Functional results and quality of life for patients with very low rectal cancer undergoing coloanal anastomosis or perineal colostomy with colonic muscular graft

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.

Functional outcomes over time following perineal pseudocontinent colostomy reconstruction after abdominoperineal resection for ultralow rectal adenocarcinoma

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.

Laparoscopic sphincter reconstruction after abdominoperineal resection: feasibility and technical aspects

BACKGROUND

Abdominal colostomy has been reported as an option with good quality of life for patients requiring abdominoperineal resection (APR) for very low rectal cancer. Some young, compliant patients, nevertheless, are very motivated to avoid abdominal colostomy following APR. Spiral smooth muscle cuff perineal colostomy as neosphincter reconstruction can be a reasonable alternative. We have published before the results of a series of sphincter reconstruction in the conventional technique following APR. As we developed our technique for colorectal resection sphincter reconstruction, we also changed to a laparoscopic approach.
 The aim of the present study was to evaluate the feasibility of laparoscopic neosphincteric reconstruction and outline the aspects of the technique.

METHODS

This retrospective study was conducted on 15 patients treated at our institution during a 6 year period for low rectal cancer by laparoscopic APR and spiral smooth muscle cuff perineal colostomy as sphincter reconstruction. At follow-up at a median time of 3.7 years (range 3-9 years) after surgery, patients underwent functional evaluation which included the modified Holschneider continence score (0-16), assessing consistency of stool, frequency, impulse, discrimination, warning period, incontinence for formed or fluid feces, soiling, wearing pads, drugs, enema where a score of 13-16 is associated with normal continence, as well as neosphincter manometry.

RESULTS

Laparoscopic sphincter reconstruction was feasible in all 15 patients. Two of the fifteen patients (13%) required secondary colostomy in the long term due to neosphincter malfunction and neosphincter perforation after enema. Four of the remaining thirteen patients (30%) were partially continent according to the Holschneider continence score (HCS) with a score of 7-12. The other 9 (70%) were continent (HCS: 13-16). Neosphincter manometry showed a median resting pressure of 33 cm H₂O (range 30-41 cm H₂O) and a median squeeze pressure of 95 cm H₂O (range 84-150 cm H₂O).

CONCLUSIONS

Laparoscopic sphincter reconstruction following APR is a feasible option offering an alternative to abdominal colostomy for selected patients.

Perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma: the muscular graft as a pseudosphincter

BACKGROUND AND STUDY AIM

The aim of this study was to analyze objectively the role of the muscular graft in the continence using manometric study in the patients who underwent pseudocontinent perineal colostomy after abdominoperineal resection for rectal adenocarcinoma.

PATIENTS AND METHODS

This was a retrospective study including all the patients from January 2002 to December 2009 who underwent an abdominoperineal resection followed by perineal pseudocontinent colostomy for ultra-low rectal adenocarcinoma and agreed to perform the manometric evaluation of the muscular graft.

RESULTS

Fifteen patients were included, six males and nine females, with a mean age of 50 years. According to Kirwan's classification, 2 (13.3%) patients had normal continence (Stage A) had 10 (66.6%) no soiling (stage B) and 3 (20%) patients had minimal soiling (Stage C). The manometric evaluation was performed after a median period of 12 months post-surgery. The mean maximal resting and squeeze pressures were respectively 41 cmH2O and 59 cmH2O and the mean colonic sensory volume was 12 ml.

CONCLUSION

This study showed that the musculae graft of Pseudocontinent Perineal colostomy acted as a hypotonic sphincter that pressure can increase during the voluntary squeeze. These data may help to clarify the functional outcomes of this technique after APR for ultra-low rectal adenocarcinoma.

Perineal pseudocontinent colostomy is safe and efficient technique for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma

Background

The aim of this study was to evaluate oncologic results and satisfaction rate results of pseudocontinent perineal colostomy (PCPC) using Schmidt’s technique in patients undergoing abdominoperineal resection (APR) for managing low rectal adenocarcinoma.

