Ileal pouch-anal anastomosis; 18 years of experience and outcomes across two generations of surgeons at a tertiary center in Sweden.

AIM: Reconstructive surgery with ileal pouch-anal anastomosis (IPAA) is the standard procedure after colectomy in patients with Ulcerative Colitis (UC) and Familial Adenomatous Polyposis (FAP). It is of interest to understand how a generation shift of the surgeons performing IPAA has affected patients' outcomes. METHOD: All consecutive patients who underwent IPAA in the period 1999-2016 at Sahlgrenska University Hospital/Östra, Gothenburg, Sweden, were included. Surgeons representing two different generations performed the surgeries during this period. The following 6-year time periods were assigned for surgeries performed by: experienced surgeons (1999-2004; Period 1); the new generation of surgeons undergoing training (2005-2010; Period 2); and the new generation of experienced surgeons (2011-2016; Period 3). The primary endpoint was post-operative complications (Clavien-Dindo ≥3b), and the secondary endpoints were the functional outcome, failure of the pouch, and mortality. Logistic analyses of the results were performed. RESULTS: Overall, 281 patients were included in the study. The rate of post-operative severe complications was lower in Period 1 [Odds Ratio (OR) 0.137; p = .01]. There was no difference in functional outcome between the groups. CONCLUSION: This study implicates that the risk of post-operative complications after IPAA is lower when the surgery is performed by a generation of more-experienced surgeons. This might support literature that concludes that surgical units that have a high throughput of patients and are staffed by surgeons who perform many procedures provide better outcomes.

A Prospective, Explorative Study to Assess Adjustment 1 Year After Ostomy Surgery Among Swedish Patients.

Having ostomy surgery changes a person's life. To assess adjustment to life with an ostomy and quality of life (QOL) 1 year after ostomy surgery, a prospective, explorative study was conducted among patients of a stoma clinic at a university hospital in Sweden. All consecutive patients who had undergone nonemergent or emergency surgery involving formation of an ostomy and who received regular follow-up at the ward and at the outpatient clinic during the first year by an enterostomal therapist (ET) were prospectively included in the study; their demographic information (including age, gender, diagnosis/reason for an ostomy, nonemergent or emergency surgery, ostomy type, preoperative counselling/siting [Yes/No], self-sufficiency in stoma care, professional activity, and whether they lived with a spouse/partner) was recorded upon admission to the study. Participants independently completed the Ostomy Adjustment Scale (OAS), a 36-item instrument, with each response scored from worst to best adjustment (1 to 6) for a total score ranging from 36-216. The tool addresses 5 factors: normal functioning, functional limitations, negative affect, positive role function, and positive affect. In addition, QOL was assessed using a visual analogue scale (0 to 100 mm) along with 2 open-ended QOL questions. Quantitative and qualitative data were included on the same questionnaire and were entered into an Excel file by 2 of the researchers. The quantitative data were transferred to statistical software for analysis; the qualitative data were analyzed according to Graneheim and Lundman. Descriptive statistics were used for quantitative data and based on nonparametric analysis, and qualitative data were analyzed using content analysis. Of the 150 patients eligible for inclusion (82 women, 68 men, median age 70 [range 21-90] years), 110 (73%) underwent nonemergent surgery, 106 (71%) had a colostomy, and 44 (29%) had an ileostomy. Most ostomies were created due to cancer (98, 65%) and inflammatory bowel disease (28, 19%), and 90% of participants were self-sufficient in ostomy care. The overall median score on the OAS was 162 with no significant differences between genders and diagnoses. The OAS scores for patients who did versus did not have preoperative counselling by an ET were 163 and 150, respectively (P = .313). Mean OAS scores were 136 for patients with cancer and an ileostomy and 163 for patients with cancer and a colostomy. Patients with cancer and an ileostomy had a significantly worse adjustment (mean 3.6 ± 1.32) than patients with cancer and a colostomy (mean 4.4 ± 1.21) in the factor Normal function (P = .015). Lowest adjustment scores were in the areas of sexual activities and attractiveness and participating in sports and physical activities; the highest scores concerned contact with an ET, feeling well informed, and knowing the correct methods of handling the ostomy. The median score for QOL for all patients was 76 (interquartile range 59-86). Three (3) categories emerged from the qualitative content analysis as obstacles to QOL: ostomy-related concerns and impact on life, limitations in physical and social activities, and negative impact on physical and mental health. The ET was found to have an important role in education and counselling to promote adjustment to life with an ostomy from preoperative to follow-up care. Future explorative studies are needed to determine how patients want questions about sex and sensitive issues to be designed and how the ET can best discuss sexuality and intimacy after ostomy surgery.

