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Background: Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery., Objective: The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer., Design: This study was designed as an international multicenter comparative cohort study., Settings: The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France., Patients: Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer., Main Outcome Measures: Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes., Results: In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02)., Limitations: This study is limited by the possible response bias., Conclusions: Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565., Resultados Funcionales Y De Calidad De Vida Posterior a La Reconstruccin De La Anastomosis En Pacientes Con Cncer De Recto Estudio Internacional Multicntrico De Cohorte Comparativo: ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565., (Copyright © The ASCRS 2021.)

Background: Patients undergoing total colectomy for IBD may develop cancer in the rectal remnant, but the association is poorly understood., Objectives: This study aimed to examine the risk and prognosis of rectal cancer after total colectomy for IBD., Design: This is a nationwide population-based study., Setting: Treatment of the patients took place in Denmark from 1977 to 2013., Patients: Patients with IBD undergoing total colectomy were included., Main Outcome Measures: We examined the incidence of rectal cancer among patients with IBD and total colectomy and compared cancer stage to that of other patients with rectal cancer in Denmark. We used Kaplan-Meier methodology to estimate survival and Cox regression to estimate adjusted mortality rate ratios following a rectal cancer diagnosis, comparing patients with and without IBD and a rectal remnant., Results: We identified 4703 patients with IBD (1026 Crohn's disease; 3677 ulcerative colitis) who underwent total colectomy with a rectal remnant. During 29,725 years of follow-up, 30 rectal cancers were observed, compared with 8 rectal cancers expected (standardized incidence ratio = 3.6 (95% CI, 2.4-5.1)). Cancer stage distributions were similar. Risk of rectal cancer 35 years after total colectomy was 1.9% (95% CI, 1.1%-2.9%). Five years after rectal cancer diagnosis, survival was 28% (95% CI, 12%-47%) and 38% (95% CI, 37%-38%) for patients with and without IBD and a rectal remnant. The adjusted mortality rate ratio 1 to 5 years after a rectal cancer diagnosis was 2.5 (95% CI, 1.6-3.9). Median time from last recorded nondiagnostic proctoscopy to rectal cancer diagnosis for patients with IBD and total colectomy was 1.1 years., Limitations: This study was limited by the few outcomes and the use of administrative and not clinical data., Conclusion: Long-term risk of rectal cancer following total colectomy for IBD was low. Survival following a diagnosis of rectal cancer was poorer for patients with IBD and total colectomy than for patients who had rectal cancer without IBD and total colectomy. Endoscopic surveillance, as it appeared to be practiced in this cohort, may be inadequate. See Video Abstract at http://links.lww.com/DCR/B497. RIESGO DE CÁNCER DE RECTO Y SUPERVIVENCIA DESPUÉS DE UNA COLECTOMÍA TOTAL POR ENFERMEDAD INFLAMATORIA INTESTINAL: UN ESTUDIO POBLACIONAL: Los pacientes sometidos a colectomía total por enfermedad inflamatoria intestinal (EII) pueden desarrollar cáncer en el remanente rectal, pero la asociación es poco conocida.Examinar el riesgo y el pronóstico del cáncer de recto después de una colectomía total para la EII.Estudio poblacional a nivel nacional.Dinamarca 1977-2013.Pacientes con EII sometidos a colectomía total.Examinamos la incidencia de cáncer de recto entre pacientes con EII y colectomía total y comparamos el estadio del cáncer con el de otros pacientes con cáncer de recto en Dinamarca. Utilizamos la metodología de Kaplan-Meier para estimar la supervivencia y la regresión de Cox para estimar las tasas de mortalidad ajustadas (aMRR) después de un diagnóstico de cáncer de recto, comparando pacientes con y sin EII y un remanente rectal.Identificamos 4.703 pacientes con EII (1.026 enfermedad de Crohn; 3.677 colitis ulcerosa) que se sometieron a colectomía total con remanente rectal. Durante 29,725 años de seguimiento, se observaron 30 cánceres de recto, en comparación con los 8 esperados [razón de incidencia estandarizada (SIR) = 3.6, (intervalo de confianza (IC) del 95%: 2.4-5.1)]. Las distribuciones de las etapas del cáncer fueron similares. El riesgo de cáncer de recto 35 años después de la colectomía total fue del 1,9% (IC del 95%: 1,1% -2,9%). Cinco años después del diagnóstico de cáncer de recto, la supervivencia fue del 28% (IC del 95%: 12% -47%) y del 38% (IC del 95%: 37% -38%) para los pacientes con y sin EII y un remanente rectal, respectivamente. La aMRR 1-5 años después de un diagnóstico de cáncer de recto fue de 2,5 (IC del 95%: 1,6-3,9). La mediana de tiempo desde la última proctoscopia no diagnóstica registrada hasta el diagnóstico de cáncer de recto en pacientes con EII y colectomía total fue de 1,1 años.Pocos resultados, uso de datos administrativos y no clínicos.El riesgo a largo plazo de cáncer de recto después de una colectomía total para la EII fue bajo. La supervivencia después de un diagnóstico de cáncer de recto fue más pobre para los pacientes con EII y colectomía total que para los pacientes con cáncer de recto sin EII y colectomía total. La vigilancia endoscópica, como parecía practicarse en esta cohorte, puede ser inadecuada. Consulte Video Resumen en http://links.lww.com/DCR/B497. (Traducción-Dr. Adrian Ortega).

Background: Watchful waiting in patients with rectal cancer with complete clinical response after chemoradiation therapy has gained increased popularity to avoid morbidity and mortality associated with surgery. Irradiation of the pelvis causes bowel dysfunction, but the effect on anorectal sensory function remains obscure in this patient category., Objective: The aim of this study was to characterize the sensory pathways of the gut-brain axis in patients with rectal cancer treated solely with chemoradiation therapy (nonconventional regime/dose) compared with healthy volunteers., Design: This is an explorative study., Settings: Sensory evaluation by rectal distension was performed and cortical evoked potentials were recorded during rapid balloon distensions of the rectum and anal canal. Latencies and amplitudes of cortical evoked potentials were compared, and the relative amplitude of 5 spectral bands from recorded cortical evoked potentials was used as an additional proxy of neuronal processing., Patients: Patients with rectal cancer solely with chemoradiation therapy (n = 13) a median of 3.2 years ago (range, 2.3-5.6 y) and healthy volunteers (n = 13) were included., Main Outcome Measures: Cortical evoked potentials were measured., Results: Patients had 35% lower rectal capacity at a maximum tolerable volume (p = 0.007). We found no differences in rectal cortical evoked potential latencies (p = 0.09) and amplitudes (p = 0.38) between groups. However, spectral analysis of rectal cortical evoked potentials showed a decrease in θ (4-8 Hz) and an increase in β (12-32 Hz) band activity in patients (all p < 0.001). Anal cortical potentials showed an increase in α (8-12 Hz) and β and a decrease in γ (32-70 Hz) band activity (all p < 0.001) in patients compared with healthy volunteers., Limitations: This is an explorative study of limited size., Conclusions: Chemoradiation therapy for distal rectal cancer causes abnormal cortical processing of both anal and rectal sensory input. Such central changes may play a role in symptomatic patients, especially when refractory to local treatments. See Video Abstract at http://links.lww.com/DCR/B270. RESPUESTA NEURONAL ANORMAL A ESTÍMULOS RECTALES Y ANALES, EN PACIENTES TRATADOS POR CÁNCER RECTAL DISTAL, CON QUIMIORRADIOTERAPIA DE DOSIS ALTA, SEGUIDA DE ESPERA VIGILANTE: La espera vigilante en pacientes de cáncer rectal, con respuesta clínica completa después de la quimiorradiación, ha ganado una mayor popularidad en evitar la morbilidad y mortalidad asociadas con la cirugía. La irradiación de la pelvis causa disfunción intestinal, pero el efecto sobre la función sensorial ano-rectal sigue siendo no claro, en esta categoría de pacientes.El objetivo de este estudio, fue caracterizar las vías sensoriales del eje intestino-cerebro en pacientes con cáncer rectal, tratados únicamente con quimiorradiación (régimen / dosis no convencional), en comparación con voluntarios sanos.Es un estudio exploratorio.Se realizó una evaluación sensorial por distensión rectal y se registraron los potenciales evocados corticales, durante las distensiones rápidas con balón en recto y canal anal. Se compararon las latencias y amplitudes de los potenciales evocados corticales, y la amplitud relativa de cinco bandas espectrales registradas, de potenciales evocados corticales, se usaron como proxy adicional del procesamiento neuronal.Pacientes de cáncer rectal, únicamente con terapia de quimiorradiación (n = 13) mediana de 3.2 años (rango 2.3-5.6) y voluntarios sanos (n = 13).Potenciales evocados corticales.Pacientes tuvieron una capacidad rectal menor del 35%, al volumen máximo tolerable (p = 0.007). No encontramos diferencias en las latencias potenciales evocadas corticales rectales (p = 0.09) y amplitudes (p = 0.38) entre los grupos. Sin embargo, el análisis espectral de los potenciales evocados corticales rectales, mostró una disminución en theta (4-8 Hz) aumento en beta (12-32 Hz), y actividad en banda en pacientes (todos p <0.001). Los potenciales evocados corticales anales mostraron un aumento en alfa (8-12 Hz) y beta, disminución en gamma (32-70 Hz), y actividad en banda (todos p <0.001), en pacientes comparados a voluntarios sanos.Este es un estudio exploratorio de tamaño limitado.La quimiorradiación para el cáncer rectal distal, ocasiona procesos corticales sensoriales anormales anales y rectales. Tales cambios centrales pueden desempeñar un papel en pacientes sintomáticos, especialmente cuando son refractarios a tratamientos locales. Consulte Video Resumen en http://links.lww.com/DCR/B270.

