines related to cancer survivorship care including formal recommendations to address the needs in early-stage rectal cancer survivors. These guidelines, in addition to new clinical research findings in survivorship will be reviewed, specifically looking at physical, psychosocial, and financial concerns in rectal cancer survivorship.

Risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma: A systematic review and meta-analysis

BACKGROUND

To further define the risk factors and incidence of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma.

METHODS

Records from five English databases and four Chinese databases. Odds ratios (OR) and 95 % confidence intervals (CI) were used to indicate the risk of inclusion of risk factors. The non-closure stoma rate used the risk difference (RD) and 95 % CI. Risk factors were evaluated for quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age ≥60 years[OR:1.57, 95%CI(1.44,1.72)], Tumor IV stage[OR:4.21, 95%CI(2.29,7.74)], American Society of Anesthesiologists (ASA)≥3[OR:1.48, 95%CI(1.33,1.65)], Neoadjuvant chemoradiotherapy[OR:1.41, 95%CI(1.09,1.82)],Open surgery[OR:1.45, 95%CI(1.09,1.93)], Postoperative chemotherapy[OR:1.37, 95%CI(1.03,1.82)], Anastomotic leakage[OR:4.61, 95%CI(2.86, 7.44)], Local recurrence[OR:7.16, 95%CI(4.70, 10.91)]. The rate of non-closure stoma after anterior resection for rectal cancer was: 0.20, 95 % CI (0.17, 0.23). The quality of evidence for stage IV tumors and anastomotic leakage was moderate, and other risk factors were low to very low.

CONCLUSIONS

Risk factors of non-closure stoma in patients with anterior resection of rectal cancer with temporary stoma were Age≥60 years, Tumor IV stage, ASA≥3, Neoadjuvant chemoradiotherapy, Open surgery, Postoperative chemotherapy, Anastomotic leakage, Local recurrence, and one in five anterior resection patients with a temporary stoma fails to close.

Patients' experiences of living with a stoma in rural areas in Northern Sweden

Introduction: Stoma complications are common and interfere with many aspects of everyday life. Stoma problems are usually managed by a specialised stoma nurse, a service not present in the rural areas of South Lapland in Sweden. The aim of this study was to describe how stoma patients in rural areas experience living with a stoma.Methods: A qualitative descriptive study with semi-structured interviews were conducted with 17 stoma patients living in rural municipalities and who received a part of their care at the local cottage hospital. Qualitative content analysis was employed.Results: Initially, the stoma was experienced as very depressing. Participants had difficulties in properly managing the dressing. Over time they learned how to properly care for their stoma, making their life easier. Both satisfaction and dissatisfaction with the healthcare were experienced. Those who were dissatisfied expressed a lack of competence in dealing with stoma-related problems.Conclusions: Living with a stoma in a rural area in northern Sweden is experienced as a learning process and acceptance of the stoma's existence is important. This study emphasises the need for increased knowledge of stoma-related problems in rural primary healthcare in order to help patients cope with everyday life.

Stoma-free Survival After Rectal Cancer Resection With Anastomotic Leakage: Development and Validation of a Prediction Model in a Large International Cohort

OBJECTIVE

To develop and validate a prediction model (STOMA score) for 1-year stoma-free survival in patients with rectal cancer (RC) with anastomotic leakage (AL).

BACKGROUND

AL after RC resection often results in a permanent stoma.

METHODS

This international retrospective cohort study (TENTACLE-Rectum) encompassed 216 participating centres and included patients who developed AL after RC surgery between 2014 and 2018. Clinically relevant predictors for 1-year stoma-free survival were included in uni and multivariable logistic regression models. The STOMA score was developed and internally validated in a cohort of patients operated between 2014 and 2017, with subsequent temporal validation in a 2018 cohort. The discriminative power and calibration of the models' performance were evaluated.

RESULTS

This study included 2499 patients with AL, 1954 in the development cohort and 545 in the validation cohort. Baseline characteristics were comparable. One-year stoma-free survival was 45.0% in the development cohort and 43.7% in the validation cohort. The following predictors were included in the STOMA score: sex, age, American Society of Anestesiologist classification, body mass index, clinical M-disease, neoadjuvant therapy, abdominal and transanal approach, primary defunctioning stoma, multivisceral resection, clinical setting in which AL was diagnosed, postoperative day of AL diagnosis, abdominal contamination, anastomotic defect circumference, bowel wall ischemia, anastomotic fistula, retraction, and reactivation leakage. The STOMA score showed good discrimination and calibration (c-index: 0.71, 95% CI: 0.66-0.76).

CONCLUSIONS

The STOMA score consists of 18 clinically relevant factors and estimates the individual risk for 1-year stoma-free survival in patients with AL after RC surgery, which may improve patient counseling and give guidance when analyzing the efficacy of different treatment strategies in future studies.

Intimacy and survivors of cancer with ostomies: findings from the Ostomy Self-management Training trial

BACKGROUND

Many people with abdominal or pelvic cancers require an ostomy during surgical treatment, which can cause significant issues with physical and emotional intimacy in relationships.

AIM

To evaluate the effect of a telehealth-based education program on intimacy over time for survivors of cancer with ostomies.

METHODS

We performed a secondary analysis of our multicenter randomized controlled trial to determine intimacy outcomes and to compare the effects of the Ostomy Self-management Training (OSMT) program vs usual care. Partnered patients were included who provided answers to the City of Hope Quality of Life-Ostomy survey for at least 2 time points during the study. We evaluated the effect of baseline information, such as gender on intimacy.

OUTCOMES

The primary outcome was intimacy, estimated by a composite score created from questions within the City of Hope Quality of Life-Ostomy survey.

RESULTS

Of 216 enrolled volunteers, 131 had a partner: 68 in the OSMT arm and 63 in the usual care arm. Of these, 48 were women and 83 were men. The tumor types represented in this study were colorectal (n = 69), urinary (n = 45), gynecologic (n = 10), and other (n = 7; eg, melanoma, liposarcoma). From the cohort, 87 answered the 5 composite intimacy score questions at 2 time points, including baseline. There was significant improvement over time in composite intimacy scores for participants in the OSMT arm vs the usual care arm.

