Faculty Bibliography

BACKGROUND:Although numerous treatments exist for fecal incontinence (FI), no consensus exists on the best treatment strategy. The aim was to review the literature and to compare the clinical outcomes and effectiveness of treatments available for FI. MATERIALS AND METHOD/METHODS:A systematic literature review was performed, from inception to May 2018, of the following databases: MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Library. The search terms used were "faecal incontinence" and "treatment". Only randomized controlled trials (RCTs) comparing treatments for FI were considered. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. RESULT/RESULTS:Forty-seven RCTs were included comparing 37 treatments and reporting on 3748 participants. No treatment ranked best or worst with high probability for any outcome of interest. No significant difference was identified between treatments for frequency of FI per week, or in changing the resting pressure, maximum resting pressure, squeeze pressure, and maximum squeeze pressure. Radiofrequency resulted in more adverse events compared to placebo. Sacral nerve stimulation (SNS) and zinc-aluminium improved the fecal incontinence quality of life questionnaire (FIQL) lifestyle, coping, and embarrassment domains compared to placebo. Transcutaneous posterior tibial nerve stimulation (TPTNS) improved the FIQL embarrassment domain compared to placebo. Autologous myoblasts and zinc-aluminium improved the FIQL depression domain compared to placebo. SNS, artificial bowel sphincter (ABS), and zinc-aluminium significantly improved incontinence scores compared to placebo. Injection of non-animal stabilized hyaluronic acid/dextranomer (NASHA/Dx) resulted in more patients with ≥50% reduction in FI episodes compared to placebo. CONCLUSION/CONCLUSIONS:SNS, ABS, TPTNS, NASHA/Dx, zinc-aluminium, and autologous myoblasts resulted in isolated improvements in specific outcomes of interest. No difference was identified in incontinence episodes, no treatment ranked best persistently or persistently improved outcomes, and many included treatments did not significantly benefit patients compared to placebo. Large multicentre RCTs with long-term follow-up and standardized inclusion criteria and outcome measures are needed.

BACKGROUND:Rectal duplication cysts are rare gastrointestinal congenital duplicate cysts with various clinical presentations that require different management. CASE PRESENTATION/METHODS:We present a case of a lady with a double rectal duplicate cyst which was found incidentally on a follow-up CT abdomen and pelvis scan. The patient initially had a mucocele excision, and following that, she had a non-contrast CT abdomen and pelvis to investigate post-operative pain. The CT scan revealed a single rectal duplicate cyst. She had a posterior approach excision to have it removed, and only intra-operatively, she was found to have a double rectal duplicate cyst. She had them both removed via a midline incision running from the perineal pigmentation and extending until the coccyx. She had another follow-up CT which showed complete excision of the cysts. CONCLUSIONS:After a thorough review of the literature regarding rectal cysts, there was no mention of a double rectal duplicate cyst. The purpose of this paper is to point out the various potential presentations of a rectal cyst as well as the idea that a double cyst is managed effectively in a similar way as the single one.

Earlier detection of colorectal cancer (CRC) results in improved survival. Existing non-invasive biomarkers have suboptimal accuracy. Neurotensin (NTS) is involved in CRC carcinogenesis. This study evaluated the diagnostic potential of plasma NTS for colorectal polyps and cancers. Participants were selected based on national CRC referral guidelines. All subjects underwent colonoscopy. Average plasma concentrations were compared across different diagnostic groups. Predictors for detecting colorectal neoplasia were identified. Receiver operator characteristic (ROC) curve analysis assessed the diagnostic accuracy of NTS. An independent biobank was used as validation group. Of 165 participants, 46 had polyps or CRC. Significantly higher plasma NTS was found in the colonic neoplasia group (603.6 pg/ml vs. 407.2 pg/ml, p < 0.01). Risk factors for colonic polyps or cancers included Log_e (plasma NTS concentration) (OR, 2.73; 95% CI, 1.33-5.59, p < 0.01), log_e (Age) (OR, 15.49; 95% CI, 2.67-89.66, p < 0.01) and cigarette smoking (OR, 3.49; 95% CI, 1.31-9.26, p = 0.01). Plasma NTS had an optimal sensitivity of 60.4% and specificity of 71.6% for the diagnosis of colorectal polyps and cancers. Similar diagnostic accuracy was obtained in the validation group. Plasma NTS has the potential to be a non-invasive biomarker for colorectal neoplasia. It appears to be more accurate than existing blood markers and is unique in being able to detect precancerous polyps.

