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PubMed1994

Interobserver agreement in defecography.

PURPOSE: This study was designed to test the reproducibility of the diagnostic assessment of defecographies in patients with a suspected disorder of defecation. METHODS: To evaluate interobserver agreement, 100 defecographic series of patients with complaints suggesting a disordered defecation were evaluated independently by three observers with a standardized questionnaire. After six weeks, a random sample of 35 of 100 defecographies was evaluated a second time with clinical data provided (history, proctologic examination). To evaluate whether the position of residual volume in the rectum would affect agreement, patients with substantial retention either in the upper or lower rectum were also evaluated separately. RESULTS: Total agreement regarding rectocele and internal prolapse was 0.81 and 0.75, respectively (1.0 = complete agreement), and was significantly higher than chance agreement. Total agreement regarding residual volume in the rectum at the end of defecography and clinical relevance of findings was not different from chance agreement, providing clinical data did not significantly improve agreement. When residual volume was situated in the lower rectum, agreement regarding incompleteness of emptying and its clinical relevance was much better (0.93). CONCLUSIONS: Interobserver agreement is good regarding the deformation of the rectum during defecography but not different from chance agreement regarding the completeness of evacuation.

Adult↗

PubMed1995

Unilateral anal electrosensation. Modified technique to improve quantification of anal sensory loss.

PURPOSE: Anal electrosensation is usually tested by an annular configured electrode that stimulates the circumference of the anus. In certain pelvic conditions, the right and left pudendal nerve function may be damaged separately and to different degrees. This may only be detected by a unilateral electrode testing each side independently. METHODS: Our study compares accuracy and sensitivity of annular and unilateral electrodes in assessing patients with hemorrhoids, perineal descent, incontinence, after low anterior resection, and constipation (107 subjects). RESULTS: In normal controls (n = 19), annular thresholds ranged from 0.5 to 2.7 mA and unilateral thresholds from 0.6 to 2.6 mA. In prolapsed hemorrhoids, unilateral was more sensitive than annular electrode in detecting deficits at the upper (P < 0.0001), mid (P < 0.005), and lower (P < 0.0005) anus. Patients with perineal descent had a sensory deficit in the upper anal canal, detected more consistently by unilateral electrode (P > 0.05). No significant abnormalities were found in neuropathic incontinence, after anterior resection and chronic constipation. Results of the unilateral electrosensory technique were found to be consistent with repeated measurements (r = 0.8878; P < 0.001). CONCLUSIONS: By being more sensitive than the annular technique, the unilateral electrode method may become, with refinement, a useful test for quantifying anal sensation.

Adult↗

PubMed2005

Long-term results after excision haemorrhoidectomy versus stapled haemorrhoidopexy for prolapsing haemorrhoids; a Belgian prospective randomized trial.

PURPOSE: To compare the postoperative evolution and the long-term efficacy after stapled haemorrhoidopexy (PPH) and Milligan-Morgan haemorrhoidectomy (MM). METHODS: In a prospective randomized study, 40 patients requiring surgical treatment for prolapsing haemorrhoids grade II or III were assigned to either MM or PPH (20 each). Postoperative pain, wound healing were evaluated, as well as anal pressures and sphincter anatomy. Mean follow-up is 46 months. RESULTS: Postoperative pain at rest and during defecation was less important after PPH if no resection of external piles or skin tags was associated (P < 0.0001). Healing time was shorter after PPH (P < 0.0001). Endoanal ultrasound remained unchanged postoperatively. Resting and squeeze pressures decreased after MM, but not after PPH (P < 0.01). After a mean follow-up of 46 months (12-56), persistent or recurrent symptoms, mostly mild and temporary, were observed after both MM and PPH, in 7 and 11 patients respectively (NS). After PPH, five patients (25%) complained of recurrent external swelling and/or prolapse (P = 0.047 vs. MM) requiring redo surgery in four of them, after 10, 13, 14 and 21 months. No redo-surgery was required after MM. Long term patient satisfaction after PPH was not better than after MM. CONCLUSIONS: Postoperative pain is less important after PPH. This advantage disappears if any resection is associated with the stapling. At medium to long-term follow-up, PPH seems to carry a higher risk of symptomatic external haemorrhoidal disease, needing further surgery.

