Biomedical subjects
R D Fry
Publications and source records attributed to R D Fry.
Anal sphincter reconstruction in the elderly: does advancing age affect outcome?
PURPOSE: This study was designed to determine whether advancing age affects outcome after anal sphincter reconstruction. METHOD: Anal sphincter reconstruction, performed on patients 55 years of age and older, was reviewed to determine if functional outcome was adversely affected by advancing age. A subgroup of patients was studied with anal manometry before and after repair and with pudendal nerve terminal motor latency (PNTML) before surgery. Results were compared with a younger group of patients. RESULTS: Between July 1986 and July 1991, 14 patients, ages ranging from 55 to 81, underwent anal sphincter reconstruction using an overlapping muscle repair. Ten patients were incontinent of solid stool and four of liquid stool. Improvement was seen in 13 of 14 patients: 7 (50 percent) complete control, 3 (21 percent) incontinent to flatus, and 4 (29 percent) incontinent to liquid stools (including the patient who failed to improve). Ten patients were studied with a continuous pull-out manometric technique and PNTML: one was not improved. There was minimum change in mean maximum resting pressure (35.0-37.9 mmHg). Mean maximum squeezing pressure increased from 66 to 75 mmHg overall. Patients with complete control had a mean maximum squeezing pressure of 81 mmHg compared with 60 mmHg in patients with residual incontinence. Mean anterior anal sphincter length increased from 2.92 cm to 3.31 cm. PNTML was normal (2.0 +/- 0.2) on one or both sides in all nine patients who improved (average, 2.1). The patient who failed to improve had abnormal nerve function bilaterally (2.4, 2.7). CONCLUSION: Anal sphincter reconstruction can be performed in elderly patients with improvements in the majority of patients. Total control can be achieved by restoring maximum squeezing pressure in a patient with normal pudendal nerve function.
Chronic effects of pelvic radiation therapy on anorectal function.
PURPOSE: The long-term effect of 4,500 cGy of preoperative radiation on anorectal function has not been prospectively evaluated. METHODS: Anal manometry was performed on 20 patients with rectal carcinoma before and four weeks after receiving 4,500 cGy of external radiotherapy. Four patients underwent proctectomies, three died, and three refused follow-up. Ten patients were available for long-term follow-up and underwent anal manometry at 14 to 42 (average, 35.5) months after initial radiotherapy. RESULTS: No significant difference in mean maximum squeeze or resting pressures was found after radiation therapy. The sphincter profile and minimum sensory threshold were unchanged. The rectoanal inhibitory reflex was present in all patients. Nine patients reported normal anal function. One patient who was incontinent before treatment remained incontinent. CONCLUSION: Preoperative radiation therapy has a minimal chronic effect on anorectal function. Incontinence after sphincter-saving operations for rectal cancer should not be attributed to preoperative radiation therapy.
Anorectal trauma and foreign bodies.
The causes of rectal trauma are many and varied. The most frequent cause is iatrogenic. Treatment depends on the severity of the injury; and the accurate assessment of the injury is essential. Rectal foreign bodies are either ingested or inserted through the anus. Foreign bodies usually can be extracted by nonsurgical methods but appropriate technique is required to avoid rectal or sphincteric laceration.
Endorectal advancement flap repair of rectovaginal and other complicated anorectal fistulas.
BACKGROUND: Surgical correction of rectovaginal and complicated anal-perineal fistulas has been associated with high rates of complications and failure of repair. METHODS: This paper reports on 107 patients treated during the past 10 years by endorectal advancement flap repair. Ninety-two percent of the patients were women with mean age of 38 years (range, 20 to 71 years). Seventy-one had low rectovaginal, 28 had anterior anal-perineal, and 8 had posterior anal-perineal fistulas. The causes were obstetric injury, 48; cryptoglandular abscess-fistula, 31; Crohn's disease, 24; and trauma or after operation, 4. The technique completely preserves the sphincter muscle, covers the internal opening of the fistula tract with healthy rectal wall, and provides counter drainage to aid healing. RESULTS: No deaths occurred in the series. Persistent or recurrent fistula occurred in 17 patients (16%). Nine patients whose initial operation failed underwent a secondary successful operation. Continence status was unchanged in 80%, improved in 18%, and was unknown in two patients who still had intestinal flow diversion. Recurrence of the fistula did not result in destruction of the sphincter mechanism in those patients who underwent simultaneous reconstructive operation. CONCLUSIONS: The endorectal advancement flap repair successfully treated 93% of the complicated anorectal fistulas, avoiding fecal diversion and improving, not injuring, sphincter function.
