Biomedical subjects

D J Schoetz

Publications and source records attributed to D J Schoetz.

At least 37 records · Page 2Linked to original sources

PubMed1996

Inpatient vs. outpatient bowel preparation for elective colorectal surgery.

BACKGROUND: Recent pressures to decrease the cost of medical care have mandated preoperative outpatient bowel preparation (OBP) for elective colorectal surgery without any data documenting equivalent quality of care. This study examined the safety and efficacy of OBP compared with inpatient bowel preparation (IBP). METHODS: Records of all patients who underwent OBP for elective colorectal resection since the inception of the OBP program from July 1993 to June 1994 were compared with records of all patients who received IBP for elective procedures from January to June 1993. RESULTS: The two groups, 90 patients who underwent OBP and 98 patients who had IBP, were well matched for age, sex, diagnosis, and operations performed. The OBP group had a shorter length of hospital stay (median, 7 vs. 9 days; P < 0.0001; chi-squared analysis), whereas the complication rate was similar (19 percent in the OBP group vs. 18 percent in the IBP group), including infectious complications (10 percent in the OBP group vs. 7 percent in the IBP group). Although operating time was similar (mean, 199 vs. 213 minutes) and estimated blood loss (mean, 528 vs. 536 ml), the OBP group had significantly higher perioperative fluid requirements: intraoperative fluids (median, 4300 vs. 3700 ml; P < 0.05; Student's t-test), intraoperative colloid administration (48 vs. 29 percent; P < 0.0002; chi-squared), 24-hour postoperative fluids (3224 vs. 2700 ml; P < 0.0001; Student's t-test), and postoperative fluid challenges (50 vs. 20 percent; P < 0.0001; chi-squared analysis). CONCLUSION: Outpatient bowel preparation for elective colorectal surgery is safe and effective. It offers shorter hospital stay, and, therefore, potentially reduces medical care cost. Patients with multiple medical problems may not tolerate extensive fluid shifts; therefore, other preoperative arrangements, such as inpatient or outpatient intravenous fluid therapy, need to be considered to minimize complications that may outweigh potential cost savings.

Ambulatory Care↗

PubMed1996

Prospective comparative study of abnormal distal rectoanal excitatory reflex, pudendal nerve terminal motor latency, and single fiber density as markers of pudendal neuropathy.

PURPOSE: This study was undertaken to determine the role of abnormal distal rectoanal excitatory reflex (RAER) as a marker of pudendal neuropathy and to compare results with pudendal nerve terminal motor latency (PNTML) and single fiber density (SFD) estimation. METHODS: Fifteen female patients (mean age, 47.1 (range, 20-70) years) referred to the pelvic floor laboratory with pelvic floor disorders (fecal incontinence, 13 patients; constipation, 2 patients) were evaluated prospectively with neurophysiologic tests and balloon reflex manometry for evidence of pudendal neuropathy. RESULTS: Pudendal nerve terminal motor latency provided evidence of pudendal neuropathy in ten patients (67 percent) and was normal in five patients (33 percent). Increased SFD confirmed denervation of the external anal sphincter in 12 patients (80 percent), being normal in 3 patients (20 percent). Distal RAER was abnormal in 13 patients (87 percent) and was normal in 2 patients (13 percent). In ten patients (67 percent), the three diagnostic modalities were in complete agreement, correctly identifying neuropathy in nine patients (60 percent) and excluding nerve damage in one patient (7 percent). Distal RAER was normal despite prolonged PNTML and increased SFD in one patient (7 percent). In two patients (13 percent), distal RAER was abnormal or absent despite normal PNTML and SFD. Pudendal nerve terminal motor latency was normal in the presence of abnormal distal RAER and increased SFD on electromyography in two patients (13 percent). CONCLUSIONS: Abnormal distal RAER compares favorably with current neurophysiologic tests used to diagnose pudendal neuropathy.

Adult↗

PubMed1996

Unilateral pudendal neuropathy. Impact on outcome of anal sphincter repair.

