Diagnosis and Management of Chronic Anastomotic Leak

Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.

The effect of pre-operative stoma-site marking on peristomal skin health and quality of life

Aim: To determine the effect of pre-operative stoma-site marking (siting) on ostomates' peristomal skin health and quality of life (QoL). Methods: The Uses and Attitudes in Ostomy (U&A Ostomy) study was conducted across 148 stoma units in Spain. Specialist stoma care nurses personally assessed each ostomate and collected demographic and clinical data. This included whether the stoma was sited before surgery, the stoma's characteristics, the type of appliance used, any stoma-related complications and frequency of leakage. Participants were also assessed using the Discolouration, Erosion, Tissue overgrowth (DET) Ostomy Skin Tool (0–15), Global Wellbeing scale (0–10) and Stoma-QoL scale (0–100). Findings: The study included 871 ostomates. Of these, 64% were male and 36% were female, the mean age was 64±13 years and the mean BMI was 26.5±11; 57.5% had a colostomy, 28.6% had an ileostomy and 13.9% had a urostomy. A stoma site had been pre-operatively marked and respected in 53.1%, marked but not respected in 2.1% and not marked in 44.8% of the cases. The proportion of new ostomates whose stoma had been sited was seen to have increased in recent years. Stoma siting was associated with a permanent ostomy (p=.0001), absence of effluent leakage (p=.008), absence of complications (p<.0001), lower DET score (p.0007), higher Stoma-QoL score (p=.018) and higher global wellbeing score (p=.0018). Multivariate analysis revealed that pre-operative stoma siting (p<.0001) and type of ostomy (p<.0001) were independent predictors of optimal peristomal skin (DET score 0). The Stoma-QoL score was higher in ostomates with pre-operative stoma siting (58.3±10.2 vs 57±10.3; p=.018). Global wellbeing was also higher in those with pre-operative stoma siting (7.6±1.8 vs 7.19±1.9; p=.0018). Conclusions: In Spain, pre-operative stoma siting is not yet consistently applied in practice, despite the educative efforts made by health professionals. Stoma siting is a first-line opportunity to reduce the occurrence of peristomal skin complications (PSCs), and thus it is associated with fewer PSCs and greater self-perceived QoL. More effort is needed to extend this practice to the majority of patients undergoing stoma-forming surgery.

Use of On-Demand Secure Cloud Video Communications for an Ostomy Self-Management Telehealth Intervention for Cancer Survivors and their Caregivers (Preprint)

BACKGROUND Ostomy Self-Management Telehealth (OSMT) intervention by nurse-educators and peers can equip ostomates with critical knowledge regarding ostomy care. A telehealth technology assessment aim was to measure telehealth engineer support requirements for telehealth technology related (TTR) incidents encountered during OSMT intervention sessions held via an on-demand secure cloud video communications (SCVC) service, “Zoom for Healthcare”. OBJECTIVE This paper examines technology challenges, issues, and opportunities encountered in the use of telehealth in the setting of an intervention RCT for cancer survivors living with a permanent ostomy. METHODS The Arizona Telemedicine Program (ATP) provided telehealth engineering support for 105 scheduled 90-120-minute OSMT SCVC sessions over a two-year period. OSMT groups included up to 15 participants, comprised of four to six ostomates, four to six peer-ostomates, two nurse educators, and one telehealth engineer. OSMT session TTR incidents were recorded in written comments collected contemporaneously by research study staff. TTRs were categorized and tallied. RESULTS 102 of 105 (97%) OSMT sessions were completed as scheduled. Three OSMT sessions were not held due to non-technology related reasons. Of the 93 ostomates who participated in OSMT sessions, 80 (86%) completed their OSMT curriculum. TTR incidents occurred in 35.3% of completed sessions with varying disruptive impact. Zero sessions were cancelled or rescheduled due to TTR incidents. Disruptions resulting from TTR incidents were minimized by following TTR incident prevention and incident response plans. CONCLUSIONS SCVC services can successfully enable ostomates to participate in ostomy self-management education by incorporating dedicated telehealth engineering support. OSMT potentially greatly expands availability of ostomy self-management education to new ostomates. CLINICALTRIAL NCT02974634

Institutional experience with total neoadjuvant therapy for low-lying rectal tumors.