Radiation therapy as definitive treatment for selected invasive rectal cancer.
BACKGROUND: Eighty-four patients with invasive rectal adenocarcinoma were definitively treated with radiation during a period of 9 years in an attempt to achieve "local control" (eradication of rectal cancer and its associated morbidity) without radical resective surgery. METHODS: Initially, endocavitary radiation alone was used in 13 patients with "ideal" carcinomas and in six patients with aggressive cancers. To improve local control, 4500 cGy external radiation before the 6000 cGy endocavitary radiation was used to treat 28 ideal lesions, 15 "nonideal" but potentially curable cancers, 14 aggressive cancers, and 8 patients with incurable metastatic disease. RESULTS: Endocavitary radiation alone resulted in local control for 8 of 13 patients with ideal carcinomas (62%); eventually 11 of 13 (85%) had control after three successful salvage abdominoperineal resections. Local control was accomplished in none of six patients with aggressive cancers. Use of external radiation before endocavitary radiation achieved local control in 93% of patients with ideal lesions, eventually 100% after two salvage abdominoperineal resections. Of the 15 nonideal but potentially curable lesions, 100% had eradication of local disease with the combined modalities. Of the 14 with aggressive cancers and 8 with metastatic disease, 19 suffered failure of local control (86%). Eight of these had local salvage by surgical resection; the others died with local failure within 6 months. CONCLUSIONS: External radiation, combined with endocavitary radiation, is excellent, definitive treatment for selected, favorable, invasive rectal cancers; however, there is little place for nonresective management of aggressive rectal cancer, even for palliation, unless life expectancy is less than 6 months.
Laparoscopic anterior resection of the rectum using a triple stapled intracorporeal anastomosis in the pig.
Laparoscopic anterior resection of the rectum was performed in the porcine model. Colorectal anastomosis was accomplished with a closed triple staple technique using a circular stapler. The anvil and shaft were passed beyond the level of resection and retrieved through the proximal transverse linear cutter staple line. The stapler post was passed through the distal rectal staple line transanally. The resulting stapled anastomosis contained portions of three staple lines. There were no anastomotic leaks or strictures at one month follow-up autopsy. The triple-stapled anastomosis via a laparoscopic approach after an anterior resection of the rectum in a pig is a safe, reliable technique.
Accuracy of transrectal ultrasound in predicting pathologic stage of rectal cancer before and after preoperative radiation therapy.
Transrectal ultrasound (TRUS) and CT scan staging of rectal cancers before, and TRUS staging after, 45 Gy of irradiation were compared with the pathologic stage of the resected specimen in 19 patients. Accuracy of TRUS before and after irradiation, and of CT scan before irradiation, was 32 percent, 63 percent, and 53 percent, respectively. CT scan before and TRUS after irradiation predicted lymph node involvement in 79 percent and 68 percent of cases, respectively. Positive predictive value for lymph node involvement before irradiation was 60 percent for CT scan and 37.5 percent for TRUS; after irradiation, it was 50 percent for TRUS. Negative predictive value was 100 percent for CT scan and TRUS before radiation and 88 percent for TRUS after irradiation. Preoperative radiation therapy makes TRUS and CT scan less effective as staging techniques. The absence of lymph nodes on TRUS and CT scan before and after irradiation is reliable.