PURPOSE: Our purpose was to study the effect of unilateral pudendal neuropathy on the results of anal sphincter repair. METHOD: Fifteen female patients who underwent external sphincter repair for fecal incontinence were studied. In all instances, incontinence was the result of obstetric delivery injury. Anal manometry and neurophysiologic investigations to document sphincter defects and pudendal neuropathy were performed in all patients. Sphincter repair was performed using an overlapping suture technique. RESULTS: All patients had anterior sphincter defects. Seven patients (47 percent) had pudendal neuropathy: six (85 percent) had unilateral neuropathy, and one (15 percent) had bilateral neuropathy. Six patients (40 percent) had excellent results; three (20 percent) had good results; four (27 percent) were improved; two (13 percent) experienced no improvement after sphincter repair. All patients with excellent results had normal pudendal nerve terminal motor latency on both sides. Of the three patients with good results, one patient had unilateral pudendal neuropathy. The patients in the remaining two groups (improved and failed) had unilateral (six patients) or bilateral (one patient) pudendal neuropathy. CONCLUSION: We conclude that both pudendal nerves must be intact to achieve normal continence after sphincter repair. Patients with unilateral pudendal neuropathy are more likely to have poor than to have good postoperative function.

Adult↗

PubMed1996

Perianal Crohn's disease. Results of local surgical treatment.

PURPOSE: This study relates our experience with local surgical management of perianal Crohn's disease. METHOD: Of 1,735 patients with Crohn's disease seen between 1980 and 1990, records of 66 patients (3.8 percent) with symptomatic perianal Crohn's disease treated by local operations were retrospectively reviewed to study outcome of local surgical intervention. RESULTS: All patients had intestinal disease that was limited to the colon in 32 patients (48 percent), ileocolonic region in 22 patients (33 percent), and ileum in 12 patients (18 percent). Types of perianal disease encountered included perianal suppuration (57), anal fistula (47), anal fissure (21), anal stenosis (5), gluteal abscess (3), scrotal abscess (2), and anovaginal fistula (2). A total of 321 episodes of anal complications necessitated 256 local surgical interventions. Local anorectal operations performed included simple incision and drainage of abscess (57), fistulotomy (35), incision and drainage of complex anorectal abscesses and fistulas and insertion of seton (24), internal sphincterotomy (6), fissurectomy (1), and anal dilation (3). Of 24 patients with horseshoe abscesses and fistulas managed with insertion of a seton and 35 patients who underwent fistulotomy as a primary procedure or in conjunction with drainage of an abscess, none experienced fecal incontinence as a direct result of the operation. Thirteen patients required proctectomy to control perianal disease, and a similar number underwent total proctocolectomy for extensive intestinal disease. Forty patients (61 percent) continue to retain a functional anus. CONCLUSION: Patients with symptomatic low anal fistula involving minimum sphincter musculature can be treated safely with fistulotomy. In treatment of patients with horseshoe abscesses and high fistulas, aggressive local surgical intervention using a seton permits preservation of the sphincter and good postoperative function.

Abscess↗

PubMed1995

Anal fissure in Crohn's disease: a plea for aggressive management.

PURPOSE: This study was undertaken to identify clinical characteristics, natural history, and results of medical and surgical treatment of anal fissures in Crohn's disease. METHODS: This is a retrospective review of patients with Crohn's disease and anal fissure. RESULTS: Of the 56 study patients, 49 (84 percent) had symptomatic fissures. Fissures were most commonly (66 percent) located in the posterior midline, and 18 patients (32 percent) had multiple fissures. Fissures healed in one-half of patients treated medically. Factors predictive of successful medical treatment included male gender, painless fissure, and acute fissure. Of 15 patients, 10 (67 percent) treated surgically healed. Fissures in seven of eight patients (88 percent) who underwent anorectal procedures healed compared with fissures in only three of seven patients (43 percent) who underwent proximal intestinal resection. In the group of 50 patients with complete follow-up studies, an anal abscess or fistula from the base of an unhealed fissure developed in 13 patients (26 percent). More fissures healed after anorectal surgery (88 percent) than after medical treatment alone (49 percent; P = 0.05) or after abnormal surgery (29 percent; P = 0.03). CONCLUSION: This series documents that unhealed fissures frequently progress to more ominous anal pathologic disease. Judicious use of internal sphincterotomy appears to be safe for fissures unresponsive to medical treatment.

