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Purpose: There is no standard program for laparoscopic surgery training in Japan, and competency in these procedures does not require the acquisition of board certification. The purpose of this survey was to investigate the current status of laparoscopic surgery training in Japan., Methods: A questionnaire survey was mailed to 2296 members of the Japan Society for Endoscopic Surgery who were between postgraduate year 3 and 10. The questionnaire inquired about laparoscopic surgical training conditions, operation case numbers, and autonomy in eight laparoscopic procedures., Results: The total response rate was 28.1%. The number of cases required to perform procedures independently was demonstrated. Most participants felt confident in performing laparoscopic appendectomy and cholecystectomy; however, they felt less confident about performing laparoscopic colectomy and gastrectomy., Conclusions: The information from this survey may be useful for surgical educators, surgical societies, and the board certification council for rebuilding the surgical training system in Japan., (© 2021. Springer Nature Singapore Pte Ltd.)

Background: Worldwide, colorectal cancer is the third most common cancer in men and the second in women. The main surgical methods for colorectal cancer patients include a conventional open colectomy and laparoscopic-assisted colectomy. Laparoscopic-assisted colectomy is associated with less blood loss, faster recovery of bowel function, and shorter hospital stays., Objective: The aim of this study was to compare the quality of life and symptom severity in patients with colorectal cancer 1 month after conventional open colectomy or laparoscopic-assisted colectomy., Methods: A comparative cross-sectional study design was conducted from September 2015 to May 2016. Participants were recruited through convenience sampling from the surgical outpatient department of a medical center in Northern Taiwan; 33 patients underwent each type of surgery., Results: The laparoscopic-assisted colectomy group scored 9.39 points higher in quality of life and lower in symptom severity by 14.88 points than the conventional open colectomy group (P = .03 and P = .05, respectively). Both groups reported low symptom severity; "changes in bowel habits" was the symptom with the highest severity. The conventional open colectomy group had higher insomnia and worried about their future more than did the laparoscopic-assisted colectomy group., Conclusions: Patients who received the laparoscopic-assisted colectomy procedure reported a better quality of life and lower symptom severity than those who received the conventional open colectomy surgical method., Implications for Practice: Patients who will have a conventional open colectomy will likely need enhanced management of symptoms and attention to their quality of life., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: We aimed to identify decision process measures associated with patient decisional regret regarding the decision to pursue elective colectomy or observation for diverticulitis., Materials and Methods: This was a single-center cross-sectional survey study. We included adult patients treated for diverticulitis between 2014 and 2019 and excluded patients who required urgent or emergent colectomy. The primary outcome was regret regarding the decision to pursue elective surgery or observation for diverticulitis, measured using the Decision Regret Scale. We used multivariable linear regression to examine hypothesized predictors of decision regret, including decisional conflict (Decision Conflict Scale and its subscales), shared decision-making, and decision role concordance., Results: Of 923 eligible patients, 133 were included in the analysis. Patients had a median of five episodes of diverticulitis (interquartile range 3-8), occurring a median of 2 y (interquartile range 1-3) before survey administration. Thirty-eight patients (29%) underwent elective surgery for diverticulitis. Decision regret (Decision Regret Scale score ≥25) was present in 42 patients (32%). After controlling for surgery, gender, health status, and years since treatment, decision regret was associated with decisional conflict and inversely associated with values clarity, decision role concordance, shared decision-making, and feeling informed, supported, and effective in decision-making (all P < 0.001)., Conclusions: Nearly one-third of survey respondents experienced regret regarding the decision between elective surgery and observation for diverticulitis. Decision regret may be reduced through efforts to improve patient knowledge, values clarity, role concordance, and shared decision-making., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Laparoscopic colectomy (LC) is a less invasive alternative to open colectomy (OC) in the treatment of stage I-III colon cancer. Research on the long-term (5-year post-diagnosis) health-related quality of life (HRQOL) of LC patients is scarce. Our study aimed to compare the long-term HRQOL and psychological well-being of stage I-III colon cancer survivors treated either with LC or OC., Methods: This study used a German population-based cohort of patients treated with either LC (n = 86) or OC (n = 980). LC patients were matched to OC patients using a propensity score. At 5-year follow-up, patients completed assessments on HRQOL (EORTC QLQ-C30 and EORTC QLQ-CR29) and psychological well-being (distress and disease/treatment burden). Least square mean scores of HRQOL were derived using linear regression. Proportions of patients with moderate/high distress and disease/treatment burden were compared with Chi-square tests., Results: In total, 81 LC patients were matched to 156 OC patients. Generally, LC patients had HRQOL comparable to OC patients, albeit LC patients reported significantly better body image (87.1 versus 81.0, p = 0.03). Distress levels were generally low and comparable between the two groups, even though LC patients were more likely to experience disease recurrence (16% versus 7%, p = 0.02) than OC patients. OC patients were more likely to feel moderate/high levels of burden associated with the treatment (72% versus 56%, p = 0.01) and the time after treatment completion (43% versus 28%, p = 0.02)., Conclusion: LC patients reported comparable long-term HRQOL outcomes but higher levels of psychological well-being than OC patients 5 years after diagnosis, even though LC was associated with higher risk of disease recurrence.

