Surgical technique in prolapse of the rectum.
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Abdomen↗
Biomedical subjects
D A Rothenberger
Publications and source records attributed to D A Rothenberger.
Long-term functional analysis of the ileoanal reservoir.
Since November 1980, 180 patients underwent abdominal colectomy, rectal mucosectomy, ileoanal reservoir construction, and ileoanal anastomosis at the authors' institutions. One hundred twenty-nine patients had restoration of intestinal continuity before the end of 1986. One hundred fourteen of these patients (88 percent) were available for follow-up at a mean length of time of 5.0 years from ileostomy closure (range, 16 to 88 months). The mean number of pouch evacuations was 5.4 +/- 2.5 during the day (range, 1 to 12) and 1.5 +/- 1.0 at night (range, 0 to 6). Ninety-one percent of patients reported perfect or almost perfect daytime continence, and 74 percent found this true at night. Sixty-three percent of patients believed their pouch function continued to improve over many years. Ninety-five percent of patients questioned would choose an ileoanal reservoir again instead of a permanent ileostomy. This long-term assessment of the function of the ileoanal reservoir confirms that it is a viable, although not perfect, option in the management of ulcerative colitis and familial adenomatous polyposis.
Activities of Daily Living↗
Ileal pouch vaginal fistulas: incidence, etiology, and management.
Some of the initial problems associated with the ileoanal reservoir have been solved. In their place, other complications have been recognized. Among these, the ileal pouch vaginal fistula stands out as a recently recognized difficult management problem. This multicenter study was undertaken to gain insight into the causes for, and treatment of, pouch vaginal fistulas. Cases were gathered from 11 surgical practices throughout North America, in which the ileoanal reservoir procedure is frequently performed. Overall, 304 females had undergone ileoanal reservoir procedures by these surgical groups. Twenty-one patients developed 22 pouch vaginal fistulas for an overall incidence of 6.9 percent. Five additional patients with pouch vaginal fistulas, whose restorative proctocolectomies were done elsewhere, were referred to these surgeons for treatment. The courses of these 26 patients form the basis of this report. This study details the risk factors which predispose in the development of a pouch vaginal fistula, as well as the various treatment options available.
Adolescent↗
Synchronous bowel anastomoses.
A retrospective review of patients who underwent double bowel resections and synchronous anastomoses without ileostomy or colostomy was undertaken. The study goal was to determine whether there was an increased incidence of complications attributable to the presence of a second anastomosis. A total of 66 patients who met the criteria were identified and divided into two groups. Group A consisted of 30 patients who had had two colonic resections and two colonic anastomoses. In Group B were 36 patients who had undergone separate colonic and small-bowel resections with two subsequent anastomoses. The indications for primary resection were: 1) adenocarcinoma, 54 percent; 2) Crohn's disease, 26 percent; 3) diverticulitis, 11 percent; 4) "other" indications, 9 percent. The indications for the second resection were: 1) metastatic adenocarcinoma, 30 percent; 2) Crohn's disease, 26 percent; 3) synchronous bowel lesions, 18 percent; 4) adhesions and enterotomies, 14 percent; 5) "other" indications, 12 percent. Overall, there were four major complications (6 percent), and 11 minor complications (17 percent). The sole anastomotic leak occurred in a patient who had undergone a double colonic resection (3%). The other major complications were one death, one ureteral complication that required reoperation, and one early small-bowel obstruction. Minor complications included two wound infections (3 percent), three seromas (5 percent), three prolonged ileus (5 percent), and three urinary infections (5 percent). These results are comparable to the best results reported for patients undergoing single colonic anastomoses. The conclusion is that it is safe to perform synchronous anastomoses without diversion provided the following conditions are present: well-prepared bowel with minimal fecal soilage, an adequate blood supply, technically good anastomoses, and lack of tension on the suture lines.
Adenocarcinoma↗
Colonic resection in the treatment of complete rectal prolapse.
For the good risk patient, nearly all surgeons recommend an abdominal approach as the surest method of eliminating a complete rectal prolapse. The most commonly performed abdominal procedures are rectal suspension-fixation operations utilizing slings of synthetic material or suture without foreign material. Occasionally both of these procedures are combined with a segmental colorectal resection. Rectal mobilization with fixation of the rectum to the sacrum alone, by whatever means, has a high rate of success with a low mortality and morbidity. The wisdom of adding colorectal resection to rectopexy in the treatment of complete rectal prolapse remains controversial. The authors favor abdominal rectopexy with sigmoid resection because it avoids foreign material, eliminates the risk of volvulus, improves bowel management problems, and has low morbidity with a low recurrence rate. In our series of 102 patients treated by rectopexy and sigmoid resection, there were no deaths and only 4 per cent morbidity related to the anastomosis. After a mean follow-up period of four years, the recurrence rate was 1.9 per cent.
Colectomy↗
Intra-operative endoscopy. University of Minnesota experience.