Methods

From January 1993 and December 2007, One hundred and forty six patients underwent successfully PCPC after abdominoperineal resection for lower rectal adenocarcinoma. There were 75 women, with an average age of 47 years old. All patients received neoadjuvant radiotherapy with or without chemotherapy. Long-term oncological results and satisfaction rate were evaluated.

Results

After a median follow up of 36 months (range 12–156) months, the five-year overall survival and disease free survival rate were 74.6% and 60.3% respectively. Local and distant recurrences occurred respectively in 10 (6,8%) and 29 (20%) patients. Seventy-seven percent (77%) of the patients were highly satisfied with this technique and only one patient was unsatisfied. However, none of them accepted the conversion to an abdominal colostomy neither would have changed PCPC for an iliac colostomy at first intent.

Conclusion

This study showed that pseudocontinent perineal colostomy is a safe and reliable pelvic reconstruction technique after abdominoperineal resection for low rectal adenocarcinoma. It provides high degree of patient satisfaction without compromising oncological results. It is a good option in selected patients, especially in Muslim countries.

Current aspects and future prospects of total anorectal reconstruction--a critical and comprehensive review of the literature

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.

Surgical strategy for low rectal cancers

The two goals of surgery for lower rectal cancer surgery are to obtain clear "curative" margins and to limit post-surgical functional disorders. The question of whether or not to preserve the anal sphincter lies at the center of the therapeutic choice. Histologically, tumor-free distal and circumferential margins of>1mm allow a favorable oncologic outcome. Whether such margins can be obtained depends of TNM staging, tumor location, response to chemoradiotherapy and type of surgical procedure. The technique of intersphincteric resection relies on these narrow margins to spare the sphincter. This procedure provides satisfactory oncologic outcome with a rate of circumferential margin involvement ranging from 5% to 11%, while good continence is maintained in half of the patients. The extralevator abdominoperineal resection provides good oncologic results, however this procedure requires a permanent colostomy. A permanent colostomy alters several domains of quality of life when located at the classical abdominal site but not when brought out at the perineal site as a perineal colostomy.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

The antegrade continence enema procedure and total anorectal reconstruction

Patients may present with anal incontinence (AI) following repair of a congenital anorectal anomaly years previously, or require total anorectal reconstruction (TAR) following radical rectal extirpation, most commonly for rectal cancer. Others may require removal of their colostomy following sphincter excision for Fournier's gangrene, or in cases of severe perineal trauma. Most of the data pertaining to antegrade continence enema (the ACE or Malone procedure) comes from the pediatric literature in the management of children with AI, but also with supervening chronic constipation, where the quality of life and compliance with this technique appears superior to retrograde colonic washouts. Total anorectal reconstruction requires an anatomical or physical supplement to the performance of a perineal colostomy, which may include an extrinsic muscle interposition (which may or may not be 'dynamized'), construction of a neorectal reservoir, implantation of an incremental artificial bowel sphincter or creation of a terminal, smooth-muscle neosphincter. The advantages and disadvantages of these techniques and their outcome are presented here.

Risk factors of poor functional results at 1-year after pseudocontinent perineal colostomy for ultralow rectal adenocarcinoma

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.

Comparison of fecal continence and quality of life between intersphincteric resection and abdominoperineal resection plus perineal colostomy for ultra-low rectal cancer

AIMS

The only two procedures for surgical treatment of ultra-low rectal cancer without a permanent abdominal stoma are the intersphincteric resection (ISR) and the abdominoperineal resection (APR) plus a perineal pseudocontinent colostomy (PCC). This study compared functional results and quality of life following these two techniques.

METHODS

Between January 1995 and December 2011, 36 patients had undergone an ISR (n = 14) or a PPC (n = 22) for very low rectal cancer. The Cleveland Clinica Florida (Wexner) fecal incontinence questionnaire and the EORTC Quality of Life questionnaire QLQ-C30 and CR38 had been administered.