Aim: Low anterior resection syndrome (LARS) severely affects the quality of life (QoL) of patients after surgery for rectal cancer. There are very few studies that have investigated LARS-like symptoms and their effect on QoL after colon cancer surgery. The aim of this study was to investigate the prevalence of functional abdominal complaints and related QoL after colon cancer surgery compared with patients with similar complaints after rectal cancer surgery., Method: All patients who underwent colorectal cancer resections between January 2008 and December 2015, and who were free of colostomy for at least 1 year, were eligible (n = 2136). Bowel function was assessed by the LARS score, QoL by the EORTC QLQ-C30 and QLQ-CR29 questionnaires. QoL was compared between the LARS score categories and tumour height categories., Results: A total of 1495 patients (70.0%) were included in the analyses, of whom 1145 had a colonic and 350 a rectal tumour. Symptoms of LARS were observed in 55% after rectal cancer resection compared with 21% after colon cancer resection. Female gender (OR 1.88, CI 1.392-2.528) and a previous diverting stoma (OR 1.84, CI 1.14-2.97) were independently associated with a higher prevalence of LARS after colon cancer surgery. Patients with LARS after colon cancer surgery performed significantly worse in most QoL domains., Conclusion: The results of this study highlight the presence of LARS-like symptoms after surgery for colonic cancer. Patients suffering from major LARS-like symptoms after colon resection reported the same debilitating effect on their QoL as patients with major LARS after rectal resection. This should be addressed by colorectal cancer specialists in order to adequately inform patients., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Aim: The low anterior resection syndrome (LARS) severely affects quality of life (QoL) after colorectal cancer surgery. There are no data about these complaints and the association with QoL in a reference population. The aim of this study was to assess LARS and the association with QoL in a reference population., Methods: Six hundred patients who visited the outpatient clinic because of general or trauma surgical indications were asked to participate in this study. They received an invitation letter containing three validated questionnaires to assess LARS (assessed with the LARS score) and both general [European Organization for the Research and Treatment of Cancer (EORTC) QLQ-C30] and colorectal-specific (EORTC QLQ-CR29) QoL., Results: Five hundred and one respondents could be included for the analyses. The median age at inclusion was 68 years and 47.3% were men. Major LARS was observed in 15% of patients (11.4% in men and 18.9% in women, P = 0.021). Women reported more urgency (P = 0.070) and incontinence for both flatus (P < 0.001) and stool (P = 0.063) compared to men. In univariate analyses, women reported major LARS significantly more often than men (OR 1.82; 95% CI 1.10-3.01). Patients with major LARS scored significantly worse in most QoL domains compared to patients with no/minor LARS., Conclusion: This is the first study demonstrating major LARS and the association with QoL in a reference population of patients without colorectal cancer. Our data can assist in the interpretation of LARS in past and future research about abdominal complaints after colorectal cancer surgery., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Background: To understand how surgeon expectation of case difficulty relates to workload for colon and rectal procedures and to identify possible surgeon-perceived drivers contributing to case difficulty., Materials and Methods: For 3 mo, surgeons were asked to complete a modified NASA-Task Load Index (NASA-TLX) questionnaire following each surgical case. Questions included items on distractions, fatigue, procedural difficulty, and expectation plus the validated NASA-TLX items. All but expectation were rated on a 20-point scale (0 = low, 20 = high). Expectation was rated on a 3-point scale (i.e., more difficult than expected, as expected, less difficult than expected). Surgeons also reported perceived drivers contributing to case ease or difficulty. Patient and procedural data were analyzed for procedures with completed surveys., Results: Seven surgeons (three female) rated 122 procedures over the research period using a modified NASA-TLX survey. Mean surgeon-perceived workload was highest for effort (mean [M] = 10.83, standard deviation [SD] = 5.66) followed by mental demand (M = 10.18, SD = 5.17), and physical demand (M = 9.19, SD = 5.60). Procedural difficulty varied significantly by procedure type (P < 0.001). Thirty-five percent of cases were considered more difficult than expected. Surgeon-perceived workload and most subscales differed significantly according to expectation level. There was no significant difference in patient factors by expectation level. Surgeons most frequently reported patient anatomy, body habitus, and operative team characteristics as drivers to difficulty and ease of cases., Conclusions: Procedural difficulty significantly differed across procedure type. More than one-third of cases were more difficult than expected, during which surgeons attributed this to operative team characteristics as well as issues in patient anatomy and body habitus., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: Patient reported outcome measures (PROMs) are self-reported measures of patients' health status or health-related quality of life at a single point in time. We aimed to evaluate the use of a colorectal PROM and conducted a focus group to further explore this and other unmet needs in our patient population treated surgically for colorectal cancer., Method: A multidisciplinary research group consisting of colorectal surgeons, nurse specialists, psychologists, sociologists and patient representatives devised a composite tool of new and existing outcome measures which was piloted in our local population (n = 35). Participants were subsequently invited to attend a semi-structured focus group during which the PROM was reviewed and an unmet needs analysis was performed. Thematic analysis of focus group transcripts was undertaken for emergent themes., Results: Initial consensus was for a tool including the EQ-5D, Functional Assessment of Cancer Therapy - Colorectal (FACT-C), the distress thermometer, a validated measure of stigma, an unmet needs analysis, and questions assessing the psychological impact of cancer. Median and interquartile range values suggested that all metrics were discriminatory with the exception of FACT-C. All participants agreed that the tool was acceptable and reflected the current state of their health and emotions. Thematic analysis of focus group transcripts identified four major themes: physical symptoms, emotional response, information provision and coping mechanisms., Conclusion: Through expert consensus, local piloting and patient focus groups we have evaluated a novel PROM for colorectal cancer. Furthermore, through our direct engagement with patients we have identified several unmet needs which we are currently exploring within the clinical service., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

Background: Although the body of evidence supporting nonoperative management for rectal cancer has been accumulating, there has been little systematic investigation to explore how physicians and patients value the tradeoffs between oncologic and functional outcomes after abdominal perineal resection and nonoperative management., Objective: The purpose of this study was to elicit patient and physician preferences for nonoperative management relative to abdominal perineal resection in the setting of low rectal cancer., Design: We conducted a standardized interviews of patients and a cross-sectional survey of physicians., Settings: Patients from 1 tertiary care center and physicians from across Canada were included., Patients: The study involved 50 patients who were previously treated for rectal cancer and 363 physicians who treat rectal cancer., Interventions: Interventions included standardized interviews using the threshold technique with patients and surveys mailed to physicians., Main Outcomes Measures: We measured absolute increase risk in local regrowth and absolute decrease in overall survival that patients and physicians would accept with nonoperative management relative to abdominal perineal resection., Results: Patients were willing to accept a 20% absolute increase for local regrowth (ie, from 0% to 20%) and a 20% absolute decrease in overall survival (ie, from 80% to 60%) with nonoperative management relative to abdominal perineal resection, whereas physicians were willing to accept a 5% absolute increase for local regrowth (ie, from 0% to 5%) and a 5% absolute decrease in overall survival (ie, from 80% to 75%) with nonoperative management relative to abdominal perineal resection., Limitations: Data were subject to response bias and generalizable to only a select group of patients with low rectal cancer., Conclusions: Offering nonoperative management as an option to patients, even if oncologic outcomes are not equivalent, may be more consistent with the values of patients in this setting. See Video Abstract at http://links.lww.com/DCR/A688.

Background: Colorectal surgery outcomes must be accurately assessed and aligned with patient priorities. No study to date has investigated the patient's subjective assessment of outcomes most important to them during and following their surgical recovery. Although surgeons greatly value the benefits of laparoscopy, patient priorities remain understudied., Objective: This study aimed to assess what aspects of patients' perioperative care and recovery they value most when queried in the postoperative period., Design: This study is an exploratory cross-sectional investigation of a defined retrospective patient population. Enrollees were stratified into subcategories and analyzed, with statistical analysis performed via χ test and unpaired t test., Settings: This study was conducted at a single academic medical center in New England., Patients: Patients who underwent a colorectal surgical resection between 2009 and 2015 were selected., Interventions: Patients within a preidentified population were asked to voluntarily complete a 32-item questionnaire regarding their surgical care., Main Outcome Measures: The primary outcomes measured were patient perioperative and postoperative quality of life and satisfaction on selected areas of functioning., Results: Of 167 queried respondents, 92.2% were satisfied with their recovery. Factors considered most important included being cured of colorectal cancer (76%), not having a permanent stoma (78%), and avoiding complications (74%). Least important included length of stay (13%), utilization of laparoscopy (14%), and incision appearance and length (2%, 4%)., Limitations: The study had a relatively low response rate, the study is susceptible to responder's bias, and there is temporal variability from surgery to questionnaire within the patient population., Conclusions: Overall, patients reported high satisfaction with their care. Most important priorities included being free of cancer, stoma, and surgical complications. In contrast, outcomes traditionally important to surgeons such as laparoscopy, incision appearance, and length of stay were deemed less important. This research helps elucidate the outcomes patients truly consider valuable, and surgeons should focus on these outcomes when making surgical decisions. See Video Abstract at http://links.lww.com/DCR/A596. See Visual Abstract at https://tinyurl.com/yb25xl66.