Early effect of external beam radiation therapy on the anal sphincter: a study using anal manometry and transrectal ultrasound.
The early of pelvic irradiation on the anal sphincter has not been previously investigated. This study prospectively evaluated the acute effect of preoperative radiation on anal function. Twenty patients with rectal carcinoma received 4,500 cGy of preoperative external beam radiation. The field of radiation included the sphincter in 10 patients and was delivered above the anorectal ring in 10 patients. Anal manometry and transrectal ultrasound were performed before and four weeks after radiotherapy. No significant difference in mean maximal squeeze or resting pressure was found after radiation therapy. An increase in mean minimal sensory threshold was significant. Histologic examination revealed minimal radiation changes at the distal margin in 8 of 10 patients who underwent low anterior resection and in 1 of 3 patients who underwent abdominoperineal resection. We conclude that preoperative radiation therapy has minimal immediate effect on the anal sphincter and is not a major contributing factor to postoperative incontinence in patients after sphincter-saving operations for rectal cancer.
Outpatient protocol for biofeedback therapy of pelvic floor outlet obstruction.
Pelvic floor outlet obstruction is a rare cause of severe constipation. Anal myectomy, subtotal colectomy, and medical therapy have limited success. The purpose of this study was to develop a short outpatient treatment using biofeedback techniques. Nine patients with severe constipation and straining resulting from pelvic floor outlet obstruction underwent complete investigation of the pelvic floor musculature and anal sphincter mechanism. Patients were unable to expel a 60-cc rectal balloon and had nonrelaxing puborectalis on defecography. The treatment protocol utilized anal surface electromyography to document improper straining and retrain pelvic floor muscles to relax during defecation. Sensory retraining with a rectal balloon, behavioral relaxation techniques, and defecation of simulated stool using a 120-cc Metamucil (Procter & Gamble, Cincinnati, OH) slurry in the rectum allowed re-establishment of normal defecation in all nine patients. Repeat training was required in three patients during follow-up. Treatment of pelvic floor outlet obstruction with outpatient retraining techniques is possible.
Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle.
We compared balloon expulsion, defecography, colonic transit times, anal manometry, and electromyography in 21 patients with severe constipation. Defecography demonstrated nonrelaxation of the sphincter during straining in all patients. Only 12 patients were unable to expel a balloon. Colonic transit was normal (five) or showed rectosigmoid delay (seven). All 12 patients were offered biofeedback. The nine patients able to expel a balloon had normal colonic transit (six) or colonic inertia (two). Rectosigmoid delay was due to severe intussusception in one patient. Anal manometry and pudendal nerve latencies revealed no difference between those who could and those who could not expel a balloon. Balloon expulsion seems to be a more reliable way to diagnose pelvic floor outlet obstruction due to nonrelaxation of the puborectalis muscle. Nonrelaxation of the sphincter on defecography should be correlated with balloon expulsion and colonic transit studies.
The surgical management of constipation.
The anal physiology laboratory plays a very important role in the selection of patients for surgical treatment for constipation. Any report which does not include reference to these methods of evaluation will not be helpful since there are several causes of constipation. The current recommended treatment for slow transit constipation is still total abdominal colectomy with ileorectal anastomosis. Treatment of pelvic floor outlet obstruction seems to be best accomplished using muscle/sensory retraining techniques since this is a functional disorder rather than an anatomical or physiological disorder. Combinations of colonic inertia, pelvic floor outlet obstruction and internal intussusception should be treated to correct the pelvic floor outlet obstruction initially, followed by correction of the colonic inertia. In this way failure will be avoided at the time of surgical treatment of the constipation.
Rectal prolapse and other pelvic floor abnormalities.
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Actinomyces as a cause of recurrent perianal fistula in the immunocompromised patient.
