Experiences and needs of patients with rectal cancer confronted with bowel problems after stoma reversal: A systematic review and thematic-synthesis.

PURPOSE: After the reversal of the temporary stoma, rectal cancer survivors are often confronted with bowel complaints largely impacting on their quality of life. This systematic review aims to identify and synthesise the experiences and needs of patients with rectal cancer confronted with bowel problems after stoma reversal. METHODS: A systematic search was performed through Pubmed, CINAHL and Web of Science. Only studies with a qualitative design were included in this review. Quality assessment was done by the critical appraisal skill programme (CASP) Qualitative Studies Checklist. A thematic-synthesis was performed. RESULTS: Of 2713 identified papers, 10 were included in this systematic review. Two general themes were identified: 'experiences and needs about bowel function before surgery' and 'experiences and needs afterwards'. Before restoration of continuity patients had to cope with the temporary stoma, and they felt uncertain about what to expect. Patients indicated that the timing of providing information was crucial but varied. Bowel problems after surgery had a physical and emotional impact on patients' family life. They were also confronted with shame and stigma. Patients were happy to be alive and cancer free but were hopeful that the bowel problems would resolve. They used several strategies to manage and cope with these symptoms. Peers and healthcare professionals proved valuable resources of support. CONCLUSION: Rectal cancer survivors experience ongoing bowel problems after treatment. Patients describe experiences and needs before rectal cancer surgery and afterwards when confronting with bowel problems. Follow-up care should be organised proactively and focus on management strategies and emotional support.

Prospective switch study comparing two irrigation systems for transanal irrigation in children.

BACKGROUND AND STUDY AIMS: Transanal irrigation (TAI) is used in children to treat constipation and incontinence. Belgium has 2 systems available: Colotip® (cheaper, however not designed for TAI) or Peristeen®. PATIENTS AND METHODS: This patient-control switch study is the first to compare 2 TAI systems. Children regularly using Colotip® for TAI were asked to participate, after consent, a visual analogue scale (VAS) rating the system and a 2-week diary (fecal continence, self-reliance, time spent on the toilet, pain, Bristol stool scale, irrigation volume and frequency of enema) were completed. Non-parametric statistics were used. RESULTS: Out of 26 children using Colotip®, 18 (69%) children participated and 5 refused (fear n=1, satisfaction Colotip® system n=7). Of these 18 children (interquartile range: 3-18 years, median 12.5 years, 9 girls) 5 patients stopped Peristeen® (pain n=1, fear n=1 and balloon loss n=3) and 2 were lost from follow up. Dropouts and included patients showed no statistical difference. In the 11 remaining patients, pseudo-continence (p 0.015), independence (p 0.01) and VAS score (p 0.007) were significantly better with Peristeen®, no difference was found in time spent on the toilet (p 0.288) and presence of pain (p 0.785). CONCLUSIONS: In children Peristeen® offered significantly higher pseudo-continence and independency. 30% refused participation because of satisfaction with the Colotip® and 30% spina bifida patients reported rectal balloon loss due to sphincter hypotony. To diminish Peristeen® failure, a test-catheter could be of value. Considering Colotip® satisfaction, both systems should be available. Patient selection for Peristeen® needs further research.

Belgian consensus guideline on the management of hemorrhoidal disease.

Introduction: Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods: A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results: Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions: The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Impact of low anterior resection syndrome (LARS) on the quality of life and treatment options of LARS - A cross sectional study.

PURPOSE: The purpose of this study was to assess the relationship between the low anterior resection syndrome (LARS) and quality of life (QOL). Furthermore, in patients with major LARS, therapeutic management options were explored. METHODS: A cohort of surviving patients, who underwent a low anterior resection for rectal cancer after long course of radiochemotherapy, were identified. These patients were treated in Ghent University Hospital between 2006 and 2016. QOL was assessed using the European Organization for Research and Treatment of Cancer Quality Of Life questionnaire-C30 and the bowel function using the LARS-score. The relationship between LARS and QOL was analysed. Patients with major LARS (≥30 points) were contacted to explore their therapeutic management of LARS. RESULTS: 69% of the participants had major LARS. QOL was closely associated with LARS. Significant differences were found between those with and without LARS in the global health status (p ≤ 0.001) and in the following functional scales: physical (p ≤ 0.001), role (p ≤ 0.001), cognitive (p = 0.04) and social (p ≤ 0.001). Patients with major LARS experienced more diarrhea (p ≤ 0.001), fatigue (p = 0.002), insomnia (p ≤ 0.001) and pain (p = 0.02), compared to patient with no/minor LARS. Most patients tried dietary regimens (71%), medication (71%) and incontinence material (63.8%) in an attempt to manage their LARS and found some of them useful. The level of the anastomosis (low) was a significant risk factor for major LARS (p=0.03). CONCLUSION: More than half of the patients in this cohort still suffered from major LARS. Patients confronted with major LARS had a lower QOL than patients with no/minor LARS. Currently, there is no gold standard for the management of LARS. Patients manage it through trial and error.