The Prevalence of Ostomy-related Complications 1 Year After Ostomy Surgery: A Prospective, Descriptive, Clinical Study.

Despite advancements in the creation and care of stomas, ostomy and peristomal skin complications are common immediately following surgery as well as in the months and years thereafter. A prospective study to determine the prevalence of ostomy and peristomal skin complications and the influence of ostomy configuration on such complications was conducted 1 year after ostomy surgery among all patients at a university hospital in Sweden. All participants received regular (10 to 14 days post discharge, 6 weeks, 3 months, 6 months, and 1 year post surgery) ostomy follow-up care by a wound ostomy continence (WOC) nurse. All consecutive elective and emergency patients who had undergone surgery to create a colostomy (end colostomy), end ileostomy, or loop ileostomy were eligible to participate. Patients who were reoperated during their first year post-surgery, patients with a urostomy, and patients with double ostomies were excluded from the study. Patient data collected included age, gender, diagnosis, elective or emergency surgery, open or laparoscopic surgical procedure, presence of a colorectal surgeon specialist at surgery, type of ostomy (colostomy, end ileostomy, loop ileostomy), preoperative ostomy siting, counseling, body mass index, American Society of Anesthesiologists classification, and radiation and/or chemotherapy status. Ostomies were evaluated by 4 WOC nurses as to stoma configuration, convexity use, patient self-sufficiency in stoma care, and complications. All 207 patients (53% women) who were eligible agreed to participate in the study. Patient median age was 70 years (range 19-94); 74% underwent elective surgery. Main diagnoses were colorectal cancer (62%) and inflammatory bowel disease (19%). Ostomy types were: colostomy (71%), end ileostomy (26%), and loop ileostomy (3%). One or more complications occurred in 35% of the patients (27% ostomy complications, 11% peristomal skin complications). A colostomy hernia was the most common surgical complication (20%), and significantly more women (69%) and emergency surgeries were noted among patients with a colostomy and an ostomy height of ≤5 mm. The use of convexity was significantly more common among patients with a stoma height of ≤5 mm than patients with stomas >5 mm (P = 0.016) and among patients having emergency operations than among patients having elective surgery (P = 0.045). Of the emergency surgeries, 37% had not been ostomy-sited (P <0.0001). With regular WOC nurse follow-up, the prevalence of peristomal skin complications in this population was low, and adequate ostomy height might have prevented the frequent use of convexity. Explorative studies are needed that consider differences in body configuration when determining optimal stoma height, especially for patients who require emergency surgery.

Ostomy-related complications after emergent abdominal surgery: a 2-year follow-up study.

