Abstract Background Perianal fistulising Crohn’s Disease (PFCD) is a challenging phenotype of IBD associated with poor outcomes. Classically, fistulae have been classified anatomically and guidelines have been generalised, with a lack of appreciation of disease heterogenicity. The recent ‘TOpCLASS classification system’ (Geldof et al. (2022) - figure below) addresses this and categorises patients based on clinical features and patient goals. There is a need to provide management guidance for PFCD that aligns with this approach, targeting differing PFCD manifestations seen in real-life. We present a consensus exercise delivering that guidance. Methods Position statements on ‘optimal’ PFCD management within the TOpCLASS classes were made via a consensus meeting in Apr 2023. The expert panel were members of the TOpCLASS Consortium, a group of PFCD specialists and researchers. This included 15 surgeons and 16 gastroenterologists, from IBD centres in Europe, North America, and Australia. Prior to the meeting, to inform provisional statements: 1) a systematic review of the literature was conducted (Oct 2021), 2) multidisciplinary team responses on the management of fictional PFCD cases from 8 leading IBD centres were obtained, and 3) an open discussion on PFCD management with the expert panel was conducted. Consensus was predefined as ≥80% ‘strongly agree’ [A+] or ‘agree with minor reservation’ [A]. Results 53 position statements were agreed by the expert panel. For Class 1 (minimal, asymptomatic) disease the panel agreed, given the lack of symptoms, there is no role for seton insertion (A+ 50%, A 50%), and no role for routine MRI monitoring in the absence of new fistula symptoms (A+ 46%, A 54%). Regarding Class 2 (chronic, symptomatic) disease, the panel agreed on detailed guidance for when fistulae are suitable for a repair attempt and where differing surgical modalities are best utilised in fistula repair. Additionally, statements on seton removal in PFCD were made, alongside statements on optimised medical therapy in Class 2 patients. Specifically, the panel suggest Infliximab first-line (A+ 80%, A 20%), ideally commenced within 30 days of initial drainage +/- seton insertion (A+ 100%). Statements were also produced regarding second-line options, topical therapy, and loss of response to biologics in PFCD. Specific statements were also developed for Class 2b, 2c-i, 2c-ii, and 4 disease, as well as on the psychological burden of PFCD. Conclusion The generated statements come from a highly expert Western group of PFCD specialists. We believe they provide pragmatic advice to gastroenterologists and IBD surgeons managing the full breadth of PFCD encountered in day-to-day practice.

Introduction:Acute and chronic anal fissures are common proctological problems that lead to relatively high morbidity and frequent contacts with health care professionals. Multiple treatment options, both topical and surgical, are available, therefore evidence-based guidance is preferred. Methods:A Delphi consensus process was used to review the literature and create relevant statements on the treatment of anal fissures. These statements were discussed and modulated until sufficient agreement was reached. These guidelines were based on the published literature up to January 2023. Results:Anal fissures occur equally in both sexes, mostly between the second and fourth decades of life. Diagnosis can be made based on cardinal symptoms and clinical examination. In case of insufficient relief with conservative treatment options, pharmacological sphincter relaxation is preferred. After 6-8 weeks of topical treatment, surgical options can be explored. Both lateral internal sphincterotomy as well as fissurectomy are well-established surgical techniques, both with specific benefits and risks. Conclusions:The current guidelines for the management of anal fissures include recommendations for the clinical evaluation of anal fissures, and their conservative, topical and surgical management.

Each year, approximately 1.4 million people worldwide are diagnosed with cancer, of which 10% are diagnosed with colorectal cancer. A colostomy can negatively affect quality of life in various ways. The aim of this study was to explore the experience and perception of participants with a permanent colostomy after rectal cancer treatment with a focus on the sexual experience. An explorative qualitative study was conducted. Semi-structured interviews were conducted in two hospitals. Fifteen participants with a permanent colostomy after treatment for rectal cancer participated. A thematic analysis was performed and investigators’ triangulation was used during data-analysis. Data-saturation was obtained in most of the themes. Five main themes were retained: (1) living with a definitive colostomy, (2) seeking control through trial-and-error, (3) in relation to the other, (4) the sexual experience, (5) the provision of care. How participants experience life with a permanent colostomy was central to the themes. Participants are often not aware of the possible consequences of a colostomy on their general and sexual experience. In addition to commonly reported sexual functional problems, such as erectile dysfunction and vaginal dryness, the psychosocial aspect plays a major role. Mainly altered self-image and feelings, such as shame and anxiety, were most frequently expressed. Healthcare providers play an essential role in the information, education and training of the ostomy carrier. Within the current care provision, sexuality is still insufficiently included in the care and treatment plan. This ensures participants feel only to a limited extent informed about the effects of the treatment on their sexual experience. There is need for a proactive approach to discuss sexuality.