Actinomycosis is an uncommon bacterial infection that has a characteristic chronic indolent course. Patients with this infection frequently undergo multiple surgical procedures before a correct diagnosis is made. Perianal actinomycosis should be suspected if a nontender perianal mass is found to contain thin purulent material and small yellow particles (sulfur granules). The diagnosis is confirmed by special stains and anaerobic cultures. Recognition of this infection is important because successful treatment requires combined surgical and antibiotic therapy. We report two patients, one with diabetes mellitus and one with human immunodeficiency virus III, who had recurrent perianal abscesses caused by Actinomyces and were treated successfully with surgical drainage and antimicrobial therapy.
Anal sphincter repair for obstetric injury: manometric evaluation of functional results.
Anal manometry before and after surgical repair on a homogeneous group of patients with anterior sphincter defect caused by obstetric injury defined the parameters affected by the repair to achieve anal continence. Between November 1985 and April 1989, 28 patients who underwent anterior anal sphincter reconstruction were studied using anal manometry and were graded for continence. Anal function was improved for 27 of 28 patients (96 percent) relative to their preoperative symptoms, and total control of solid and liquid stools was restored in 21 patients (75 percent). Anal manometry demonstrated that complete control of continence could be achieved if anal sphincter length, resting pressure, and squeeze pressure were restored to normal. Our results showed that sphincter length was improved in 20 patients (71 percent), resting pressure in 16 patients (57 percent), and squeeze pressure in 22 patients (79 percent). The most important factor in achieving normal function of the anal sphincter is restoration of a normal squeeze pressure.
Anal sphincter reconstruction: anterior overlapping muscle repair.
Anal sphincter reconstruction for anal incontinence was performed in 55 women between 1973 and 1987 at The Jewish Hospital of St. Louis. The mean age was 34 years (range, 22-75 years). Incontinence was due to obstetric injury in 48 patients and to fistulotomy in 7 patients. Patients suffered from complete incontinence (41), incontinence of liquid stool and flatus (11), or incontinence of flatus only (3). All patients underwent an anterior overlapping sphincter muscle reconstruction, and one patient also had a posterior repair. Complete continence was restored in 28 patients, and partial continence was achieved in 24 patients. Only three patients remained totally incontinent. Clinical assessment did not accurately reflect functional outcome after 1 year of follow-up. No factor predicting outcome was found retrospectively. Clinical assessment of a patient's outcome may be inaccurate unless specific questions are asked. The use of a perineal drain reduced infection but did not affect outcome. Previous repair or associated rectovaginal fistula does not affect outcome. Sphincter injury owing to fistula disease may result in poor outcome after repair.
Squamous cell carcinoma of the anal canal.
Between 1979 and 1988, 33 patients with squamous cell carcinoma of the anal canal were treated with chemoradiation. There were 24 women and 9 men, from 37 to 90 years of age (median: 63 years). Complete tumor regression occurred in 29 of the 33 patients (88%), only one of whom later developed recurrence. In the other four patients, there was persistent tumor after 3 months; three of these patients died within 2 years; and one is alive with distant metastases 2 years later. During the first 5 years of the study, seven patients with complete tumor regression underwent planned abdominoperineal resection following chemoradiation. Four of the abdominoperineal resection specimens were free of tumor, but three were not. These three patients, who had abdominoperineal resection within 3 months of chemoradiation, are disease-free. Ten of the 29 patients who had complete tumor regression had biopsies of the primary site 3 months after treatment. All biopsies were negative for residual carcinoma. At present, 26 patients (79%) are alive and disease-free from 2 to 10 years post-treatment (median: 4 years). Two patients died of unrelated causes, four of cancer, and one is alive with cancer. Complications of the chemoradiation required surgical intervention in two patients, and two others developed severe hematologic toxicity, for a complication rate of 12% (4 of 33 patients). There was no treatment-related mortality. These results support the efficacy of chemoradiation treatment for carcinoma of the anal canal. They suggest that abdominoperineal resection no longer need be part of the planned initial management, and that posttreatment biopsy of the primary site is unnecessary, unless palpable or visible abnormalities are present 3 months after treatment.
Current options in the management of rectal cancer.
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