Adult↗

PubMed2006

Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the impact of laxatives on a wide range of symptoms in patients with symptomatic hemorrhoids. METHODS: We searched using the following sources: MEDLINE, EMBASE, CINAHL and CENTRAL, BIOSIS, AMED, Papers First and Proceedings; study authors, industry, and experts in the field. We included all published and unpublished parallel group randomized controlled trials comparing any type of laxative to placebo or no therapy in patients with symptomatic hemorrhoids. Two reviewers independently screened studies for inclusion, retrieved all potentially relevant studies, and extracted data on study population, intervention, prespecified outcomes, and methodology. RESULTS: Seven trials randomized 378 patients to fiber or a nonfiber control. Studies were of moderate quality for most outcomes. Meta-analyses using random effects models suggested that fiber has an apparent beneficial effect. The risk of not improving/persisting symptoms decreased by 47% in the fiber group (RR = 0.53, 95% CI 0.38-0.73) and the risk of bleeding by 50% (RR = 0.50, 95% CI 0.28-0.89). Studies with multiple follow-ups, usually at 6 wk and at 3 months, showed consistent results over time. Results are also compatible with large treatment effects in prolapse, pain, and itching, but even in the pooled analyses confidence intervals were wide and compatible with no effect (RR = 0.79, 95% CI 0.37-1.67; RR = 0.33, 95% CI 0.07-1.65; and RR = 0.71, 95% CI 0.24-2.10, respectively). One study suggested a decrease in recurrence. Results showed a nonsignificant trend toward increases in mild adverse events in the fiber group (RR = 6.0, 95% CI 0.57-64.8). CONCLUSIONS: Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids.

Constipation↗

PubMed1997

[Diagnosis with defecography of puborectal muscle syndrome].

The puborectalis syndrome is a defecation disorder supported by the nonrelaxation of puborectalis sling with consequent dyschezia. We report on a series of 98 patients submitted to clinical examination, defecography, anorectal manometry, electromyography and intestinal transit time studies. Puborectalis anatomy and physiology are briefly reviewed. The main symptoms of puborectalis syndrome in our patients were incomplete defecation (89%) and intermittent evacuation (63%); 28% of patients turned to finger defecation. In all patients, defecography showed an abnormal increase in puborectalis impression on the posterior anorectal wall, reduced anorectal angle opening under straining (mean value: 113 degrees) and prolonged expulsion time with barium pooling in the ampulla (mean evacuation time: 38 seconds). Such anorectal abnormalities as rectal mucosal prolapse (47 cases) and anterior rectocele (36 cases) were also associated. In 33 of 98 patients (34% of cases), sling assessment by bidigital palpation at preliminary clinical examination revealed puborectalis hypertonia, which was later confirmed at defecography. Manometry was not specific for the diagnosis of puborectalis syndrome, detecting increased external anal sphincter pressure under straining in 24 of 35 patients (68.8%). Puborectalis activity was increased under straining in 16 subjects submitted to electromyography. Intestinal transit time studies showed a typical expulsion delay and radiopaque marker pooling in the ampulla in 18 of 23 patients (78.2%). In our experience, defecography is a useful, simple and noninvasive method for the accurate diagnosis of the puborectalis syndrome.

Defecation↗

PubMed1985

Long-term follow-up of concomitant band ligation and sclerotherapy for internal hemorrhoids.