Unplanned readmissions heavily affect the cost of health care and are used as an indicator of performance. No clear data are available regarding beyond-total mesorectal excision (bTME) procedure. Aim of the study is to identify patient-related and surgery-related factors influencing the 30-day readmissions after bTME. Retrospective data were collected from 220 patients who underwent bTME procedures at single centre between 2006 and 2016. Patient-related and operative factors were assessed, including body mass index (BMI), age, gender, American Society of Anaesthesiologists' (ASA) score, preoperative stage, neo-adjuvant therapy, primary tumour vs recurrence, the extent of surgery. The readmission rate was 8.18%. No statistically significant association was found with BMI, ASA score, length of stay and stay in the intensive care unit, primary vs recurrent tumour or blood transfusions. Not quite statistically significant was the association with pelvic side wall dissection (OR 3.32, p = 0.054). Statistically significant factors included preoperative stage > IIIb (OR: 4.77, p = 0.002), neo-adjuvant therapy (OR: 0.13, p = 0.0006), age over 65 years (OR: 5.96, p = 0.0005), any re-intervention during the first admission (OR: 7.4, p = 0.0001), and any post-operative complication (OR: 9.01, p = 0.004). The readmission rate after beyond-TME procedure is influenced by patient-related factors as well as post-operative morbidity.

Colorectal cancer (CRC) is the third cause of cancer-related death worldwide. It has been estimated that more than one million new cases occur every year. Several studies have investigated the role of host bacteria as agents protecting against or increasing the risk of CRC, but few have assessed the fungal microbiome in patients with CRC. Fungal dysbiosis has been studied in colorectal diseases (e.g. inflammatory bowel diseases), but few researches compared the fungal microbiome of CRC patients with those of controls. The current study represents a systematic review aimed at assessing the expression and diversity of fungi in patients with CRC and non-CRC individuals. Here, we discuss the fungal species that could be implied in CRC development and alterations that can be induced by the presence of CRC, and the potential implications for future research.

PURPOSE/OBJECTIVE:This study aims to establish the ability of patient-reported outcome measures (PROMs) and anorectal manometry (ARM) in predicting the need for surgery in patients with fecal incontinence (FI). METHODS:Between 2008 and 2015, PROMs data, including the Birmingham Bowel and Urinary Symptoms Questionnaire (BBUSQ), Short Form 36 (SF-36), Wexner Incontinence Score and ARM results, were prospectively collected from 276 patients presenting with FI. Spearman rank was used to assess correlations between specific PROMs questions and ARM assessments of sphincter motor function. Binomial regression analyses were performed to identify factors predictive of the need for surgery. Finally, receiver operating characteristic (ROC) curve analyses were performed to establish the utility of individual ARM and PROMs variables in predicting the need for surgical intervention in patients with FI. RESULTS:Two hundred twenty-eight patients (82.60%) were treated conservatively while 48 (17.39%) underwent surgery. On univariate analyses, all 4 domains of the BBUSQ, all 8 domains of the SF-36, and the Wexner Incontinence Score were significant predictors of surgery. Additionally, maximum resting pressure, 5-second squeeze endurance, threshold volume, and urge volume were significant. On ROC curve analyses, the only significant ARM measurement was the 5-second squeeze endurance. PROMs, such as the incontinence domain of the BBUSQ and five of the SF-36 domains, were identified as fair discriminators of the need for surgery. CONCLUSION/CONCLUSIONS:PROMs are reliable predictors of maximal treatment in patients with FI and can be readily used in primary care to aid surgical referrals and can be applied in hospital settings as an aid to guide surgical treatment decisions.