CLINICAL IMPLICATIONS

Our OSMT intervention had a positive effect on factors that contribute to intimacy for survivors of cancer with ostomies, suggesting that a survivorship curriculum can improve their experiences after ostomy surgery.

STRENGTHS AND LIMITATIONS

OSMT allowed for discussion of intimacy and other sensitive topics, which can be challenging. These discussions demonstrate benefit to participants and can serve as frameworks for cancer treatment providers. The focus of this work on partnered participants provides insight into the interpersonal challenges of a life with an ostomy, but it may overlook the important perspectives of nonpartnered participants and the partners themselves. Furthermore, limited power prevented us from conducting subgroup analyses exploring the effects of factors such as gender and tumor type on intimacy.

CONCLUSION

At 6-month follow-up, the novel intimacy composite score indicated improvement for participants completing the OSMT intervention. Future research studies with higher power will validate this intimacy measurement and identify intimacy differences in similar populations based on tumor type.

The impact of restorative proctectomy versus permanent colostomy on health-related quality of life after rectal cancer surgery using the patient-generated index

BACKGROUND

The impact of bowel dysfunction versus colostomy on quality of life after rectal cancer surgery is poorly understood.

BACKGROUND

To evaluate the quality of life after rectal cancer surgery in patients with colostomy versus restorative proctectomy.

METHODS

A mixed-methods study measuring quality of life using the Patient-Generated Index, patients were asked to list up to 5 areas of their life affected by their surgery. Areas were then weighted according to patients' preferences for improvement to generate a score from 0-100. The areas reported by patients were linked to the International Classification of Functioning for content analysis. Bowel dysfunction was measured using the low anterior resection syndrome score, and patients were then grouped according to (1) colostomy, (2) no/minor, or (3) major low anterior resection syndrome. Quality of life was compared between groups.

RESULTS

Overall, 121 patients were included (colostomy n = 39, restorative proctectomy n = 82). There were no differences in demographics, neoadjuvant radiotherapy, or time to follow-up between groups. In the restorative proctectomy group, 53% had no/minor, and 47% had major low anterior resection syndrome. Overall, patients with colostomy had significantly lower quality-of-life scores than those with restorative proctectomy. However, patients with major low anterior resection syndrome scored similarly to those with colostomy. On content analysis, patients with colostomies reported more problems with sexual function, body image, and sports. Patients with restorative proctectomy reported more problems with sleep, using transportation, and taking care of themselves.

CONCLUSION

Colostomy has a more detrimental impact on quality of life than restorative proctectomy. However, bowel dysfunction severity is important to consider. The patient experience between treatments differs.

Functional preservation benefits of minimal surgery for extramammary Paget's disease

As extramammary Paget's disease (EMPD) sometimes invades and metastasizes from the skin to the mucosa, radical surgical resection of these lesions is often difficult. The purpose of this study was to analyse the association between surgical margins and survival as well as the benefit of functional preservation over complete resection, in patients with EMPD. We retrospectively analysed 230 patients diagnosed with EMPD between 1969 and 2020. Patient and treatment characteristics were recorded. Since our centre is a specialized hospital and almost all patients were referred from other hospitals, we reviewed their referral letters. Prognostic factors and survival time were also analysed. Among 230 patients, 78 (33.9%) had positive margins. The presence of margin positive lesions increased the local recurrence rate but was not significantly correlated with survival. Of all the patients who had received a thorough explanation about the surgical procedure in the referring hospital, 43.8% were scheduled for surgeries that would result in functional impairment, and all of them had function-preserving surgeries at our hospital with a 10-year survival rate of 100%. Our result suggest that less invasive surgery preserves anogenital and urethral function may be an acceptable option for EMPD treatment.

Artificial intelligence based system for predicting permanent stoma after sphincter saving operations

Although the goal of rectal cancer treatment is to restore gastrointestinal continuity, some patients with rectal cancer develop a permanent stoma (PS) after sphincter-saving operations. Although many studies have identified the risk factors and causes of PS, few have precisely predicted the probability of PS formation before surgery. To validate whether an artificial intelligence model can accurately predict PS formation in patients with rectal cancer after sphincter-saving operations. Patients with rectal cancer who underwent a sphincter-saving operation at Taipei Medical University Hospital between January 1, 2012, and December 31, 2021, were retrospectively included in this study. A machine learning technique was used to predict whether a PS would form after a sphincter-saving operation. We included 19 routinely available preoperative variables in the artificial intelligence analysis. To evaluate the efficiency of the model, 6 performance metrics were utilized: accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiving operating characteristic curve. In our classification pipeline, the data were randomly divided into a training set (80% of the data) and a validation set (20% of the data). The artificial intelligence models were trained using the training dataset, and their performance was evaluated using the validation dataset. Synthetic minority oversampling was used to solve the data imbalance. A total of 428 patients were included, and the PS rate was 13.6% (58/428) in the training set. The logistic regression (LR), Gaussian Naïve Bayes (GNB), Extreme Gradient Boosting (XGB), Gradient Boosting (GB), random forest, decision tree and light gradient boosting machine (LightGBM) algorithms were employed. The accuracies of the logistic regression (LR), Gaussian Naïve Bayes (GNB), Extreme Gradient Boosting (XGB), Gradient Boosting (GB), random forest (RF), decision tree (DT) and light gradient boosting machine (LightGBM) models were 70%, 76%, 89%, 93%, 95%, 79% and 93%, respectively. The area under the receiving operating characteristic curve values were 0.79 for the LR model, 0.84 for the GNB, 0.95 for the XGB, 0.95 for the GB, 0.99 for the RF model, 0.79 for the DT model and 0.98 for the LightGBM model. The key predictors that were identified were the distance of the lesion from the anal verge, clinical N stage, age, sex, American Society of Anesthesiologists score, and preoperative albumin and carcinoembryonic antigen levels. Integration of artificial intelligence with available preoperative data can potentially predict stoma outcomes after sphincter-saving operations. Our model exhibited excellent predictive ability and can improve the process of obtaining informed consent.