RESULTS

There were no differences in gender, age, the interval between surgery and questionnaire responses, preoperative TNM staging, perioperative treatment, the laparoscopic approach and circumferential margin involvement rate between the groups. The ISR and PPC led to no difference in quality of life (Qol) and continence with a median Wexner score of respectively 11 and 10 (P = 0.403) and a fecal incontinence rate of 58.2% and 41% (P = 0.221). The incontinent patients had experienced worse social functioning and tended to have worse overall health. The patients who had undergone ISR had more defecation problems and evacuation difficulties.

CONCLUSION

Qol and continence are similar between ISR and PPC.

Sequence characterization of cDNA sequence of encoding of an antimicrobial Peptide with no disulfide bridge from the Iranian mesobuthus eupeus venomous glands

Background

Scorpion venom glands produce some antimicrobial peptides (AMP) that can rapidly kill a broad range of microbes and have additional activities that impact on the quality and effectiveness of innate responses and inflammation.

Objectives

In this study, we reported the identification of a cDNA sequence encoding cysteine-free antimicrobial peptides isolated from venomous glands of this species.

Materials and Methods

Total RNA was extracted from the Iranian mesobuthus eupeus venom glands, and cDNA was synthesized by using the modified oligo (dT). The cDNA was used as the template for applying Semi-nested RT- PCR technique. PCR Products were used for direct nucleotide sequencing and the results were compared with Gen Bank database.

Results

A 213 BP cDNA fragment encoding the entire coding region of an antimicrobial toxin from the Iranian scorpion M. Eupeus venom glands were isolated. The full-length sequence of the coding region was 210 BP contained an open reading frame of 70 amino with a predicted molecular mass of 7970.48 Da and theoretical Pi of 9.10. The open reading frame consists of 210 BP encoding a precursor of 70 amino acid residues, including a signal peptide of 23 residues a propertied of 7 residues, and a mature peptide of 34 residues with no disulfide bridge. The peptide has detectable sequence identity to the Lesser Asian mesobuthus eupeus MeVAMP-2 (98%), MeVAMP-9 (60%) and several previously described AMPs from other scorpion venoms including mesobuthus martensii (94%) and buthus occitanus Israelis (82%).

Conclusions

The secondary structure of the peptide mainly consisted of α-helical structure which was generally conserved by previously reported scorpion counterparts. The phylogenetic analysis showed that the Iranian MeAMP-like toxin was similar but not identical with that of venom antimicrobial peptides from lesser Asian scorpion mesobuthus eupeus.

Comparison of Colonic J-pouch and Straight Coloanal anastomosis after Low Anterior Resection

Background

The tendency towards sphincter preserving for low rectal cancers with low anterior resection, has led to the technique of straight coloanal anastomosis (SCAA) or colonic J-pouch anal anastomosis (CPAA).

Objectives

The aim of our study was to compare functional outcomes, complication rates and quality of life (QoL) after LAR with either a straight or colonic J pouch anastomosis.

Patients and Methods

In 88 patients with rectal tumors located in lower third, who were candidate for LAR with coloanal anastomosis. They were divided for reconstruction using either SCAA (n= 47) or CPAA (n= 41) from January 2007 to May 2009. Functional results were assessed after closure of temporary loop ileostomy, 6 months postoperatively. Quality of life (QoL) was measured using European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30.

Results

The two groups were matched for gender, age, and preoperative chemotherapy and radiotherapy. There were no significant differences between the SCAA and CPAA groups relative to anastomotic leakage. Among patients with CPAA, the mean of 24 hours bowel movements, daytime bowel movements, incontinence scores, and incidence of urgency were significantly lower than those in the SCAA group. Also, patients with a CPAA had a significantly better quality of life.

Conclusions

CPAA provided not only better functional results than SCAA, but also improved quality of life, thus may be the better choice.

Sequence characterization of cDNA sequence of encoding of an antimicrobial Peptide with no disulfide bridge from the Iranian mesobuthus eupeus venomous glands

BACKGROUND

Scorpion venom glands produce some antimicrobial peptides (AMP) that can rapidly kill a broad range of microbes and have additional activities that impact on the quality and effectiveness of innate responses and inflammation.

OBJECTIVES

In this study, we reported the identification of a cDNA sequence encoding cysteine-free antimicrobial peptides isolated from venomous glands of this species.