Adolescent↗

PubMed1995

Latency measurement of rectoanal reflexes.

PURPOSE: Latency values of rectoanal reflexes may be altered in disorders of the pelvic floor. Evaluation of this relatively uninvestigated aspect of rectoanal reflexes may have diagnostic implications in patients with disorders of defecation. METHODS: We studied the latency of rectoanal inhibitory and excitatory reflexes to sequential balloon distention of the rectum with 60 ml and 120 ml of air in 14 normal controls (mean age, 41.5 (range, 19-66) years), in 14 patients with fecal incontinence (FI) (mean age, 44.2 (range, 28-72) years), and in 14 patients with slow transit constipation (STC) (mean age, 40.6 (range 22-68) years). RESULTS: The mean latency of inhibition (FI = 5.3 seconds; STC = 4.6 seconds; controls = 5.1 seconds) was remarkably similar for the three groups (P = 0.19). The mean latency of excitation in the proximal anal canal (FI = 2.8 seconds; STC = 2.5 seconds; controls = 2.8 seconds) was comparable in the three groups (P = 0.58). The mean latency of excitation in the distal anal canal (FI = 4.8 seconds; STC = 2.6 seconds; controls = 2.7 seconds) was prolonged in patients who were incontinent compared with the other two groups (P < 0.01). CONCLUSIONS: Proximal rectoanal excitation and inhibitory reflexes, when present, have a constant latency, irrespective of the underlying condition. The different latency values for proximal and distal rectoanal excitatory reflexes in patients with FI may indicate disparate denervation damage to the external anal sphincter.

Adult↗

PubMed1995

Distal rectoanal excitatory reflex: a reliable index of pudendal neuropathy?

PURPOSE: Denervation of the extrinsic anal sphincter and pudendal neuropathy are confirmed by electrophysiologic or electromyographic testing, techniques that may not be available universally and require special equipment and training. A simple manometric test that is easy to perform and complements existing studies was performed to confirm pudendal neuropathy. METHODS: Fourteen patients with excessive defecatory straining and 30 patients with idiopathic fecal incontinence were studied by electrophysiology and balloon reflex manometry. Pudendal nerve terminal motor latency (PNTML) and rectoanal excitatory reflex were evaluated for abnormalities. Results were compared with 20 controls who had no anorectal complaints and who had similar testing performed. RESULTS: In controls, PNTML was normal in all but one person. Rectoanal excitatory reflex could be elicited in all controls with either 20 or 40 ml of air. Four different types of balloon reflex responses were observed in patient groups: diminutive excitation, delayed excitation, excitation at high volume of distention only, and absent excitation. Ten patients with fecal incontinence had normal PNTML but abnormal distal excitatory reflex, 5 patients had abnormal PNTML but normal distal excitatory reflex, and 15 patients had both PNTML and excitatory reflex that were abnormal. In patients with excessive defecatory straining, results of both tests were abnormal in six patients, and eight patients had abnormal excitatory reflex but normal PNTML. CONCLUSION: Pudendal neuropathy may result in abnormalities of excitatory reflex morphology or other characteristics. Abnormal distal excitatory reflex may complement electrophysiologic findings or may serve as a suitable alternative to confirm pudendal neuropathy in centers where facilities for formal testing are not available.

Adult↗

PubMed1995

Rediversion after ileal pouch-anal anastomosis. Causes of failures and predictors of subsequent pouch salvage.