PHaLIR: prevent hernia after loop ileostomy reversal-a study protocol for a randomized controlled multicenter study

BACKGROUND

Rectal cancer is a common cancer worldwide. Surgery for rectal cancer with low anterior resection often includes the formation of a temporary protective loop ileostomy. The temporary ostomy is later reversed in a separate operation. One complication following stoma closure is the development of a hernia at the former stoma site, and this has been reported in 7-15% of patients. The best method to avoid hernia after stoma closure is unclear. The most common closure is by suturing only, but different forms of mesh have been tried. Biological mesh has in a randomized trial halved hernia incidence after stoma reversal. Biosynthetic mesh and retromuscular mesh are currently being evaluated in ongoing studies.

METHODS

The present multicenter, double-blinded, randomized, controlled study will compare standard suture closure of the abdominal wall in loop ileostomy reversal with retromuscular synthetic mesh at the stoma site. The study has been approved by the Regional Ethical Review board in Stockholm. Patients aged 18-90 years, operated on with low anterior resection and a protective loop ileostomy for rectal cancer and planned for ileostomy reversal, will be considered for inclusion in the study. Randomization will be 1:1 on the operation day with concealed envelopes. The estimated sample size is intended to evaluate the superiority of the experimental arm and to detect a reduction of hernia occurrence from 12 to 3%. The operation method is blinded to the patients and in the chart and for the observer at the 30-day follow-up. The main outcome is hernia occurrence at the stoma site within 3 years postoperatively, diagnosed through CT with strain. Secondary outcomes are operation time, length of hospital stay, pain, and 30-day complications.

DISCUSSION

This double-blinded randomized controlled superiority study will compare retromuscular synthetic mesh during the closure of loop ileostomy to standard care. If this study can show a lower frequency of hernia with the use of prophylactic mesh, it may lead to new surgical guidelines during stoma closure.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03720262. Registered on October 25, 2018.

Limitations on participation and global quality of life among CRC survivors with permanent stomas: moderated mediation analysis of psychological distress and family functioning

PURPOSE

Although a cancer diagnosis and stoma creation leave colorectal cancer (CRC) survivors with significant limitations on participation in life activities that would impair their global quality of life (QoL), the underlying psychological mechanisms are understudied. The aim of this cross-section study was to examine whether psychological distress mediates the association of limitations on participation in life activity with global QoL, and whether family functioning moderated the indirect effects of limitations on participation in life activities on global QoL through psychological distress.

METHODS

CRC survivors with permanent stomas (n = 282) completed questionnaires assessing socio-demographic and clinical characteristics, limitations on participation in life activities, psychological distress, family functioning, and global QoL. The mediation model and moderated mediation model were conducted using the PROCESS macro for SPSS.

RESULTS

Mediation analysis showed that the association of limitations on participation in life activities with global QoL was partially mediated by psychological distress (indirect effect = -0.087, 95% CI = -0.135 to -0.041). Moderated mediation analysis indicated that the indirect effects of limitations on participation in life activities on global QoL through psychological distress were significantly moderated by family functioning. Specifically, the indirect effects decreased were significant as family functioning levels increased.

CONCLUSION

CRC survivors with permanent stomas experienced poor global QoL. The moderated mediation model provides a better understanding of how limitations on participation in life activities, psychological distress, and family functioning work together to affect global QoL. Interventions aiming to improve QoL among CRC survivors with permanent stomas should consider targeting these aspects.

Comparison of sexual function of people with colorectal cancer with and without colostomy bag in Iran: a comparative cross-sectional study

The aim of this study was to investigate and compare sexual function in individuals with colorectal cancer, with and without a colostomy bag. A quantitative, descriptive-comparative design was employed, and a cluster random sampling method was used to recruit 252 patients with colorectal cancer. Data collection tools included a participants characteristics form, the International Index of Erectile Function (IIEF) for men, and the Female Sexual Function Index (FSFI) for women. The mean IIEF total score for men with a colostomy was 26.17 ± 15.30, and for men without a colostomy, it was 29.05 ± 17.14. The mean FSFI total score for women with a colostomy was 6.40 ± 7.21, and for women without a colostomy, it was 9.10 ± 14.67. There was no statistically difference in IIEF scores between men with and without colostomy bags (p > 0.05). However, women with colostomy bags had significantly lower FSFI scores compared to women without colostomy bags (p < 0.05). Addressing sexual concerns in individuals with colorectal cancer is crucial for enhancing their sexual well-being and overall quality of life. Comprehensive support, timely interventions, and targeted services are essential to help patients navigate the challenges and improve their overall well-being.

A prediction model for moderate to severe cancer-related fatigue in colorectal cancer after chemotherapy: a prospective case‒control study

AIMS

The study aims to develop a model to predict the risk of moderate to severe cancer-related fatigue (CRF) in colorectal cancer patients after chemotherapy.

METHODS

The study population was colorectal cancer patients who received chemotherapy from September 2021 to June 2022 in a grade 3 and first-class hospital. Demographic, clinical, physiological, psychological, and socioeconomic factors were collected 1 to 2 days before the start of chemotherapy. Patients were followed up for 1 to 2 days after the end of chemotherapy to assess fatigue using the Piper Fatigue Scale. A random sampling method was used to select 181 patients with moderate to severe CRF as the case group. The risk set sampling method was used to select 181 patients with mild or no CRF as the control group. Logistic regression, back-propagation artificial neural network (BP-ANN), and decision tree models were constructed and compared.