MATERIALS AND METHODS

Total RNA was extracted from the Iranian mesobuthus eupeus venom glands, and cDNA was synthesized by using the modified oligo (dT). The cDNA was used as the template for applying Semi-nested RT- PCR technique. PCR Products were used for direct nucleotide sequencing and the results were compared with Gen Bank database.

RESULTS

A 213 BP cDNA fragment encoding the entire coding region of an antimicrobial toxin from the Iranian scorpion M. Eupeus venom glands were isolated. The full-length sequence of the coding region was 210 BP contained an open reading frame of 70 amino with a predicted molecular mass of 7970.48 Da and theoretical Pi of 9.10. The open reading frame consists of 210 BP encoding a precursor of 70 amino acid residues, including a signal peptide of 23 residues a propertied of 7 residues, and a mature peptide of 34 residues with no disulfide bridge. The peptide has detectable sequence identity to the Lesser Asian mesobuthus eupeus MeVAMP-2 (98%), MeVAMP-9 (60%) and several previously described AMPs from other scorpion venoms including mesobuthus martensii (94%) and buthus occitanus Israelis (82%).

CONCLUSIONS

The secondary structure of the peptide mainly consisted of α-helical structure which was generally conserved by previously reported scorpion counterparts. The phylogenetic analysis showed that the Iranian MeAMP-like toxin was similar but not identical with that of venom antimicrobial peptides from lesser Asian scorpion mesobuthus eupeus.

Quality of life after rectal resection for cancer, with or without permanent colostomy

BACKGROUND

For almost one hundred years abdominoperineal excision has been the standard treatment of choice for rectal cancer. With advances in the techniques for rectal resection and anastomosis, anterior resection with preservation of the sphincter function has become the preferred treatment for rectal cancers, except for those cancers very close to the anal sphincter. The main reason for this has been the conviction that the quality of life for patients with a colostomy after abdominoperineal excision was poorer than for patients undergoing an operation with a sphincter-preserving technique. However, patients having sphincter-preserving operations may experience symptoms affecting their quality of life that are different from stoma-patients.

OBJECTIVES

To compare the quality of life in rectal cancer patients with or without permanent colostomy.

SEARCH METHODS

We searched PUBMED, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Colorectal Cancer Group's specialised register. Abstract books from major gastroenterological and colorectal congresses were searched. Reference lists of the selected articles were scrutinized.

SELECTION CRITERIA

All controlled clinical trials and observational studies in which quality of life was measured in patients with rectal cancer having either abdominoperineal excision/Hartmann's operation or low anterior resection, using a validated quality of life instrument, were considered.

DATA COLLECTION AND ANALYSIS

One reviewer (JP) checked the titles and abstracts identified from the databases and hand search. Full text copies of all studies of possible relevance were obtained. The reviewer decided which studies met the inclusion criteria. Both reviewers independently extracted data. If information was insufficient the original author was contacted to obtain missing data. Extracted data were cross-checked and discrepancies resolved by consensus.

MAIN RESULTS

Sixty-nine potential studies were identified. Thirty-five of these, all non-randomised and representing 5127 participants met the inclusion criteria. Fourteen trials found that people undergoing abdominoperineal excision/Hartmann's operation did not have poorer quality of life measures than patients undergoing anterior resection. The rest of the studies found some difference, but not always in favour of non-stoma patients. Due to clinical heterogeneity and the fact that all studies were observational trials, meta-analysis of the included studies was not possible.

AUTHORS' CONCLUSIONS

The studies included in this review do not allow firm conclusions as to the question of whether the quality of life of people after anterior resection is superior to that of people after abdominoperineal excision/Hartmann's operation. The included studies challenges the assumption that anterior resection patients fare better. Larger, better designed and executed prospective studies are needed to answer this question.