This review of intraoperative endoscopies was undertaken to identify the accepted and the controversial indications, to report the results and complications, and to determine the impact the procedure had on the operation performed. This retrospective review identified 78 patients who had undergone 82 intraoperative endoscopic exams between 1981 and 1987. Sixty-nine patients underwent intraoperative colonoscopy (84%), six had upper enteroscopy (7%), and seven had total gut endoscopy (9%). Indications were as follows: the inability to fully colonoscope preoperatively (29%), Crohn's disease (19%), malignant polypectomy site (12%), gastrointestinal bleeding (12%), routine screening to rule out synchronous lesions (12%), non palpable colonic lesions (11%), and miscellaneous (4%). Intraoperative endoscopy was successful in 89 per cent of patients. The exams provided information that altered the planned operation in 27 per cent of cases. There were four complications that may have been related to the endoscopic exams. All resolved without the need for further surgery. It is concluded that intraoperative endoscopy can greatly influence the operation performed in a significant percentage of cases. The clear cut indications for its use at this time are location of malignant polypectomy sites, adhesions or tortuous colon that prevents complete preoperative colonoscopy, chronic gastrointestinal bleeding, and location of non palpable bowel lesions. Controversial indications that we feel will prove useful include Crohn's disease and acute gastrointestinal bleeding. Intraoperative endoscopy is best used as an adjunct to preoperative endoscopy and not as a substitute for it.
Colonic Diseases↗
Repair of simple rectovaginal fistulas. Influence of previous repairs.
The results of 81 endorectal flap advancements for simple rectovaginal fistulas are reported. Simple fistulas are defined as less than 2.5 cm in diameter, low or mid vaginal septum in location, and infectious or traumatic in origin. Essentially, the technique is advancement of a flap of mucosa, submucosa, and circular muscle over midline approximation of internal sphincter muscle. The mean patient age was 34 years old (range, 18 to 76 years). The causes were obstetrical injury (74 percent), perineal infection (10 percent), operative trauma (7 percent), and unknown (8 percent). Overall, the repair was successful in 83 percent of patients. Success correlated with the number of previous repairs, i.e., none: 88 percent success; one: 85 percent success; two: 55 percent success. There were 25 concomitant overlapping sphincteroplasty procedures. Only minor complications ensued, with no mortality. This repair is recommended for patients with no or one previous repair because of its lack of mortality, minimal morbidity, ease of concomitant sphincteroplasty, and avoidance of a colostomy. For patients with two or more earlier repairs, a muscle interposition should be considered.
Adult↗
Balloon sphincterography. Clinical findings after 200 patients.
There are two muscular mechanisms of fecal continence. The anal sphincter squeezes the anal canal, thus lengthening it and increasing its resistance. The puborectalis kinks the distal rectum, preventing the transmission of intra-abdominal pressures into the anal canal. Balloon sphincterography simultaneously records the shape of the anal canal and distal rectum and measures the strength of the puborectalis and anal sphincter muscles. This allows the physician to evaluate the function of these important muscles in patients with symptomatic defecation disorders such as constipation, incontinence, and rectal prolapse. A cylindrical balloon is connected by a hose to a fluid reservoir filled with liquid barium. The deflated balloon is placed into the anal canal and inflated by raising the fluid reservoir in increments. Fluoroscopy visualizes the balloon's shape and video records the results. Quantitative sphincterogram measurements in patients with defecation disorders include (the three measurements in each category refer respectively to incontinent patients [N = 87], prolapse patients without incontinence [N = 26], and constipated patients [N = 65]); anorectal angle (degrees + S.D.): 114 + 28, 103 + 18, 95 + 19; anal canal length (mm + S.D.): 33 + 11, 38 + 10, 39 + 10; squeeze pressure (cm H2O + S.D.): 68 + 23, 80 + 16, 91 + 22, and opening pressure (cm H2O + S.D.): 52 + 25, 67 + 22, 81 + 24. The method is useful in identifying specific defects, such as paradoxic puborectalis contractions, that can cause constipation, and injuries to the sphincters that can cause incontinence. In over 280 patients with a wide variety of defecation disorders, sphincterography has yielded information not available by standard manometric techniques. It augments the findings of defecography.
Anal Canal↗
Tube decompression of the dilated colon.
With the technique described herein, decompression of a massively dilated colon is effectively accomplished, allowing resection to proceed safely. This method of decompression has allowed us to perform colonic resection in all patients with toxic megacolon seen in recent years. It is desirable to remove the infected and inflamed colon in such a circumstance. We have not resorted to blowhole colostomies in cases of toxic megacolon, as this leaves the colon, which is the septic source, within the abdominal cavity. This technique has also been used successfully to expedite subtotal colectomy and ileosigmoid anastomosis in patients with obstructing lesions of the left side. It allows colonic decompression and on-table bowel preparation by irrigation with antiseptics such as povidone-iodine (Betadine).
Humans↗
Pelvic floor physiology.
