Current aspects and future prospects of total anorectal reconstruction - a critical and comprehensive review of the literature

PURPOSE: Many rectal cancer patients undergo abdominoperineal excision worldwide every year. Various procedures to restore perineal (pseudo-) continence, referred to as total anorectal reconstruction, have been proposed. The best technique, however, has not yet been defined. In this study, the different reconstruction techniques with regard to morbidity, functional outcome and quality of life were analysed. Technical and timing issues (i.e. whether the definitive procedure should be performed synchronously or be delayed), oncological safety, economical aspects as well as possible future improvements are further discussed. METHODS: A MEDLINE and EMBASE search was conducted to identify the pertinent multilingual literature between 1989 and 2013. All publications meeting the defined inclusion/exclusion criteria were eligible for analysis. RESULTS: Dynamic graciloplasty, artificial bowel sphincter, circular smooth muscle cuff or gluteoplasty result in median resting and squeezing neo-anal pressures that equate to the measurements found in incontinent patients. However, quality of life was generally stated to be good by patients who had undergone the procedures, despite imperfect continence, faecal evacuation problems and a considerable associated morbidity. Many patients developed an alternative perception for the urge to defecate that decisively improved functional outcome. Theoretical calculations suggested cost-effectiveness of total anorectal reconstruction compared well to life with a permanent colostomy. CONCLUSIONS: Many patients would be highly motivated to have their abdominal replaced by a functional perineal colostomy. Given the considerable morbidity and questionable functional outcome of current reconstruction technique improvements are required. Tissue engineering might be an option to design an anatomically and physiologically matured, and customised continence organ.

Domain Globalization: Using Languages to Support Technical and Social Coordination

When a project is realized in a globalized environment, multiple stakeholders from different organizations work on the same system. Depending on the stakeholders and their organizations, various (possibly overlapping) concerns are raised in the development of the system. In this context a Domain Specific Language (DSL) supports the work of a group of stakeholders who are responsible for addressing a specific set of concerns. This chapter identifies the open challenges arising from the coordination of globalized domain-specific languages. We identify two types of coordination: technical coordination and social coordination. After presenting an overview of the current state of the art, we discuss first the open challenges arising from the composition of multiple DSLs, and then the open challenges associated to the collaboration in a globalized environment.