Background: Impact of restorative proctocolectomy failure on fertility has not been studied and is greatly relevant., Objective: The purpose of this study was to evaluate the impact of restorative proctocolectomy failure on birth rate in women and men, along with in vitro fertilization incidence and success., Design: This was a retrospective registry-based cohort study over 17 years., Settings: Records for parenting a child were cross-linked with patient records. In women, in vitro fertilization records were cross-linked. All data were prospectively registered., Patients: Patients of fertile age with ulcerative colitis between 1994 and 2010 were identified in Danish national databases. Patients with restorative proctocolectomy and restorative proctocolectomy failure were identified as subgroups., Main Outcome Measures: Birth rate ratios and in vitro fertilization incidence and success were measured., Results: We included 11,939 women and 13,569 men with ulcerative colitis. A total of 711 women and 730 men had restorative proctocolectomy; 114 women and 90 men had failure. Birth rate in women with failure was significantly reduced compared with women without (birth rate ratio = 0.50 (95% CI, 0.29-0.82)). In men with failure, birth rate tended to be lower compared with men without (birth rate ratio = 0.74 (95% CI, 0.51-1.05)). In vitro fertilization incidence was similar with and without failure (HRs adjusted for age at start of follow-up = 0.98 (95% CI, 0.58-1.67]). In vitro fertilization success was significantly lower with failure compared with ulcerative colitis (OR adjusted for age at start of follow-up = 0.36 (95% CI, 0.4-0.92))., Limitations: Information on patients leading up to restorative proctocolectomy failure is lacking. Failure patients may have had children during a period with pouch function. Therefore, the impact of failure may be underestimated., Conclusions: Restorative proctocolectomy failure impairs birth rate, primarily in women. Although in vitro fertilization incidence is similar in women with and without failure, the likelihood of giving birth after in vitro fertilization is reduced. See Video Abstract at http://links.lww.com/DCR/B202. IMPACTO SOBRE LA FERTILIDAD DESPUéS DEL FRACASO DE LA PROCTOCOLECTOMíA RESTAURADORA EN HOMBRES Y MUJERES CON COLITIS ULCEROSA: UN ESTUDIO DE COHORTE DE 17 AñOS: No se ha estudiado el impacto de la falla de la proctocolectomía restauradora en la fertilidad y es muy relevante.Evaluar el impacto del fracaso de la proctocolectomía restauradora en la tasa de natalidad en mujeres y hombres, junto con la incidencia y el éxito de la fertilización in vitro.Estudio de cohorte retrospectivo basado en el registro de más de 17 años.Los registros de crianza de un niño se cruzaron con los registros de pacientes. En las mujeres, los registros de fertilización in vitro se cruzarón. Todos los datos se regitraron de forma prospectiva.Los pacientes de edad fértil con colitis ulcerosa entre 1994-2010 fueron identificados en las bases de datos nacionales danesas. Los pacientes con proctocolectomía restauradora y fracaso de la proctocolectomía restauradora se identificaron como subgrupos.Tasas de natalidad e incidencia y éxito de la fertilización in vitro.Se incluyeron 11939 mujeres y 13569 hombres con colitis ulcerosa. 711 mujeres y 730 hombres tuvieron proctocolectomía restauradora; 114 mujeres y 90 hombres tuvieron fracaso. La tasa de natalidad en las mujeres con fracaso se redujo significativamente en comparación con las mujeres sin fracaso (tasa de natalidad: 0,50; IC del 95% [0,29; 0,82]). En los hombres con fracaso, la tasa de natalidad tendió a ser más baja en comparación con los hombres sin fracaso (tasa de natalidad: 0,74; IC del 95% [0,51; 1,05]). La incidencia de fertilización in vitro fue similar con y sin falla (aHR: 0.98, IC 95% [0.58; 1.67]). El éxito de la fertilización in vitro fue significativamente menor con el fracaso en comparación con la colitis ulcerosa (aOR: 0.36 IC 95% [0.4; 0.92]).Falta información sobre los pacientes que conducen al fracaso de la proctocolectomía restauradora. Los pacientes con fracaso pueden haber tenido hijos durante un período con función de bolsa. Por lo tanto, el impacto del fracaso puede ser subestimado.El fracaso de la proctocolectomía restauradora afecta la tasa de natalidad, principalmente en mujeres. Aunque la incidencia de la fertilización in vitro es similar en las mujeres con y sin fracaso, la probabilidad de dar a luz después de la fertilización in vitro se reduce. Consulte Video Resumen en http://links.lww.com/DCR/B202. (Traducción-Dr Gonzalo Hagerman).

Background: Low anterior resection syndrome is pragmatically defined as disordered bowel function after rectal resection leading to a detriment in quality of life. This broad characterization does not allow for precise estimates of prevalence. The low anterior resection syndrome score was designed as a simple tool for clinical evaluation of low anterior resection syndrome. Although the low anterior resection syndrome score has good clinical utility, it may not capture all important aspects that patients may experience., Objective: The aim of this collaboration was to develop an international consensus definition of low anterior resection syndrome that encompasses all aspects of the condition and is informed by all stakeholders., Design: This international patient-provider initiative used an online Delphi survey, regional patient consultation meetings, and an international consensus meeting., Participants: Three expert groups participated: patients, surgeons, and other health professionals from 5 regions (Australasia, Denmark, Spain, Great Britain and Ireland, and North America) and in 3 languages (English, Spanish, and Danish)., Main Outcome Measure: The primary outcome measured was the priorities for the definition of low anterior resection syndrome., Results: Three hundred twenty-five participants (156 patients) registered. The response rates for successive rounds of the Delphi survey were 86%, 96%, and 99%. Eighteen priorities emerged from the Delphi survey. Patient consultation and consensus meetings refined these priorities to 8 symptoms and 8 consequences that capture essential aspects of the syndrome., Limitations: Sampling bias may have been present, in particular, in the patient panel because social media was used extensively in recruitment. There was also dominance of the surgical panel at the final consensus meeting despite attempts to mitigate this., Conclusions: This is the first definition of low anterior resection syndrome developed with direct input from a large international patient panel. The involvement of patients in all phases has ensured that the definition presented encompasses the vital aspects of the patient experience of low anterior resection syndrome. The novel separation of symptoms and consequences may enable greater sensitivity to detect changes in low anterior resection syndrome over time and with intervention.

Background: The risk of pelvic sepsis following IPAA for ulcerative colitis may have changed with changes in medical and surgical treatment, but data are scarce., Objectives: This study aims to examine temporal changes in the risk of pelvic sepsis following IPAA for ulcerative colitis and to ascertain risk factors associated with pelvic sepsis., Design: This is a nationwide cohort study., Setting: This study was conducted in Denmark from 1996 to 2013., Patients: Patients were operated on with an IPAA for ulcerative colitis., Main Outcome Measures: Pelvic sepsis was defined and validated as the occurrence of anastomotic leakage, pelvic abscesses or fistulas, or an operation for these conditions, recorded in a nationwide registry. Cumulative risks were calculated by using death as a competing risk. Multivariate Cox regression was used to examine the effects of calendar periods (1996-1999, 2000-2004, 2005-2009, and 2010-2013) on hazards ratios for pelvic sepsis, adjusting for age, sex, comorbidity, annual hospital volume, pelvic sepsis in the 12 months preceding surgery, operative stage (1-, 2-, modified 2-, or 3-stage), laparoscopy, and preoperative treatment with biological medicine within 12 weeks before surgery., Results: Of 1456 patients, 244 (16.8%) experienced pelvic sepsis. The 1-year risk increased by calendar period (1996-1999: 2.5%, 2000-2004: 4.5%, 2005-2009: 7.4%, and 2010-2013: 9.6%). The adjusted hazard ratio for pelvic sepsis increased by an average 4.4% (95% CI, 1.3-7.6) per year in the study period. In general, patients were older and had more comorbidities at IPAA in recent years than in earlier years, and more had experienced pelvic sepsis in the 12 months preceding the operation., Limitations: This study was register based. There were no data on important clinical variables to determine the causes of an increased risk over calendar periods., Conclusion: In this nationwide cohort study, the 1-year risk of pelvic sepsis following primary IPAA for ulcerative colitis increased 4-fold from 1996 to 2013. See Video Abstract at http://links.lww.com/DCR/A956.