RESULTS

A total of 362 patients consisting of 241 derivation samples and 121 validation samples were enrolled. Comparing the three models, the prediction effect of BP-ANN was the best, with a receiver operating characteristic (ROC) curve of 0.83. Internal and external verification indicated that the accuracy of prediction was 70.4% and 80.8%, respectively. Significant predictors identified were surgery, complications, hypokalaemia, albumin, neutrophil percentage, pain (VAS score), Activities of Daily Living (ADL) score, sleep quality (PSQI score), anxiety (HAD-A score), depression (HAD-D score), and nutrition (PG-SGA score).

CONCLUSIONS

BP-ANN was the best model, offering theoretical guidance for clinicians to formulate a tool to identify patients at high risk of moderate to severe CRF.

Society for Immunotherapy of Cancer (SITC) clinical practice guideline on immunotherapy for the treatment of gastrointestinal cancer

Gastrointestinal (GI) cancers, including esophageal, gastroesophageal junction, gastric, duodenal and distal small bowel, biliary tract, pancreatic, colon, rectal, and anal cancer, comprise a heterogeneous group of malignancies that impose a significant global burden. Immunotherapy has transformed the treatment landscape for several GI cancers, offering some patients durable responses and prolonged survival. Specifically, immune checkpoint inhibitors (ICIs) directed against programmed cell death protein 1 (PD-1), either as monotherapies or in combination regimens, have gained tissue site-specific regulatory approvals for the treatment of metastatic disease and in the resectable setting. Indications for ICIs in GI cancer, however, have differing biomarker and histology requirements depending on the anatomic site of origin. Furthermore, ICIs are associated with unique toxicity profiles compared with other systemic treatments that have long been the mainstay for GI cancer, such as chemotherapy. With the goal of improving patient care by providing guidance to the oncology community, the Society for Immunotherapy of Cancer (SITC) convened a panel of experts to develop this clinical practice guideline on immunotherapy for the treatment of GI cancer. Drawing from published data and clinical experience, the expert panel developed evidence- and consensus-based recommendations for healthcare professionals using ICIs to treat GI cancers, with topics including biomarker testing, therapy selection, and patient education and quality of life considerations, among others.

Long-term incidence of depression in rectal cancer patients with or without stoma: a population-based cohort study

Purpose

Significant improvements have been made in the surgical treatment of rectal cancer with a higher sphincter-saving rate without compromising oncologic results. There have been studies about the quality of life of rectal cancer patients after surgery. However, no study has reported the long-term annual incidence of depression after rectal cancer surgery according to stoma status. The objective of this study was to determine the annual incidence of depression after rectal cancer surgery and the factors affecting it, especially the prevalence of depression according to the presence or duration of a stoma.

Methods

Using the Korea National Health Insurance Service database, patients who underwent radical surgery for rectal cancer from 2002 to 2019 were searched. We analyzed the incidence and risk factors of depression in patients who underwent radical surgery for rectal cancer according to stoma status.

Results

Annual incidence of depression in rectal cancer patients was decreasing annually for 15 years after surgery. There was no statistically significant difference in the incidence of depression according to the stoma status. However, the diagnosis of depression within 1 year after surgery was statistically significantly increased in the permanent stoma group.

Conclusion

There was no difference in the overall incidence of depressive disorders among patients with rectal cancer based on their stoma status. However, a permanent stoma seems to increase the incidence in the first year after surgery. Education and intensive assessments of depressive disorders in patients with permanent stoma within 1 year after surgery are needed, particularly for female patients who are under 50 years old.

The sexuality experience of stoma patients: a meta-ethnography of qualitative research

BACKGROUND

As the quality of life of stoma patients has become a research hotspot, sexual health as an integral part of patients' lives has received more and more attention. However, there is a lack of comprehensive reviews on the sexual experiences of patients with stomas. This study aims to synthesize the qualitative literature on the subjective experience of stoma patients' sexual life, to identify their sexual needs, and to provide evidence for the content and methods of sexual health interventions for healthcare professionals.

METHODS

PubMed, Embase, Web of Science, CINAHL, and Scopus were searched for qualitative studies on the sexual experience of stoma patients (from the inception to January 2023). Titles, abstracts, and full texts were reviewed by two researchers. We used the Critical Appraisal Program (CASP) checklist to assess the quality of included articles.

RESULTS

A total of 1388 articles were retrieved, and eight studies were included. Data was extracted, including three main themes: 1) sexual problems due to changes in physical function and psychological disorders; 2) the relationship with spouse changes; 3) the cognition of sexual life and the need for sexual knowledge.

CONCLUSION

Healthcare professionals should pay attention to the sexual life status and sexual health needs of stoma patients and their partners, and give professional guidance and support in treatment and nursing to improve the quality of sexual life of stoma patients.

Comparison of specimen extraction site and another site for protective loop ileostomy in laparoscopic low anterior rectal resection: a retrospective comparative study

BACKGROUND

Protective loop ileostomy is commonly performed in laparoscopic low anterior rectal resection to prevent the serious complications of anastomotic fistula. It is usually created at the right lower quadrant of the abdomen and another wound is required for stoma. The study aimed to evaluate the outcomes of ileostomy at the specimen extraction site (SES) and another site (AS) beside the auxiliary incision.

METHODS

A retrospective analysis was conducted on 101 eligible patients with pathologically diagnosed adenocarcinoma of the rectum from January 2020 to December 2021 in the study center. According to whether the ileostomy was at the specimen extraction site, patients were divided into SES group (40 patients) and AS group (61 patients). Clinicopathological characteristics, the intraoperative details, and postoperative outcomes of the two groups were measured.

RESULTS

Univariate analysis showed that the operative time was significantly shorter and the blood loss was significantly less in the SES group than in the AS group during laparoscopic low anterior rectal resection, the time to first flatus was significantly shorter, and the pain was significantly less in the SES group than in the AS group during ileostomy closure. The postoperative complications were similar in both groups. Multivariable analysis showed that ileostomy at the specimen extraction site was a significant factor influencing the operative time and blood loss of rectal resection, and influencing the pain and the time to first flatus during ileostomy closure.