In rectal cancer surgery, there are two surgical options: A low anterior resection with preservation of the anal sphincter and an abdominoperineal resection with resection of the sphincter and formation of a permanent stoma. When the sphincter is not compromised, both surgical options are, from an oncological point of view, comparable. Given the need to take patients’ perspective into account, the choice of rectal cancer surgery is a value-based choice. To facilitate this, there is a growing interest in the use of decision aids. It helps patients to participate in weighing the impact of different treatment options on their QoL. The aim of this study was to explore the expectations of healthcare professionals (HCPs) and to evaluate the impact of using a decision aid in daily practice. A multi-centre explorative study was conducted. Individual semi-structured interviews with 16 interprofessional HCPs responsible for the care of patients with rectal cancer were performed. Thematic analysis was used during data-analysis and investigators’ triangulation was applied during analysis. First, HCPs felt that a decision aid would enable them to provide information in a more neutral and uniform way. Second, it was believed that the decision aid enhanced the understanding of the different aspects of QoL. Moreover, a shared decision was hypothesised to enable patients to accept consequences of rectal cancer surgery, such as bowel problems or a stoma. Additionally, it was believed to empowering patients and increasing their involvement in the treatment decision. Finally, some key issues for implementation were highlighted, such as reorganising the preoperative consultation, a consensus on the most appropriate moment to use the decision aid and the need for training. Several HCPs mentioned the added value of a nurse-led consultation, complementary to the physician. Using a decision aid to facilitate preoperative consultations was an added value according to HCPs. Before implementation, several key issues need to be taken into account. A nurse-led consultation could be an added value to facilitate shared decision making. A follow-up study will explore the impact on patients.

After sphincter-saving rectal cancer surgery, many patients experience bowel problems called low anterior resection syndrome (LARS). Especially major LARS (LARS-score ≥ 30) has a negative impact on patients’ quality of life. Our previous research has shown that these patients have several information and counselling needs towards healthcare professionals. Patients without LARS (LARS score 0-20) or with minor LARS (LARS-score 21-29) experience less bowel problems which has less impact on their quality of life. The aim of this study was to explore the dynamics in experiences, information and counselling needs of patients without or with minor LARS. A qualitative study based on the principles of a grounded theory was conducted. Rectal cancer survivors without LARS or with minor LARS were purposefully recruited in three large hospitals. Patients with major LARS, patients who have had an abdominoperineal resection with permanent stoma and patients who do not speak Dutch were excluded. Semi-structured interviews were performed. The constant comparative method and investigators’ triangulation were used during data-analysis. Fourteen patients were interviewed of which six patients without LARS and seven with minor LARS according to the LARS-score. In the first months, all 14 patients experienced LARS which had an impact on their family or working life. However, these symptoms improved over time resulting in a controllable situation. Additionally, patients described that LARS became less dominant and other symptoms such as peripheral neuropathy due to neoadjuvant chemotherapy were perceived worse. Factors such as having previous bowel problems during treatment, comparing themselves to patients experiencing major LARS or feeling euphoria about avoiding a permanent stoma reinforced their coping strategy. The amount of information patients received beforehand varied. Patients who received a high information load experienced anxiety but stated that this information was necessary to be prepared. The symptoms of patients without or with minor LARS were more controllable and became less dominant compared to major LARS. These insights are important to organize care for patients without or with minor LARS.