Background: Complete mesocolic excision improves the long-term outcome of colon cancer but might carry a risk of bowel dysfunction., Objective: This study aimed to investigate whether right-sided complete mesocolic excision is associated with an increased risk of long-term bowel dysfunction and reduced quality of life compared with conventional colon cancer resections., Design: Data were extracted from a population-based study comparing complete mesocolic excision and conventional colon cancer resections and from a national questionnaire survey regarding functional outcome., Settings: Elective right-sided colon resections for stage I to III colon adenocarcinoma were performed at 4 university colorectal centers between June 2008 and December 2014., Patients: Seven hundred sixty-two patients were eligible to receive the questionnaire in November 2015., Main Outcome Measures: The primary outcomes measured were the risk of diarrhea (Bristol stool scale score of 6-7), 4 or more bowel movements daily, and the impact of bowel function on quality of life. Secondary outcomes were other bowel symptoms, chronic pain, and quality of life measured by the European Organisation for Research and Treatment of Cancer QLQ-C30., Results: One hundred forty-one (63.8%) and 324 (59.9%) patients undergoing complete mesocolic excision and conventional resections responded after a median of 3.99 (interquartile range, 2.11-5.32) and 4.11 (interquartile range, 3.01-5.53) years (p = 0.04). Complete mesocolic excision was not associated with increased risk of diarrhea (adjusted OR, 1.07; 95% CI, 0.57-1.95; p = 0.84), 4 or more bowel movements daily (adjusted OR, 1.16; 95% CI, 0.57-2.24; p = 0.68), or lower quality of life (adjusted OR, 0.84; 95% CI, 0.49-1.40; p = 0.50). Complete mesocolic excision was associated nonsignificantly with nocturnal bowel movements, but not associated with chronic pain or other secondary outcomes., Limitations: This study was limited by the retrospective design with unknown baseline symptoms. Responding patients were younger but without obvious selection bias. The outcome "diarrhea" seemed somehow sensitive to information bias., Conclusion: Right-sided complete mesocolic excision seems associated with neither bowel dysfunction nor impaired quality of life when compared with conventional surgery. See Video Abstract at http://links.lww.com/DCR/A665.

Background: Sexual dysfunction and impaired quality of life is a potential side effect to rectal cancer treatment., Objective: The objective of this study was to develop and validate a simple scoring system intended to evaluate sexual function in women treated for rectal cancer., Design: This is a population-based cross-sectional study., Settings: Female patients diagnosed with rectal cancer between 2001 and 2014 were identified by using the Danish Colorectal Cancer Group's database. Participants filled in the validated Sexual Function Vaginal Changes questionnaire. Women declared to be sexually active at follow-up were randomly assigned to 2 groups: one for development and one for validation. Logistic regression analyses identified items for the score, and multivariate analysis established a weighted-score value allocated to each item, adding up to the total score. The validity of the score was tested in the validation group., Patients: Female patients with rectal cancer above the age of 18 who underwent abdominoperineal resection, Hartmann procedure, or total/partial mesorectal excision were selected., Main Outcome Measures: The primary outcome measured was the quality of life that was negatively affected because of sexual problems., Results: A total of 466 sexually active women responded. The score includes 7 items with a range of 0 to 29 points. Score ≥9 indicates sexual dysfunction. The score has a sensitivity/specificity of 76%/75% detecting patients bothered by sexual dysfunction with a negative impact on quality of life., Limitations: This study was limited by the large amount of nonresponders., Conclusions: Living up to our demands for a short and easy-to-use validated tool, we have developed the Rectal Cancer Female Sexuality score. It captures, with high sensitivity, the essential problems of female sexuality seen from the perspective of a surviving rectal cancer patient. See Video Abstract at http://links.lww.com/DCR/A576.

Background: Birth rates in males with ulcerative colitis and ileal pouch-anal anastomosis have not been studied., Objective: This study aimed to estimate birth rates in males and females with ulcerative colitis and study the impact of ileal pouch-anal anastomosis., Design: This was a retrospective registry-based cohort study that was performed over a 30-year period., Settings: Records for parenting a child from the same period were cross-linked with patient records, and birth rates were calculated using 15 through 49 years as age limits. All data were prospectively registered., Patients: All patients with ulcerative colitis and ulcerative colitis with ileal pouch-anal anastomosis between 1980 and 2010 were identified in Danish national databases., Main Outcome Measures: The primary outcomes measured were birth rates in females and males with ulcerative colitis and ulcerative colitis with ileal pouch-anal anastomosis., Results: We included 27,379 patients with ulcerative colitis (12,812 males and 14,567 females); 1544 had ileal pouch-anal anastomosis (792 males and 752 females). Patients with ulcerative colitis have slightly reduced birth rates (males at 40.8 children/1000 years, background population 43.2, females at 46.2 children/1000 years, background population 49.1). After ileal pouch-anal anastomosis, males had increased birth rates at 47.8 children/1000 years in comparison with males with ulcerative colitis without ileal pouch-anal anastomosis (40.5 children/1000 years), whereas females had reduced birth rates at 27.6 children/1000 years in comparison with females with ulcerative colitis without ileal pouch-anal anastomosis (46.8 children/1000 years)., Limitations: Only birth rates were investigated and not fecundability. Furthermore, there is a question about misattributed paternity, but this has previously been shown to be less than 5%., Conclusions: Ulcerative colitis per se has little impact on birth rates in both sexes, but ileal pouch-anal anastomosis surgery leads to a reduction in birth rates in females and an increase in birth rates in males. This has clinical impact when counseling patients before ileal pouch-anal anastomosis surgery.

Background: Magnetic anal sphincter augmentation is a novel technique for the treatment of patients with fecal incontinence., Objective: The current study reports the long-term effectiveness and safety of this new treatment modality., Design: This was a prospective multicenter pilot study., Settings: The study was performed at 4 clinical sites in Europe and the United States., Patients: The cohort included patients with severe fecal incontinence for ≥6 months who had previously failed conservative therapy and were implanted with a magnetic anal sphincter device between 2008 and 2011., Main Outcome Measures: Adverse events, symptom severity, quality of life, and bowel diary data were collected., Results: A total of 35 patients (34 women) underwent magnetic anal sphincter augmentation. The median length of follow-up was 5.0 years (range, 0-5.6 years), with 23 patients completing assessment at 5 years. Eight patients underwent a subsequent operation (7 device explantations) because of device failure or complications, 7 of which occurred in the first year. Therapeutic success rates, with patients who underwent device explantation or stoma creation counted as treatment failures, were 63% at year 1, 66% at year 3 and 53% at year 5. In patients who retained their device, the number of incontinent episodes per week and Cleveland Clinic incontinence scores significantly decreased from baseline, and there were significant improvements in all 4 scales of the Fecal Incontinence Quality of Life instrument. There were 30 adverse events reported in 20 patients, most commonly defecatory dysfunction (20%), pain (14%), erosion (11%), and infection (11%)., Limitations: This study does not allow for comparison between surgical treatments and involves a limited number of patients., Conclusions: Magnetic anal sphincter augmentation provided excellent outcomes in patients who retained a functioning device at long-term follow-up. Protocols to reduce early complications will be important to improve overall results.

Background: After the introduction of complete mesocolic excision, a new pathological evaluation of the resected colon cancer specimen was introduced. This concept has quickly gained acceptance and is often used to compare surgical quality. The grading of colon cancer specimens is likely to depend on both surgical quality and the training of the pathologist., Objective: The purpose of this study was to validate the principles of the pathological evaluation of colon cancer specimens., Design: This was an exploratory study., Settings: The study was conducted in Aarhus, Denmark, and Leeds, United Kingdom., Patients: Colon cancers specimens were used., Main Outcome Measures: The agreement of gradings between participants was of interest. Four specialist GI pathologists and 2 abdominal surgeons evaluated 2 rounds of colon cancer specimens, each at 2 separate time points. Each round contained 50 specimens. After the first round, a protocol of detailed principles for the grading procedure was agreed on. Results from an experienced pathologist were considered as the reference results., Results: In the first round, the distribution of gradings between participants showed substantial variation. In the second round, the variation was reduced. Intraobserver agreement was mostly fair to good, whereas interobserver agreement was frequently poor. This did not significantly change from round 1 to round 2., Limitations: The small sample size of 100 specimens provided a very small number of specimens resected in the muscularis propria plane, which renders the evaluation of this group potentially unreliable. The evaluations were made on photos and not on fresh specimens., Conclusions: This study demonstrates significant variation in the pathological evaluation of colon cancer specimens. It demonstrates that it cannot be used in clinical studies, and care should be taken when comparing results between different hospitals.

Background: Restorative anterior resection is considered the optimal procedure for most patients with rectal cancer and is frequently preceded by radiotherapy. Both surgery and preoperative radiotherapy impair bowel function, which adversely affects quality of life., Objective: This study aimed to report symptoms associated with and key predictors for bowel-related quality-of-life impairment., Design: The study included a cross-sectional cohort., Settings: This was a multicenter study from 12 United Kingdom centers., Patients: A total of 578 patients with rectal cancer underwent curative restorative anterior resection between 2001 and 2012 (median, 5.25 years postsurgery)., Main Outcome Measures: Patients completed outcome measures that assessed bowel dysfunction (low anterior resection syndrome score), incontinence (Wexner score), and quality of life (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30), plus an anchor question: "Overall how does bowel function affect your quality of life?", Results: The response rate was 80% (462/578). Overall, 85% (391/462) of patients reported bowel-related quality-of-life impairment, with 40% (187/462) reporting major impairment. A large difference in global quality of life (22 points; p < 0.001) was reported for "none" versus "major" impairment, with greatest symptom severity being diarrhea (25 points; p < 0.001), insomnia (24 points; p < 0.001), and fatigue (20 points; p < 0.001). Regression analysis identified major impairment in 60% and 45% of patients with low rectal cancer treated with and without preoperative radiotherapy compared with 47% and 33% of middle/upper rectal cancers with and without preoperative radiotherapy., Limitations: Advances in radiotherapy delivery and improvements in posttreatment symptom control, although currently of limited efficacy, imply that the content of this consent aid should be re-evaluated in 5 to 10 years., Conclusions: Before a restorative anterior resection, patients with rectal cancer should be informed that bowel-related quality-of-life impairment is common. The key risk factors are neoadjuvant therapy and a low tumor height. This study presents quality-of-life and functional outcome data, along with a consent aid, that will enhance this preoperative patient discussion.