CONCLUSION

Compared to ileostomy at AS, protective loop ileostomy at SES was time-saving and less bleeding during laparoscopic low anterior rectal resection, and more quick to first flatus and less pain during stoma closure, and did not lead to more postoperative complications. The median incision of the lower abdomen and the left lower abdominal incision were both good sites for ileostomy.

International Validation of the EORTC QLQ-ANL27, a Field Study to Test the Anal Cancer-Specific Health-Related Quality-of-Life Questionnaire

PURPOSE

The European Organisation for Research and Treatment of Cancer (EORTC) health-related quality of life questionnaire for anal cancer (QLQ-ANL27) supplements the EORTC cancer generic measure (QLQ-C30) to measure concerns specific to people with anal cancer treated with chemoradiotherapy. This study tested the psychometric properties and acceptability of the QLQ-ANL27.

METHODS AND MATERIALS

People with anal cancer were recruited from 15 countries to complete the QLQ-C30 and QLQ-ANL27 and provide feedback on the QLQ-ANL27. Item responses, scale structure (multitrait scaling, factor analysis), reliability (internal consistency and reproducibility) and sensitivity (known group comparisons and responsiveness to change) of the QLQ-ANL27 were evaluated.

RESULTS

Data from 382 people were included in the analyses. The EORTC QLQ-ANL27 was acceptable, comprehensive, and easy to complete, taking an average 8 minutes to complete. Psychometric analyses supported the EORTC QLQ-ANL27 items and reliability (Cronbach's α ranging from 0.71-0.93 and test-retest coefficients above 0.7) and validity of the scales (particularly nonstoma bowel symptoms and pain/discomfort). Most scales distinguished people according to treatment phase and performance status. Bowel (nonstoma), pain/discomfort, and vaginal symptoms were sensitive to deteriorations over time. The stoma-related scales remained untested because of low numbers of people with a stoma. Revisions to the scoring and question ordering of the sexual items were proposed.

CONCLUSIONS

The QLQ-ANL27 has good psychometric properties and is available in 16 languages for people treated with chemoradiotherapy for anal cancer. It is used in clinical trials and has a potential role in clinical practice.

Surgical treatment of stomal prolapse: A systematic review and meta-analysis of the literature

AIM

This study aimed to assess success, recurrence, and overall complication rates among different surgical procedures for stomal prolapse.

METHODS

This study was a PRISMA-compliant systematic review. PubMed, Scopus, and Google Scholar were searched until March 2022. Studies that assessed surgical treatments of stomal prolapse in adults were included. The primary outcome was recurrence of stomal prolapse and the secondary outcome was 30-day complications. A random-effect meta-analysis was used to estimate the weighted mean rates of recurrence.

RESULTS

Six studies published (111 patients; 103 males) were included. 52 (46.8%) patients had end colostomies, 35 (31.5%) had loop colostomies. Seven procedures were assessed and included local stoma reconstruction (40%), stapled local repair (27%), modified Altemeier technique (10%), mesh strip repair (9%), stoma relocation (6%) redo laparotomy repair (5%), and colectomy and end ileostomy (3%). The weighted mean recurrence rate after local stoma reconstruction was 37.2% (95% CI: -1.8 to 76.3), higher than that after the stapled local repair technique (14.9%; 95% CI: 1.7-28.2). The crude recurrence rate of the modified Altemeier technique was 20%, and of stoma relocation was 66.6%. No recurrence was detected after the mesh strip technique (n = 10). The median follow-up ranged between 7 months and 2.5 years.

CONCLUSION

Several surgical techniques are available to treat stomal prolapse. Local stoma reconstruction may be associated with high rates of recurrence while the stapled local repair and modified Altemeier procedure has relatively low recurrence. Further larger studies are needed to compare the efficacy of these techniques.

Do colorectal cancer patients with a postoperative stoma have sexual problems? A pooling up analysis of 2566 patients

PURPOSE

This study aimed to evaluate the effect of the stoma on sexual function in colorectal cancer patients.

METHODS

Search strategy was conducted in four databases including PubMed, Embase, the Cochrane Library, and Medline on Nov 20, 2022. After that, the quality of eligible studies was assessed by the Newcastle Ottawa Scale (NOS) and the Agency for Healthcare Research Quality (AHRQ). In order to evaluate the sexual function between the stoma group and the non-stoma group, mean values and standard deviation were pooled for scores in questionnaires, and odds ratio and 95% confidence intervals were pooled for self-designed problems. Results were shown in forest plots; Egger's test and the trim and fill analysis were used for assessing the publication bias. All the data analyses above were performed by STATA 16.0 software.

RESULTS

Six cohort studies and three cross-sectional studies were included for this pooling up analysis. As for the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-C38), male patients with stomas had more sexual problems (mean differences = 0.32, 95% confidence intervals = 0.01 to 0.63, I² = 67.80%, P = 0.05); however, other indicators including sexual functioning, sexual enjoyment, and female sexual problems had little difference between the two groups. As for other questionnaires and problems, stoma did not have an impact on sexual function.

CONCLUSION

The stoma after surgery was not significantly associated with the sexual function of female patients with colorectal cancer and was associated with worse scores on only sexual problems for males.

Systematic review with meta-analysis: Current and emerging models of preoperative psychological preparation for individuals undergoing stoma surgery

OBJECTIVE

Stoma surgery is a profoundly life changing event that can result in a range of negative psychological and mental health outcomes, often requiring significant postoperative adaption. While postoperative avenues of support to address these outcomes exist, there remains a lack of preoperative psychological preparation for surgical candidates in standard models of care. The present systematic review and meta-analysis aims to examine the current and emerging models of psychological preparation available to stoma surgery candidates during the preoperative period.

METHODS

A systematic search of PubMed, Embase, Emcare, PsycINFO, CINAHL, and SCOPUS was conducted. All studies examining the effects of preoperative psychological interventions targeting postoperative psychological adjustment and/or mental health outcomes for individuals planning to undergo or who had undergone stoma surgery were included.