From 1978 to 1983, 111 patients with symptomatic internal hemorrhoids were treated as outpatients by a modification of the Barron ligation technique. Each ligated hemorrhoid was injected with a sclerosant. Follow-up, available for 94 of the patients, ranged from 2 to 60 months (mean 18 months). Presenting symptoms were bleeding in 75 (80%) of the 94 patients, pain in 46 (49%), pruritus in 22 (23%) and prolapse in 24 (26%). Results were excellent in 51 (54%) patients, good in 20 (21%) and fair in 9 (10%). Fourteen (15%) patients had unsatisfactory results; only 4 of these required hemorrhoidectomy. The other 10 had residual symptoms but did not require further treatment. Nine patients had minor complications, which included pain lasting 24 to 72 hours in seven, bleeding in one and syncope in one. The addition of sclerotherapy to traditional band ligation for the management of internal hemorrhoids has the advantages of exciting a greater inflammatory reaction between the mucosa and submucosa and preventing premature slipping of the band. The authors conclude that this method of therapy is effective for symptomatic hemorrhoids and that surgical hemorrhoidectomy is seldom indicated.

Adult↗

PubMed1984

A vaginal approach to the treatment of genital prolapse.

The surgical treatment of 409 patients with genital prolapse is described. The procedure, which invariably included hysterectomy, concentrated upon one of the major complaints of these patients, i.e., their stress-incontinence. Special care was taken not to shorten the urethral length. Two hundred of these patients were available for a relatively long follow-up period ranging from 7 to 13 yr. Within the first post-operative year, stress-incontinence appeared to have been cured in 90% of the patients. The long-term results show that the percentage of continent women has diminished to 81, which is an important finding probably not attributable to the surgical technique. In the long term, the second most frequent complaint of low back pain has recurred in 29% of our patients.

Female↗

PubMed1977

Procidentia of the rectum after the pull-through operation: an unusual complication and report of two cases.

Procidentia or complete prolapse of the rectum following the pull-through operation is unusual, if not altogether rare. It appears to be a late complication of the procedure. A multitude of factors may be implicated in its genesis, and certainly the inadequacy of the pelvic floor is principal among them. Though the exact mechanism is not entirely clear, we favor an intussusceptive process for the reasons and observations cited. It is surmised that its late appearance is primarily due to the formation of adhesions that effectively fix the bowel to the sacrum. The process of aging and ensuing laxity of tissues subsequently detract from this protective factor. Perineal repair was used in both cases but, in the ultimate analysis, the procedure of choice should be individualized, based upon the surgeon's own judgment and experience and particular circumstances attending procidentia.

Aged↗

PubMed1988

[Evaluation of the mechanism determining the painful symptomatology after proctological interventions].

In order to evaluate the importance of the contraction of the perineal muscular system in causing the symptomatology following a hemorrhoidal prolapse operation, a drug, dantrolene sodium which has a known myorelaxant action due to a partial inhibition of the release of calcium ions from the sarcoplasmic reticulum in the muscular cell was used. The double-blind study involved 40 patients, of whom 20 were treated with sodium dantrolene in doses of 25 mg, twice a day, for seven days; the remaining 20 with a placebo. Symptoms, consumption of pain-killers and need for catheters, were monitored daily, while hemochemical parameters were checked before the start, and at the end of the study. The results obtained showed a similar post-operative trend in the patients receiving dantrolene and in the controls. This is interpreted as an indirect demonstration that the mechanism of pain is primarily due to the inflammatory factors rather than due to contraction of the perineal muscles.

Adult↗

PubMed2002

Second-line treatment for faecal incontinence.

BACKGROUND: In the treatment of faecal incontinence, more than 30% of patients experience continuation of their problem. We discuss new therapeutic procedures for dealing with faecal incontinence. METHODS: Discussion of authors' own work in relation to the literature. RESULTS: First-line care includes diets, constipating drugs, biofeedback therapy, anal repair and operations for prolapse and fistulas. For the failures of these first-line treatments there is hope with second-line therapies. Creation of a neosphincter is possible with a dynamic graciloplasty (DGP) or an artificial bowel sphincter (ABS). A DGP is a conventional graciloplasty with the addition of implanted electrodes and a stimulator that transforms the muscle into an automatic contracting sphincter. ABS comprises an inflatable cuff around the anus that is filled from a pressure-regulating balloon. The cuff can be emptied with an implanted pump. CONCLUSIONS: DGP and ABS give good results in 56%-88% of cases. For patients with an anatomical intact but nonfunctioning sphincter there is a new treatment: sacral nerve stimulation. This gives continence in a high percentage of cases, but experience is rather limited. Second-line treatment for faecal incontinence is successful and should be considered in cases where initial therapies fail.