Background: Distress is common among cancer and surgical patients and can lead to worse outcomes if untreated. The objective of this study was to explore sources of distress among colorectal cancer patients undergoing surgery., Materials and Methods: This was a qualitative study using in-depth, semistructured, one-on-one interviews in an academic setting. Patients were recruited if they had a pathologically confirmed diagnosis of colon or rectal cancer. Purposive sampling was used to recruit patients who were about to undergo (preoperative), or had recently undergone (postoperative), curative resection for colorectal cancer., Results: All participants (n = 24) reported experiencing distress during treatment. Participants identified sources of distress preoperatively (negative emotional reaction to diagnosis, distress from preconception of cancer diagnosis, and distress interacting with healthcare system). Sources of distress during in-hospital recovery included negative emotional reaction to having a surgery and negative emotions experienced in the hospital. Postoperative sources of distress included mismatch of expectations and experience of recovery, dealing with distressing physical symptoms and complications after surgery, and distress worrying about recurrence. Participants identified other sources of distress that were not time-specific (distress related to social support network, from disruption of life, and worrying about death)., Conclusions: Our results highlight a potential role for a comprehensive screening program to identify which patients require assistance with addressing sources of distress during the surgical experience. Understanding how sources of distress may vary by time will help us tailor interventions at different time points of the surgical experience., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aim: The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires., Method: In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data., Results: We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant., Conclusion: We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings., (Colorectal Disease © 2017 The Association of Coloproctology of Great Britain and Ireland.)

Background: It was previously shown that appropriate distribution of immune cells between different tissues and organs of the body is required for proper function of the immune system. Our previous experiments demonstrated that surgical trauma in mice induces Tγδ lymphocyte migration from peripheral blood to peritoneal lymphoid organs. Tγδ cells have regulatory activity as they suppress the cell-mediated immune response in vitro via TGF-β. In the current study, we aim to evaluate the influence of surgery on both Taβ and Tγδ lymphocyte distribution in patients that underwent operation., Materials and Methods: We investigated the percentage of Tαβ and Tγδ cells in peripheral blood of patients undergoing standard surgical procedures (gastric resection, colorectal resection, cholecystectomy, and strumectomy) before and 3 days after operation. The percentage of Tαβ and Tγδ cells was evaluated by FACS Canto II cytofluorimeter., Results: We showed that only major surgery located in the peritoneal cavity (gastric and colorectal surgery) decreases the percentage of Tγδ cells in peripheral blood as opposed to less traumatic surgery (strumectomy and cholecystectomy) which does not have such effect. However, significant reduction of Tγδ cells after operation was only observed in a group of patients that underwent gastrectomy. Additionally, we found that gastrectomy results in significant reduction of cumulative Tγδ CD4 and Tγδ CD25 lymphocyte counts., Conclusion: Surgery results in decreased percentage of Tγδ lymphocytes in peripheral human blood, and this correlates with the severity and location of the surgical trauma. This observation may help to predict postoperative recovery after gastroabdominal surgery.

Background: Total abdominal colectomy with ileorectal anastomosis for Crohn's colitis is acceptable in the presence of a suitable rectum. Intentional IPAA has been proposed for diffuse Crohn's proctocolitis without enteric or anoperineal disease., Objective: The aim of this study was to evaluate the long-term outcomes of sphincter-saving procedures for large-bowel Crohn's disease., Design: Patients with preoperative Crohn's disease diagnosis undergoing intentional IPAA and ileorectal anastomosis were included., Settings: The study was conducted at a tertiary care research center., Patients: Ileorectal anastomosis was performed in 75 patients with Crohn's disease, whereas 32 patients underwent intentional IPAA., Main Outcome Measures: Long-term functional results and permanent stoma requirement of sphincter-saving operations were assessed. Quality of life and postoperative medication use were also compared with a control group of patients undergoing total proctocolectomy and end ileostomy., Results: Patients undergoing ileorectal anastomosis were older and had longer disease duration, higher prevalence of perianal and penetrating disease, and history of small-bowel resection than those receiving IPAA. Indications for surgery, preoperative use of immunomodulators, and postoperative use of biologics were also significantly different. Although functional defecatory outcomes were comparable, reported quality of life 3 years after surgery was significantly better in patients who underwent IPAA than in patients with ileorectal anastomosis. Patients with IPAA were associated with significantly lower cumulative rates of surgical recurrence (HR = 0.28 (95% CI, 0.09-0.84); p = 0.017), indefinite stoma diversion (HR = 0.35 (95% CI, 0.13-0.99); p = 0.039), and proctectomy with end ileostomy (HR = 0.27 (95% CI, 0.07-0.96); p = 0.030) than those with ileorectal anastomosis., Limitations: The study was limited by its retrospective nature and small sample size., Conclusions: Contemporary patients selected to have intentional IPAA for Crohn's colitis have disease characteristics very different from those selected to have ileorectal anastomosis. Long-term follow-up confirms intentional IPAA as an acceptable option in selected patients with Crohn's colitis.

Aim: Older data suggest that colonic resection has a negative impact on continence and quality of life. The aim of this study was to evaluate the functional outcome of colonic resections for colonic cancer and diverticulitis and its influence on quality of life., Methods: Patients who underwent colonic resection between 2005 and 2013 were identified from a prospective database. A survey with two questionnaires [Faecal Incontinence Quality of Life (FIQL) scale, Short Form 12 (SF-12)] and additional questions concerning bowel function was sent to all patients., Results: Colonic resection was performed in 362 patients in the study period; 297 patients returned the questionnaires (response rate 82.0%). Faecal urgency or incontinence more than once a month was present in 15% of patients and 25% of patients reported that bowel symptoms limited their quality of life. The mean total FIQL score for all patients was 3.58. The SF-12 score was comparable to a reference population without prior colonic resection. Patients after right-sided resections had liquid stool more often than others (45.3% vs 38.7%, P = 0.011). No differences in bowel function and quality of life were detected between resections for colonic cancer and diverticulitis., Conclusion: Most patients experience no limitation in bowel function after segmental colectomy. Those with limitations in bowel function still seem to cope well, as the quality of life is not severely affected. Nevertheless, most patients with lower functional scores also had lower quality of life scores. Whether surgery is a relevant factor has to be questioned, as the prevalence of faecal incontinence in a comparable population without prior surgery is almost identical., (Colorectal Disease © 2016 The Association of Coloproctology of Great Britain and Ireland.)