PURPOSE: The aim of this study was to understand better the cause and predictability of pouch failure requiring rediversion after ileal pouch-anal anastomosis and to assess the ultimate outcome of patients in a large ileal pouch series who required rediversion. METHODS: Data from 460 patients completing ileal pouch-anal anastomosis at one institution were recorded from both a prospectively accumulated ileal pouch registry and patient medical records. RESULTS: Of 460 patients, 21 (4.6 percent) who underwent ileal pouch-anal anastomosis required rediversion. Five of these patients subsequently had successful restoration of pouch continuity, leaving a permanent failure rate of 16 of 460 patients (3.5 percent). The most common reasons for rediversion were pouch fistula formation (12) and poor functional results (5). Preoperative factors, including age, previous colectomy, and indication for colectomy, did not predict eventual need for rediversion. Patients requiring rediversion had significantly higher rates of postoperative complications (95 vs. 43 percent; P < 0.001). Specifically, this group had a higher rate of postoperative pouch fistula (57 vs. 3.4 percent; P < 0.001). Additionally, a final diagnosis of Crohn's disease significantly predicted the need for rediversion. Permanent pouch failure occurred in 36.8 percent of patients with a final diagnosis of Crohn's disease compared with 1.4 percent of patients with a final diagnosis of ulcerative colitis (P < 0.001). All five salvaged patients had fistula formation in the absence of Crohn's disease. CONCLUSIONS: The overall rate of permanent pouch failure is low. The majority of failures were related to fistula formation associated with Crohn's disease or poor functional results. Pouches complicated by fistulas not associated with Crohn's disease can be salvaged with temporary rediversion.

Adenomatous Polyposis Coli↗

PubMed1995

Treatment of Hirschsprung's disease in the adult. Report of five cases.

PURPOSE: Between 1983 and 1991, five adult patients were diagnosed and treated for Hirschsprung's disease. Mean age was 37 (range, 13-45) years. Three patients had classic Hirschsprung's disease, and two had findings consistent with short segment disease. Each patient had a history of disabling, lifelong constipation. METHODS: Diagnosis was established with the aid of barium enema study, anorectal manometry, and tissue biopsy. RESULTS: Three patients with classic disease underwent resection of diseased bowel, rectal mucosectomy, and anastomosis between the ganglion-containing bowel and anus. All three patients had excellent functional improvement in the perioperative period. Two patients with findings consistent with short segment Hirschsprung's disease were treated by anorectal myectomy. Neither patient obtained lasting relief.

Adolescent↗

PubMed1995

Relationship between manometric anal waves and fecal incontinence.

PURPOSE: The significance of manometric anal waves is uncertain, and their fate and diagnostic importance are unknown. It is conceivable that in neurogenic fecal incontinence (NFI) the frequency and amplitude of these waves may be altered into specific, recognizable patterns. Evaluation of this unexplored relationship between fecal incontinence and anal manometric waves has potential diagnostic use. METHODS: Anal motility was studied in 20 patients, each with NFI and traumatic fecal incontinence (TFI), and results were compared with findings in 20 control subjects to determine changes in frequency and amplitude of anal waves in fecal incontinence. RESULTS: Frequency of slow waves when present (NFI = 9.5/minute; TFI = 9.5/minute; control subjects = 9.1/minute) was identical in the three groups (P > 0.05). Amplitude of slow waves (NFI = mean, 4.3 mmHg; TFI = mean, 3.9 mmHg; control subjects = mean, 6.6 mmHg) was reduced in patients who were incontinent compared with control subjects but failed to reach statistical significance (P > 0.05). Frequency of ultraslow waves when present (NFI = mean, 0.75/minute; TFI = mean, 0.6/minute; control subjects = mean, 1.2/minute) was not statistically different between the three groups (P > 0.05). Amplitude of ultraslow waves (NFI = mean, 10.5 mmHg; TFI = mean, 23.4 mmHg; control subjects = mean, 29.6 mmHg) was significantly reduced in NFI vs. control subjects (P < 0.01) and between TFI vs. control subjects (P < 0.05). CONCLUSIONS: Manometric slow and ultraslow waves, when present, retain their frequency characteristics, irrespective of underlying disease. Amplitude of slow waves was not statistically different from control subjects, but the amplitude of ultraslow waves was significantly decreased in patients who were incontinent.