PURPOSE: The aim of this study was to prospectively evaluate ostomy-related complications and describe ostomy configuration in patients undergoing acute abdominal surgery. SUBJECTS AND SETTING: The study sample comprised 144 patients with a median age of 67 years (IOR: 53.5-78 years) who underwent an intestinal ostomy as part of an acute abdominal surgical procedure. The research setting was the surgical and gynecological clinics at the Sahlgrenska University Hospital in Gothenburg, Sweden. METHODS: Ostomy configuration, diameter, height, and the presence of stomal and peristomal complications were assessed by a WOC nurse 1 to 2 times while in hospital, once at the ostomy outpatient clinic 2 weeks after discharge, and at 3, 6, 12, and 24 months following ostomy creation. RESULTS: The types of ostomies evaluated were end colostomy (58%), end ileostomy (18%), loop ileostomy (17%), and loop colostomy (7%). Most stomal or peristomal complications occurred within 1 year after surgery (31 of 57; 54.4%). Necrosis, separation, and stenosis were most common in patients with an end colostomy. Peristomal skin complications occurred in 45% of subjects during the first 6 months after surgery. The ostomy's diameter decreased significantly during the hospital course and over the first 2 weeks following hospital discharge in patients with end colostomy (P< .0001), end ileostomy (P< .0081), loop ileostomy (P= .008), and loop colostomy (ns). Patients with a low ostomy had peristomal skin problems ranging between 21% and 57% over this time period. The frequency of using a pouching system that incorporated convexity was highest in the case of loop ileostomy, used in 67% at 6 months. CONCLUSION: During the first 2 weeks after discharge, the physical configuration of the ostomy evolves and the pouching system must be frequently adjusted by a WOC nurse. Stomal and peristomal complications are prevalent during the first 2 postoperative years and especially during the first 6 months.

Perceptions of phantom rectum syndrome and health-related quality of life in patients following abdominoperineal resection for rectal cancer.

PURPOSE: The aim of the study was to investigate how patients described their perceptions of phantom rectum syndrome after abdominoperineal resection and ostomy creation, and its influence on daily living and health-related quality of life. A further aim was to find out strategies patients use to alleviate phantom rectum syndrome sensations. SUBJECTS AND SETTING: Twenty-five patients who underwent abdominoperineal resection and a colostomy (18 men and 7 women; median age 5 63 years; range, 40-78 years) at Sahlgrenska University Hospital, Göteborg, Sweden, participated in the study. METHODS: At follow-up 8 months postsurgery, a WOC nurse interviewed patients with a structured questionnaire about the experience of nonpainful and painful sensations in the perineal area. Health-related quality of life was evaluated using a general cancer-specific instrument (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire version 3.0). RESULTS: Twenty-four patients (96%) experienced painful or nonpainful phantom rectum syndrome at some point during the first 8 postoperative months. The nonpainful sensations (20 patients) occurred in connection with emptying of feces via the stoma, when performing colostomy irrigation, at rest, or in various positions. Fifteen patients experienced painful sensations, characterized as pins and needles, pain in the perineal area, stinging, and burning occurring mostly in sitting positions. Patients with painful sensations had statistically significant higher scores regarding pain and lower scores for social function than those without painful sensations (P < .031). Phantom rectum symptoms caused worries and concerns and influenced daily life in 29% (n = 5). CONCLUSIONS: Phantom rectum syndrome is prevalent in patients undergoing abdominoperineal resection and ostomy creation. Information about phantom rectum syndrome should be shared preoperatively and during follow-up in order to promote optimal quality of life and alleviate bothersome symptoms and concerns associated with phantom rectum syndrome.

Experiences of living with increased risk of developing colorectal and gynaecological cancer in individuals with no identified gene mutation.

BACKGROUND: In most families with familial cancers, mutations have not been demonstrated; thus, healthy individuals cannot be tested for mutation status. As a consequence, many persons at risk of familial cancer live with an unknown, but presumably high, risk of developing cancer. AIM: The aim of this study was to describe individuals' perceptions of living with an increased risk of colorectal and gynaecologic cancer where the gene mutation is unknown. METHODS: Interviews were conducted with 30 individuals with familial colorectal cancer. These persons have no known mutation and therefore should be considered presumptive carriers. In connection with the interviews, all participants were offered to take part in a surveillance programme consisting of a colonoscopy and gynaecological examinations. The interview transcriptions were analysed by the use of qualitative content analysis. RESULTS: Two themes emerged from the analyses: first, living under a threat with two subthemes, threat awareness and distancing oneself from the threat. The second theme, living with uncertainty, was divided into four subthemes: influencing one's family, being on the safe side, facing emotions evoked by examinations and trust and disappointment to the medical services. CONCLUSION: These persons live with a lifelong uncertainty with a varying intensity depending on what happens throughout the life trajectory. They have no diagnosis or patient group to relate to; therefore, the entire situation is often perceived as abstract. Thus, providing information and counselling needs to be more deeply elucidated, and we need to address both situational and existential ways of uncertainty. This will, however, require professionals of all disciplines to understand the meaning of uncertainty and help ensure that its adverse effects are decreased with adequate nursing interventions.