123 Background: Surgery has traditionally been the primary treatment for rectal cancer with consideration of neoadjuvant and adjuvant therapies based on stage. Recent studies have shown that Total Neoadjuvant Therapy (TNT) may provide excellent outcomes, with a possibility of non-operative management in patients with rectal cancer. This study is an initial report of our institution’s watchful waiting strategy. Methods: Patients with Stage II-III, low rectal adenocarcinomas treated from 2015-2018 with TNT were retrospectively reviewed. Patients were surgical candidates with no planned surgery. All patients received definitive radiation (median dose 54 Gy, range 50-56 Gy, at 1.8-2 Gy/fx) with concurrent Xeloda, with additional chemotherapy delivered either prior to or following chemoradiation. Kaplan-Meier (KM) method was utilized to estimate the 2 year permanent ostomy and surgery free survivals. Univariate and multivariate analysis using binary logistic regression were performed to assess the odds ratio (OR) of the need for surgery, with 95% confidence interval (CI). Results: 28 patients were treated with TNT with a median age of 59 years (range 32-79 yrs) and median follow up of 24 months (range 6-51 mon). Reasons for TNT included: clinical trial (50%, n = 14), patient desire to avoid surgery (43%, n = 12), and history of LDR prostate brachytherapy (7%, n = 2). The majority of patients had Stage III disease (68%, n = 19). Median tumor distance from the anal verge was 3 cm (range 0-7 cm). 75% (n = 21) of patients were initially managed without surgery, with 5 patients requiring LAR and 2 requiring APR for residual disease. 4 patients initially treated without surgery experienced local recurrence (LR) requiring APR, with a median time to LR of 20 months (range 12-27 mon). The KM estimated 2 year permanent ostomy and surgery free survivals were 69% and 56% respectively. Distant metastases occurred in two patients at 2 and 7 months post RT. An incomplete response on post-treatment MRI predicted eventual receipt of surgery (p = 0.012, OR = 19.8, 95% CI 1.9-202, compared to complete responders). Conclusions: These results support the growing evidence that TNT may provide a non-surgical option for select patients with low lying rectal cancer.

Convivência conjugal com o parceiro estomizado e suas implicações sociais e afetivas: estudo comparativo

La evaluación del problema de la estomía y sus implicaciones sociales y emocionales en la vida conyugal con un compañero estomizado es el punto de origen de este estudio. La condición de la persona con estomía permanente puede afectar actividades sociales y diarias con sus cónyuges. Objetivo: Analizar los aspectos sociales y afectivos de la convivencia diaria del cónyuge y su compañero con estomía intestinal definitiva. Método: Estudio comparativo del tipo caso-control, de naturaleza cuantitativa, realizado con cónyuges de estomizados, del Distrito Federal, Brasil. La muestra estuvo compuesta por 108 personas, siendo 36 cónyuges del estomizados llamado Grupo Caso y 72 cónyuges de no estomizados, titulado Grupo Control. Los datos fueron recolectados de octubre de 2011 a junio de 2012. Resultados: Mostraron que el Grupo Caso cuando comparado al Grupo Control, presentó menor frecuencia a restaurantes, eventos colectivos y participa menos de actividades de ocio. En cuanto a los hábitos en practicar actividades físicas, a la percepción sobre la estabilidad de la convivencia marital y a la evaluación de la relación afectiva fueron verificados índices similares en ambos grupos. Conclusión: El cónyuge y su compañero estomizado sufren cambios en la convivencia diaria, pero el vínculo conyugal y los lazos afectivos de la pareja permanecen inalterados: The evaluation of the ostomy problem and its social and emotional implications on the conjugal life with a partner with colostomy is the starting point of this study. The condition of a person with a permanent ostomy can influence social and daily activities with their spouses. Objective: To analyze the social and affective aspects of daily coexistence of the spouse and his partner with a definite intestinal ostomy. Method: Comparative study of case control type of quantitative nature, conducted with spouses of ostomized patients paired to the non ostomized in the Federal District, Brazil. The study included 108 spouses of whom 36 spouses of the ostomized called the Case Group and 72 of the non ostomized entitled Control Group. The data was collected from October 2011 to June 2012. Results: The results show that the case group when compared to the control group presented a lower frequency to restaurants, collective events and participates less in leisure activities. In regard to the habits of practicing physical activities, the perception concerning stability in marital coexistence and the evaluation of affective relation, similar rates were observed in both groups. Conclusion: The spouse and his ostomized partner suffered from changes in daily conviviality and the affective bonds of the couple remained unchanged. A avaliação do problema da estomia e suas implicações sociais e emocionais na vida conjugal com um parceiro com colostomia é o ponto de partida deste estudo. A condição da pessoa com estomia permanente pode influenciar atividades sociais e diárias com seus cônjuges. Objetivo: analisar os aspectos sociais e afetivos da convivência diária do cônjuge e seu parceiro com estomia intestinal definitiva. Método: Estudo comparativo do tipo caso controle, de natureza quantitativa, realizado com cônjuges de estomizados, pareado aos de não estomizados, do Distrito Federal, Brasil. A amostra foi composta por 108 pessoas, sendo 36 cônjuges de estomizados denominado Grupo Caso e 72 cônjuges de não estomizados, intitulado Grupo Controle. Os dados foram coletados de outubro de 2011 a junho de 2012. Resultados: Mostraram que o Grupo Caso quando comparado ao Grupo Controle, apresentou menor frequência a restaurantes, a eventos coletivos e participa menos de atividades de lazer. Quanto aos hábitos em praticar atividades físicas, à percepção acerca da estabilidade da convivência marital e à avaliação da relação afetiva, foram verificados índices semelhantes em ambos os grupos. Conclusão: O cônjuge e seu parceiro estomizado sofrem mudanças na convivência diária, mas o vinculo conjugal e os laços afetivos do casal permanecem inalterados.