Purpose: The purpose of this study was to assess the relationship between the low anterior resection syndrome (LARS) and quality of life (QOL). Furthermore, in patients with major LARS, therapeutic management options were explored. Methods: A cohort of surviving patients, who underwent a low anterior resection for rectal cancer after long course of radiochemotherapy, were identified. These patients were treated in Ghent University Hospital between 2006 and 2016. QOL was assessed using the European Organization for Research and Treatment of Cancer Quality Of Life questionnaire-C30 and the bowel function using the LARS-score. The relationship between LARS and QOL was analysed. Patients with major LARS (>= 30 points) were contacted to explore their therapeutic management of LARS. Results: 69% of the participants had major LARS. QOL was closely associated with LARS. Significant differences were found between those with and without LARS in the global health status (p < 0.001) and in the following functional scales: physical (p < 0.001), role (p < 0.001), cognitive (p = 0.04) and social (p < 0.001). Patients with major LARS experienced more diarrhea (p < 0.001), fatigue (p = 0.002), insomnia (p < 0.001) and pain (p = 0.02), compared to patient with no/minor LARS. Most patients tried dietary regimens (71%), medication (71%) and incontinence material (63.8%) in an attempt to manage their LARS and found some of them useful. The level of the anastomosis (low) was a significant risk factor for major LARS (p=0.03). Conclusion: More than half of the patients in this cohort still suffered from major LARS. Patients confronted with major LARS had a lower QOL than patients with no/minor LARS. Currently, there is no gold standard for the management of LARS. Patients manage it through trial and error.

Introduction : Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking. Methods : A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020. Results : Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids. Conclusions : The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

BACKGROUND AND STUDY AIMS:Transanal irrigation (TAI) is used in children to treat constipation and incontinence. Belgium has 2 systems available: Colotip® (cheaper, however not designed for TAI) or Peristeen®.PATIENTS AND METHODS:This patient-control switch study is the first to compare 2 TAI systems. Children regularly using Colotip® for TAI were asked to participate, after consent, a visual analogue scale (VAS) rating the system and a 2-week diary (fecal continence, self-reliance, time spent on the toilet, pain, Bristol stool scale, irrigation volume and frequency of enema) were completed. Non-parametric statistics were used.RESULTS:Out of 26 children using Colotip®, 18 (69%) children participated and 5 refused (fear n=1, satisfaction Colotip® system n=7). Of these 18 children (interquartile range: 3-18 years, median 12.5 years, 9 girls) 5 patients stopped Peristeen® (pain n=1, fear n=1 and balloon loss n=3) and 2 were lost from follow up. Dropouts and included patients showed no statistical difference. In the 11 remaining patients, pseudo-continence (p 0.015), independence (p 0.01) and VAS score (p 0.007) were significantly better with Peristeen®, no difference was found in time spent on the toilet (p 0.288) and presence of pain (p 0.785).CONCLUSIONS:In children Peristeen® offered significantly higher pseudo-continence and independency. 30% refused participation because of satisfaction with the Colotip® and 30% spina bifida patients reported rectal balloon loss due to sphincter hypotony. To diminish Peristeen® failure, a test-catheter could be of value. Considering Colotip® satisfaction, both systems should be available. Patient selection for Peristeen® needs further research.

More sphincter saving procedures are being performed for rectal cancer. The majority of patients expects to resume life as from before diagnosis, but the reality turns out to be different when they are confronted with the low anterior resection syndrome (LARS). This is characterized by frequent toilet visits, clustering, urgency, and incontinence. Patients are unsure what to expect after treatment. Healthcare professionals seem to underestimate the impact of LARS on patients’ lives. The aim of our study was to get insight in the needs of patients with major LARS. A multi-centre qualitative study with a grounded theory approach was conducted. Patients were recruited through purposive sampling and later through theoretical sampling. Individual semi-structured interviews with patients confronted with major LARS were performed. Data-analysis was done by the constant comparative method using NVIVO (QRS international, v12) and investigators’ triangulation was applied during analysis. The study was approved by the Institutional Review Board. A total of 28 patients was interviewed until data saturation. Before surgery patients’ need for information varied according to their individual coping mechanisms. Some patients required information before surgery to set their expectations, whilst others considered this too overwhelming because of the large amount of information about their treatment trajectory. Counseling afterwards, however, was crucial for patients who did not prefer to receive information beforehand. When confronted with LARS, patients desired that healthcare professionals clarified the expected evolution of their symptoms and to recognize the impact of LARS . Additionally, patients expressed the wish for proactive counselling with an easy accessible and approachable healthcare professional. Patients expressed several needs regarding the care for their bowel problems. It is vital that healthcare professionals have good knowledge of LARS and the challenges that patients can face, as they have an important role in informing and counseling the patients.