Sexual function after failed ileal pouch-anal anastomosis.

BACKGROUND AND AIMS: Failure of ileal pouch-anal anastomosis (IPAA) occurs in around 10% of the patients. Compared to patients with functioning pouches, health related quality of life is deteriorated after failure. Sexual function in patients with pouch failure is however poorly studied. The aim was to study sexual function in patients with pelvic pouch failure; patients with functioning pouches were used as controls. The hypothesis was that patients with pouch failure have worse sexual function. METHODS: 36 patients with pouch failure were compared with 72 age and sex-matched controls with ulcerative colitis and functioning pouches. The patients answered a set of questionnaires concerning sexual function (Female Sexual Function Index [FSFI] and International Index of Erectile Function [IIEF]), body image (BIS-scale) and health-related quality of life (SF-36). RESULTS: Both women and men with pouch failure scored lower than controls in the FSFI and IIEF questionnaires. However, none of the observations were statistically significant. The scores in the failure group (for both sexes) were below the cut-off level for sexual dysfunction. Scores for the BIS instrument were significantly lower for both sexes in the failure group. Women and men in the failure group scored lower than the controls in all domains of the SF-36, however statistically significant only for the social function domain in men. CONCLUSIONS: The hypothesis, that a failed IPAA is associated with worse sexual function, was not confirmed. Compared to patients with functioning pouches, patients with pouch failure have inferior body image.

Long-term adjustment to living with an ileal pouch-anal anastomosis.

PURPOSE: The aim of this study was to describe long-term adjustment to life with an ileal pouch-anal anastomosis after surgery for ulcerative colitis, to investigate the relationship of pouch function to adjustment, and to explore factors affecting quality of life. METHODS: A total of 369 patients treated between 1982 and 1993 were included in the study. Questionnaires designed to assess bowel (pouch) function (Öresland score) and disease-specific adjustment (Swedish version of the Ostomy Adjustment Scale), plus open-ended questions regarding quality of life, were sent by mail. Open-ended questions were analyzed with qualitative content analysis. RESULTS: A total of 252 patients (84%) returned the disease-specific adjustment questionnaire (141 males/111 females); median age, 51 (range, 26-77) years; median follow-up, 15 (range, 10-21) years after construction of the ileal pouch-anal anastomosis. High adjustment ratings were found for all statements, with the maximum median score of 6 on 28 of the 36 items. Items with the lowest ratings (median score, 5) pertained to things one would do if not for the IPAA, feeling free to travel, ability to enjoy sexual activities, comfort with body image, ability to laugh about awkward situations, confidence in the appliance, and whether the surgery helped with decisions on what things are most important in life. Participants with the lowest adjustment scores had low bowel function scores (P < .0001). Open-ended quality of life questions were answered by 150 patients (59.5%). The most important areas for quality of life were health, family, restroom access, and friends. Five categories emerged from the qualitative content analysis: living a "normal" life, food restrictions, physical limitations, influence of restroom access on social life, and being dependent on medical care. CONCLUSIONS: Most participants had adjusted well to life with an ileal pouch-anal anastomosis and considered life to be normal. Good public restrooms were important for quality of life. Improving pouch function may help patients adjust to the postoperative state, but deeper understanding of reasons for poor adjustment despite good pouch function is needed.

Concerns and quality of life before surgery and during the recovery period in patients with rectal cancer and an ostomy.