Background: Eliciting the priorities of cancer survivors is essential to address the specific needs of cancer survivor subgroups., Objective: The purpose of this study was to describe the greatest challenges related to treatment for long-term rectal cancer survivors., Design: This was an observational study with a cross-sectional survey., Settings: The study included members of Kaiser Permanente Northern California and Northwest health plans., Patients: A survey was mailed to long-term (≥5 years postdiagnosis) survivors of rectal cancer who had an anastomosis, temporary ostomy, or permanent ostomy., Main Outcome Measures: The main outcome was measured with an open-ended question about the greatest challenge related to cancer surgery. We categorized responses using a grounded theory approach with double coding for reliability. Bonferroni-adjusted χ values were used to assess differences in the proportions of subgroups who mentioned challenges within each response category., Results: The survey completion rate was 61% (577/953); 76% (440/577) of participants responded to the greatest challenge question. The greatest challenges for respondents were bowel/ostomy management (reported by 44%), negative psychosocial effects (37%), late effects of treatment (21%), comorbidities and aging (13%), postoperative recovery (5%), and negative healthcare experiences (5%). Survivors with temporary ostomy or anastomosis were more likely than survivors with permanent ostomy to report late effects (p < 0.0001 and p = 0.01). Survivors with anastomosis were less likely than survivors with permanent ostomy to report negative psychosocial impacts (p = 0.0001)., Limitations: Generalizability is restricted by the lack of ethnically and racially diverse, uninsured (non-Medicare-eligible population), and non-English-speaking participants. Because the survey was cross-sectional and included respondents at different times since diagnosis, we could not adequately address changes in the greatest challenges over time., Conclusions: Our results reveal the need for bowel/ostomy management, psychosocial services, and surveillance for late effects in survivorship and supportive care services for all survivors of rectal cancer, regardless of ostomy status. The perspective of long-term survivors with anastomosis reveals challenges that may not be anticipated during decision making for treatment (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A254)., Competing Interests: The other authors have no conflicts of interest to disclose.

Background: Historically, stage I rectal cancer was treated with total mesorectal excision. However, there has been growing use of local excision, with and without adjuvant therapy, to treat these early rectal cancers. Little is known about how patients and providers choose among the various treatment approaches., Objective: The purpose of this study was to identify patient roles, preferences, and expectations as they relate to treatment decision making for patients with stage I rectal cancer., Design: This is a population-based study., Settings: The study included a geographically diverse population and health-system-based cohort., Patients: A total of 154 adults with newly diagnosed and surgically treated stage I rectal cancer between 2003 and 2005 were included., Main Outcome Measures: We compared patients by surgical treatment groups, including total mesorectal excision and local excision. Clinical, sociodemographic, and health-system factors were assessed for association with patient decision-making preferences and expectations., Results: A total of 80% of patients who underwent total mesorectal excision versus 63% of patients who underwent local excision expected that surgery would be curative (p = 0.04). The total mesorectal excision group was less likely to report that radiation would cure their cancer compared with the local excision group (27% vs 63%; p = 0.004). When asked about their preferred role in decision making, 28% of patients who underwent total mesorectal excision preferred patient-controlled decision making compared with 48% of patients who underwent local excision (p = 0.046). However, with regard to the treatment actually received, 38% of the total mesorectal excision group reported making their own surgical decision compared with 25% of the local excision group (p = 0.18)., Limitations: The study was limited by its sample size., Conclusions: The preferred decision-making role for patients did not match the actual decision-making process. Future efforts should focus on bridging the gap between the decision-making process and patient preferences regarding various treatment approaches. This will be particularly important as newer innovative procedures play a more prominent role in the rectal cancer treatment paradigm., Competing Interests: The authors have no conflicts of interest to declare.

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society., (© 2016 American Cancer Society.)

Adolescents are in a transitional phase of life characterized by major physical, emotional, and psychological challenges. Living with ulcerative colitis is experienced as a reduction of their life quality. Initial treatment of ulcerative colitis is medical, but surgery may be necessary when medical treatment ceases to have an effect. No research-based studies of adolescents' experience of the hospital period after surgery for ulcerative colitis exist. The objective of the study was to identify and describe adolescents' lived experiences while hospitalized after surgery for ulcerative colitis. This qualitative study was based on interviews with eight adolescents. Analysis and interpretation were based on a hermeneutic interpretation of meaning. Three themes were identified: Body: Out of order; Seen and understood; and Where are all the others? The adolescents experience a postoperative period characterized by physical and mental impairment. Being mentally unprepared for such challenges, they shun communication and interaction. The findings demonstrate the importance of individualized nursing care on the basis of the adolescent's age, maturity, and individual needs. Further study of adolescent patients' hospital stay, focusing on the implications of being young and ill at the same time, is needed.

Objective: To investigate knowledge and fear of colorectal cancer (CRC) risk in inflammatory bowel disease (IBD) patients., Methods: A 12-item self-administered questionnaire, developed after a careful literature review, was administered to all consecutive IBD patients treated with infliximab who were followed up at Nancy University Hospital (Vandoeuvre-lès-Nancy, France) between February and May 2012., Results: Altogether 100 patients including 72 with Crohn's disease (CD) were included. Only 7.0% of patients spontaneously mentioned CRC risk as a main feature of IBD and 37.0% as a potential IBD complication. CRC was the most feared complication by 26 patients [ulcerative colitis (UC) 46.4% vs CD 18.1%, P < 0.01]. Two-thirds of patients knew that IBD increases CRC risk (UC 81.9% vs CD 57.1%, P = 0.02). Their main source of information was their gastroenterologist (52.0%). On the best screening method for CRC, 86.0% of the respondents mentioned colonoscopy. Only 32.0% of patients knew that it has to be performed 10 years after diagnosis. In case of dysplasia, 51.0% of the patients would not undergo colectomy (CD 59.7% vs UC 28.6%, P < 0.01), mainly due to the fear of having ostomy bags. Only one-quarter of UC patients were aware of the chemopreventive effect of 5-aminosalicylates on CRC risk., Conclusions: Two-thirds of IBD patients are aware of the risk of CRC. UC patients have a better knowledge of this risk and are more afraid of this complication. Our results underscore the need for therapeutic education about CRC in IBD patients., (© 2016 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Background: Compared with conventional laparoscopic surgery, single-incision laparoscopic surgery produces better cosmetic benefits. The aim of this study was to investigate the learning curve for single-incision laparoscopic anterior resection (SILAR) for sigmoid colon cancer using multidimensional methods., Study Design: From September 2009 through May 2014, one hundred and thirteen patients underwent SILAR for sigmoid colon cancer by a single surgeon at Severance Hospital. The learning curve was analyzed using moving average, cumulative sum control chart (CUSUM), and risk-adjusted CUSUM methods. For risk-adjusted CUSUM, surgical failure was defined as conversion to open surgery or conventional laparoscopic surgery, morbidity within 30 days after surgery, <12 harvested lymph nodes, or local recurrence., Results: Using the moving average method, the peak point for operation time occurred at the 65(th) case (173 minutes). The CUSUM method also showed the operation time peak point at the 65(th) case. However, the risk-adjusted CUSUM curve did not ascend after the 61st case. The operation time and hospital stay for the 60 phase 1 patients (cases 1 to 60) were longer than for 53 phase 2 patients (cases 61 to 113) (166.6 vs 140 minutes; p < 0.001 and 7.1 vs 5.5 days; p = 0.009). Phase 2 patients had a significantly larger tumor diameter and more harvested lymph nodes., Conclusions: The learning curve for SILAR for sigmoid colon cancer was 61 to 65 cases according to multidimensional statistical analyses. Single-incision laparoscopic anterior resection is feasible for surgeons experienced in laparoscopic surgery. However, SILAR required more cases for proficiency than the number previously reported for conventional laparoscopic surgery, likely because of its technical challenges., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Aim: Laparoscopic colorectal resection results in improved cosmetic outcome and better presumed body image. Laparoscopic NOSE colectomy omits an incision for specimen extraction and is supposed to further improve postoperative cosmesis. This study aimed to assess the cosmetic benefit., Method: Forty-nine patients who underwent a NOSE colectomy for bowel endometriosis from September 2009 to September 2013 were matched for age, American Society of Anesthesiologists (ASA) grade and body mass index (BMI) with patients who underwent a conventional laparoscopic colectomy for the same indication. Patients were asked to complete a questionnaire consisting of a body scale and a cosmetic scale and the Patient Scar Assessment Questionnaire (PSAQ) including five subscales (appearance, symptoms, scar consciousness, satisfaction with appearance and satisfaction with symptoms)., Results: Patient demographics were similar between both groups. Patients were assessed at a median postoperative follow-up of 41 months in the NOSE colectomy group and 35 months in the conventional resection group. The median body image questionnaire score was 15 for NOSE colectomy and 18 for conventional resection (P = 0.027). The respective median PSAQ scores were 56 and 71 (P = 0.002). There was a good relationship between the PSAQ score and the body image questionnaire (Spearman correlation coefficient 0.82)., Conclusion: Depending on the scoring system used, the cosmetic outcome may be better after NOSE colectomy than conventional laparoscopy in patients having surgery for endometriosis. The comprehensive body image questionnaire, being shorter and easier to use, could be a valid tool for assessing cosmesis after NOSE procedures., (Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.)