Sexual function of long-term rectal cancer survivors.

209 Background: Many rectal cancer survivors report problems with intimacy and sexual function after surgery. The extent of these problems is not well known. Methods: Long-term rectal cancer survivors (5+ years post-diagnosis) who were members of Kaiser Permanente with permanent ostomy (n = 183) or sphincter-sparing surgery (N = 394) completed a mailed survey. Participants were identified through tumor registries and health plan data. Items from the City of Hope Quality of Life Colorectal Cancer scale assessed disruption to intimate relationships due to the surgery on a scale of 0-10, with 10 indicating the least disruption. Other items assessed current experiences of and satisfaction with sexual function as well as comfort being undressed in front of a partner. Results: Survey response rate was 60.5% (N = 577). Respondents’ average age was 73 years, 41% were female, 63% were married or partnered at the time of survey, and 30% reported being sexually active. Fifteen percent of those who were not sexually active feared resuming sexual activity. Thirty-five percent of all respondents found their sexual activity unsatisfying. Of the 236 female respondents, 24% reported current problems with vaginal dryness, 12% with vaginal stricture, and 9% with vaginal pain. Of the 341 male respondents, 64% reported current problems getting an erection and 65% with maintaining one. Survivors with ostomy vs. sphincter-sparing surgery reported more interference with personal relationships (6.4 vs. 8.3, p < .001) and less ability to be intimate (5.1 vs. 7.0, p < .0001). A higher percentage with ostomy also reported discomfort being undressed in front of their partner (40.6% vs. 10.6%, p < .001). Conclusions: Many rectal cancer survivors were unsatisfied with their sexual activity. One in ten women reported vaginal stricture, which can be mitigated by early intervention. Nearly 1/4 reported problems (dryness, pain) that can be addressed at any phase of survivorship. Two thirds of men reported trouble with getting an erection and with maintaining one, indicating a significant opportunity for intervention in this cohort. Sexual function did not differ significantly between surgery groups. In line with previous reports, survivors with ostomy had more intimacy and body image problems.

Dietary and behavioral adjustments to control bowel function by long-term colorectal cancer survivors.

573 Background: Bowel dysfunction is a known complication of colorectal cancer (CRC) treatment, and has a detrimental impact on survivors’ health-related quality of life (HRQOL). The prevalence of dietary and behavioral modifications in CRC survivors has been described in only a small number of studies. To better understand dietary and behavioral adjustments that long-term (≥ 5 years) CRC survivors make to regulate their bowel function, we performed a mixed methods analysis, comparing survivors with a permanent ostomy and those with anastomosis. Methods: CRC survivors with or without permanent ostomies were surveyed with the modified version of the City of Hope Quality of Life for Ostomy tool (N=919).Dietary adjustments were compared by ostomy status (ostomy versus anastomosis) and higher quartile versus lower quartile HRQOL scores.Student’s t-tests were used to compare HRQOL measures between groups. Qualitative data from 13 focus groups (N=63) and interviews with 30 female ostomates were analyzed to explore specific strategies used for regulating bowel function. Results: CRC survivors make substantial andpermanent dietary adjustments following treatment. The majority of survivors reported that they took more than one month to feel comfortable with their diet, and many (10% to 18%) never became comfortable. No significant dietary adjustment differences were noted based on ostomy status. Survivors who took less time (<1 month) to feel comfortable with their diet and for their appetite to return had better HRQOL (p < 0.001) ≥ 5 years later. Adjustments to control bowel function consisted of four overall strategies: dietary adjustments, behavioral adjustments, exercise, and medications. Conclusions: CRC survivors use a multitude of adaptive strategies to control their bowel function. Many survivors struggle with unpredictable bowel function continually for the rest of their lives, and many never find any set of management strategies to achieve regularity. Understanding the myriad of adjustments made by CRC survivors will lead to evidence-based recommendations to foster positive adjustments after cancer treatment.