External coloanal anastomosis without covering stoma in low-lying rectal cancer

The aim of this study was to evaluate the safety and functional outcome of external coloanal anastomosis without covering stoma in treating low-lying rectal cancer. All patients undergoing the coloanal anastomosis for low lying rectal carcer in the Department of General Surgery, Minia University Hospital, between May 2006 and May 2009 were included. Seventy two patients underwent coloanal anastomosis, and follow up was available for all patients. Mean follow up period was 12.6 ± 4.7 months. Postoperatively, fecal continence was normal in 84.7% of patients. Postoperative complications included anastomotic fistula in 3 patients (4.2%) and anastomotic stenosis in 6 patients (8.3%). There was no effect of pre or postoperative adjuvant therapy on the procedure outcome. There was no local recurrence during follow up period. Three patients died at the end of follow up period due to distant metastasis. In treatment of low-lying rectal cancer, abdominoperineal resection should be avoided if coloanal anastomosis provides similar control of the disease as it is safe and has good functional results and acceptable complication rate.

Sexual (dys)function and the quality of sexual life in patients with colorectal cancer: a systematic review

BACKGROUND

To determine (i) the prevalence of sexual (dys)function in patients with colorectal cancer and (ii) treatment-related and sociodemographic aspects in relation to sexual (dys)function and the quality of sexual life. Recommendations for future studies are provided.

METHODS

A systematic search was conducted during the period 1990 to July 2010 that used the databases PubMed, PsychINFO, The Cochrane Library, EMBASE, and OVID Medline.

RESULTS

Eighty-two studies were included. The mean quality score was 7.2. The percentage of preoperatively potent men that experienced sexual dysfunction postoperatively varied from 5% to 88%. Approximately half of the women reported sexual dysfunction. Preoperative radiotherapy, a stoma, complications during or after surgery, and a higher age predicted more sexual dysfunction with a strong level of evidence. Type of surgery and a lower tumor location predicted more sexual dysfunction with a moderate level of evidence. Insufficient evidence existed for predictors of the quality of sexual life. Current studies mainly focus on biological aspects of sexual (dys)function. Furthermore, existing studies suffer from methodological shortcomings such as a cross-sectional design, a small sample size, and the use of nonstandardized measurements.

CONCLUSION

Sexuality should be investigated prospectively from a biopsychosocial model, hereby including the quality of sexual life.

How low is low? Evolving approaches to sphincter-sparing resection techniques

Although advances in rectal cancer staging may ultimately be accurate enough to reliably exclude disease outside the rectal wall (thereby allowing local approaches to be more widely and safely applied) and advances in the use of neoadjuvant chemo- and radiation therapy may ultimately produce more "complete responders" that can be accurately identified and spared surgery altogether, as it stands, radical resection forms the basis of curative treatment for rectal cancer. However, the concepts that guide the surgeon in choosing the optimal approach in radical resection are changing. In the past, the decision as to how to proceed surgically with radical resection was based primarily on the level of the tumor above the anal verge or anorectal ring. The issue was primarily "How low is the tumor?" and "Is the distal margin safe?" A more modern approach focuses attention on achieving a negative circumferential margin despite what historically may seem to be a very minimal distal margin, the current issue is not "How low is the tumor?" so much as it is "How deep does the tumor go?". This shift in focus has been a major impetus in the evolution of sphincter sparing resection techniques.

Perineal colostomy with spiral smooth muscle graft for neosphincter reconstruction following abdominoperineal resection of very low rectal cancer: long-term outcome

BACKGROUND

To avoid abdominal colostomy and improve quality of life, several types of anorectal reconstruction following abdominoperineal resection have been proposed. The aim of this study was to assess functional results and the quality of life of patients with very low rectal cancer after abdominoperineal resection and neosphincter reconstruction by perineal colostomy with a colonic muscular cuff.

PATIENTS AND METHODS

Twenty-seven patients who had undergone neosphincter reconstruction with a perineal spiral cuff plasty after abdominoperineal resection were included in a retrospective study to evaluate long-term outcome. The functional results were analyzed using anal manometry and the continence score. The quality of life was measured with the global and disease-specific questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 and C38.