Adult↗

PubMed1995

Rectal mucosectomy in the treatment of giant rectal villous tumors.

PURPOSE: Rectal mucosectomy, a technique adapted from restorative proctocolectomy, has been used to treat large rectal villous tumors. We compared morbidity, tumor control, and functional outcome following rectal mucosectomy with the results of more conventional transanal excision and piecemeal snaring and fulguration in patients with large rectal villous tumors. METHODS: We retrospectively reviewed the charts of inpatients who had undergone transanal surgery for villous tumors. RESULTS: Between 1983 and 1993, rectal mucosectomy, transanal excision, and snaring and fulguration were performed, respectively, in 12, 26, and 23 patients with large rectal villous tumors. Tumors treated by rectal mucosectomy had a larger mean diameter (8.5 cm) than those treated by transanal excision or snaring and fulguration (4.5 cm and 4.2 cm, respectively; P < 0.0001, analysis of variance). After a mean follow-up of 47 months, incidence of tumor persistence was 17 percent following rectal mucosectomy, 20 percent following transanal excision, and 40 percent following snaring and fulguration (P = 0.04, chi-squared). Tumor recurrence was 8 percent after rectal mucosectomy compared with 36 and 44 percent, respectively, after transanal excision (P = 0.09, chi-squared) and snaring and fulguration (P = 0.04, chi-squared). Clinically significant postoperative bleeding did not occur after rectal mucosectomy; 17 percent of patients had persistent mild incontinence. CONCLUSIONS: Rectal mucosectomy for villous tumors, a new application of an established technique, is safe and associated with low rates of tumor persistence and recurrence. Rectal mucosectomy may result in mild incontinence and should be reserved for large or circumferential lesions. For smaller lesions, transanal excision results are more reliable tumor eradication than snaring and fulguration.

Adenoma, Villous↗

PubMed1995

Can manometric parameters predict response to biofeedback therapy in fecal incontinence?

PURPOSE: Biofeedback therapy may improve fecal control in up to 50 percent to 92 percent of patients with fecal incontinence. Identification of favorable manometric parameters before biofeedback therapy may help in selection of patients suitable for such therapy. METHODS: Twenty-eight patients with fecal incontinence (idiopathic, 11; iatrogenic trauma, 8; obstetric trauma, 9) who underwent biofeedback therapy were studied to determine whether manometric parameters could predict the result of therapy. Biofeedback was given using a computer software program designed to strengthen the external anal sphincter with auditory and visual feedback. RESULTS: Thirteen patients (46.4 percent) achieved excellent results; eight patients (28.6 percent) had good results, but seven patients (24.5 percent) failed to improve after biofeedback therapy. Resting or squeeze anal canal pressure, pressure volume, sphincter length, sphincter fatigue rate, and cross-sectional asymmetry of the entire sphincter before biofeedback failed to reveal any statistically significant differences between responders and nonresponders. However, the cross-sectional asymmetry of the high-pressure zone within the sphincter at rest was greater in nonresponders than in responders (not improved, 25.8 percent; good result, 20.2 percent; excellent result, 15.4 percent; P < 0.07). This difference was even greater on squeeze (not improved, 21 percent; good result, 17.6 percent; excellent result, 13.2 percent; P < 0.04). The number of biofeedback sessions, response on bearing down, and quality of rectoanal excitatory reflex were not reliable indicators of outcome. No statistical difference was found in mean resting and squeeze pressures after biofeedback between responders and non-responders. CONCLUSIONS: Except for increased cross-sectional asymmetry in the high-pressure zone, which may be a forerunner of adverse outcome, manometric parameters before biofeedback do not predict response to biofeedback therapy. Improvement in continence may be independent of resting and squeeze pressures achieved after biofeedback therapy.