Background: The potential advantages of robot-assisted laparoscopy are being increasingly investigated, although data on its efficacy in benign colorectal surgery are scarce., Objective: We compared the early postoperative outcome in robot-assisted IPAA with open surgery procedures., Design: This was an observational study based on prospectively collected data obtained from chart reviews., Setting: The single-center data set covers patients operated on from January 13, 2004, to September 16, 2014, at a specialist center., Patients: Patients with ulcerative colitis undergoing IPAA surgery were included., Main Outcome Measures: Study end points included the duration of operation, admission length, complications (Clavien-Dindo), reoperations, and readmissions., Results: Eighty-one robot-assisted and 170 open IPAA procedures were performed. The duration of operation was significantly longer for robot-assisted laparoscopic procedures (mean difference, 154 minutes; CI, 140-170). During a mean follow-up of 102 days, no significant differences in the distribution of complications were found (Spearman p = 0.12; p = 0.07), and no postoperative deaths occurred in either group. Postoperative admission length was shorter following robot-assisted procedures (mean difference, -1.9; CI, -3.5 to -0.3), whereas 40% of patients were readmitted, compared with 26% of patients who had open surgery (OR, 1.9; CI, 1.1-3.4). Pouch failure occurred in 3 patients (1 following robot-assisted laparoscopy; 2 following open surgery). On multivariate regression analyses, robot-assisted laparoscopy was associated with a significantly longer duration of operation (mean difference, 159 minutes; CI, 144-174), and more readmissions for any cause (OR, 2; CI, 1.1-3.7)., Limitations: This was a nonrandomized, single-center observational study., Conclusion: In this implementation phase, robot-assisted IPAA surgery offers acceptable short-term outcomes. The limitations of this observational study call for randomized controlled trials with long-term follow-up and exploration of functional results.

Background: An increasing number of patients are surviving a diagnosis of rectal cancer. The majority of the patients are treated with the sphincter-sparing surgical procedure low anterior resection, and 50% to 90% of these patients experience bowel dysfunction, known as the low anterior resection syndrome. No previous studies have investigated the association between the low anterior resection syndrome and quality of life in an international setting with the use of a validated instrument for the classification of the low anterior resection syndrome., Objective: The aim of this study was to investigate the association between quality of life and the low anterior resection syndrome in European patients who have had rectal cancer., Design: The study was designed as an international cross-sectional study involving 5 centers in 4 European countries., Patients: All patients had undergone low anterior resection for rectal cancer, had no stoma, had no dissemination or recurrence at the time of the study, and were at least 16 months past surgery., Interventions: The patients received by mail the Low Anterior Resection Syndrome Score and the quality-of-life questionnaire EORTC QLQ-C30., Main Outcome Measures: Eight subscales were selected to be the focus of this study: global quality of life; physical, role, emotional, and social functioning; fatigue; constipation; and diarrhea., Results: A total of 796 patients were included, which corresponds to a response rate of 75.0%. In comparison with patients without low anterior resection syndrome, patients with major low anterior resection syndrome fared substantially worse in all selected subscales (difference ≥ 10 points, p < 0.01), with the exception of constipation., Limitations: The cross-sectional design prevents an evaluation of causality., Conclusions: The quality of life of patients who have had rectal cancer is closely associated with the severity of the low anterior resection syndrome. Therefore, it is important that clinicians and researchers focus on this syndrome to improve the prevention and the treatment of bowel dysfunction and the information given to patients.

Background: Women with anal sphincter injuries have an increased risk of developing fecal incontinence despite surgical intervention., Objective: The aim of this study was to evaluate the long-term risk of fecal incontinence after primary anal sphincter reconstruction and its impact on quality of life., Design: This was a cohort study., Settings: This study was performed at Aarhus University Hospital., Patients: Women with complete anal sphincter rupture (exposed) from 1976 to 1991 and a control group of parous women (nonexposed) were included., Main Outcome: The primary outcomes measured were fecal incontinence, Wexner score, St Mark incontinence score, and quality of life., Results: A total of 363 women were included (125 exposed and 238 nonexposed). The mean age was 50.4 years (95%CI: 49.8-51.0), with 22.2 years (95% CI: 21.7-22.6) of follow-up. At the time of follow-up, 49% of exposed women and 74% of nonexposed women were continent. Complete anal sphincter tear increases the risk of fecal incontinence twofold (relative risk = 2.00; 95%CI: 1.52-2.63). No other risk factors were identified. The mean Wexner score was 1.7 (95%CI: 1.3-2.1) vs 1.1 (95%CI: 0.7-1.4) (p = 0.02), and the mean St Mark score was 2.8 (95% CI: 2.1-3.4) vs 1.4 (95%CI: 1.0-1.9) (p < 0.001) in the exposed and nonexposed groups. Severity of fecal incontinence had a significant impact on the quality of life independent of exposure., Limitation: The cohort is relatively young; a short postmenopausal period limits the assessment of hormonal status and the effect of postmenopausal hormone replacement therapy., Conclusion: Complete obstetric anal sphincter tear increases the long-term risk of fecal incontinence twofold. When present, the severity of the incontinence symptoms is minor and the risk of incontinence for solid stool is not increased in comparison with the general population. Anal sphincter rupture is the only independent risk factor for fecal incontinence. The severity of fecal incontinence had the same impact on quality of life in both groups.

Background: The use of the vertical rectus abdominis myocutaneous flap in reconstruction after abdominoperineal resection or pelvic exenteration for neoplasia is well documented. However, functional outcomes after vaginal reconstruction, including sexual function, are poorly described., Objective: This study aimed to examine sexual function in women following extensive pelvic surgery with colpectomy and vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap., Design: This study is a retrospective review of medical records in combination with patient questionnaires. Nonresponders were followed up with a second contact., Settings: This study was performed at a tertiary care university medical center (Colorectal Section, Department of Surgery P, Aarhus University Hospital, Denmark), Patients: All women undergoing pelvic surgery and simultaneous vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap between 2004 and 2010 at our department were identified from a patient database. Thirty women who were alive at the time of identification were included in the study., Main Outcome Measures: Sexual function before and after surgery was evaluated by the use of the Sexual function Vaginal changes Questionnaire. The main outcome end point was whether the patient was sexually active after vaginal reconstruction., Results: Twenty-six participants (87%) answered the questionnaire. Fifty percent of patients reported an active sex life before surgery. In general, patients reported an unchanged desire for both physical and sexual contact after surgery. However, only 2 patients (14%) reported being sexually active after surgery., Limitations: This was a retrospective study with a heterogeneous cohort involving several types of cancers and surgical procedures. Factors other than vertical rectus abdominis myocutaneous flap reconstruction itself may interfere with the sexual function., Conclusion: Extensive pelvic surgery with colpectomy leads to sexual dysfunction even when the vagina is reconstructed with a vertical rectus abdominis myocutaneous flap. This knowledge may improve the quality of information given to this group of patients before surgery.

Background: Sacral nerve modulation has been reported as a minimally invasive and effective treatment for constipation refractory to conservative treatment., Objective: This study aimed to evaluate the efficacy and sustainability of sacral nerve modulation for constipation in the medium term (up to 6 years) and to investigate potential predictors of treatment success., Design: We performed a retrospective review of prospectively collected data., Settings: The study was performed at 2 tertiary-care centers in Europe with expertise in pelvic floor disorders and sacral nerve modulation., Patients: Patients were eligible if they had had symptoms of constipation persisting for at least 1 year, if conservative treatment (dietary modification, laxatives and biofeedback therapy) had failed, and if predefined excluded conditions were not present., Intervention: The first phase of the treatment process was percutaneous nerve evaluation. If this was successful, patients underwent sacral nerve modulation therapy with an implanted device (tined-lead and implantable pulse generator)., Main Outcome Measure: Follow-up was performed at 1, 3, 6, and 12 months, and yearly thereafter. Outcome was assessed with the Wexner constipation score., Results: A total of 117 patients (13 men, 104 women) with a mean age of 45.6 (SD, 13.0) years underwent percutaneous nerve evaluation. Of these, 68 patients (58%) had successful percutaneous nerve evaluation and underwent implantation of a device. The mean Wexner score was 17.0 (SD, 3.8) at baseline and 10.2 (SD 5.3) after percutaneous nerve evaluation (p < .001); the improvement was maintained throughout the follow-up period, although the number of patients continuing with sacral nerve modulation at the latest follow-up (median, 37 months; range, 4-92) was only 61 (52% of all patients who underwent percutaneous nerve evaluation). The sole predictive factor of outcome of percutaneous nerve evaluation was age: younger patients were more likely than older patients to have a successful percutaneous nerve evaluation phase., Limitations: The study was limited by a lack of consistent outcome measures., Conclusions: : Despite improvement in Wexner scores, at the latest follow-up sacral nerve modulation was only being used by slightly more than 50% of the patients who started the first phase of treatment. Further studies are needed to reassess the efficacy and sustainability of sacral nerve modulation.