Pelvic floor physiology is poorly understood. The funnel shape of the pelvic floor and anal canal is uniquely developed to provide discriminatory continence of gas, liquid, and solid. Proximally, the pelvic floor consists of the pubococcygeus and iliococcygeus muscles. Distally, the anal canal is surrounded by the internal and external sphincter muscles. The anorectal ring is situated between the proximal pelvic floor and the distal anal canal. It is the site of the puborectalis muscle, which is anatomically, neurologically, and functionally merged with the deep portion of the external sphincter muscle. It is at this site that unique forces act to create both a flutter valve and the anorectal angle with the flap valve. Extrinsic pressures at this level reinforce both the flap valve and the flutter valve. Intrinsic pressures are generated by all of the surrounding muscles to produce a high-pressure zone. These factors are critical, but many other factors, such as rectal capacity, compliance, colonic transit, motility, and sensory mechanisms, also interact in a complex way to provide normal continence and defecation. Not surprisingly, no single test allows a complete assessment of the interactions of all these factors. Nevertheless, analysis of components thought to be important in pelvic floor physiology has contributed significantly to the understanding of normal as well as abnormal physiology. Although clinical evaluation continues to be the cornerstone of the diagnosis of pelvic floor disorders, anorectal physiological testing has contributed significantly to our understanding of the dynamics of the pelvic floor. With the refinement of existing techniques and the addition of new investigative tools, it is anticipated that knowledge of pelvic floor physiology will continue to grow.
Anal Canal↗
Palliation for rectal cancer. Resection? Anastomosis?
There is no agreement regarding the proper management of patients with advanced carcinoma of the rectum. We performed a study to clarify whether palliative resection with or without primary anastomosis is worthwhile and safe. Among 679 patients managed for cancer of the rectum, 125 were considered incurable and underwent palliative procedures. High and low anterior resections were performed in nine and 57 cases, respectively, abdominoperineal resection in 26, Hartmann's procedure in three, simple diverting colostomy in 17, and transanal excision in 13. The overall postoperative mortality rate was 0.8%. Postoperative morbidity was 18% in abdominal operations and none in local excisions. Among patients treated by abdominal resections, only one required subsequent reoperation for colonic obstruction secondary to local recurrence. The median survival was 6.4 months for patients treated by diverting colostomy, 14.8 months for abdominally resected cases, and 14.7 months for transanal excisions. We conclude that palliative resection, often with primary anastomosis or local transanal excision, can be done safely in patients with incurable rectal cancer. We believe this approach improves the quality of the remaining life for these patients.
Adenocarcinoma↗
The S ileal pouch-anal anastomosis.
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Adolescent↗
Restorative proctocolectomy with ileal reservoir.
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Adenomatous Polyposis Coli↗
Balloon topography. A simple method of evaluating anal function.
Balloon topography was developed to simultaneously measure anal canal pressure, anal canal length, and anorectal angle. It is performed using a cylindrical flexible balloon placed into the anal canal and rectum and filled with liquid radiopaque contrast dye under low pressure. The pressure of the dye inside the balloon is controlled by the investigator, and does not vary with changes in balloon volume. The shape of the balloon within the anal canal is recorded using fluoroscopy and plain radiopaques. The patient receives less radiation than he would receive during a single contrast barium enema. We have performed the test on 27 subjects including a normal control, rectal prolapse patients, and incontinent patients. Early results demonstrate the usefulness of the test in examining anal sphincter and pelvic floor function in maintaining fecal continence in health and disease. The test measures multiple aspects of anopelvic function simultaneously that previously required separate investigations.
Aged↗
The management of procidentia. 30 years' experience.
This is a retrospective study evaluating 179 patients with complete rectal prolapse operated on at the University of Minnesota affiliated hospitals from 1953 to 1983 with no mortality. One hundred and two of 138 patients who underwent abdominal proctopexy and sigmoid resection were followed from six months to 30 years with a recurrence rate of 1.9 percent. Twenty-two of the 33 patients who underwent perineal rectosigmoidectomy were followed from six months to three years with no recurrence. Nine patients who underwent abdominal proctopexy and subtotal colectomy because of colonic inertia associated with procidentia were followed from one to six years with no recurrence. Patient interviews revealed that 72 to 80 percent considered their results as excellent or good. Incontinence or persistent constipation caused the remaining patients to consider their results fair or poor, despite anatomic correction of the prolapse. Abdominal proctopexy and sigmoid resection was more likely to result in improvement of continence than was perineal rectosigmoidectomy.
Adolescent↗
Morbidity of internal sphincterotomy for anal fissure and stenosis.
Internal sphincterotomy is thought by most surgeons to have minimal complications. We retrospectively reviewed 306 patients following internal sphincterotomy to determine the incidence of any complications. Major complications (requiring reoperation) caused by fistula, bleeding, abscess, or unhealed wounds occurred in ten patients (3 percent). Minor complications caused by pruritus, persistent wound, pain, bleeding, abscess, discharge, urgency, impaction, or defects of continence occurred in 110 patients (36 percent). Complications were lowest for closed sphincterotomy (20 percent) and highest for open sphincterotomy alone (55 percent). All patients were cured of anal fissure or stenosis. Long-term follow-up (average 4.3 years) revealed a 22 percent incidence of persistent minor complications. Defects in continence caused 15 percent of total long-term morbidity. Minor complications occur frequently after internal sphincterotomy for anal fissure and stenosis. Closed sphincterotomy has the lowest complication rate. Long-term minor defects in continence occur in a significant number of patients.
Adult↗