Safety and preliminary efficacy of electrostatic precipitation during pressurized intraperitoneal aerosol chemotherapy (PIPAC) for unresectable carcinomatosis.

INTRODUCTION: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) was recently introduced to treat unresectable peritoneal metastases. Adding an electrostatic field may enhance charged droplet precipitation and tissue penetration, resulting in improved anticancer efficacy. We report for the first time its safety and preliminary efficacy. MATERIALS AND METHODS: Patients underwent PIPAC combined with an electrostatic field, using the Ultravision™ apparatus. Adverse events were scored with the Common Terminology Criteria. Treatment response was assessed after more than one PIPAC, using clinical symptoms, tumor markers, CT imaging and histological regression. RESULTS: Forty-eight patients (median age, 61 y) with diverse primary tumors underwent 135 procedures (median per patient, 3). Most (65.2%) were treated as outpatient. Twenty-eight (58.3%) patients received concomitant chemotherapy. The most frequent treatment-related toxicities were anemia (grade 1 to 3, 13 [9.6%]), ileus (grade 1 to 3, 5 [3.7%]), anorexia (grade 1 to 3, 6 [4.4%]), nausea (grade 1 to 3, 5 [3.7%]) and vomiting (grade 1 to 3, 7 [5.2%]). There was no grade 4 or 5 morbidity. Twenty (41.7%) patients did not complete three treatments, mainly because of disease progression (n = 13). After two procedures, there were one responder and 8 non-responders. After three treatments, we observed 11 responders, two patients with stable disease, and 15 non-responders. All but one patient with therapy response received simultaneous chemotherapy. CONCLUSION: Electrostatic precipitation during PIPAC is well tolerated and safe. After three procedures and concomitant chemotherapy, response or stable disease is achieved in approximately half of cases. These findings warrant prospective trials in homogeneous patient cohorts.

Rectal red blood loss in a healthy toddler is not always a juvenile polyp.

Aim Heterotopic gastric mucosa is a well-known congenital anomaly in Meckel's diverticula and duplication cysts. Solitary heterotopic gastric mucosa in the rectum is a rare and frequently overlooked abnormality. Starting from a patient history, the literature is searched and all cases reported over the past 20 years are reviewed and compared to a summary of the older cases. Differences between adult and childhood presentation are outlined and our patient is compared with prior reported cases. Case A 3-year-old girl presented with recurrent rectal blood loss caused by heterotopic gastric mucosa without duplication cyst. She was endoscopically treated with two-stage endoscopic surgical dissection (ESD). Up to now, rectal heterotopic gastric mucosa has been reported in 34 adults and 24 children, including this patient. There is an overall male dominance (69%). Presenting complaints in children were recurrent fresh blood loss per anum (96%), pain (46%), perineal ulcers (25%), diarrhoea (8%) and one patient had an ano-cutaneous fistula. Endoscopy revealed a mucosal elevation with a slightly different aspect (33%), a polyp (42%) and a solitary ulcer (25%). Endoscopy in adults reveals more frequently polyps compared to children. Treatment in childhood is mainly surgical where adults are more frequently treated with endoscopic techniques. Conclusion In a child with recurrent rectal bleeding in good general health, it is important to withhold heterotopic gastric mucosa in the differential diagnosis and take sufficient biopsies during endoscopy.

Effect of neoadjuvant radiation dose on surgical and oncological outcome in locally advanced esophageal cancer.