PURPOSE:After the reversal of the temporary stoma, rectal cancer survivors are often confronted with bowel complaints largely impacting on their quality of life. This systematic review aims to identify and synthesise the experiences and needs of patients with rectal cancer confronted with bowel problems after stoma reversal.METHODS:A systematic search was performed through Pubmed, CINAHL and Web of Science. Only studies with a qualitative design were included in this review. Quality assessment was done by the critical appraisal skill programme (CASP) Qualitative Studies Checklist. A thematic-synthesis was performed.RESULTS:Of 2713 identified papers, 10 were included in this systematic review. Two general themes were identified: 'experiences and needs about bowel function before surgery' and 'experiences and needs afterwards'. Before restoration of continuity patients had to cope with the temporary stoma, and they felt uncertain about what to expect. Patients indicated that the timing of providing information was crucial but varied. Bowel problems after surgery had a physical and emotional impact on patients' family life. They were also confronted with shame and stigma. Patients were happy to be alive and cancer free but were hopeful that the bowel problems would resolve. They used several strategies to manage and cope with these symptoms. Peers and healthcare professionals proved valuable resources of support.CONCLUSION:Rectal cancer survivors experience ongoing bowel problems after treatment. Patients describe experiences and needs before rectal cancer surgery and afterwards when confronting with bowel problems. Follow-up care should be organised proactively and focus on management strategies and emotional support.

Introduction: Pressurized intraperitoneal aerosol chemotherapy (PIPAC) was recently introduced to treat unresectable peritoneal metastases. Adding an electrostatic field may enhance charged droplet precipitation and tissue penetration, resulting in improved anticancer efficacy. We report for the first time its safety and preliminary efficacy. Materials and methods: Patients underwent PIPAC combined with an electrostatic field, using the Ultravision (TM) apparatus. Adverse events were scored with the Common Terminology Criteria. Treatment response was assessed after more than one PIPAC, using clinical symptoms, tumor markers, CT imaging and histological regression. Results: Forty-eight patients (median age, 61 y) with diverse primary tumors underwent 135 procedures (median per patient, 3). Most (65.2%) were treated as outpatient. Twenty-eight (58.3%) patients received concomitant chemotherapy. The most frequent treatment-related toxicities were anemia (grade 1 to 3, 13 [9.6%1), ileus (grade 1 to 3, 5 [3.7%]), anorexia (grade 1 to 3, 6 [4.4%]), nausea (grade 1 to 3, 5 [3.7%]) and vomiting (grade 1 to 3, 7 15.2%]). There was no grade 4 or 5 morbidity. Twenty (41.7%) patients did not complete three treatments, mainly because of disease progression (n = 13). After two procedures, there were one responder and 8 non-responders. After three treatments, we observed 11 responders, two patients with stable disease, and 15 non-responders. All but one patient with therapy response received simultaneous chemotherapy. Conclusion: Electrostatic precipitation during PIPAC is well tolerated and safe. After three procedures and concomitant chemotherapy, response or stable disease is achieved in approximately half of cases. These findings warrant prospective trials in homogeneous patient cohorts. (C) 2019 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.