RESULTS

Overall, 15 publications meeting inclusion criteria were identified, encompassing 1565 total participants. Intervention types ranged from psychoeducational, counselling, and practical based skills, examining the postoperative outcomes of anxiety, depression, quality of life, adjustment, self-efficacy, and systematic improvements to standard models of care. Five studies examining postoperative anxiety were included for meta-analysis, demonstrating an overall significant effect (SMD = -1.13, 95% CI -1.96 to -0.30, p = .008). Due to the high level of heterogeneity between remaining studies, articles examining postoperative outcomes other than anxiety were synthesised in narrative form.

CONCLUSION

Despite some promising advancements in the field, there remains insufficient evidence to judge the overall effectiveness of current and emerging models of preoperative psychological preparation on postoperative psychological outcomes for individuals facing stoma surgery.

Management of treatment-related sequelae following colorectal cancer

AIM

Colorectal cancer survivors are one of the most rapidly growing groups of patients living with and beyond cancer. In a national multidisciplinary setting, we have examined the extent of late treatment-related sequelae in colorectal cancer survivors and present the scientific evidence for management of these conditions in this patient category with the aim of facilitating identification and treatment.

METHOD

A systematic search for existing guidelines and relevant studies was performed across 16 and 4 databases, respectively, from inception to 2021. This yielded 13 guidelines and 886 abstracts, of which 188 were included in the finalized guideline (231 included for full text review). Secondarily, bibliographies were cross-referenced and 53 additional articles were included.

RESULTS

Symptoms have been divided into overall categories including psychosocial, bowel-related, urinary, sexual (male and female), pain/neuropathy and fatigue symptoms or complaints that are examined individually. Merging and grading of data resulted in 22 recommendations and 42 management strategies across categories. Recommendations are of a more general character, whereas management strategies provide more practical advice suited for initiation on site before referral to specialized units.

CONCLUSION

Treatment-related sequelae in colorectal cancer survivors are common and attention needs to be focused on identifying patients with unmet treatment needs and the development of evidence-based treatment algorithms.

Predictors of Psychological Distress among Patients with Colorectal Cancer-Related Enterostomy: A Cross-sectional Study

OBJECTIVE

To identify variables that may predict psychological distress in patients with an enterostomy.

METHODS

Investigators recruited 77 patients with a stoma from a stoma clinic according to the inclusion criteria. Patients' psychological distress was assessed with the Distress Thermometer (DT) tool, and their personality type was determined by the Eysenck Personality Questionnaire. Researchers also collected demographic and disease-related data. Predictive values were estimated using multiple regression analyses.

RESULTS

The mean DT score of all patients was 5.94 (SD, 1.81), and approximately 85.7% consistently suffered from psychological distress. Being unmarried and having peristomal complications were associated with higher psychological distress, whereas having a monthly income 5,000 ¥ or more was associated with lower levels of distress. Moreover, patients with a melancholic personality type tended to have higher DT scores, which could act as a strong independent predictor for psychological distress.

CONCLUSIONS

The majority of patients with a stoma endured moderate to severe psychological distress during follow-up care. Exploring the related factors that predict the levels of psychological distress could enable clinicians to identify at-risk patients as early as possible and thus provide optimal care for improving patients' quality of life.

Perianal Bowen's disease treated with radiotherapy preserving anal function with a unique skin reaction considered as 'tumoritis'

Bowen's disease (BD) is a form of intraepidermal squamous cell carcinoma (SCC), and it occasionally occurs on the perianal site. BD is often treated with surgical excision; however, sometimes surgical excision for perianal BD cannot preserve anal function. We report the case of a 72-year-old man presenting with perianal pain and BD. He was treated with Radiotherapy (RT) and preserved his normal anal sphincter function without any recurrence or late adverse event. Moreover, we observed the unique skin reaction called 'tumoritis', which is characterized by mucosal inflammation. Tumoritis indicates the true extent of the tumor and evaluating the tumor or lesion size based on the extent of tumoritis when performing RT is important.

Impact of Prediagnosis Risk of Major Depressive Disorder and Health-Related Quality of Life on Treatment Choice for Stage II-III Rectal Cancer

PURPOSE

We hypothesized that depressive symptoms and health-related quality of life (HRQOL) reported by patients before their cancer diagnoses would be associated with treatment choice for stage II and III rectal cancer, specifically whether patients underwent surgery.

METHODS

The Surveillance, Epidemiology, and End Results and Medicare Health Outcomes Survey linked data set was used to identify patients with stage II-III rectal adenocarcinoma diagnosed between 2004 and 2013 who had completed the health outcomes survey within 36 months before their cancer diagnoses. Risk for major depressive disorder (MDD) was determined on the basis of responses to screening questions for depressive disorders. HRQOL was assessed using the Mental Component Summary and Physical Component Summary of the 36-Item Short Form Survey and Veterans RAND 12-Item Health Survey. Using univariable and multivariable analyses, we assessed for associations between health survey responses and ultimate treatment modality.

RESULTS

We identified 142 evaluable patients, of whom 109 (76.8%) underwent surgery. Thirty patients (21.1%) met criteria for being at risk for MDD before their cancer diagnoses. Patients at risk for MDD underwent surgery less often than those not at risk (P = .0499), and this association strengthened after adjusting for patient characteristics (odds ratio, 0.17; 95% CI, 0.04 to 0.82; P = .027). There was a nonsignificant trend between higher Mental Component Summary scores (indicating higher self-reported mental HRQOL) and increased frequency of undergoing surgery (P = .081). There were no significant associations between the Physical Component Summary and treatment modality.

CONCLUSION

In Medicare beneficiaries with stage II-III rectal cancer, those at risk for MDD underwent standard-of-care treatment with surgery less frequently. Further studies are warranted to assess the effect of mental health on clinical decision making in this patient population.