Background: There is a lack of knowledge on the incidence and management of suboptimal therapeutic effect and the complications associated with sacral nerve stimulation for fecal incontinence and constipation., Objective: This study aimed to review current literature on postoperative issues and to propose a treatment algorithm., Data Source: PubMed, MEDLINE, and EMBASE were searched using the keywords "sacral nerve stimulation," "sacral neuromodulation," "fecal incontinence," and "constipation" for English-language articles published from January 1980 to August 2010. A further search was conducted on a wider literature using the keywords "complication," "adverse effect," "treatment failure," "equipment failure," "infection," "foreign-body migration," "reoperation," "pain," and "algorithm.", Study Selection: Four hundred sixty-one titles were identified, and after a title and abstract review, 135 were subjected to full article review; 89 were finally included in this review. Five articles were added by manual search and consensus., Results: Forty-eight studies were identified as cohort studies reporting on postoperative issues, including 1661 patients who underwent percutaneous nerve evaluation and 1600 patients who proceeded to sacral nerve stimulation therapy. Pooled data showed that the most common problem during percutaneous nerve evaluation was lead displacement (5.3%). The incidence of suboptimal outcome, pain, and infection after implantation was 12.1%, 13.0%, and 3.9%., Limitations: There was significant underreporting of untoward events, because 60% of the studies did not report complications during percutaneous nerve evaluation, and suboptimal outcome after implantation was not disclosed in 44% of the studies., Conclusions: The incidence of untoward events associated with sacral nerve stimulation appears to be low. However, there is a significant underreporting of the incidence. Using the information from the structured and systematic literature review, we formulated a clinically relevant guideline for reporting and managing postoperative issues. The guideline can provide a framework for clinical practice.

Background: Extralevator abdominoperineal excision for low rectal cancer includes resection of the pelvic floor as a part of the operative technique to reduce the risk of tumor-involved section margins., Objective: This study aimed to compare perineal defect reconstruction with a fasciocutaneous gluteal flap vs biological mesh regarding healing and occurrence of perineal hernia., Design: Retrospective review of medical records comparing surgical methods during 2 consecutive periods., Settings: Tertiary care university medical center (Colorectal Section, Surgical Department P, Aarhus University Hospital, Denmark)., Patients: Patients with low rectal cancer who underwent extralevator abdominoperineal excision from December 2005 through October 2008 were included., Intervention: The perineum was reconstructed with a fasciocutaneous gluteal flap in the first period and with a biological mesh in the second period., Main Outcome Measures: We assessed rates of perineal wound infection requiring surgical intervention and perineal hernia diagnosed by clinical examination., Results: The study comprised 57 patients: 33 patients with gluteal flap and 24 with biological mesh reconstruction. Perineal hernia developed in 7 (21%) patients in the gluteal flap group and in none (0%) of the patients in the mesh group (P < .01). Median follow-up was 3.2 (1.7-4.3) years for gluteal flap and 1.7 (0.4-2.2) years for biologic mesh. All hernias occurred within the first postoperative year (median, 6 months; range, 1-12 months). Infectious complications were seen in 2 patients (6%) with a gluteal flap and in 4 patients (17%) with mesh repair (P = .26). After 3 months, all patients were completely healed except for 1 patient in each group with a persistent perineal sinus. The median (range) hospital stay was 14 (8-23) days in the flap group and 9 days (6-35) in the mesh group (P < .05)., Limitations: This was a nonrandomized retrospective observational study comparing 2 methods used in different time periods., Conclusion: We recommend biological mesh reconstruction of the pelvic floor after extralevator abdominoperineal resection because this method can achieve a high healing rate with an acceptable risk of infection, a low hernia rate, and a shorter hospital stay without donor-site morbidity.

Objective: This study aimed to test the hypothesis that sacral nerve stimulation affects afferent vagal projections to the central nervous system associated with frontal cortex activation in patients with fecal incontinence., Patients: Nine women and one man received temporary sacral nerve stimulation with permanent electrodes as a treatment for fecal incontinence., Interventions: We used positron emission tomography to record indices of regional cerebral blood flow before and after 30 minutes of continuous stimulation. We repeated this procedure after 2 weeks of continued stimulation, before and 30 minutes after arrest of the stimulation., Results: The initial stimulation activated a region of the contralateral frontal cortex that normally is active during focused attention. After 2 weeks of stimulation, this activation had been replaced by activity in parts of the ipsilateral caudate nucleus, a region of the brain thought to be specifically involved in learning and reward processing., Conclusions: Sacral nerve stimulation induces changes in cerebral activity consistent with an effect on afferent projections of the vagus. The initial activation of the frontal cortex may reflect focused attention, whereas the subsequent activation of the caudate nucleus may reflect recruitment of mechanisms involved in learning and reward processing. These changes may contribute to the improved continence, which is an acquired result of the stimulation.

Background: Magnetic sphincter augmentation, a successful treatment of gastroesophageal reflux disease, has been applied to treat fecal incontinence. The purpose of this feasibility study was to understand the safety profile as well as the potential benefit of this new device when it is implanted in patients with fecal incontinence., Methods: A magnetic anal sphincter device was surgically implanted in candidates with documented fecal incontinence of more than 2 episodes per week at 3 investigational centers in Europe and the United States following ethics/institutional review board approval. The magnetic anal sphincter device was placed around the anal canal via a single anterior incision. All data were collected prospectively. The primary outcome measure was the reduction of incontinent episodes based on a daily continence diary., Results: To date 14 patients have been implanted with the device (all female; mean age, 62.8 y; range, 41-74 y) with a median follow-up of 6 months. There have been no intraoperative complications. Mean hospital stay was 3 days; range, 1 to 7 days. Adverse events were observed in 7 patients. Three patients are no longer implanted with a device; 2 devices were removed and one passed spontaneously following a separation at the suture connection. Five patients with 6-month follow-up demonstrated a mean reduction in the number of average weekly incontinence episodes from 7.2 to 0.7 (90.9%) and a mean reduction in Wexner Continence Score from 17.2 to 7.8 (54.7%). Compared with baseline, quality of life improved in all 4 domains of the fecal incontinence quality of life (FIQoL) scoring system. No patients have reported that their condition has worsened. Two patients at 1-year follow-up both reported perfect continence., Conclusion: This preliminary study describes the use of a new device to treat fecal incontinence. Compared with existing devices, implantation is simple and it requires no adjustments from the physician or patient once the device is implanted. Initial assessment with a small number of patients shows promising outcomes with a limited incidence of complications and good restoration of continence.

Purpose: Sacral nerve stimulation is an emerging treatment for patients with severe constipation. There has been no substantial report to date on suboptimal outcomes and complications. We report our experience of more than 6 years by focusing on incidents and the management of reportable events., Methods: A retrospective review was performed on patients who underwent sacral nerve stimulation for constipation between August 2002 and September 2008. Collected data included patients' demographic data, type and management of suboptimal outcomes and complications, and stimulation parameters at the time of reportable events., Results: Thirty-eight patients (32 women; mean age, 45.6 y; SD, 11.8; range, 21-66) received a permanent stimulator after a successful test period. The mean treatment duration was 25.7 months (SD, 20.4; range, 0-70). Twenty-two patients (58%) experienced at least one reportable event attributable to the treatment. The total of 58 reportable events were noted, including lack or loss of efficacy, pain, and undesired change of sensation. Reprogramming successfully managed 28 reportable events (48%), 19 events (33%) required surgical interventions, and 3 adverse events led to discontinuation of the treatment., Conclusions: Nearly 60% of patients who received sacral nerve stimulation for constipation experienced at least one reportable event. Although the events were often resolved by reprogramming, more than one-third required surgical intervention or discontinuation of therapy. Patients undergoing sacral nerve stimulation for constipation need to be informed of these possibilities. A systematic assessment is needed to identify the cause and optimize the management of reportable events.

Purpose: Sacral nerve stimulation is one of many new surgical modalities for fecal incontinence. Short-term results from sacral nerve stimulation have been more encouraging than those from other modalities. The aim of this study was to report the outcome of percutaneous nerve evaluation tests and sacral nerve stimulation for the treatment of fecal incontinence from a single center covering a period of 6 years since the procedure was introduced., Methods: All of the candidates for a percutaneous nerve evaluation test and sacral nerve stimulation seen at our anal physiology unit between March 2001 and March 2007 were included in the study., Results: A total of 177 patients with fecal incontinence (160 females), median age 59.5 (range, 27-88) years, underwent a percutaneous nerve evaluation test. Of these patients, 142 (80%) had a positive test, including 21 of 25 (84%) patients who required a repeat percutaneous nerve evaluation test. Because of a functional failure, 16 patients underwent a revision of the permanent electrode, 7 of whom (44%) were satisfied with the functional result after the revision. Of 126 patients, 15 (12%) have undergone an explantation, with an infection rate of only 1.6%. Overall, after a median follow-up of 24 (range, 3-72) months, the median Wexner incontinence score decreased from 16 (range, 6-20) to 10 (range, 0-20) (P < .0001). In the 10 patients who underwent at least 6 years of treatment, the effect was sustained, as the median Wexner incontinence score decreased from 20 (range, 12-20) to 7 (range, 2-11) (P < .0001)., Conclusion: Sacral nerve stimulation is a simple, safe, and minimally invasive technique with low morbidity and excellent results, which appear to be maintained for the first 6 years after the procedure. For patients who underwent the treatment, median Wexner incontinence score decreased significantly after a median follow-up of 24 (range, 3-72) months. Twelve percent were explanted. The infection rate was 1.6%.

Introduction: Sacral nerve stimulation has become an established treatment for patients with fecal incontinence. However, the mechanism of its action remains obscure. We aim to assess whether sacral nerve stimulation improves patients' ability to retain rectal content., Methods: Patients who had been treated successfully with sacral nerve stimulation underwent four retention tests during which the stimulator was turned either on or off. Both the patients and investigators were blinded to the status of the stimulator. The retention test results were assessed for interassessment agreement and for any differences between the on and off phases. Wexner scores, anorectal physiology tests, and patients' perceptions of stimulator settings were also recorded., Results: Nineteen patients (16 women; mean age, 57.5 years) took part in the study. Retention tests showed moderate interassessment agreement (weighted Cohen's kappa index, 0.45). There were no sharp differences in retained volume between the stimulator's on and off phases (median 50 (range, 0-300) mL vs. 50 (range, 0-300) mL; P = 0.85)., Conclusion: Sacral nerve stimulation does not alter patients' ability to retain rectal content. Further studies are needed to investigate the mechanism of sacral nerve stimulation.