INTRODUCTION: Neoadjuvant chemoradiation (CRT) confers a survival benefit in locally advanced esophageal cancer. The optimal dose of radiotherapy remains undefined. METHODS: From a prospective database, we identified patients who received CRT followed by Ivor Lewis esophagectomy. Surgical complications, pathological response, and oncological outcome were compared between patients who received a radiotherapy (RT) dose of 36 Gy (group 1) versus a dose of > 40 Gy (group 2). RESULTS: 147 patients were evaluated : 109 received 36 Gy, while 38 received 41-50 Gy. Mean age was 61 ± 9 years (84% male). Median hospital stay was 16 days. Anastomotic leakage occurred in 4.0%. Pulmonary complications occurred in 41.8%, neither being influenced by RT dose. Complete resection (R0) was achieved in 95% (group 1) and 100% (group 2), P = 0.3. Pathological complete response (pCR) was observed in 19% (group 1) and 37% (group 2), P = 0.04. Local recurrence developed in 9% in group 1, and 3% in group 2 (P = 0.3), but regional recurrence developed significantly higher in the low dose group (28% vs 3%, P < 0.001). Metastatic recurrence occurred in 48% in group 1 and 13% in group 2 (P < 0.001). CONCLUSIONS: In patients with locally advanced esophageal cancer a higher RT dose does not affect surgical outcome, enhances pCR rate, and reduces the locoregional and metastatic recurrence risk.

A new variable phenotype in spinocerebellar ataxia 27 (SCA 27) caused by a deletion in the FGF14 gene.

We present a young boy whose mild ataxia and abnormal eye movements repeatedly deteriorated with fever, making him unable to sit or walk during fever episodes. SNP-array analysis identified a 202 kb deletion in chromosome 13q33.1 containing the fibroblast growth factor (FGF)14 gene, which is associated with spinocerebellar ataxia (SCA) 27. This 13q deletion was also present in the proband's mother and grandmother. The mother was unable to perform tandem gait walking and had abnormal eye movements but had never sought medical attention. The grandmother predominantly had a postural tremor. FGF14 regulates brain sodium channels, especially in the cerebellum. Sodium channels can be fever sensitive. This family demonstrates phenotypic variability of FGF14 deletions (SCA 27), fever sensitivity of ataxia and the added value of SNP-array analysis in making a diagnosis.

Training models in laparoscopy: a systematic review comparing their effectiveness in learning surgical skills.

BACKGROUND: Surgery has traditionally been learned on patients in the operating room, which is time-consuming, can have an impact on the patient outcomes, and is of variable effectiveness. As a result, surgical training models have been developed, which are compared in this systematic review. METHODS: We searched Pubmed, CENTRAL, and Science Citation index expanded for randomised clinical trials and randomised cross-over studies comparing laparoscopic training models. Studies comparing one model with no training were also included. The reference list of identified trials was searched for further relevant studies. RESULTS: Fifty-eight trials evaluating several training forms and involving 1591 participants were included (four studies with a low risk of bias). Training (virtual reality (VR) or video trainer (VT)) versus no training improves surgical skills in the majority of trials. Both VR and VT are as effective in most studies. VR training is superior to traditional laparoscopic training in the operating room. Outcome results for VR robotic simulations versus robot training show no clear difference in effectiveness for either model. Only one trial included human cadavers and observed better results versus VR for one out of four scores. Contrasting results are observed when robotic technology is compared with manual laparoscopy. CONCLUSION: VR training and VT training are valid teaching models. Practicing on these models similarly improves surgical skills. A combination of both methods is recommended in a surgical curriculum. VR training is superior to unstructured traditional training in the operating room. The reciprocal effectiveness of the other models to learn surgical skills has not yet been established.

Morbidity and mortality in ageing HIV-infected haemophilia patients.