Background: Due to better surgical techniques and radiotherapy there is an increase in sphincter saving procedures for rectal cancer. The benefit of this approach is the lack of a permanent stoma but it conducts a big change in the bowel habits namely LARS. When a permanent stoma could be avoided these patients are prepared to make extensive adjustments in order to accept the new lifestyle without a stoma. Patients experience a number of functional, psychological and social problems. These symptoms worsen immediately after the surgery and improve in the following months. However some patients experience permanent difficulties. Literature identifies that 60 to 90% of all patients suffer from LARS with a negative impact on the quality of life (QOL). Methods: A cohort of surviving patients, who underwent a low anterior resection for rectal cancer, were identified. These patients were treated in the University Hospital in Ghent between January 1, 2006 until September 15, 2016. QOL was assessed using the EORTC QLQ C30 questionnaire and the bowel function using the validated LARS score. The relationship between LARS and QOL and the risk factors for developing LARS were analyzed. Patients with a major LARS score (≥ 30 points) were contacted to explore their management of LARS. Results: A total of 121 patients were included in this study. 69% of these had major LARS. QOL was closely associated with LARS. Significant differences were found in the global health status, functional (physical, role, cognitive and social) and symptom (fatigue, pain, insomnia and diarrhea) scales. The height of the anastomosis was a risk factor for major LARS. Most patients used dietary regimens, medication and incontinence material in an attempt to manage their LARS. Conclusions: The removal of a temporary stoma signifies for many patients and their social network the completion of treatment. However, after several years, 69% of these patients are still suffering from bowel difficulties. Patients with major LARS have a significant decreased QOL. For this reason it is imperative that the caregiver is aware of this problem. At this time there is no golden standard for the management of LARS. Patients and their informal caregivers are managing this condition through trial and error. Legal entity responsible for the study: Gastrointestinal surgery University Hospital Ghent. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Aim Heterotopic gastric mucosa is a well-known congenital anomaly in Meckel's diverticula and duplication cysts. Solitary heterotopic gastric mucosa in the rectum is a rare and frequently overlooked abnormality. Starting from a patient history, the literature is searched and all cases reported over the past 20 years are reviewed and compared to a summary of the older cases. Differences between adult and childhood presentation are outlined and our patient is compared with prior reported cases. Case A 3-year-old girl presented with recurrent rectal blood loss caused by heterotopic gastric mucosa without duplication cyst. She was endoscopically treated with two-stage endoscopic surgical dissection (ESD). Up to now, rectal heterotopic gastric mucosa has been reported in 34 adults and 24 children, including this patient. There is an overall male dominance (69%). Presenting complaints in children were recurrent fresh blood loss per anum (96%), pain (46%), perineal ulcers (25%), diarrhoea (8%) and one patient had an ano-cutaneous fistula. Endoscopy revealed a mucosal elevation with a slightly different aspect (33%), a polyp (42%) and a solitary ulcer (25%). Endoscopy in adults reveals more frequently polyps compared to children. Treatment in childhood is mainly surgical where adults are more frequently treated with endoscopic techniques. Conclusion In a child with recurrent rectal bleeding in good general health, it is important to withhold heterotopic gastric mucosa in the differential diagnosis and take sufficient biopsies during endoscopy.

Introduction : Neoadjuvant multimodality treatment confers a survival benefit in locally advanced oesophageal cancer patients. The optimal dose of radiotherapy (RT) remains undefined. Aim : To analyse the effect of RT dose on surgical outcome and survival in patients treated with multimodality treatment followed by surgery in locally advanced oesophageal cancer. Methods : This was a retrospective comparative study based on a prospectively collected database. Patients with clinical stage III oesophageal cancer were treated with a combination of RT, cisplatin 80 mg/m2, and 5-FU 800 mg/m2. Radiation dose was 36 Gy (group 1) or 45-50 Gy (group 2), depending on the referring physician. Ivor Lewis oesophagectomy was performed after a 6-8 weeks period. Surgical and pathological outcome was compared using Fisher exact test. Overall survival (OS) and disease free survival (DFS) were calculated using the Kaplan Meier method, and the effect of RT dose on survival was tested using univariate (log rank test) analysis. Results : A total of 134 patients were evaluated : 108 received 36 Gy, and 26 received 45-50 Gy. Mean age at surgery was 61 ± 9.43 years, and 84% were male. Median length of postoperative hospital stay was 17 days. Overall postoperative 30 day or in hospital mortality was 7.5%, and anastomotic leakage occurred in 4.1% ; neither was influenced by RT dose. Pathological complete response (pCR) was observed in 15.5% (group 1) and 31% (group 2), P = 0.09. No differences were observed in downstaging of either the T stage or the N stage. Overall five year OS and DFS were 35.1% and 38.3% respectively. In univariate analysis, a higher RT dose was associated with a significantly better DFS (P = 0.01), but not OS (P = 0.6). Conclusion : In patients with locally advanced oesophageal cancer treated with neoadjuvant chemoradiation, a higher RT dose does not affect surgical outcome, enhances pCR rate and improves DFS without affecting OS.