Purpose: Electrical sacral anterior root stimulation with a selective anodal block may relieve difficulties with bowel evacuation by selective colorectal activation and anal sphincter suppression. This study compares rectal evacuation induced by anodal block with that induced by unselective stimulation., Methods: The sacral anterior roots were stimulated with cuff electrodes in seven chloralose-anesthetized minipigs. Anodal block and unselective stimulation were applied in random order and compared by anorectal manometry and by the obtained colorectal evacuation. Evacuation was quantified scintigraphically after retrograde radioactive paste installation., Results: Unselective stimulation evoked sphincter activation which obstructed rectal evacuation during the 30-second stimulation period, after which poststimulation evacuation occurred (mean, 13%; P < 0.05). Anodal block reduced the anal canal pressure by median 83% compared with unselective stimulation. With unrestrained evacuation, a different evacuation pattern (mean, 18%; P < 0.05) occurred within the first ten seconds of the stimulation period and evacuated volume was higher (P = 0.08). Colonic evacuation reached a mean of 17% with unselective stimulation and 11% with anodal block., Conclusion: Anodal block and unselective sacral root stimulation induce rectal evacuation and colonic luminal transport in pigs. However, anodal block may improve stimulation-induced defecation by enabling a near-physiologic defecation pattern.

Purpose: This study evaluated long-term results of transanal irrigation for defecation disturbances., Methods: Three hundred and forty-eight patients [248 women and 100 men; median age 52 years (range, 5-85)] suffering from constipation and fecal incontinence were introduced to transanal irrigation. Patients using transanal irrigation at follow-up received a mailed questionnaire describing bowel function and practical procedures. Results from patients not responding and patients no longer using transanal irrigation were drawn from hospital records and telephone interviews. Background variables were analysed using multivariate logistic regression., Results: After a mean follow-up of 21 months (range, 1-116) 163 of 348 patients (47 percent) had a successful outcome from treatment with transanal irrigation. Success rates varied between patients with different underlying pathology: neurogenic bowel dysfunction, 67 of 107 (63 percent); anal insufficiency, 36 of 70 (51 percent); sequela to anorectal surgery, 14 of 48 (29 percent); idiopathic constipation, 27 of 79 (34 percent); and miscellaneous, 19 of 44 (43 percent). Factors correlating with positive outcome were neurogenic bowel dysfunction and anal insufficiency as underlying pathology, low rectal volume at urge to defecate, low maximal rectal capacity, and low anal squeeze pressure increment. Two nonfatal bowel perforations were found in approximately 110,000 irrigation procedures., Conclusions: Transanal irrigation is simple and safe for long-term treatment for defecation disturbances with greatest benefit in patients with neurogenic bowel dysfunction.

Purpose: The impact of comorbidity on the outcome of colorectal cancer is poorly understood. We examined the prevalence of comorbidity and its impact on survival among Danish colorectal cancer patients., Methods: The hospital discharge registries in northern Denmark were used to identify 13,190 patients diagnosed with colorectal cancer between 1995 and 2006, and to assess their comorbidity using the Charlson Comorbidity Index. We obtained product limit estimates of 1-year and 5-year crude survival based on three levels of comorbidity. To quantify the impact of comorbidity on mortality, we used Cox's proportional hazards regression analysis to compute the mortality rate ratio., Results: One-third of the patients had recorded comorbid conditions. Patients with moderate and severe comorbidity (Charlson scores 1-2 and score 3+) had considerably higher 1-year and 5-year mortality rates compared to patients without comorbidity. For colon cancer patients, 1-year estimates in 2004 to 2006 were mortality rate ratio1-2 = 1.2 (95 percent confidence interval, 1.0-1.5) and mortality rate ratio3+ = 1.8 (95 percent confidence interval, 1.4-2.3). For rectal cancer patients with severe comorbidity, the negative impact on survival increased over time., Conclusions: Comorbidity was a strong negative prognostic factor for survival among colorectal cancer patients.

Purpose: This retrospective study reviewed long-term results in a large group of adult patients treated with antegrade colonic enema and antegrade colonic enema combined with a colostomy., Methods: Retrospective chart review identified 80 patients (64 females, mean age 51) surgically treated between 1993 and 2007 for fecal incontinence or constipation. Surgical treatments included 69 appendicostomies, 13 tapered ileum, 3 cecal tube, and 25 appendicostomy/neoappendicostomy combined with a colostomy. A 44-item questionnaire was mailed considering bowel regimen, complications, bowel function, social function, and quality of life., Results: Sixty-nine patients were available for follow-up (mean follow-up, 75 months). Thirty patients (38 percent) had surgical complications. Forty-three patients (62 percent) were still performing antegrade continence enema and 8 patients (12 percent) no longer needed it. Accordingly, treatment was successful in 51 patients (74 percent). Twenty-seven patients (63 percent) had side effects. Evaluation of bowel function, social function, and quality of life all showed significant improvement. Antegrade continence enema was successful in patients with neurologic disabilities (67 percent), anorectal injury (53 percent), idiopathic fecal incontinence (50 percent), and idiopathic fecal constipation (42 percent). Antegrade continence enema was successful in patients with constipation, incontinence, and mixed symptoms. Results did not differ between appendicostomy, neoappendicostomy, and the combined appendicostomy/neoappendicostomy and colostomy., Conclusion: Long-term results were favorable in most patients treated with antegrade continence enema for fecal incontinence or constipation.

Purpose: Pelvic nerve stimulation evokes a complex motility response in the pig rectum with a proximal decrease and a distal increase in cross-sectional area. This study investigated whether the distal increase in the cross-sectional area is because of smooth muscle relaxation mediated by nitric oxide., Methods: The pelvic nerves were stimulated with cuff electrodes in ten chloralose-anesthetized minipigs. Pressure, volume, and cross-sectional areas at five positions in the rectum were obtained during stimulation to examine the effect of N(G)-nitro-L-arginine (an inhibitor of nitric oxide synthase) injection., Results: Stimulation evoked a median pressure decrease of 13 cm H(2)O (range, 0-27; P < 0.05; n = 10) in the anal canal, a pressure increase of 6 cm H(2)O (range,-15 to 30; P < 0.05; n = 10) in the rectum and a decrease of 39 mL (range, 30-63; P < 0.05; n = 6) in rectal volume. Rectal cross-sectional areas decreased 33 percent (range, 5-56; P < 0.02; n = 7) in the proximal part and increased 32 percent (range, 9-67; P < 0.02; n = 8) in the distal part. N(G)-nitro-L-arginine eliminated the increase in the distal rectal cross-sectional area (n = 5) and the decrease in anal canal pressure (n = 9) in all tested animals., Conclusion: Pelvic nerve stimulation evokes distal rectal relaxation in pigs, sensitive to N(G)-nitro-L-arginine, which suggests that this smooth muscle response is mediated by nitric oxide.

Purpose: This study was designed to evaluate the effect of temporary sacral nerve stimulation in patients with diarrhea-predominant irritable bowel syndrome., Methods: Symptoms of diarrhea-predominant irritable bowel syndrome and disease-specific quality of life was evaluated in six patients before and during percutaneous sacral nerve evaluation test. Primary end points were differences between total irritable bowel syndrome symptom score and total quality of life score before and during stimulation. Secondary end points were differences between the variable domains., Results: Percutaneous sacral nerve evaluation test was performed in five women and one man (median age, 33 (range, 26-54) years). The irritable bowel syndrome symptom score decreased from 48.9 to 28.3 (P = 0.004). Pain, bloating, and diarrhea were significantly reduced from 7.9, 13.5, and 17.3 to 4.4, 7.2, and 10.6, respectively (P = 0.02, P = 0.01, P = 0.03). The irritable bowel syndrome quality of life score decreased from 99.3 to 59.6 (P = 0.009). Daily activities, emotional distress, eating habits, and fatigue were significantly reduced from 26.9, 22.2, 15.2, and 23.2 to 16.9, 13.3, 8, and 14.4, respectively (P = 0.02, P = 0.02, P = 0.02, P = 0.007). Two weeks after cessation of stimulation, the patients had symptoms as before stimulation., Conclusions: Temporary sacral nerve stimulation provides a significant reduction in diarrhea-predominant irritable bowel symptoms and improves quality of life. Further studies with permanent implantation and double-blind crossover ON-and-OFF-stimulation to evaluate the impact of placebo effect are needed.

Purpose: The modern treatment of pseudomyxoma peritonei is cytoreductive surgery plus intraperitoneal chemotherapy resulting in a survival of up to 70 percent after 20 years. The goal of this study was to investigate the impact on quality of life of this very aggressive treatment, which has not been done before., Methods: Twenty-three prospective patients underwent cytoreductive surgery and early postoperative intraperitoneal chemotherapy for pseudomyxoma peritonei. Patients were followed in clinic 3, 6, 12, 18, and 24 months after surgery and had CT scan of the abdomen every 6 months. Quality of life was prospectively assessed with the generic quality of life instrument Short Form-36 Questionnaire, together with the two symptom-specific instruments--European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, and Colorectal Cancer Module 38--before surgery and at every postoperative visit., Results: Complete cytoreduction was achieved in 21 patients. No patients died within 30 days. Seventy percent of patients had one or more complications during or after surgery, but all had recovered. Fourteen percent had an asymptomatic recurrence detected within two years. The impact on quality of life of the disease and of its treatment was very modest despite the high morbidity after the treatment. There was a significant decrease in the scores on the Short Form-36 Questionnaire scales of physical dimension and role physical three months after surgery, only returning to normal after another three months. The other scores corresponded to the scores in a normal population., Conclusions: Cytoreductive surgery plus early postoperative intraperitoneal chemotherapy is an extensive treatment with a high morbidity but with relatively little impact on quality of life in patients with pseudomyxoma peritonei.