Over 25 years of follow-up is now available for HIV-infected haemophilia patients. The aim of this study was to retrospectively asses the morbidity and mortality of HIV infection and the effects of HAART in these patients. Data on HIV infection, its treatment and all types of comorbidity were collected from medical records of all 60 HIV-positive haemophilia patients who were treated at the Van Creveldkliniek since 1980 and compared with data from 152 HIV-negative patients with severe haemophilia and the general age-matched male population. AIDS developed in 27 patients (45%), while 31 patients died (52%). Death was solely or partially AIDS-related in 71%. Development of AIDS and AIDS-related deaths declined strongly after the introduction of HAART. Only one major ischaemic cardiovascular event occurred in our study population. Of the 27 patients who were still treated at our clinic in 2010, 25 (93%) were on HAART. They had more often hypertension and diabetes, but less often overweight and obesity and lower cholesterol levels than the general population. The occurrence of spontaneous intracranial bleeding was higher in HIV-positive haemophilia patients on HAART than in HIV-negative patients with severe haemophilia (16.6 vs. 1.2 per 1000 patient years). Since the introduction of HAART, the impact of HIV infection on morbidity and survival has decreased. The increased prevalences of hypertension and diabetes, however, warrant regular screening. HIV-positive haemophilia patients on HAART appear to have an increased risk of spontaneous intracranial bleeding.

Multiple magnet ingestion: a real challenge for the paediatric surgeon.

The paediatric population aged 1-3 years represents about 80% of patients presenting with foreign body ingestion. Only 10 to 20% of ingested foreign bodies will fail to pass through the entire gastrointestinal tract. The decision to remove them is based on location, size and nature of the foreign body. In particular, ingestion of multiple magnets or magnets and other metallic objects require a more aggressive management.

Life-threatening side effects of malabsorptive procedures in obese patients necessitating conversion surgery: a review of 17 cases.

BACKGROUND: Malabsorptive surgery (MAS) can cause huge weight loss but is also known for its serious side effects. We investigated whether conversion surgery is an effective treatment for MAS-induced complications. METHODS: We searched our hospital database for patients who underwent conversion surgery after MAS. Any complication was recorded till time of conversion. The conversion techniques and their effect on the course of the patients were analyzed and compared to the situation after MAS. RESULTS: We identified 17 patients who suffered a wide range of complications after biliopancreatic diversion (BPD) (n = 11), biliopancreatic diversion with duodenal switch (BPD-DS) (n = 4), or distal gastric bypass (D-GBP) (n = 2). After a (mean +/- SD) period of 6.0 +/- 3.6 years the MAS was either converted to a gastric bypass (GBP) in 6 patients or an elongation of the common limb (ECL) in 9 patients. Two conversions were atypical. After a (mean +/- SD) follow-up of 2.4 +/- 2.5 years the majority of blood test results improved. The incidence of most complaints diminished except abdominal discomfort, critical illness polyneuropathy, need for total parenteral nutrition (TPN), wheelchair dependency, and asthenia. One patient died of irreversible liver failure after 3 liver transplantations. Two patients died of cachexia. The preferred conversion technique is still unclear. CONCLUSIONS: MAS can cause invalidating and life-threatening side effects. If there are signs of incipient deterioration in organ function and/or nutritional status, conversion surgery should not be delayed. Although we have the impression that early conversion causes better outcome, many patients experience lifelong postoperative complications.

Beneficial effect of successful HCV treatment in patients with inherited bleeding disorders, assessed by liver stiffness measurements.

Hepatitis C infection is a major comorbidity in patients with inherited bleeding disorders. Successful antiviral treatment leads to a reduction in liver fibrosis, as shown by liver biopsies. Liver stiffness measurement (LSM) is a non-invasive method of assessing liver fibrosis. The aim of this cohort study was to evaluate the long-term effect of successful antiviral treatment, using LSM, in HCV-infected patients with inherited bleeding disorders. The LSM were performed in 2005 (LSM 1) and 2009 (LSM 2) in 39 patients who were successfully treated for HCV. The change in liver fibrosis between LSM 1 and 2 was assessed. The median duration of HCV infection was 28.8 years. A total of 22 patients (56%) underwent successful antiviral treatment before LSM 1 (group 1), and 17 patients between LSM 1 and LSM 2 (group 2). The median time since antiviral treatment was 8.8 years in group 1 and 2.5 years in group 2. In group 1, the median results of LSM 1 and 2 were similar (6.0 vs. 5.6 kPa, P-value 0.36), so overall, patients remained stable. In three patients in this group, all treated more than 15 years ago, an increase of liver stiffness was shown. Group 2 showed a significant improvement in median LSM results (10.3 vs. 6.1 kPa, P-value <0.01), with decrease of liver stiffness in 82%. Even after a long HCV infection duration, successful antiviral treatment led to a significant improvement of fibrosis, measured by LSM, mainly in the first few years after completing treatment.