RESULTS

Median follow-up time was 105 months (range, 18-185 mo). The median Holschneider continence score of the study sample was 13 (continent), with a range of 10 (partially continent) to 16 (continent), thus demonstrating satisfactory functional results. The functional assessment was completed by neosphincter manometry which revealed a median resting vs compression pressure of 40 vs 96 cmH2O with a range of 5 to 81 cmH2O vs 49 to 364 cmH2O. The quality-of-life analyses showed an above-average score for both global health and disease-specific status.

CONCLUSION

Spiral cuff colostomy with reconstruction after abdominoperineal resection of very low distal rectal cancer offers a surgical option for a selective group of patients with reasonable functional long-term results and an improved quality of life.

Benefits of perineal colostomy on perineal morbidity after abdominoperineal resection

PURPOSE

Abdominoperineal resection has a high rate of postoperative morbidity of the perineal wound. This study aimed to determine the effects of perineal colostomy on perineal morbidity after abdominoperineal resection.

METHODS

All patients who underwent an abdominoperineal resection for rectal adenocarcinoma between 1993 and 2007 were studied. Two groups were identified and compared who had undergone either an iliac colostomy or a perineal colostomy.

RESULTS

The analysis included 110 patients (iliac colostomy group, n = 41; perineal colostomy group, n = 69). There were fewer instances of pelviperineal morbidity (P = .008) and fewer instances of wound dehiscence (P = .02) in the perineal colostomy group, which resulted in a shorter time to healing (35.3 vs 45.1 d, respectively; P = .04). There was no specific postoperative morbidity in any patient and no difference between the 2 groups regarding long-term perineal morbidity. The benefits from perineal colostomy were statistically significant in patients who received radiation therapy in terms of pelviperineal morbidity (P = .01) and healing time (50.8 vs 35.9 days, respectively; P = .02), whereas no difference was found in patients who had not received radiation therapy.

CONCLUSION

Perineal colostomy is a safe and functionally acceptable procedure for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma. In the present study, there was no additional morbidity related to perineal colostomy, and this procedure was associated with a decrease in perineal morbidity and healing time compared with primary perineal closure, in particular, after radiotherapy treatment.

Sphincter-sparing resection for rectal cancer

Although there is still a place for abdominoperineal resection in the treatment of rectal cancer, the state of the art is sphincter-preserving resection. Even for the lowest of rectal cancers, using a combination of neoadjuvant chemo/radiation, total mesorectal excision, and intersphincteric proctectomy and colonic J-pouch to anal anastomosis, sphincter preservation can be achieved for most patients. The key concept in pushing sphincter preservation forward has been the realization that the deep, circumferential, or lateral margin is all-important. Unless the rectal tumor involves the external sphincter muscle, there is no oncologic need to remove it, and following resection of the tumor, gastrointestinal tract continuity can be restored.

Oncologic and functional results after abdominoperineal resection plus pseudocontinent perineal colostomy for epidermoid carcinoma of the anus

PURPOSE

Surgical treatment for epidermoid carcinoma of the anus is reserved for patients after failure of primary chemoradiotherapy and consists of abdominoperineal resection with permanent iliac colostomy. The purpose of this study was to analyze the oncologic and the functional outcomes after abdominoperineal resection and pseudocontinent perineal colostomy for epidermoid carcinoma of the anus after external radiation at maximal doses (60 Gy).

METHODS

Between 1990 and 2006, 95 patients underwent abdominoperineal resection for an epidermoid carcinoma of the anus. Eighteen (19 percent) underwent construction of a pseudocontinent perineal colostomy. Functional results were evaluated prospectively at regular intervals.

RESULTS

Complete resection (R0) was obtained in 17 of 18 patients. After a median follow-up of 33 (range, 12-198) months, 15 of 18 patients were alive, and 11 were disease free. Five-year overall and disease-free survival rates were 67 and 53 percent, respectively. Functional outcomes were available for 16 patients. According to the Kirwan score, 15 were continent, and 13 did not require pad protection. Overall, 15 of 16 patients were satisfied.

CONCLUSION

Pelvic reconstruction with a pseudocontinent perineal colostomy does not compromise the beneficial effect of salvage surgery, seems to be safe and feasible even after a high dose of radiotherapy, and provides a high degree of satisfaction.