PURPOSE: Rectal cancer is the most common reason for a person to undergo ostomy surgery. The aim of this study was to assess concerns and health-related quality of life (HRQOL) before surgery and during the first 6 months following ostomy surgery in the presence of rectal cancer. SUBJECTS AND SETTINGS: The sample comprised 57 patients at a university hospital in Gothenburg, Sweden. Their median age was 66 years (range, 30-87); 35 men and 22 women participated in the study. METHODS: Participants prospectively answered questionnaires preoperatively, and at 1, 3, and 6 months postoperatively. Concerns were assessed using the rating form of the Inflammatory Bowel Disease Patient Concerns, and HRQOL was evaluated using the 36-Item Short Form Health Survey. Results were compared with population norms. RESULTS: Participants expressed concerns associated with developing cancer, being a burden on others, and related to the uncertain nature of disease. Health-related quality of life scores dropped significantly in 6 of 8 domains when preoperative scores were compared to those obtained 1 month postoperatively, but scores improved at 6 months. There were significant differences between preoperative study group scores and population norms on physical and emotional role function, social function, and for mental health domains. Significant differences persisted when population norms were compared to study group scores 6 months following surgery on all these domains except mental health. Participants identified good relations with significant others, social and leisure activities, psychological issues, and health as important for maintaining QOL. Obstacles to maintaining QOL included fatigue, pain, illness-induced limitations in life, and worries over what their new life would entail. CONCLUSION: Surgical management of rectal cancer raises concerns and profoundly impairs QOL during the first several postoperative months.

Analysis of patient selection and external validity in the Swedish contribution to the COLOR trial.

OBJECTIVE: The colon cancer laparoscopic or open resection (COLOR) trial is an international, randomised controlled trial comparing outcomes of open and laparoscopic surgery for colon cancer. The main purpose of this study was to determine representability by comparing included and nonincluded patients in the participating Swedish centres. DESIGN: At eight centres, which included 391 of the 422 Swedish patients, a local database search was performed to identify retrospectively all patients (n = 2,384) who underwent surgery for colon cancer during the inclusion period, and data was retrieved from medical records. RESULTS: Four hundred fifty-six patients were randomised, 65 of whom were excluded post randomisation (group 2), leaving 391 patients in the study (group 1). For 1,566 patients, valid exclusion criteria were found (group 3). Thus, 362 patients were eligible but not included (group 4). Relative to group 1, patients in group 4 had a significantly higher American Society of Anaesthesiologists (ASA) score, more advanced tumour stage and difference regarding the resections performed. Results showed that 1470 patients (62%) could be calculated as feasible for laparoscopic colon resection (LCR) in a clinical, nontrial situation. CONCLUSIONS: The study population in the Swedish part of the COLOR trial was representative of the eligible population with the exception of comorbidity, where those actually included had less severe comorbidity than the nonincluded but eligible patients. In Sweden, 50-60% of colon cancer patients can be operated on by laparoscopy.

Long-term outcome after ileal pouch-anal anastomosis: function and health-related quality of life.

PURPOSE: This study was designed to investigate long-term pouch function and health-related quality of life in a single, large cohort of patients with ileal pouch-anal anastomosis for ulcerative colitis. METHODS: Data from 370 patients were included in the study. Thirty-nine patients (11 percent) did not have a functioning pouch (failures) but were included in the health-related quality of life analyses. Pouch function (Oresland score) and health-related quality of life (Short Form-36) were evaluated by postal questionnaires. A total of 88 percent of the patients with a functioning ileal pouch-anal anastomosis returned the questionnaires vs. 76 percent of the failures. Median follow-up time after ileal pouch-anal anastomosis was 15 years vs. 11 years after failure. An age-matched and gender-matched reference sample (n = 286) was randomly drawn from the Swedish Short Form-36 database. RESULTS: Median bowel frequency was six per 24 hours: 76 percent emptied the reservoir at night, 23 percent had urgency, 12 percent had evacuation difficulties, and 17 percent experienced soiling during the day. Fifty-two percent of the males and 32 percent of the females suffered from soiling at night. More than one-half of the patients had occasional perianal soreness, 6 percent considered the pouch to be a social handicap, and 94 percent were satisfied with their pouch. Patients with a functioning ileal pouch-anal anastomosis did not differ from the reference sample on any Short Form-36 domain, except for a reduced score in General Health (P = 0.02). Pouch function was positively correlated to health-related quality of life. Patients with pouch failure had reduced health-related quality of life in most domains. CONCLUSIONS: Patients' satisfaction is high and functional outcome is good after ileal pouch-anal anastomosis. Poor pouch function affects health-related quality of life negatively. Patients with failure after ileal pouch-anal anastomosis are substantially limited in a variety of health-related quality of life domains.

