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The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. This Clinical Practice Guidelines Committee is charged with leading internationa

Up to 30% of patients who have ulcerative colitis are faced with the complex decision between end ileostomy and IPAA. We developed a decision aid to encourage shared decision making between patients and surgeons.The aim of this study is to determine whether a decision aid is effective and acceptable for surgical patients with ulcerative colitis and their treating surgeons.This was a prospective cohort study.Patients and surgeons were enrolled from 3 colorectal surgery clinics.Consecutive adult patients with ulcerative colitis who were candidates for IPAA and end ileostomy were selected.Patients used a multilingual decision aid before meeting with the surgeon.We measured changes in knowledge, treatment preference, and stage of decision making, as well as preparation for decision making, patient satisfaction, and surgeon satisfaction after using the decision aid.Twenty-five patients were enrolled; 5 had previously undergone subtotal colectomy. After using the decision aid, patients' knowledge scores improved by 39% (p0.006), 6 patients changed their treatment preference, and 8 reported increased certainty in treatment preference. The median for preparation for decision making was 75 of 100. Patient satisfaction with the decision aid (median score, 37/41) and surgeon satisfaction with the clinical encounter (median score, 38/45) were high. Patients who previously underwent subtotal colectomy had lower preparation for decision-making scores (median score, 58 vs 78 for surgery-naïve patients, p = 0.06), and did not report increased certainty in treatment preference after using the decision aid.The study included a small sample with no comparison group.A novel decision aid for surgical patients with ulcerative colitis appears to be effective and acceptable in patients and surgeons from diverse clinical settings. Patients who have not yet initiated surgical treatment seem to benefit most. Future studies to validate the knowledge questionnaire and test the decision aid in a randomized fashion are warranted.

Bowel dysfunction, including frequency, fecal urgency, stool consistency, and evacuation symptoms, contributes to fecal incontinence.The purpose of this study was to examine the impact of a vaginal bowel control system on parameters of bowel function, including frequency, urgency, stool consistency, and evacuation.This was a secondary analysis of a multicenter, prospective clinical trial.This study was conducted at 6 sites in the United States, including university hospitals and private practices in urogynecology and colorectal surgery.A total of 56 evaluable female subjects aged 19 to 75 years with 4 or more fecal incontinence episodes on a 2-week bowel diary were included.The study intervention was composed of the vaginal bowel control system, consisting of a vaginal insert and pressure-regulated pump.Subjects completed a 2-week baseline diary of bowel function before and after treatment completed at 1 month. Fecal urgency, consistency of stool (Bristol score), and completeness of evacuation were recorded for all bowel movements.Use of the insert was associated with an improvement in bowel function across all 4 categories. Two thirds (8/12) of subjects with a high frequency of daily stools (more than 2 per day) shifted to a normal or low frequency of stools. Analysis of Bristol stool scale scores demonstrated a significant reduction in the proportion of all bowel movements reported as liquid (Bristol 6 or 7), from 36% to 21% (p = 0.0001). On average, 54% of stools were associated with urgency at baseline compared with 26% at 1 month (p0.0001). Incomplete evacuations with all bowel movements were reduced from 39% to 26% of subjects at 1 month (p = 0.0034).The study follow-up period was 1 month (with an optional additional 2 months).The vaginal bowel control system was associated with an improvement in bowel symptoms and function, including reduced bowel movement frequency, less fecal urgency, increased solid consistency, and improved evacuation in patients with significant fecal incontinence.

Background Although social support is important for quality of life in patients undergoing surgery for ulcerative colitis, the impact of surgery on patient relationships is not known. Objective We examined relationship parameters in patients with ulcerative colitis and their partners before and 6 months after surgery. Design This was a prospective cohort in which we performed an exploratory analysis. Settings Patients were enrolled from an academic medical center. Patients Surgical patients with ulcerative colitis and their partners were invited to participate. Interventions Patients underwent proctocolectomy in 1, 2, or 3 stages. Main outcome measures We measured quality of life and sexual function in patients, as well as relationship quality, empathy, and sexual satisfaction in patients and partners before and 6 months after surgery using validated questionnaires. Results The study sample consisted of 74 participants, including 37 patients (25 men and 12 women) and their opposite-sex partners. Quality of life improved significantly in male and female patients after surgery. Sexual function scores also improved after surgery in male and female patients; however, the changes reached statistical significance in male patients only. Sexual satisfaction scores improved significantly after surgery in female patients and their partners. There was little change in relationship quality or empathy after surgery, with the exception of slightly improved relationship quality reported by male partners. In general, patients and partners reported levels of relationship quality and empathy similar to normative populations. Limitations This study included a small, highly selected sample. Conclusions Male and female patients with ulcerative colitis have high-quality relationships that are not negatively affected by surgical treatment. Changes in sexual function do not necessarily coincide with changes in sexual satisfaction in this patient population. Future studies should evaluate the effect of high-quality relationships on surgical outcomes.

Background As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial. Objective The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents. Design This is a retrospective cohort study. Setting This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services. Patients Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included. Main outcome measures The primary outcomes measured were fecal incontinence and the 1-year mortality rate. Results Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022). Limitations Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice. Conclusions Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.

T he American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Few existing measures assess constipation-specific quality of life. This study sought to develop a valid and reliable quality-of-life measure for constipation.First, we created a preliminary instrument that assessed quality-of-life domains affected by constipation: body image, eating, mood, and relationships with others. We conducted focus groups both with patients with constipation seeking treatment and the health care providers who treat them. Next, a 59-item questionnaire was given to 240 subjects with constipation (83% female) and 103 healthy volunteers (63% female). Test-retest reliability and discriminant, convergent, and divergent validity were assessed.Exploratory factor analysis revealed four domains: Social Impairment (five items), Distress (six items), Eating Habits (three items), and Bathroom Attitudes (four items). Internal consistency and test-retest reliability for all subscales was high (Cronbach's alpha = 0.89; intraclass correlation coefficient = 0.87). All domains discriminated well between subjects with constipation and healthy volunteers (P0.001). Convergent validity was excellent: all subscales correlated highly with the Irritable Bowel Syndrome Quality of Life Scale total score (P0.001) and the Medical Outcomes Study Short Form-36 physical component and mental component summary scores (P0.001). Scores from our Constipation-Related Quality of Life measure were not significantly correlated with the Social Desirability Scale, demonstrating divergent validity.Our findings support the reliability and validity of the Constipation-Related Quality of Life measure. Future validation of the Constipation-Related Quality of Life measure for assessing changes in quality of life in response to treatments for constipation is needed.

Rectourethral fistula is a rare complication of pelvic surgery, trauma, or inflammation. The many techniques for repairing these fistulas vary in their success rates. Our goal was to describe the use of a dartos muscle interposition flap for repair of these fistulas. We performed a retrospective review of eight patients who underwent repair of a rectourethral fistula with a dartos muscle interposition flap. We describe the success rate and patient-related factors that may have affected success. The technique of dartos muscle interposition is described and compared with other previously described techniques. Six of eight patients had healing of their fistulas documented by follow-up cystogram. Dartos muscle interposition is a straightforward technique that can result in successful fistula repair but should not be used in patients with risk factors for poor wound healing, such as an immunocompromised state or previous radiation therapy.