Applying interpretable machine learning algorithms to predict risk factors for permanent stoma in patients after TME

Objective

The purpose of this study was to develop a machine learning model to identify preoperative and intraoperative high-risk factors and to predict the occurrence of permanent stoma in patients after total mesorectal excision (TME).

Methods

A total of 1,163 patients with rectal cancer were included in the study, including 142 patients with permanent stoma. We collected 24 characteristic variables, including patient demographic characteristics, basic medical history, preoperative examination characteristics, type of surgery, and intraoperative information. Four machine learning algorithms including extreme gradient boosting (XGBoost), random forest (RF), support vector machine (SVM) and k-nearest neighbor algorithm (KNN) were applied to construct the model and evaluate the model using k-fold cross validation method, ROC curve, calibration curve, decision curve analysis (DCA) and external validation.

Results

The XGBoost algorithm showed the best performance among the four prediction models. The ROC curve results showed that XGBoost had a high predictive accuracy with an AUC value of 0.987 in the training set and 0.963 in the validation set. The k-fold cross-validation method was used for internal validation, and the XGBoost model was stable. The calibration curves showed high predictive power of the XGBoost model. DCA curves showed higher benefit rates for patients who received interventional treatment under the XGBoost model. The AUC value for the external validation set was 0.89, indicating that the XGBoost prediction model has good extrapolation.

Conclusion

The prediction model for permanent stoma in patients with rectal cancer derived from the XGBoost machine learning algorithm in this study has high prediction accuracy and clinical utility.

No Reduction in Parastomal Hernia Rate 3 Years After Stoma Construction With Prophylactic Mesh: Three-year Follow-up Results From STOMAMESH-A Multicenter Double-blind Randomized Controlled Trial

OBJECTIVE

The primary objective was to compare rates of parastomal hernia (PSH) 3 years after stoma construction with prophylactic mesh or no mesh. A secondary objective was to compare complications requiring reintervention within 3 years.

BACKGROUND

Recent studies have shown that a prophylactic mesh does not reduce the rate of PSH contrary to older studies. Long-term data on efficacy and safety is however scarce.

METHODS

A randomized controlled double-blind multicenter trial. Patients planned for permanent end colostomy were randomized to either prophylactic mesh in the retromuscular position around the stoma site or no mesh. They were evaluated for PSH clinically and with computed tomography (CT) 3 years after stoma construction. Medical records of all patients included were also reviewed at 3 years to detect any abdominal or abdominal wall surgery during that period.

RESULTS

A total of 232 patients were randomized. At 3 years, 154 patients were available for clinical evaluation and 137 underwent a CT scan. No significant difference in PSH rates was seen between the treatment allocation arms (clinical: P =0.829 and CT: P =0.761, respectively), nor was there a significant difference in the number of reinterventions, but 2 patients had their mesh removed at emergency surgery.

CONCLUSIONS

Prophylactic mesh does not reduce the rate of PSH and cannot be recommended for routine use.

The watch-and-wait strategy versus radical resection for rectal cancer patients with a good response (≤ycT2) after neoadjuvant chemoradiotherapy

Purpose

This study aims to oncologic outcomes of the watch-and-wait (WW) strategy compared with radical resection (RR).

Methods

Patients with rectal cancer who received neoadjuvant chemoradiotherapy (nCRT) and achieved ≤ycT2 between 2008 and 2016 were included. The mean follow-up time was 61 months (range, 0-168 months). Recurrence-free survival (RFS), local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were compared. A total of 446 patients were included, and WW was adopted for 34 patients.

Results

WW patients were older (P = 0.022) and less advanced initial cT stage (P = 0.004). Ten patients in the WW group (29.4%) experienced local regrowth. Later, distant metastases occurred in 7 of these patients. The 5-year RFS (74.1% vs. 79.5%), DMFS (74.1% vs. 81.6%), and OS (90.4% vs. 87.7%) for the WW and RR groups were not statistically different. However, LRFS in the WW group was significantly lower (65.1% vs. 97.0%, P < 0.001). The initial cT stage was associated with RFS (P = 0.019) and LRFS (P = 0.037). WW was an independent risk factor for LRFS (P < 0.001) and DMFS (P = 0.024). After 1:4 propensity score matching between the WW and RR groups, there was no difference in RFS and OS. However, the 5-year LRFS (67.5% vs. 96.5%) and DMFS (73.2% vs. 86.4%) demonstrated a statistically significant difference between the groups.

Conclusion

By appointing the WW strategy, oncologic safety was not ensured. The WW strategy must be implemented with caution in patients with ≤ycT2 stage, particularly those with advanced initial cT stage.

The Quality of Life of Patients with Surgically Treated Colorectal Cancer: A Narrative Review

INTRODUCTION

Quality of life is a topic increasingly being addressed by researchers. Due to the increasing incidence of colorectal cancer, this issue is particularly relevant. Despite the increasing number of publications on this topic each year, it still requires further research. The aim of this study was to analyze the available literature from the past 10 years, addressing the topic of QoL in patients with colorectal cancer which has been treated surgically.

MATERIAL AND METHODS

This review is based on 93 articles published between 2012 and 2022. It analyzes the impact of socioeconomic factors, the location and stage of the tumor, stoma and the method of surgical treatment on patients' QoL and sexual functioning.

RESULTS

CRC has a negative impact on patients' financial status, social functioning, pain and physical functioning. Patients with stage II or III cancer have an overall lower QoL than patients with stage I. The more proximally the lesion is located to the sphincters, the greater the negative impact on the QoL. There was a significant difference in favor of laparoscopic surgery compared with open surgery. In patients with a stoma, the QoL is lower compared with patients with preserved gastrointestinal tract continuity. The more time has passed since surgery, the more the presence of a stoma has a negative impact on QoL. Surgery for CRC negatively affects patients' sex lives, especially in younger people and among men.