Electrodes, Implanted↗

PubMed2001

Colostomy for anorectal anomalies: high incidence of complications.

PURPOSE: The aim of this study was to characterize the type and incidence of complications related to colostomy formation in newborn infants with anorectal anomalies. METHODS: The authors reviewed a 5-year (1994 to 1999) experience of a single institution in the management of neonates with high and intermediate anorectal anomalies who required colostomy at birth. Patients with colostomy still in place have been excluded from the study to maximize the chances of detecting colostomy-related complications. RESULTS: There were 80 neonates with anorectal malformations, of whom, 49 (31 boys and 18 girls) were included in the study. The site of colostomy was sigmoid colon (n = 32), transverse colon (n = 7), and descending colon (n = 10). Thirty-nine colostomies were loop, and the remaining 7 were divided. The median birth weight was 2.96 kg (range, 1.46 to 3.88). The age at colostomy formation was 2 days (range, 1 to 210). Mechanical complications related to colostomy formation were observed in 16 infants (32%) with 3 infants having more than 1 mechanical complication. These included prolapse in 8 (50%), intestinal obstruction (adhesions, intussusception, and volvulus) in 7 (44%), and skin dehiscence in 3 (19%). One neonate had necrotizing enterocolitis (NEC) after colostomy formation. Urinary tract infection was observed after colostomy in 14 infants (29%). The incidence of urinary tract infection was not higher in infants who had loop colostomy (11 of 39, 28%) compared with infants who had divided colostomy (3 of 10, 30%). There were no differences in the incidence of colostomy-related complications and urinary tract infection between male and female infants. There were no deaths in this series. CONCLUSIONS: Formation of colostomy for anorectal anomalies should not be considered a minor procedure. In our experience the incidence of complications after colostomy formation is high. The incidence of urinary tract infections does not seem to be affected by the type of colostomy performed.

Age Factors↗

PubMed2005

[Analysis of the relationship between stoma position and postoperative effects of procedure for prolapse and hemorrhoids in the treatment of hemorrhoids].

OBJECTIVE: To explore the relationship between stoma position and postoperative effects of procedure for prolapse and hemorrhoids (PPH) in the treatment of hemorrhoids. METHODS: Four hundred and one hemorrhoid patients were treated with circular stapler. II hemorrhoids, 45 cases; III-IV hemorrhoids, 356 cases. The position of stoma located 1 cm up dentate line, 219 cases; 1-2 cm up dentate line, 87 cases; 2-3 cm up dentate line, 60 cases; 3-4 cm up dentate line, 25 cases; > 4 cm up dentate line, 10 cases. The patients were followed from one week to two years postoperatively. RESULTS: Postoperative effects and procidentia rates have significant association with the position of stoma. If the distance between position of stoma and dentate line is < or = 2 cm, the postoperative procidentia rate was 1.1%, lower than that of the distance > or = 4 cm. CONCLUSIONS: The complication and procidentia rate of PPH is associated with the stoma position. The stoma position should be no more than 2 cm to dentate line.

Female↗

PubMed2003

Urogynaecological and obstetric issues in women with the exstrophy-epispadias complex.