Background: Proctectomy for ulcerative colitis (UC) can be performed via intramesorectal (IME) or total mesorectal excision (TME)., Methods: We compared patient-reported bowel and sexual function among IME versus TME UC patients (September 2000 to March 2011) using the Memorial Sloan-Kettering Cancer Center Bowel Function scale, Fecal Incontinence Quality of Life, Fecal Incontinence Severity Index, Female Sexual Function Instrument, and International Index of Erectile Dysfunction surveys., Results: Eighty-nine IME versus TME patients (35 ± 2 years, 57% male, 62% IME) had similar baseline characteristics, although IME patients had more open procedures (P ≤ .03). IME patients reported better fecal continence (P = .009) but similar fecal incontinence-related quality of life (P ≥ .44). For sexual function, there were no differences for either women (Female Sexual Function Instrument; P ≥ .20) or men (International Index of Erectile Dysfunction; P ≥ .22)., Conclusions: IME appears to be associated with better fecal continence but no difference in overall bowel or sexual function compared with TME in patients with UC., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the changes in quality of life (QOL) over a 1-year follow-up period in patients submitted to laparoscopic colorectal resection for the treatment of deep endometriosis., Methods: A prospective observational cohort study (Canadian Task Force Design Classification II) involving 40 women with intestinal deep endometriosis was conducted between June 2007 and September 2008 at the Department of Obstetrics and Gynecology, Santa Casa Medical School, Sao Paulo, Brazil. Prior to the surgical procedure, all patients received magnetic resonance studies of the pelvis and rectal echoendoscopy, which suggested intestinal involvement of the disease in all cases. The patients received laparoscopic colorectal resections and treatment for other endometriotic lesions. The subjects completed the QOL SF-36 at 3 time points (T0 pre-operatively; T1 6 months post-operatively; and T2 1 year post-operatively)., Results: The physical functioning, role physical, social functioning and role emotional subscales evidenced the most substantial median increases for T0, T1 and T2. The pain, general health, vitality and mental health domains showed slight changes and increases in medians but did not increase to the same extent as the previous group. Significant improvements were observed in all domains of the SF-36 throughout the study period (p < 0.05). Physical health-related QOL domains showed greater improvement than mental health domains. Analyses of age, parity and body mass index as potential factors influencing the impact of surgery on QOL revealed no differences. Therefore, these factors were not used as prognostic indicators for the surgical procedure or for patient follow-up. In addition, we noted that the patients with poorest results on the initial QOL questionnaire showed the greatest improvements at the end point., Conclusion: The study results showed that laparoscopic colorectal segment resection for endometriosis had a positive impact on QOL in this patient group. The positive effects persisted 1 year after surgery.

Unlabelled: The aim of the study was to describe changes in postoperative fatigue, quality of life, physical performance, and body composition in patients undergoing laparoscopic colonic cancer surgery., Material and Methods: In a follow-up study from 2009-2011 at two regional hospitals in Denmark we examined 62 patients having a right hemicolectomy ora sigmoid resection performed. The main outcome measures were fatigue level subjectively scored from 1 ("fit") to 10 ("fatigued") on a modified visual analogue scale and by objective measurements of hand grip and knee extension strength, work capacity, weight, and lean body mass. Quality of life was assessed using the SF-36 questionnaire and pain using an ordinal scale. Patients were examined preoperatively, 1-2 and 4 weeks postoperatively., Results: Eight patients (13%) were converted to open surgery and the median bleeding (95% confidence interval of the median) was 75 (50-100) ml. One to two weeks after surgery the fatigue level and pain when moving had increased significantly (p=0.0011 and p=0.0002 respectively) and the SF-36 physical component quality of life score decreased (p<0.0001) when compared to preoperatively. However, at 4 weeks postoperatively fatigue level, pain, and quality of life scores were at the preoperative level. There were no significant changes from preoperatively to postoperatively in any of the measures of physical performance, whereas there was a slight reduction in weight and lean body mass after the operation. CONCLUSIONS. Laparoscopic colonic cancer surgery was associated with a short lasting increased fatigue and pain and reduced quality of life, but no significant reduction in physical performance after surgery.

Background: Anastomotic leaks after colorectal resections for cancer are a leading cause of postoperative morbidity, mortality, and long hospital stay. Few data exist on the potentially deleterious effect of the anastomotic leaks after proctectomy for cancer on patient health-related quality of life., Objective: The aim of this study was to explore the effect of clinically evident anastomotic leaks on health-related quality of life after rectal cancer excision., Design: This is a case-matched study., Settings: This study was conducted in a Greek academic surgical department., Patients: Included were 25 patients undergoing low anterior resection complicated by an anastomotic leak (Clavien classification II, n = 14, and III, n = 11) and 50 patients undergoing low anterior resection with an uncomplicated course., Main Outcome Measures: Health-related quality-of-life data were prospectively collected at fixed assessment time points (baseline, 3, 6, and 12 months postoperatively) by the use of validated questionnaires (Medical Outcomes Study Short Form 36, Gastrointestinal Quality of Life Index, European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-C30, and European Organization of Research and Treatment of Cancer Quality of Life Questionnaire-CR29)., Results: "Leak" patients required a longer hospitalization. Although the numbers of initially constructed defunctioning loop ileostomies were not significantly different between cases and controls, "leak" patients were required to remain with a stoma significantly more often at all postoperative assessment time points. No differences were observed in the baseline scores between the 2 groups. Physical function of "leak" patients was significantly worse at all postoperative assessment time points. At 6 and 12 months, their emotional and social function and overall quality-of-life scores were significantly decreased in comparison with the patients with an uncomplicated course. "Leak" patients experienced significantly more "stoma-related problems" and "sore skin" around the stoma site., Limitations: Limited number of patients, restriction of follow-up to the end of the first year, and heterogeneity in terms of the presentation, severity, and management of anastomotic leaks were the limitations of this study., Conclusions: Anastomotic leaks have an adverse effect on postoperative health-related quality of life.