Randomized trial of health-related quality of life after open and laparoscopic surgery for colon cancer.

BACKGROUND: Randomized controlled trials (RCTs) have reported improved or unchanged three-year survival following laparoscopic colon resection (LCR) for colon cancer compared with that following open resection (OCR). The aim of this study was to determine health-related quality of life (HRQL) in patients randomized to laparoscopic or open resection for colon cancer. METHODS: In total, 285 patients (130 LCR, 155 OCR) from seven Swedish centers were included. HRQL was assessed preoperatively and at 2, 4, and 12 weeks postoperatively with the EQ-5D and EORTC QLQ-C30 instruments. RESULTS: The LCR patients did significantly better on the social function component of the EORTC QLQ-C30 at two and four weeks and on the role function component at two weeks. CONCLUSION: Laparoscopic resection for colon cancer improved quality of life during the first postoperative month.

Continent cutaneous urinary diversion is still a valid alternative after cystectomy for bladder carcinoma.

OBJECTIVE: We compared patient opinions concerning reservoir/bladder function as well as quality of life (QOL) after cystectomy for bladder carcinoma and continent cutaneous urinary diversion or orthotopic bladder reconstruction. MATERIAL AND METHODS: Fifteen patients with Kock reservoirs (11 females, 4 males) and 11 men with orthotopic bladders answered the European Organization for Research and Treatment of Cancer quality-of-life questionnaire-C30 as well as specially constructed questions concerning reservoir/bladder function. The glomerular filtration rate (GFR) was determined using Cr-EDTA or iohexol clearance. RESULTS: Functioning and global health/QOL scales did not differ between the two groups of operated patients or between diverted patients and gender- and age-matched groups from the general population. The majority of the patients were satisfied/very satisfied with their diversion but more patients were troubled by leakage in the orthotopic bladder group than in the Kock reservoir group. The GFR was similar in the two groups. CONCLUSION: Continent cutaneous urinary diversion is associated with fewer leakage problems than orthotopic bladder reconstruction after cystectomy for bladder carcinoma.

Thirty years of experience living with a continent ileostomy: bad restrooms--not my reservoir--decide my life.

OBJECTIVE: This study describes long-term adjustment of people with a continent ileostomy. SUBJECTS AND METHODS: Subjects were 68 people (25 males and 43 females) who underwent an operation for ulcerative colitis with a continent ileostomy (Kock pouch). The median number of years subjects had lived with a continent reservoir was 31 (range 29-36) at follow-up and the median subject age was 60 (40-89). Subjects completed a 36-item questionnaire designed to assess adjustment to ostomy surgery. Subjects ranked the questionnaire using a 6-point Likert scale; a response alternative "not relevant" was available. Content analysis was conducted on subjects' responses to an open-ended question covering aspects of their quality of life. RESULTS: High median adjustment ratings were found for all 36 statements; the maximum median rating of 6 appeared on 28 items. Eight items with the lowest median ratings were in the following domains: embarrassing situations, activity, body image, sexuality, and good care. Five items on medical care and 3 items on sexuality were most frequently considered "not relevant" by respondents. The most frequently mentioned quality-of-life domains were family, health, friends, and employment. Content analysis indicated that respondents were self-reliant, although they indicated that they experienced considerable impediments to bowel evacuation outside of the home. CONCLUSIONS: In the long-term, people with a continent ileostomy have good self-care. The quality and availability of public restrooms, however, reduces their daily activities away from home.