Purpose: Sacral nerve stimulation is an effective treatment for fecal incontinence. Some have recommended to "switch off" the pacemaker during the night to extend the lifetime of the expensive pacemaker. This study was designed to investigate whether a nightly "switch off" affects the clinical results of sacral nerve stimulation., Methods: Twenty patients successfully treated with sacral nerve stimulation (19 females; median age, 59 (range, 36-72) years) were randomized to: Group A, pacemaker continuously "on" for three weeks followed by three weeks with the pacemaker "off" during the night, or Group B, opposite order. Daily bowel-habit diary, Wexner, and St. Mark's incontinence scores were obtained., Results: One failed to return the daily bowel-habit diary, leaving 19 participating patients. Median Wexner incontinence score increased from 6 (range, 2-14) to 7 (range, 3-16) during the "off" period (P = 0.04), whereas St. Mark's incontinence score increased from 10 (range, 3-16) to 11 (range, 3-18; P = 0.03). Median number of days with soiling per three weeks increased from 0 (range, 0-12) to 1 (range, 0-15) during the "off" period (P = 0.008). Seven of 19 had more days with soiling during the "off" period. Defecation frequency per three weeks increased from 26 (range, 11-71) to 34 (range, 9-70) during the "off" period (P = 0.19). Only four continued with a nightly "switch off" after the study., Conclusions: It could be considered to recommend compliant patients to "switch off" the pacemaker during the night to extend the lifetime of the pacemaker. One-third experienced increased soiling, and they should turn the pacemaker on all day and night. Among the remaining, only a minor proportion will be motivated for turning the pacemaker off.

Purpose: Traditionally sphincter repair has not been performed during the puerperium. This prospective study was designed to determine the long-term outcome of delayed primary or early secondary sphincteroplasty in the puerperium., Methods: Between 1991 and 2005, 22 females underwent delayed primary or early secondary repair after third-degree or fourth-degree anal sphincter rupture. Delayed primary reconstruction was performed more than 72 hours after delivery. Early secondary reconstruction was performed within 14 days postpartum. The reconstruction of the anal sphincter was performed without a covering stoma, in all cases. A control group of 19 age-matched and parity-matched females, without known anal sphincter injury after vaginal delivery, were included. Current degree of continence and associated quality of life were determined by a fecal incontinence severity questionnaire and a quality of life questionnaire., Results: None of the females had complications postoperatively. Mean follow-up was 50 (range, 2-155) months in the case group and 60 (range, 12-132) months in the control group. At time of follow-up, the Wexner score was 4.1 (range, 0-13) in females with delayed primary or early secondary reconstruction and 1.1 (range, 0-8) in the control group (P<0.01). The inconvenience of incontinence after reconstruction was significantly higher (P<0.01) compared with the control group, but the quality of life was not significantly affected (P=0.75)., Conclusions: It is safe to perform a delayed primary or early secondary reconstruction without a covering stoma in females who have sustained a third-degree or fourth-degree obstetric tear. The long-term functional outcome is acceptable.

Purpose: Manometry and pressure-volume measurements are commonly used to study anorectal physiology. However, the methods are limited by several sources of error. Recently, a new impedance planimetric system has been introduced in a porcine model. It allows simultaneous determination of anorectal pressures and multiple rectal luminal cross-sectional areas. This study was designed to study normal human rectoanal motility by means of impedance planimetry with multiple rectal cross-sectional areas and rectal and anal pressure., Methods: Twelve healthy volunteers (10 females), aged 24 to 53 years, were studied during one-hour fasting and one hour after a meal. Rectal cross-sectional areas were determined at five levels each 2 cm apart, as well as rectal and anal pressure., Results: A number of rectoanal motility patterns were observed. A total of 25 episodes with very localized cyclic rectal contractions detected at only one of five channels were observed lasting two to four minutes with a median frequency of three per minute (range, 2-6). A total of 44 episodes of cyclic rectal contractions propagating over two or more channels were detected lasting 2 to 36 minutes. Most were associated with contractions of the anal canal. A significant increase in rectal contractile activity was observed after the meal (P < 0.05). Single rectal contractions were observed in 11 subjects, and the majority were located to one channel and lasted less than 40 seconds. In two subjects who felt a need to defecate during the experiment, the cross-sectional area at all channels showed strong cyclic contractile activity and the anal pressure increased by approximately 100 percent., Conclusions: The new rectal impedance planimetry system allows highly detailed description of rectoanal motility patterns. It has promise as a new method for description of rectoanal motility in further studies.

Placing of ileal conduit at the time of pelvic exenteration in combination with a same-side vertical rectus abdominis myocutaneous flap is controversial. We report our experience with the placement of the ileal conduit at the same side as the donor site of the vertical rectus abdominis myocutaneous flap in 12 patients and describe our technical approach.

Purpose: Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation., Methods: Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29-79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for "first sensation," "desire to defecate," and "maximal tolerable volume," rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up., Results: Median Wexner incontinence score decreased from 16 (range, 6-20) to 4 (range, 0-12; P < 0. 0001). Median "first sensation" increased from 43 (range, 16-230) ml to 62 (range, 4-186) ml (P = 0.1), median "desire to defecate" from 70 (range, 30-443) ml to 98 (range, 30-327) ml (P = 0.011), and median "maximal tolerable volume" from 130 (range, 68-667) ml to 166 (range, 74-578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0-109) cm H(2)O to 38 (range, 0-111) cm H(2)O (P = 0.045). No significant increase in maximum squeeze pressure was observed., Conclusions: For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level.

Purpose: Elderly patients with colorectal cancer undergo surgery with curative intent less frequently than younger patients, and survival declines with increasing age. We compared relative survival of colorectal cancer among patients older than 75 years with that of younger patients in Denmark during the period 1977 to 1999. We also examined trends in choice of initial treatment., Methods: From the files of the nationwide population-based Danish Cancer Registry, we identified all cases of colorectal cancer diagnosed between 1977 and 1999. We then linked this data to information on survival obtained from the Danish Register of Causes of Death and from the Central Population Register., Results: During the entire study period, short-term and long-term relative survival improved for patients of all ages, but the improvement was more pronounced among elderly patients (>75 years). Radical resection was increasingly chosen as the initial treatment for elderly patients; during the 1995 to 1999 period it was performed on approximately 50 percent of such patients, almost as frequently as among younger patients., Conclusions: Relative survival of elderly colorectal cancer patients (>75 years) improved in Denmark between 1977 and 1999. In the most recent period studied, 1995 to 1997, only minor differences in five-year relative survival were observed among younger, middle-aged, and elderly patients. A simultaneous increase in the rate of radical resection among elderly patients, reflecting more effective treatment, may underlie this finding.

Purpose: Adjuvant radiotherapy in the treatment of rectal cancer has been shown to increase long-term morbidity causing severe anorectal dysfunction with physiologic changes whose interaction remains poorly understood. This study examines long-term anorectal morbidity from adjuvant postoperative radiotherapy., Methods: In a prospective study, patients with Dukes B or C rectal carcinoma were randomized to postoperative radiotherapy or no adjuvant treatment after anterior resection. The long-term effect of radiotherapy on anorectal function in a subset of surviving patients was assessed from a questionnaire on subjective symptoms and from physiology laboratory evaluation and flexible sigmoidoscopy., Results: Twelve of 15 patients (80 percent) treated with radiotherapy had increased bowel frequency compared with 3 of the 13 patients (23 percent) who did not have radiation therapy (P = 0.003). The former group had loose or liquid stool more often (60 vs. 23 percent, P = 0.05), had fecal incontinence more often (60 vs. 8 percent, P = 0.004), and wore pad more often (47 vs. 0 percent, P = 0.004). They also experienced fecal urgency and were unable to differentiate stool from gas more often. Endoscopy revealed a pale and atrophied mucosa and telangiectasias in the irradiated patients. Anorectal physiology showed a reduced rectal capacity (146 vs. 215 ml, P = 0.03) and maximum squeeze pressure (59 vs. 93 cm H2O, P = 0.003) in the radiotherapy group. Impedance planimetry demonstrated a reduced rectal distensibility in these patients (P < 0.0001)., Conclusions: Adjuvant postoperative radiotherapy after anterior resection causes severe long-term anorectal dysfunction, which is mainly the result of a weakened, less sensitive anal sphincter and an undistensible rectum with reduced capacity.

Fecal incontinence is a common condition that causes major impairment of social life. Sacral nerve stimulation is a promising treatment in idiopathic fecal incontinence when conventional treatments have failed. However, new indications for sacral nerve stimulation are emerging. The present case shows that sacral nerve stimulation for treatment of fecal incontinence may be justified in other diseases in which fecal incontinence is a major problem.