Background: The aim of the present study was to prospectively determine health-related quality of life (HRQoL) changes and affecting factors after elective laparoscopic colectomy for cancer., Methods: The SF-36, EORTC QLQ-C30 and QLQ-CR29, and Gastrointestinal Quality of life Index (GIQLI) were used to assess 85 patients preoperatively and at 1, 3, 6, and 12 months., Results: An initial drop form baseline values was observed in 3 of 8 SF-36 domains, 3 of 5 QLQ-C30 functional scales and 1 of 5 GIQLI subscales. Emotional functioning (EF) was better postoperatively even from the first month (p = 0.03). Most functional domains were improved compared to baseline. The statistically significant changes (p < 0.05) were in the SF-36: general health (GH) (3 months), physical function (PF) (12 months) and role limitations due to emotional problems (12 months); in the QLQ-C30: EF (12 months); in the GIQLI: the global score and PF at 12 months and EF (3, 6, 12 months). From the first month after surgery, most QLQ-C30 "symptom" items were better than baseline. QLQ-CR29 "anxiety" and the "defecation problems" scales were significantly better than baseline at 1, 12 and at 6, 12 months (p < 0.05). Advanced stage (III) and chemotherapy were linked to worse EF, social function (SF), GH and global quality of life (QOL) at 3 and 6 months (p < 0.01). Males appeared to have a worse HRQoL than females at 3 and 6 months, and in 5 of 8 SF-36 domains and 3 of 5 GIQLI subscales at 12 months (p < 0.05). According to the QLQ-CR29, rectal surgery was associated more often with "impotence," "stoma problems" and "incontinence" up to 6 months, and ostomies with "embarrassment" and "stoma problems" (p < 0.05)., Conclusions: HRQoL generally improved over the first year after laparoscopic colectomy reaching even better levels than before surgery. There was an early postoperative improvement in patients' emotional status. The main factors affecting HRQoL seem to be tumor stage, chemotherapy and male sex.

Purpose: The surgeons of the future will need to have advanced laparoscopic skills. The current challenge in surgical education is to teach these skills and to identify factors that may have a positive influence on training curriculums. The primary aim of this study was to determine if fundamental aptitude impacts on ability to perform a laparoscopic colectomy., Methods: A practical laparoscopic colectomy course was held by the National Surgical Training Centre at the Royal College of Surgeons in Ireland. The course consisted of didactics, warm-up and the performance of a laparoscopic sigmoid colectomy on thesimulator. Objective metrics such as time and motion analysis were recorded. Each candidate had their psychomotor and visual spatial aptitude assessed. The colectomy trays were assessed by blinded experts post procedure for errors., Results: Ten trainee surgeons that were novices with respect to advanced laparoscopic procedures attended the course. A significant correlation was found between psychomotor and visual spatial aptitude and performance on both the warm-up session and laparoscopic colectomy (r > 0.7, p < 0.05). Performance on the warm-up session correlated with performance of the laparoscopic colectomy (r = 0.8, p = 0.04). There was also a significant correlation between the number of tray errors and time taken to perform the laparoscopic colectomy (r = 0.83, p = 0.001)., Conclusion: The results have demonstrated that there is a relationship between aptitude and ability to perform both basic laparoscopic tasks and laparoscopic colectomy on a simulator. The findings suggest that there may be a role for the consideration of an individual's inherent baseline ability when trying to design and optimise technical teaching curricula for advanced laparoscopic procedures.

Patients make medical decisions in consultation with their partner, family, and friends. However, little is known about the ways in which these close others influence their decisions, particularly with respect to discrete decisions such as those related to medical treatments. This cross-sectional study investigated their influence on the surgical decisions of inflammatory bowel disease patients referred for surgery to remove their colon (N = 91). Guided by research on social control and classic research on power and influence in close relationships, we identified four types of close other decision influence: persuasion, assistance with understanding, indirect influence, and negative influence. Linear logistic and regression analyses showed that patients were more likely to have surgery when their close other used persuasion, and they reported lower decisional conflict when their close other helped them understand the decision. Patients were less likely to have surgery and reported greater decisional conflict when their close other used negative influence tactics. Findings demonstrate the importance of considering social context when investigating patient decision making.

Unlabelled: The concept of "health" is defined by the World Health Organization (WHO) as a state of complete physical, mental and social well-being and not merely the absence of disease. Currently, one of the most widely used questionnaires of general type is the SF-36 Health Status Survey, proposed the Boston Institute for Health and created on the basis of other already existing tools for assessing QOL. Translated into Russian and testing methodology was conducted by the Institute of clinical and pharmacological studies (St. Petersburg). Any surgical intervention, in particular the removal of part of the colon can lead to a restriction of all aspects (physical, mental and social) of a normal human life. The goal of treatment of any disease should be considered as improving the quality of life of the patient on a background of positive clinical dynamics, assessing the quality of life indicators, which depend on many external and internal factors., Aim: to study the quality of life of patients after hemicolectomy, depending on the type of colon resection and the level of endotoxemia., Results: Analysis of quality of life of patients after undergoing surgery--hemicolectomy carried out using questionnaire SF-36 indicates a decline in general condition and mental health in patients after left-sided hemicolectomy. The study showed a close pathogenetic relationship between endotoxemia and decreased quality of life of patients after hemicolectomy.

Background/aim: Limited data are available about inflammatory bowel disease-patients' knowledge of disease and associated risks. We assessed patients' knowledge of disease and its associated risks/complications, and their perspectives on current recommendations for colectomy when low-grade dysplasia is found., Methods: Inflammatory bowel disease-patients at a regional patient-information-day were asked to anonymously complete a survey (group-A). A 2nd group was recruited online through the Dutch inflammatory bowel disease-patients' association (group-B)., Results: In group-A, 109 inflammatory bowel disease-patients completed the survey (76% Crohn's disease, 24% ulcerative colitis, 78% female). Thirty-three patients (30%) were unaware of their disease-localization; 30% thought inflammatory bowel disease shortened their life-expectancy; 26% thought it was likely for a severe complication to occur during colonoscopy. Patients estimated their 10-year colorectal carcinoma-risk at 25%. Mean perceived colorectal carcinoma-associated mortality-risk was 13%. Patients would agree to colectomy if their current colorectal carcinoma-risk was at least 53% and 70% would refuse physicians' recommendation for colectomy if dysplasia were detected with a 20% risk of concomitant colorectal carcinoma. Group-B (n=393 inflammatory bowel disease-patients) verified the results above. However, fewer patients (52%) would refuse physicians' recommendation for colectomy, p=0.01., Conclusion: Inflammatory bowel disease-patients are ill-informed about their disease and its associated risks. Improvement of patient-education is necessary to appropriately involve patients in the decision-making process., (Copyright © 2010 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Adjuvant chemotherapy of oral uracil/ftorafur (UFT) plus leucovorin (LV) has been accepted as the standard of care in the treatment of patients with stage II and III carcinoma of the colon. The objective of the study was to compare HRQOL reported by patients receiving oral UFT plus LV (UFT/LV group) versus no adjuvant treatment (control group) following surgery for colorectal cancer., Methods: Ninety nine patients in the UFT/LV group and 83 in the control group participated. HRQOL was assessed with the European Organization for Research and Treatment of Cancer QLQ-C30 and HRQOL data measured longitudinally following surgery were compared between the groups., Results: Eighty-eight percent (87 of 99) received all scheduled doses of UFT plus LV during the first three cycles, and 82 percent (81 of 99) did so for five cycles. The most common type of toxicity in the UFT/LV group was fatigue, which was generally mild. Six patients each had grade 3 diarrhea or anorexia. There were significant differences in the scores for role function, and specific limitations such as fatigue, nausea, and vomiting, dyspnoea, appetite loss, and financial difficulties, which deteriorated in the UFT/LV group., Conclusions: HRQOL in colorectal cancer patients with adjuvant chemotherapy with oral UFT plus LV deteriorated during this phase of treatment compared with those with surgery alone, despite the biased stage of tumor between the groups. Symptom management and social support would improve HRQOL in such a group of patients.