Adult↗

PubMed1995

State of the defunctionalized sphincter in patients undergoing ileoanal pouch anastomosis.

PURPOSE: Our aim was to determine manometric status and functional outcome of the ileoanal pouch procedure in a subset of patients with defunctionalized anal sphincters as a result of long-term fecal diversion. METHODS: The anal manometric profiles of 12 patients defunctionalized for one year or more were compared with 26 patients with nondefunctionalized anal sphincters. Functional data were obtained from the Lahey Clinic Ileoanal Pouch Registry. RESULTS: Preoperative manometric data revealed a mean resting pressure of 91.5 mmHg in the nondefunctionalized group vs. 68.7 mmHg in the defunctionalized group; mean squeezing pressure was 171.7 mmHg (nondefunctionalized group) vs. 102.3 mmHg (defunctionalized group); and squeezing pressure volume was 1,283,000 mmHg3 (nondefunctionalized group) vs. 585,000 mmHg3 (defunctionalized group). Functionally both groups had a mean of 6.1 bowel movements in a 24-hour period and could defer defecation for a mean of 2 hours. Leakage occurred in 22 percent of the defunctionalized group and 17 percent of the nondefunctionalized group (P = 0.35). CONCLUSION: Despite physiologic perturbations, the long-term, defunctionalized anal sphincter can adequately support a restorative procedure without regard to timing of pouch creation.

Adenomatous Polyposis Coli↗

PubMed1995

Suppurative pylephlebitis and pylethrombosis: the role of anticoagulation.

Suppurative thrombophlebitis of the portal vein resulting from inflammatory intra-abdominal conditions is a rare complication that may result in pylethrombosis and portal hypertension. A case is presented with documented pylethrombosis caused by diverticulitis. Color flow Doppler scanning was used to establish the diagnosis. Systemic anticoagulation therapy was added to the antibiotic regimen because of postoperative propagation of the clot. Anticoagulation therapy prompted resolution of the episode. Long-term follow-up studies demonstrated recanalization of the portal vein. Anticoagulation should be instituted with documented acute pylethrombosis caused by inflammatory disease of the abdomen.

Acute Disease↗

PubMed1994

Parastomal hernia. Is stoma relocation superior to fascial repair?

OBJECTIVE: To evaluate methods of parastomal hernia repair. DESIGN: Retrospective analysis. SETTING: Two tertiary care institutions. PATIENTS: Eighty patients undergoing 94 parastomal hernia repairs between 1983 and 1991. INTERVENTIONS: Three methods of repair were examined: fascial repair, stoma relocation, and fascial repair with prosthetic material. MAIN OUTCOME MEASURE: Parastomal hernia recurrence and short- and long-term complications. RESULTS: Fifty-five (93%) of 59 living patients were available and examined at a median of 31.5 months following repair, providing 68 repairs for consideration. Fascial repair was used in 36 cases, stoma relocation in 25 cases, and fascial repair with prosthetic material in seven cases. Overall, 63% of patients developed a recurrent parastomal hernia and 63% had at least one postoperative complication. Following first-time repair, parastomal hernia recurrence developed in 22 (76%) of 29 patients who had fascial repair but in only six (33%) of 18 patients who had stoma relocation (P < .01). When repair was undertaken for recurrent parastomal hernia, fascial repair failed in all seven cases, stoma relocation failed in five (71%) of seven cases, and fascial repair with prosthetic material failed in one (33%) of three cases. The only factor that significantly affected the recurrence rate was the technique of repair. Complications were more common following stoma relocation (88%) than following fascial repair (50%) (P < .05). In particular, incisional hernias developed in 52% of patients following stoma relocation but in only 3% of patients following fascial repair. When postoperative occurrence of all abdominal-wall hernias was compared, there was no significant difference between the fascial repair group (29 [81%] of 36 repairs) and the stoma relocation group (17 [68%] of 25 repairs). Furthermore, the reoperation rate for hernia repair was nearly identical (31% vs 28%) between these two groups. CONCLUSIONS: Parastomal hernia repair is often unsuccessful and rarely without complication. For first-time parastomal hernia repairs, stoma relocation is superior to fascial repair. For recurrent parastomal hernias, repair with prosthetic material is the most promising of a group of poor alternatives.