The burden of HCV treatment in patients with inherited bleeding disorders.

Many patients with inherited bleeding disorders are infected with hepatitis C virus (HCV). Antiviral treatment, consisting of pegylated interferon and ribavirin, has many side-effects. The aim of the study was to prospectively assess the occurrence and course of side-effects and changes in health-related quality of life (HRQoL) during antiviral treatment in patients with inherited bleeding disorders and chronic HCV. Forty-seven patients were followed during antiviral treatment. Side-effects of treatment were recorded, and the Beck Depression Inventory and the RAND-36 HRQoL questionnaire were administered at regular intervals. Frequently reported side-effects were fatigue (100%), headache (94%), pruritus and skin rash (94%), concentration problems (89%), decreased appetite (89%), fever, irritability and hair loss (all 85%). Many side-effects disappeared soon after end of treatment, but 4 weeks after cessation fatigue, concentration problems and sleeping problems were still present in more than 30% of patients. Dose reduction was necessary in 21 patients (45%), mostly because of decreasing weight or haemoglobin levels. Two patients stopped treatment prematurely because of side-effects. Depression was present in 28 patients (60%). HRQoL decreased significantly during treatment in all RAND-36 domains, and increased again within 4 weeks after treatment. Major side-effects were similar in patients with successful (n = 31, 66%) and unsuccessful antiviral treatment. In patients with inherited bleeding disorders and chronic HCV, antiviral treatment has many, but mostly transient side-effects and a significant impact on quality of life. Careful follow-up and management of side-effects will ensure optimal compliance and treatment results.

Liver stiffness measurements to assess progression of fibrosis in HCV-infected patients with inherited bleeding disorders.

Hepatitis C is a major co-morbidity in patients with inherited bleeding disorders, leading to progressive liver fibrosis and eventually cirrhosis. Liver stiffness measurement (LSM) is a non-invasive way of assessing the extent of liver fibrosis. This article describes our experience with serial LSM to assess prospectively progression of fibrosis in a cohort of patients with inherited bleeding disorders and chronic hepatitis C. A total of 84 patients underwent serial LSMs, with a median interval of 3.7 years. The change in LSM results over time was assessed. Overall, there was no significant difference between the median results of LSM 1 and LSM 2. The median result of LSM 2 was low (6.6 kPa), after a median duration of infection of 37 years. On the individual level, deterioration of LSM results of more than 2 kPa was seen in 13 patients (16%), 44 patients (52%) remained stable and 27 patients (32%) showed improvement of LSM results of more than 2 kPa. These results are comparable with those of paired liver biopsy studies. LSM appears to be a good alternative for liver biopsies in patients with hepatitis C and inherited bleeding disorders, although the interpretation of the unexpected improvement we found in some of our patients is not straightforward. LSMs will be repeated in our patient population in a few years to be able to better assess the value of serial LSM.

Long-term results of a prospective study on laparoscopic adjustable gastric banding for morbid obesity.

BACKGROUND: The objective of this study was to study the long-term outcome of adjustable gastric banding in the treatment of morbid obesity. In Europe, the preference for gastric band has declined in favor of Roux-Y-gastric bypass. METHODS: This is a follow-up of a prospective study on a large cohort of patients after laparoscopic gastric banding (LAGB) for morbid obesity. RESULTS: Complete data were collected on 656 patients (88%) from a cohort of 745 patients. After a median follow-up of 95 months (range 60-155), the mean BMI dropped from 41.0 ± 7.3 to 33.2 ± 7.1 kg/m², with a 46.2 ± 36.5% excess weight loss (EWL). A more than 50% EWL was achieved in 44% of patients. The band was still in place in 77.1% of patients; conversion to gastric bypass after band removal was carried out in 98 (14.9%) patients, while a simple removal was done in only 52 (7.9%) patients. Band removal was more likely in women and patients with a higher BMI. CONCLUSIONS: After LAGB, band removal was necessary for complications or insufficient weight loss in 24% of patients. Nearly half of the patients achieved a more than 50% EWL, but in 88%, a more than 10% EWL was observed. LAGB can achieve an acceptable weight loss in some patients, but the failure in one out of four patients does not allow proposing it as a first-line option for the treatment of obesity.