Prophylaxis against bone loss in Kock reservoir patients with reduced glomerular filtration rate.

OBJECTIVE: We investigated whether treatment with calcium carbonate and vitamin D3 can improve the bone mineral content of patients with ileal reservoirs for continent urinary diversion and a reduced glomerular filtration rate (GFR). MATERIAL AND METHODS: Twenty-six patients with Kock reservoirs were included in the study. Bone mineralization was determined using dual-energy X-ray absorptiometry. Kidney function was estimated from Cr-EDTA clearance and serum cystatin C concentration. Osteocalcin and parathyroid hormone in serum were also measured. Patients with reduced GFR were treated with calcium carbonate and vitamin D3 perorally. RESULTS: Bone mineral density in the femur neck and hip increased in the treatment group, as reflected by an improved T score. CONCLUSION: Patients with ileal reservoirs for continent urinary diversion and reduced kidney function should be supplemented with calcium carbonate and vitamin D3 in order to reduce the long-term risk of osteoporosis.

Luminal nitric oxide in ileal reservoirs for continent cutaneous diversion or orthotopic bladder reconstruction.

OBJECTIVES: To measure mucosal inflammation as reflected in nitric oxide (NO) production in ileal reservoirs for the storage of urine and to correlate it with the growth of bacteria as well as CRP. METHODS: Intraluminal gas NO concentrations were determined using the chemoluminescence technique in 25 patients with continent cutaneous ileal reservoirs (Kock pouch) and 12 patients with orthotopic bladders (hemi-Kock or T-pouch). NO concentrations were determined in both intestinal reservoir gas and silicon catheter balloon gas. Urinary culture and blood CRP determinations were performed. RESULTS: NO concentrations in reservoir gas were higher than in silicon catheter balloons. Bacteriuria was associated with approximately 20 times higher NO concentrations than sterile urine. NO concentrations did not differ between continent cutaneous reservoirs or orthotopic bladders when due attention was paid to variance in the rate of bacteriuria. Elevated CRP was associated with higher NO concentrations. Bacteriuria with acinetobacter, enterococci and pseudomonas appeared to cause comparatively lower NO concentrations. The inflammatory response of reservoir walls to bacteriuria did not decrease with time. CONCLUSIONS: Urine in itself causes much less intestinal wall inflammation than bacteriuria, as reflected in NO production. High CRP values are associated with high NO concentrations. The inflammatory response varies with the bacterial specimens.

Effects of recombinant erythropoietin in palliative treatment of unselected cancer patients.

PURPOSE: The purpose is to evaluate relationships between objectively assessed exercise capacity and subjectively assessed scoring of physical functioning and well-being after erythropoietin treatment in cancer patients on palliative care. EXPERIMENTAL DESIGN: Unselected cancer patients (n = 108) who experienced progressive cachexia were randomized to receive either anti-inflammatory treatment alone (indomethacin) or recombinant erythropoietin plus indomethacin to prevent the appearance of disease-induced anemia and thereby protect patients' exercise capacity. Follow-up investigations of nutritional status, exercise capacity, and health-related quality of life assessed by SF-36 and the European Organization for Research and Treatment of Cancer QLQ-C30 were compared. RESULTS: Effective treatment by erythropoietin on top of basal whole body anti-inflammatory treatment was confirmed and indicated by time course changes of biochemical, physiologic, and nutritional objectives, whereas individual self-reported scoring of physical functioning and general health did not indicate a clear-cut effectiveness, particularly at moderately subnormal hemoglobin levels. CONCLUSIONS: Discrepancies between objective and subjective self-reported measures may be either fundamental or indicate scoring limitations for evaluation of therapeutic results. Present results demonstrate a clinical benefit of erythropoietin treatment in cancer patients with subnormal to normal hemoglobin levels, whereas the patients' own subjective scoring was insufficient to sense such improvements. The discrepancy may be either fundamental or methodological but emphasizes the importance to document therapeutic outcome in both subjective and objective perspectives in palliative care of cancer patients.