Adult↗

PubMed1994

Fertility and sexual and gynecologic function after ileal pouch-anal anastomosis.

PURPOSE: This study was designed to determine the incidence of infertility, gynecologic problems, and sexual dysfunction after ileal pouch-anal anastomosis (IPAA). METHODS: A questionnaire was sent to 206 females who underwent pouch surgery at a single institution from 1980 through 1991. Response rate was 53 percent (110/206). The computerized registry of the 206 females undergoing IPAA at this institution was reviewed to add additional data. RESULTS: Mean age at pouch construction was 32 (range, 14-61) years. Mean time from pouch surgery to survey was 49 (range, 1-132) months. Fifty-seven females had 119 children before pouch surgery, and 23 children were born to 19 females after IPAA (5 vaginal deliveries, 18 Cesarean sections). Eighteen females experienced infertility after IPAA. Thirty patients had persistent dyspareunia. Pelvic cysts developed in 15 patients; 11 patients required surgery. CONCLUSIONS: Although childbirth appears safe, gynecologic problems, such as dyspareunia and formation of pelvic cysts, may be underestimated after IPAA. The effects of IPAA on fertility are still unknown.

Adolescent↗

PubMed1994

Cholangiocarcinoma and Crohn's disease.

Cholangiocarcinoma is an infrequent complication of inflammatory bowel disease. Although increasing numbers of cholangiocarcinomas are being reported in association with ulcerative colitis, the occurrence of this disease in patients with Crohn's disease is rare. To understand this complication better, we have reported the case of a patient with Crohn's disease in whom cholangiocarcinoma subsequently developed and reviewed the literature.

Cholangiocarcinoma↗

PubMed1994

Biofeedback training is useful in fecal incontinence but disappointing in constipation.

BACKGROUND: Successful biofeedback therapy has been reported in the treatment of fecal incontinence and constipation. It is uncertain which groups of incontinent patients benefit from biofeedback, and our impression has been that biofeedback is more successful for incontinence than for constipation. PURPOSE: This study was designed to review the results of biofeedback therapy at the Lahey Clinic. METHODS: Biofeedback was performed using an eight-channel, water-perfused manometry system. Patients saw anal canal pressures as a color bar graph on a computer screen. Assessment after biofeedback was by manometry and by telephone interview with an independent researcher. RESULTS: Fifteen patients (13 women and 2 men) with incontinence underwent a mean of three (range, 1-7) biofeedback sessions. The cause was obstetric (four patients), postsurgical (five patients), and idiopathic (six patients). Complete resolution of symptoms was reported in four patients, considerable improvement in four patients, and some improvement in three patients. Manometry showed a mean increase of 15.3 (range, -3-30) mmHg in resting pressure and 35.7 (range, 13-57) mmHg in squeezing pressure after biofeedback. A successful outcome could not be predicted on the basis of cause, severity of incontinence, or initial manometry. Twelve patients (10 women and 2 men) with constipation underwent a mean of three (range, 1-14) biofeedback sessions. Each had manometric evidence of paradoxic nonrelaxing external sphincter or puborectalis muscle confirmed by defography or electromyography. All patients could be taught to relax their sphincter in response to bearing down. Despite this, only one patient reported resolution of symptoms, three patients had reduced straining, and three patients had some gain in insight. CONCLUSIONS: Biofeedback helped 73 percent of patients with fecal incontinence, and its use should be considered regardless of the cause or severity of incontinence or of results on initial manometry. In contrast, biofeedback directed at correcting paradoxic external sphincter contraction has been disappointing.

Adolescent↗