The study was designed to compare patients after laparoscopic and conventional colectomy with regard to early postoperative mood, cognitive function, and neurocognitive variables S100beta and neuron-specific enolase (NSE). Forty-five laparoscopic and 25 open colectomies were enrolled into the prospective study. Outcome measurements were positive and negative postoperative mood (BSKE), neuropsychological tests (Trail-Making Test; word reproduction; Stroop Test), and serum biochemical parameters (S100beta; NSE). Following laparoscopic procedure, patients described significantly better positive mood (P< .05), tended to require less time in the Trail-Making Test and Stroop Test, and had lower postoperative serum concentrations of S100beta compared to conventional colectomy patients (P< .01). The current results revealed several group differences, which, in their entirety, seem to represent a more beneficial outcome after laparoscopic colonic surgery.

Patients with inflammatory bowel disease (IBD) are one of only three groups at high risk for colorectal cancer (CRC), a leading cause of cancer-related mortality. Yet, no research has examined psychological effects of their high-risk status. The present study offered an initial investigation of three potential predictors of patient distress: disease duration, family history of cancer, and perceived social support. Longer disease duration and stronger family history of cancer are associated with elevated CRC risk in this already high-risk population. Perceived support was conceptualized as a resource that could decrease vulnerability to distress or buffer adverse psychological effects of disease duration and family history. Men and women (n = 223) with IBD participating in a colon disease family registry completed measures for this cross-sectional study. Family history of CRC and non-colorectal cancers among first-degree relatives (FDRs) and more distant relatives (DRs) was examined separately. Hierarchical multiple regression analyses revealed that having greater perceived support predicted lower generalized distress (p<0.001). Having an FDR history of CRC predicted higher CRC-specific distress (p = 0.02). Having a DR history of CRC also predicted higher CRC-specific distress, but only among patients diagnosed more recently (p = 0.03). Clinical implications of these findings are discussed along with future research directions., (Copyright 2007 John Wiley & Sons, Ltd.)

Purpose: Low anterior resection has become the operation of choice for mid rectal or low rectal cancer. A defunctioning stoma is routinely created at some centers to decrease the risk of leakage requiring surgical intervention. This study was designed to evaluate the quality of life in patients undergoing low anterior resection with a temporary ileostomy., Methods: A prospective longitudinal study was conducted in 22 patients with rectal cancer who underwent low anterior resection with a loop ileostomy. Quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-CR38 questionnaires. Twenty-five patients who underwent high anterior resection for rectosigmoid cancer were studied concurrently to evaluate the impact of major colorectal resection without a stoma., Results: Patients' scores on the quality of life questionnaires generally improved after high anterior resection; however, for patients who underwent low anterior resection, the scores for physical and role functioning before ileostomy closure were worse than the preoperative values. The scores on the quality of life questionnaires generally improved after ileostomy closure. Ileostomy closure required a short hospital stay and was rarely associated with complications., Conclusion: Patients who underwent low anterior resection with ileostomy had significant reductions in physical and role functioning, which apparently improved after ileostomy closure. Similar declines in these quality of life variables were not found in patients who underwent high anterior resection. A temporary ileostomy should be created in selected patients with the highest risk of anastomotic leakage. Increased resources for not only surgical care but also for stoma therapy are necessary for patients who undergo low anterior resection with a temporary ileostomy.

Unlabelled: The aim of our study is to value the quality of life (QOL) in patients with colo-rectal cancers in the region of tunisian center and to compare it to the QOL in a healthy population unhurt of cancer., Methods: Our population is made by 80 patients treated for coloractal cancers. The population witness includes 80 healthy individuals unhurt of cancers. The assessment of the QOL in patients is achieved with the specific colo-rectal cancer questionnaire: the FACT-C. The comparison of the QOL in the 2 populations is made by the general questionnaire of quality of life of Spitzer., Results: The QOL in patients is good in 55% of cases, average in 44% of cases and bad in 11% of cases. The QOL is better in case of favourable socioeconomic conditions (p < 0,05), colic localization (p < 0.015), absence of metastases (p< 0.05), not mutilating surgery (p < 0.01) especially the absence of stoma (p < 0.001) and the restoring of the continuity (p < 0.002), absence of pain (p < 0.0001), absence of current treatment (p < 0.01). The comparison of the different domains of QOL between the 2 groups (patients and healthy) finds a better QOL in healthy group, in all domains except for the relational ship domain witch turned to be comparable for the 2 samples.

Purpose: The aim of this study was to investigate whether brief psychologic interventions to reduce perioperative stress may improve the postoperative course of patients undergoing abdominal surgery., Methods: We used a randomized, controlled, partially blinded trial to evaluate the differential effectiveness of two brief psychologic interventions (guided imagery and progressive muscle relaxation) on analgesic requirement, pain perception, pulmonary function, duration of postoperative ileus, and fatigue after conventional resection of colorectal carcinoma in elderly cancer patients., Results: Sixty patients (20 guided imagery, 22 relaxation, 18 control) were evaluated. Acceptance of the brief psychologic interventions was high and 90 percent of the patients indicated that they would recommend it to other patients. Analgesic consumption (P = 0.6) and subjective pain intensity at rest (P = 0.3) and while coughing (P = 0.3) were not different between groups. Recovery of pulmonary function, duration of postoperative ileus, and subjective postoperative fatigue were also not influenced. When the data from intervention groups were pooled, again no benefits were detected compared with the control group., Conclusions: Brief psychologic interventions such as guided imagery and relaxation yielded a very positive patient response but did not show a clinically relevant influence on the postoperative physiologic course of elderly patients undergoing conventional resections of colorectal cancer.