CONCLUSIONS

This study may contribute to the identification of the factors that affect the QoL of patients with surgically treated colorectal cancer. This will allow even more effective and complete treatment, facilitating patients' return to normal physical, mental and social functioning.

The Quality of Life of Patients with Colorectal Carcinoma and Stoma

Surgical treatment and formation of a stoma can be lifesaving for colorectal cancer patients. However, the quality of life is often impaired in patients with stoma. The goal of this study is to determine the quality of life of patients with stoma and cancer, and the relationship between the quality of life and characteristics of these patients.

The study was conducted from 2018 to 2020 and included a total of 64 patients of both sexes with colorectal cancer and temporary or permanent stoma. The European Organization for Research and Treatment of Cancer with Quality of Life Questionnaire (EORTC QLQC29-30) and the anonymous WHO Quality of Life Questionnaire SF-36 were used for self-assessment of quality of life.

Our study included 39 (61.0%) men and 25 (39.0%) women. 24 patients (37.5%) had colostomy, 14 patients (21.9%) had ileostomy, and 26 patients (40.6%) underwent surgery for resection of colorectal cancer without stoma. A significant number of women were in the group of patients with a permanent stoma (p = 0.01). There was no statistically significant difference in the assessment of general health (p = 0.680) and quality of life (p = 0.721) during the past month in relation to gender. Patients without a stoma rated their general health better compared to those with stoma and the difference reached statistical significance (p = 0.035). There was no statistically significant difference in the assessment of quality of life between the group of patients with stoma and without stoma, as well as between the patients of different age groups.

Patients with stoma rated their general health as worse, but not their quality of life.

Evaluating the outcomes of primary anastomosis with hand-sewn full-circular reinforcement in managing perforated left-sided colonic diverticulitis

Background

It is a challenge to avoid stoma formation in emergency surgery of perforated left-sided diverticulum. The hand-sewn full-circular reinforcement of the colorectal anastomosis is used during complete pelvic peritonectomy to avoid a diverting ileostomy. This study examined the effect of applying the reinforcement method to perforated left-sided colonic diverticulitis with respect to the permanent stoma rate and cost-effectiveness.

Materials and methods

This historical cohort study examined all patients who underwent emergency surgery for perforation of a left-sided diverticulum at the Hyogo Prefectural Amagasaki General Medical Center between July 2015 and September 2019. The cohort was divided into two groups: those who underwent conventional method (Group F) and those for whom the hand-sewn full-circular reinforcement method was actively performed (Group L).

Results

The number of patients who underwent emergency surgery which did not lead to an ostomy increased significantly from 12% (3/25) in Group F to 42% (11/26) in Group L (P = 0.0015). The rate of permanent stoma decreased from 80% in Group F to 27% in Group L (P < 0.001). Total treatment costs for patients under the age of 80 in Group L were significantly lower than those in Group F (2170000 ± 1020000 vs 3270000 ± 1960000 JPY; P = 0.018).

Conclusions

In emergency surgery for left-sided perforated colonic diverticulitis, applying the hand-sewn full-circle reinforcement of the anastomotic site may reduce stoma formation at the initial surgery and consequently decrease permanent stoma rate and contribute to cost-effectiveness without increasing complications such as anastomotic leakage.

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Primary anastomosis was used as an emergency approach to perforated diverticulitis.

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Primary anastomosis was reinforced by a hand-sewn serosal suture.

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Full-circle reinforcement of the anastomosis may decrease the permanent stoma rate.

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Full-circle reinforcement of the anastomosis may be cost effective in approach to perforated diverticulitis.

The Lived Experience of Jordanian Persons With a Stoma: A Qualitative Study

Individuals may live with an intestinal stoma either temporarily or for the rest of their lives. The purpose of this study was to understand the lived experience of Jordanian persons living with a stoma. Qualitative design was employed via semistructured interviews with 22 Muslim participants who had an intestinal stoma. Thematic analysis of the transcripts resulted in 3 main themes. The first core theme was stoma burden, which represented difficulties and challenges resulting from the creation of a stoma. This theme was divided into 4 subthemes: physical, self-care, social, and psychological burdens. The second theme was the adaptation to a stoma, whereas the third theme was suggestions for healthcare providers to decrease stoma burden. Conclusively, these themes conveyed that the presence of supportive family members and qualified healthcare providers can decrease the burden of a stoma. Generally, persons with a stoma (ostomates) experienced stoma-related physical, social, psychological, and financial burdens. Therefore, ostomates were in need of training, psychosocial therapy, and more follow-ups to prevent and treat stoma complications and adapt to living easily with the stoma.

Continuing Care Bundle in Elderly Patients with Rectal Cancer after Radical Resection with Permanent Stoma

Objective. A continuing care bundle can achieve a better outcome than a single implementation after discharge. This study aims to investigate the effect of this intervention in elderly patients with rectal cancer after radical resection with a permanent stoma. Methods. Elderly patients diagnosed with rectal cancer underwent radical resection with permanent stoma, they were divided into the control group (n = 42) and bundle group (n = 42). The control group received the conventional care, and the bundle group received the continuing care bundle in addition to the conventional care. At 1- and 3-month after discharge, self-efficacy, self-care knowledge, ability to change stoma appliances, negative emotions, quality of life, and patient satisfaction were observed. Results. The increased levels of self-efficacy, self-care knowledge, and ability to change stoma appliances were displayed in the bundle group after discharge as compared with that in the control group, along with the enhanced score of SF-36 subscales, including physical function (PF), role physical (RP), global health (GH) and vitality (V), social function (SF), and mental health (MH). Furthermore, patients showed alleviated depression and anxiety after the continuing care bundle as compared to those after conventional care. Besides, the bundle groups had higher patient satisfaction than the control group. Conclusions. Continuing care bundle can serve as an effectiveness intervention in elderly rectal cancer patients after radical resection with permanent stoma via increasing self-efficacy and self-care knowledge, enhancing the ability to change stoma appliance, reliving the negative emotion, and improving quality of life and patient satisfaction.