OBJECTIVE: To review of the sexual and urogynaecological issues faced by a large cohort of women with the exstrophy-epispadias complex (EEC). PATIENTS AND METHODS: The study comprised 83 women and girls with EEC; a confidential survey was mailed to identify their social and sexual concerns. Fifty-six women had classical bladder exstrophy (CBE), 13 had female epispadias (FE) and 14 had cloacal exstrophy (CE). Data on the initial method of reconstruction and urogynaecological problems were obtained from a review of the hospital records. Information on continence, infection and sexual function was obtained from 34 completed surveys. RESULTS: The bladder was closed in 51 patients with CBE and 13 with CE. Urinary calculi developed in 10 patients with CBE, two with FE and three with CE. Vaginal and uterine prolapse occurred an earlier age in patients with EEC. Eight women had 13 pregnancies, eight of which resulted in normal healthy children. Overall continence was achieved in 85% of the women surveyed. Urinary tract infections remained a frequent problem for women with EEC; only 27% of respondents indicated that they were infection-free. Women aged > 18 years (24) who responded indicated that they had appropriate sexual desire; 16 were sexually active and the mean age for commencing sexual activity was 19.9 years. Six patients had dyspareunia and 10 indicated that they had orgasms. However, five additional patients indicated that they had restricted intercourse, as they were dissatisfied with the cosmesis of their external genitalia. CONCLUSIONS: Sexual and gynaecological issues become increasingly important in patients with EEC as they become adults. Understanding these issues faced by patients with EEC as they mature will permit better counselling of future patients.

Adolescent↗

PubMed1991

[Rectal cysts and rectal functional disorders after surgical treatment for genital prolapse].

From 1966 to 1984, 417 female patients were operated for genital prolapse in the department of surgical gynecology of the Salpêtrière Hospital (Pr Blondon's department). The results of the surgical treatment were studied in the posterior perineum from an anatomical (rectocele) and functional point of view (indiced rectal disorders). This study allows drawing several conclusions: when the context leads to deciding to operate the prolapse through an abdominal approach, it is desirable, in order to reduce the risk of postoperative rectocele, to systematically insert a posterior prosthetic band, which will be tethered as low as possible on the posterior aspect of the vaginal (after a sufficiently low extensive rectovaginal cleaving). The Orr-Loygue rectopexy must remain indicated for rectal prolapse, even more so as it is associated with incontinence. Since this procedure often causes constipation of even more complex exoneration disorders, it must be reserved for prolapse associated to a large rectocele (type IV) or an invalidating dyschezia.

Constipation↗

PubMed1992

Symptomatic hemorrhoids: current incidence and complications of operative therapy.

Hemorrhoidal disease affects more than one million Americans per year. We reviewed the treatment pattern for patients who presented with symptomatic hemorrhoids to our large university-affiliated group practice over a 66-month period. Over 21,000 patients presented to the practice with bleeding, thrombosis, or prolapse. Only 9.3 percent of patients required operative therapy. Conservative therapy was given to 45.2 percent of patients, while rubber band ligation was performed on 44.8 percent of patients. We retrospectively reviewed the complications and length of stay for a subset of patients undergoing operative therapy during the 66-month study period. Postoperative urinary complications (retention or infection) were seen in 20.1 percent of patients. Delayed hemorrhage was seen in 2.4 percent of patients. In-hospital length of stay was 2.5 days, which is approximately two days less than the length of stay found in a similar review of our practice in 1978. We conclude that over 90 percent of symptomatic hemorrhoids can be treated conservatively or with rubber band ligation, and, as surgery is reserved for only the most severe cases, complication rates may not decrease. However, we expect that in-hospital length of stay will continue to decrease over the ensuing years.

Female↗

PubMed1996

Excellent outcome using selective criteria for rectocele repair.