Palliative nutritional intervention in addition to cyclooxygenase and erythropoietin treatment for patients with malignant disease: Effects on survival, metabolism, and function.

BACKGROUND: The role of nutrition in the palliative treatment of patients with malignancy-related cachexia is unclear. The goal of the current study was to determine whether specialized, nutrition-focused patient care could improve integrated whole-body metabolism and functional outcome in unselected weight-losing patients with malignant disease who were receiving systemic antiinflammatory (cyclooxygenase [COX]-inhibitory) treatment along with erythropoietin (EPO) support. METHODS: Three hundred nine patients with malignant disease who experienced progressive cachexia due to solid tumors (primarily gastrointestinal lesions) were randomized to receive a COX inhibitor (indomethacin, 50 mg twice daily) and EPO (15-40,000 units per week) along with specialized, nutrition-focused patient care (oral nutritional support and home total parenteral nutrition [TPN]) provided on a patient-by-patient basis to attenuate inflammation, prevent anemia, and improve nutritional status. Control patients received the same indomethacin and EPO doses that study patients received without the added nutritional support. All patients were treated and followed until death. Biochemical assays (blood, liver, kidney, and thyroid), nutritional state assessment (food intake and body composition), and exercise testing with simultaneous measurement of whole-body respiratory gas exchange before and during exercise were performed before the start of treatment and then at regular intervals during the treatment period (every 2-30 months after treatment initiation). Statistical analyses were performed on 'intention-to-treat' and 'as-treated' bases. RESULTS: Home TPN was provided to approximately 50% of the study patients without severe complications. Over the entire observation period, rhEPO prevented the development of anemia in both study patients and control patients. Intention-to-treat analysis revealed an improvement in energy balance for nutritionally supported patients (P < 0.03); no other significant differences in outcome between study patients and control patients were observed. As-treated analysis demonstrated that patients receiving nutrition experienced prolonged survival (P < 0.01), which was accompanied by improved energy balance (P < 0.001), increasing body fat (P < 0.05), and a greater maximum exercise capacity (P < 0.04). A trend toward increased metabolic efficiency at maximum exercise (P < 0.06) for study patients relative to control patients also was observed. CONCLUSIONS: The results of the current study strongly support that nutrition is a limiting factor influencing survival and that nutritional support protects integrated metabolism and metabolic function in patients with progressive cachexia secondary to malignant disease.

Health-related quality of life and pouch function in continent ileostomy patients: a 30-year perspective.

PURPOSE: The principal aim of this study was to assess long-term pouch durability and health-related quality of life in an original series of patients operated on with a continent ileostomy. PATIENTS: Data from 68 of 88 patients who had a continent ileostomy performed at Sahlgrenska University Hospital between 1967 and 1974 were analyzed. Median age at follow-up was 60 (range, 40-89) years and median follow-up was 31 (range, 29-36) years. METHODS: Patients were sent a questionnaire on pouch function along with the Short Form-36 Health Survey 2.0. A random age-matched and gender-matched sample was drawn from the Swedish national Short Form-36 Health Survey norm database to compare with the patient group. RESULTS: The majority of the patients reported good physical condition and satisfactory pouch function. Patients evacuated the pouch a median of four times every 24 hours. Twelve patients (18 percent) had leakages. Forty-four patients (65 percent) had had at least one postoperative revision to restore continence. Generally minor peristomal skin irritation occurred in seven patients (10 percent). Patients with concurrent complaints (mostly age related) reported poorer health-related quality of life. Nevertheless, 78 percent of the patients rated their overall health as good, very good, or excellent. The patients' Short Form-36 Health Survey scores were comparable to reference values. CONCLUSIONS: Although revisional operations may be needed to restore continence, continent ileostomy has a good durability. Pouch function was satisfactory and patients' satisfaction was high. Health-related quality of life levels were similar to those of the general population.