Purpose: The effect of sacral nerve stimulation was studied in 45 patients with fecal incontinence., Methods: All patients were initially tested in general anesthesia. Sacral nerves 2, 3, and 4 were tested on both sides. If a perineal/perianal muscular response to sacral nerve stimulation could be obtained, electrodes were implanted for a three-week test-stimulation period. If sacral nerve stimulation resulted in at least a 50 percent reduction in incontinence episodes during the test period, a system for permanent sacral nerve stimulation was implanted., Results: When tested in general anesthesia, 43 of 45 patients had a muscular response to sacral nerve stimulation and had electrodes implanted for the three-week test period. Percutaneous electrodes were used in 34 patients, and 23 of these had at least a 50 percent reduction in incontinence episodes, whereas the electrodes dislocated in 7 patients and 4 had a poor response. Permanent electrodes with percutaneous extension electrodes were used primarily in 9 patients and after dislocation of percutaneous electrodes in an additional 6 patients; 14 of these had a good result. In the last patient, no clinical response to stimulation with the permanent electrode could be obtained. A permanent stimulation system was implanted in 37 patients. After a median of six (range, 0-36) months follow-up, five patients had the system explanted: three because the clinical response faded out, and two because of infection. Incontinence score (Wexner, 0-20) for the 37 patients with a permanent system for sacral nerve stimulation was reduced from median 16 (range, 9-20) before sacral nerve stimulation to median 6 (range, 0-20) at latest follow-up ( P < 0.0001). There was no differences in effect of sacral nerve stimulation in patients with idiopathic incontinence (n = 19) compared with spinal etiology (n = 8) or obstetric cause of incontinence (n = 5). Sacral nerve stimulation did not influence anal pressures or rectal volume tolerability., Conclusions: Sacral nerve stimulation in fecal incontinence shows promising results. Patients with idiopathic, spinal etiology, or persisting incontinence after sphincter repair may benefit from this minimally invasive treatment.

Purpose: This study aimed to evaluate the colorectal luminal transport obtained by retrograde colonic washout with a new scintigraphic technique., Methods: Nineteen patients (5 with spinal cord lesion, 6 with idiopathic fecal incontinence, and 8 with idiopathic constipation) treated with retrograde colonic washout took indium-111-labeled polystyrene pellets to label the bowel contents. Technetium-99m-diethylene-triamine-pentaacetic acid was mixed with the irrigation fluid to assess its extent within the colorectum. Scintigraphy was performed before and after a standardized washout procedure. The colorectum was divided into four segments: the cecum and ascending colon, the transverse colon, the descending colon, and the rectosigmoid. Assuming ordered evacuation of the colorectum, the contribution of each colonic segment to the total evacuation was expressed in percent of the original segmental counts. The contributions of each segment were summed to reach a total defecation score (range, 0-400), and directional segmental transports were estimated., Results: The defecation score in patients with idiopathic constipation (median, 59; range, 21-130) differed significantly (P < 0.05) from the scores in those with spinal cord lesions (median, 204; range, 108-323) and idiopathic fecal incontinence (median, 188; range, 155-234). Thus, patients with spinal cord lesion or idiopathic fecal incontinence were able to empty most of the rectosigmoid and most of the descending colon, but those with idiopathic constipation could only empty 59 percent of the rectosigmoid. The irrigation fluid on average reached a point just beyond the right colic flexure that correlated with the defecation score (r(2) = 0.58, P < 0.001)., Conclusion: The effect of retrograde colonic washout was significantly better in spinal cord lesion and idiopathic fecal incontinence than in idiopathic constipation, and its effect correlated with the extent to which the irrigation fluid had entered the colorectum.

Purpose: This study was designed to examine the long-term changes in physical performance, body composition, and bone mineral density in patients with ulcerative colitis undergoing ileoanal anastomosis with J-pouch. Patients were also screened for abnormalities in blood biochemistry., Methods: Maximal isometric strength (sum of pinching, hand grip, arm flexion, and knee extension), work capacity (ergometer test at 1.5 W/kg), pulmonary function, body composition (dual-energy x-ray absorptiometry scan), and fatigue level were assessed before surgery and four to six years later., Results: Of 24 patients examined preoperatively, 12 females and 8 males were retested. At follow-up, their mean age +/- standard deviation was 38 +/- 9 years, weight was 76 +/- 14 kg, and height was 173 +/- 7 cm. Compared with preoperative assessments, muscular strength had increased 10.6 +/- 17.2 percent (P = 0.015), work capacity 10.4 +/- 13.3 percent (P = 0.003), total tissue mass 4.6 +/- 5.4 kg (P = 0.001), lean tissue mass 2.3 +/- 2.2 kg (P < 0.001), fat mass 2.2 +/- 3.7 kg (P = 0.014), and bone mineral density 1.6 +/- 2.4 percent (P = 0.008). Seventeen of 20 patients had biochemical abnormalities., Conclusions: After ileoanal anastomosis with J-pouch, muscular strength and work capacity improved concomitant with an increase in total tissue mass, lean tissue mass, fat mass, and bone mineral density. Biochemical abnormalities were common.

Purpose: Most patients with spinal cord injuries suffer from constipation or fecal incontinence. This study was designed to observe rectal wall properties and the rectoanal inhibitory reflex in patients with acute and chronic spinal cord injury., Methods: Rectal wall properties were studied by rectal impedance planimetry, a method for simultaneous registration of pressure and rectal cross-sectional area during distention. Twenty-five patients with spinal cord injury (14 with supraconal lesions and 11 with conal/cauda equina lesions) were studied one to four weeks after injury, and 17 were available for follow-up after 6 to 14 months. Results were compared with 15 healthy volunteers., Results: Rectal tone was significantly higher (P < 0.05) than normal in patients with acute and chronic supraconal lesions but significantly lower (P < 0.05) in patients with acute and chronic conal/cauda equina lesions. The proportion of subjects with single giant rectal contractions was significantly higher than normal (33 percent) after acute supraconal spinal cord injury (77 percent; P = 0.02) but not after acute conal/cauda equina lesions (45 percent; P = 0.69). Phasic giant contractions only occurred in patients with spinal cord injury (once or more in 8 of 25 patients), but they were not correlated with the level of the lesion. Rectal tone and the number of giant rectal contractions did not change significantly from the acute to the chronic phase of spinal cord injury. The amplitude of the rectoanal inhibitory reflex at distention pressures of 5 and 10 cm H2O was significantly lower than normal in patients with acute and chronic conal/cauda equina lesions (acute, -5 and 44 percent vs. 37 and 82 percent (P < 0.05); chronic, 6 percent (P < 0.05) and 66 percent (P = NS)) but not in patients with supraconal spinal cord injury (acute, 32 and 83 percent; chronic, 61 and 85 percent (all P = NS))., Conclusion: Rectal tone is stimulated by the sacral spinal cord but inhibited by supraspinal centers within the central nervous system. Likewise, rectal contractility is inhibited by supraspinal centers, and the rectoanal inhibitory reflex is stimulated by the sacral spinal cord. Alterations caused by either type of spinal cord lesion are present after one to four weeks and do not change significantly within the first year.

Background: Significant associations between perineal descent and pudendal nerve latency have previously been described in fecally incontinent patients. This has led to the hypothesis that pelvic floor muscle and nerve injury initiated by childbirth might progress and cause fecal incontinence., Purpose: The study contained herein was undertaken to test whether changes in perineal position and pudendal nerve latency were associated in a population of healthy middle-aged women., Methods: A cross-sectional study of 144 women were selected randomly from the Danish National Register; they had a mean age of 50 (range, 45-57) years and a mean parity of 2 (range, 0-6). Perineal position at rest and during simulated defecation and pudendal nerve terminal motor latency were measured. All examinations were performed by one of the authors (AMR) and without the knowledge of parity., Results: The perineal position both at rest and during straining was significantly lowered, and the pudendal nerve terminal motor latency was significantly prolonged with increasing numbers of vaginal deliveries (data not shown). There was, however, no association between pudendal nerve terminal motor latency and perineal position at rest (correlation coefficient, r = -0.15, P = 0.1) or during simulated defecation (r = -0.08, P = 0.4)., Conclusion: Small but significant effects of vaginal deliveries were detected in a random population of healthy perimenopausal women. However, because perineal descent and pudendal nerve latency were not associated, our findings do not support the hypothesis that damage induced by vaginal delivery to the pudendal nerves and pelvic floor will progress.

Purpose: This study was designed to describe the frequency and severity of colorectal problems among patients with spinal cord lesions and to determine whether these problems are associated with age, gender, time since the lesion, and level and severity of the lesion., Patients and Methods: A detailed questionnaire describing colorectal and bladder function was sent to all 589 members of The Danish Paraplegic Association; 424 responded (72 percent)., Results: Only 19 percent felt a normal desire to defecate, whereas the remaining patients felt no desire to defecate (38 percent) or a combination of abdominal discomfort (37 percent) and headache, physical uneasiness, and perspiration (25 percent). Digital stimulation of the anal canal before defecation or digital evacuation of the rectum was used regularly by 65 percent of patients. Fecal incontinence was experienced by 75 percent of patients; however, most patients only had a few episodes of fecal incontinence each month (15 percent) or each year (56 percent). Overall, 39 percent of patients reported that colorectal dysfunction caused some or major restrictions on social activities or on their quality of life, and 30 percent regarded colorectal complaints to be worse than both bladder and sexual dysfunction. The severity of most symptoms was significantly correlated with the severity of the lesion, and the self-reported impact on social activities or quality of life was significantly more severe among women than men., Conclusion: Colorectal dysfunction is very common among spinal cord-injured patients, often causing restriction on social activities and quality of life. Therefore, these problems deserve more attention in the treatment of spinal cord-injured patients.