PURPOSE: The aim of this study was to review our experience with patients with rectoceles using very selective criteria for operative repair and to critically review our surgical results. METHODS: This is a review of patients selected for rectocele repair between 1989 and 1994. RESULTS: Two hundred seventy-nine patients were evaluated for pelvic outlet symptoms in our clinic. Defecography was performed in 180 patients; rectocele was seen in 143 patients (79 percent; 135 females and 8 males). On physical examination, 132 patients had a palpable rectocele (73 percent). Rectocele repair was recommended for 35 patients (13 percent); 33 (32 females and 1 male) underwent this procedure. Mean age was 55 (range, 16-78) years. Although many patients complained of constipation, incontinence and pelvic pain, in these 33 patients criteria for repair included the sensation of a vaginal mass or bulge that required digital support and/or rectal digitizing for evacuation (58 percent), retention of barium in the rectocele on defecography (55 percent), or a very large rectocele with internal anterior rectal wall prolapse (6 percent). A hysterectomy had been performed previously in 47 percent of women repaired. Rectocele repair was performed by a standard transanal approach in 31 patients and transabdominally in 2 patients. Hospital stay averaged 3.7 (range, 1-8) days. Few postoperative complications occurred; urinary retention was the most common (18 percent). All patients were followed postoperatively, and 26 patients (79 percent) answered a standardized questionnaire. Mean follow-up was 31 (range, 5-64) months. Eighty percent of patients questioned who initially complained of a vaginal mass or bulge reported complete resolution (significant improvement by the sign test, P < 0.5). Subjectively, 92 percent of patients questioned reported improvement in their preoperative symptoms and satisfaction with the operation. CONCLUSION: Rectoceles are frequently identified during defecography, which is performed for pelvic floor complaints, yet are often asymptomatic. In contrast to other recent reports of rectocele repair, our data indicate that careful selection of patients using specific criteria may result in very good clinical results.

Constipation↗

PubMed1990

Morphology and immunoperoxidase studies of intestinal adenomatosis in the blue fox, Alopex lagopus.

In a blue fox farm about 300 of 400 weanling pups were affected with diarrhoea and prolapse of the rectum. About 40 pups died in an emaciated state after a few days of disease. Eight pups were submitted for examination. Pathological findings were restricted to the caecum, proximal colon and rectum, with occasional extension to the ileum. Affected areas revealed a thick and rigid intestinal wall, a narrow lumen and a thickened, wrinkled and sometimes ulcerated mucosa. Histologically, the mucosa showed long tortuous crypts outlined by a high pseudostratified epithelium which lacked goblet cells. Epithelial cells revealed increased basophilia, and mitoses were seen along the entire crypt length and in the surface epithelium. Silver impregnation showed curved organisms in the apical cytoplasm of the altered epithelial cells. Penetration of the muscularis mucosa by the altered epithelial cells was frequent. The avidin-biotin-immunoperoxidase complex (ABC) technique revealed positive organisms in the apical cytoplasm of altered epithelial cells, when rabbit antisera against different biotypes and serotypes of Campylobacter jejuni and Campylobacter coli were used. Antisera against Campylobacter sputorum subsp. muscosalis and Campylobacter hyointestinalis were negative.

Adenoma↗

PubMed2001

Follow-up confirms sustained benefit of circumferential stapled anoplasty in the management of prolapsing haemorrhoids.

BACKGROUND: Circumferential stapled anoplasty is gaining popularity as a safe and effective treatment in the surgical management of haemorrhoids and mucosal prolapse. However, little is known about the medium- and long-term durability of this procedure. The aim of this study was to evaluate the medium-term results of stapled anoplasty in maintaining symptom remission and to identify possible procedure-related adverse effects. METHODS: Of a consecutive series of 85 stapled anoplasties in 83 patients, 64 patients were eligible for 6-month review; 50 patients were seen in surgical outpatient clinics and seven were contacted by telephone. All patients attending the outpatient clinic were questioned about current symptoms and overall satisfaction with the procedure. The staple line was palpated digitally and inspected at proctoscopy. RESULTS: Median (interquartile range) symptom scores were 6 (5--8) before operation compared with 0 (0--1) at 6 months (P < 0.01). There was no deterioration in symptoms between 6-week and 6-month follow-up. No recurrences and no procedure-related adverse effects, in particular impaired continence or persistent anal pain, were identified. CONCLUSION: The initial promising results of circumferential stapled anoplasty in effectively treating haemorrhoidal symptoms appear to be sustained at 6-month follow-up.

Follow-Up Studies↗