Introduction: The objective of this study was to determine whether initial azathioprine therapy, followed by ileocolic resection if azathioprine fails, or initial ileocolic resection without a trial of azathioprine is the preferred treatment strategy in steroid-dependent, terminal ileal Crohn's disease., Methods: A Markov, decision analytic model was developed to simulate a 36-month course for a patient with steroid-dependent, terminal ileal Crohn's disease who would initially take azathioprine or have ileocolic resection. Clinically important outcomes in the model included side effects and effectiveness of azathioprine and postoperative complications, mortality, and recurrence following ileocolic resection. The probabilities and utilities for these variables were derived from previously published studies., Results: Initial azathioprine therapy offered a relatively small benefit of 0.45 quality-adjusted life-months over initial ileocolic resection. The model was sensitive to utility for being symptom-free on azathioprine and utility for being symptom-free postoperatively., Conclusions: Initial azathioprine therapy and initial ileocolic resection are both reasonable treatment strategies in this setting. The preferred treatment strategy is highly dependent on the quality of life that can be achieved with each treatment option. Therefore, individual response and symptom control with each treatment must be strongly considered in this treatment decision.

Rectal cancer presents a unique challenge to oncologists and patients due to the location and anatomy of the rectum and the difficulties inherent in pre-operative staging. These issues are especially important with distal rectal tumors when patients may face the decision of tumor control without sphincter preservation or more limited surgical procedures that may potentially compromise tumor control and thus survival. Current options for sphincter preservation for low-lying rectal tumors are preoperative radiotherapy with or without chemotherapy for tumor downstaging, local excision with or without adjuvant chemoradiation and low anterior resection with coloanal anastomosis. Pretreatment evaluation, by radiologic studies and pathologic predictors of lymph node involvement, is an integral part of determining which patients are suitable candidates for treatment with local excision. Preoperative chemoradiotherapy is a treatment option for some patients who are not initially considered to be candidates for sphincter preservation. Many investigators have suggested that the rate of sphincter preservation in patients with rectal cancer may be improved following preoperative chemotherapy and radiation. For properly selected patients, local excision holds promise as a means of achieving sphincter preservation.

Background: The benefits of laparoscopic colectomy (LC) vs open colectomy (OC) for the treatment of benign disease have not yet been clearly demonstrated with regard to long-term consequences and health-related quality of life (HRQL). The aim of this study was to compare LC and OC in terms of outcome and HRQL and to determine whether a generic nonspecific instrument for HRQL assessment is valid in postoperative follow-up., Methods: Forty-nine patients who underwent LC for elective right hemicolectomy (RH) or sigmoid resection (SR) for benign polyps or uncomplicated diverticular disease between 1992 and 2000 were evaluated and compared to 50 controls treated by OC in the same period. All patients were evaluated by postal questionnaire to determine recurrence rates and surgery-related complications. HRQL was assessed by the SF-36 Physical and Mental Component Summary Score (PCS, MCS) and by the SF-36 Health Survey, which measures eight different health-quality domains, including physical and social functioning (PF, SF), general health perception (GH), physical and emotional role limitations (RP, RE), body pain (BP), vitality (VT), and mental health (MH)., Results: The LC and OC patients were similar in age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and diagnosis. There were significant differences between the two groups in resection type (26 RH:23 SR in LC vs 16 RH:34 SR in OC, p = 0.03) and length of follow-up (median, 39 and 53.5 months, respectively, p = 0.04), but neither parameter was predictive of the main SF-36 scores (PCS and MCS). There were no differences between the groups in recurrence rates (8% in LC vs 11% in OC) or surgery-related complications, including incisional hernias (16.3% in LC vs 17% in OC) and small bowel obstructions (2% in LC vs 10.4% in OC). None of the eight SF-36 Health Survey domains or the PCS or MCS scores showed significant differences between LC and OC patients in HRQL. However, occurrence of hernia after surgery was predictive of lower SF-36 scores, specifically in PF (p = 0.047), GH (p = 0.045), SF (p = 0.047), MH (p = 0.041), and MCS (p = 0.037). In addition, small bowel obstruction was significantly associated with lower scores in BP (p = 0.008), GH (p = 0.008), SF (p = 0.013), RE (p = 0.026), MH (p = 0.003), and MCS (p = 0.003)., Conclusion: LC was not different from OC for selected indications that measure long-term outcome and HRQL. SF-36 appears to be an appropriate instrument to measure postoperative HRQL, showing responsiveness to changes in objective outcome measures.

The conventional and accepted treatment for curative resection of colon cancer is laparotomy with hemicolectomy for right or left sided lesions. The technique of colon resection through an open laparotomy incision is well known. Over the past several years, laparoscopically assisted colectomy has been developed and studied, following the explosion of laparoscopic technology from the cholecystectomy experience and with acquisition of advanced general laparoscopic techniques. The right, left or sigmoid colon can be mobilized and regional lymphadenectomy performed using laparoscopic instruments and video-imaging equipment. The advantage of laparoscopic colectomy is the use of small abdominal port site and wound incisions which translate to reduced postoperative pain and analgesic requirement, earlier return of bowel function and normal physical activities, and shorter hospital stay without increasing health care costs. Laparoscopic colectomy compares favorably with open colectomy in terms of surgical morbidity and mortality. The laparoscopic approach has been shown to be technically and oncologically feasible with equivalent lymph node harvest from mesenteric lymphadenectomy and achieves adequate proximal and distal margins of colonic resection. Despite initial early anecdotal reports of port site cancer recurrence in laparoscopically assisted colectomy, port site recurrence is rare and its incidence is similar to incisional recurrences in conventional open colectomy. Recent prospective comparative studies have demonstrated equivalent patient survival and equivalent local or distant colon cancer recurrences for open versus laparoscopic curative resection of colon cancer.

Laparoscopic colon surgery is gaining acceptance for benign conditions, but cannot yet be considered an established procedure for malignancy. The main reported benefit of the technique is the reduction in length of hospital stay. Other potential benefits such as cosmesis, improvement in quality of life, physiologic and immunologic advantages, as well as reduced complication rates have not been clearly demonstrated. Concerns about laparoscopic colon surgery for cancer including the possibility of inadequate resection, tumor staging, and altered tumor spread due to pneumoperitoneum have only been partially addressed by retrospective and experimental studies and require a prospective randomized trial for definitive resolution. Details of the trial currently underway sponsored by the National Institutes of Health are described. Although innovations in clinical practice and increased familiarity account for the expanding popularity of laparoscopic colon surgery, results from this and similar worldwide trials are needed before this approach can be recommended for cancer.

Background: Surgeons often "know" preoperatively which patients will achieve good postoperative quality of life (QOL). This intuition is probably based on impressions of the patient's personality. The present aim was to examine whether preoperative personality traits predict postoperative QOL., Methods: In 53 patients undergoing pelvic pouch surgery for ulcerative colitis the relationship between preoperative personality traits, and surgical functional outcome and QOL was examined at a median of 17 months postoperatively. Personality assessment instruments (KAPP and KSP), and specific measures of alexithymia were used. Postoperatively, the Psychosocial Adjustment to Illness Scale (PAIS), and surgical functional outcome scales were used., Results: Using multiple correlation/regression, analysis lack of alexithymia, poor frustration tolerance, anxiety proneness, and poor socialization (resentment over childhood and present life situation) were found to predict poor postoperative QOL., Conclusions: The findings suggest personality traits, in addition to surgical functional outcome, to be important for the patient's postoperative QOL.