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Biomedical subjects

W R Schouten

Publications and source records attributed to W R Schouten.

At least 19 recordsLinked to original sources
PubMed2003

Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas.

BACKGROUND: The aim of the study was to identify variables affecting the outcome of transanal advancement flap repair (TAFR) for perianal fistulas of cryptoglandular origin. METHODS: Between 1995 and 2000, a consecutive series of 105 patients (65 women, 40 men), with a median age of 44 (range 19-72) years was included in the study. The patients were recruited from the colorectal departments of two university medical centres. Patients with a rectovaginal fistula and those with a fistula due to Crohn's disease were excluded. The following variables were assessed: age, sex, number of previous attempts at repair, preoperative seton drainage, fistula type, presence of horseshoe extensions, location of the internal opening, postoperative drainage, body mass index and the number of cigarettes smoked per day. The results were analysed by means of multiple logistic regression. RESULTS: The median follow-up was 14 months. No differences were observed between the two centres. TAFR was successful in 72 patients (69 per cent). None of the variables affected the outcome of the procedure, except for smoking habit of the patient. In patients who smoked the observed healing rate was 60 per cent, whereas a rate of 79 per cent was found in patients who did not smoke. This difference was statistically significant (P = 0.037). Moreover, a significant correlation was observed between the number of cigarettes smoked per day and the healing rate (P = 0.003). CONCLUSION: Cigarette smoking affects the outcome of TAFR in patients with a cryptoglandular perianal fistula.

Adult↗
PubMed2002

[The malignant side of chronic inflammatory bowel disease].

Patients with chronic inflammatory bowel disease (IBD) have a higher risk of colorectal carcinoma, and present with this malignancy at a younger age than non-IBD individuals. In three patients, two men aged 20 and 36 years and one woman aged 34 years, colorectal cancer developed at a young age, following a long history of ulcerative colitis. Surveillance for colorectal cancer in IBD patients needs to be performed by regular colonoscopy with extensive biopsy sampling for the detection of dysplasia, regarded by many as predictive for colon carcinoma. Whenever a dysplasia-associated lesion or mass or a highgrade dysplasia is identified, there is a strong indication for colectomy. When low-grade dysplasia is found, the findings should be discussed with the patient and it should be decided whether the patient should resume surveillance or opt for colectomy.

Adenocarcinoma↗
PubMed2002

[Sacral neuromodulation is effective in the treatment of fecal incontinence with intact sphincter muscles; a prospective study].

OBJECTIVE: To evaluate the therapeutic effect of sacral neuromodulation on faecal incontinence in patients with structurally intact sphincters. DESIGN: Prospective. METHOD: In the period April 1st, 2000 to November 30th, 2001, patients with faecal incontinence and structurally intact sphincters were included, with or without previous surgery, in whom medicinal treatment and biofeedback therapy gave no improvement. Incontinence was defined as involuntary loss of stool at least once a week, which was objectified by completion of a 3-week bowel habit diary. Patients underwent 3 weeks of trial stimulation during which they also kept a diary. The trial stimulation was considered successful if the diary showed a > or = 50% improvement in continence. RESULTS: 38 patients (31 women) with an average age of 54 years (range: 26-73) underwent trial stimulation. Trail stimulation was carried out using a permanent electrode in 6 patients and using peripheral neural evaluation in the remaining 32 patients. Two patients did not respond to peripheral neural evaluation. Upon assessment after the trial stimulation period. continence was found to have improved by > or = 50% in 31 (82%) patients. The number of incontinence episodes decreased by an average of 86% (range: 50-100). In 27 patients an implantable pulse generator was implanted for continuous stimulation. During the average follow-up of 6 months the effect remained satisfactory. Anal manometry during stimulation showed no increase of sphincter pressures. CONCLUSION: Sacral neuromodulation was of therapeutic value in most of the patients treated for faecal incontinence without sphincter damage.

Adult↗
PubMed2002

The outcome of transanal advancement flap repair of rectovaginal fistulas is not improved by an additional labial fat flap transposition.

Transanal advancement flap repair (TAFR) has been advocated as the treatment of choice for patients with low rectovaginal fistulas. Recently, several studies have reported a significantly lower healing rate. We also encountered low healing rates after TAFR. In an attempt to improve our results, we added labial fat flap transposition (LFFT) to the TAFR of rectovaginal fistulas. The aim of the present study was to evaluate the outcome after TAFR and to investigate the impact of an additional LFFT. Between 1991 and 1997, 21 consecutive patients of median age 33 years underwent TAFR. The etiology of the fistulas was: obstetric injury (n=9), cryptoglandular abscess (n=8) and wound infection after anterior anal repair (n=4). The first 9 patients underwent TAFT with (n=3) or without (n=6) anterior anal repair. In the following 12 patients, LFFT was added to the advancement flap. In 4 of these a concomitant anterior anal repair was performed. The median follow-up was 15 months. The overall healing rate was 48%. In the first 9 patients, in whom no additional LFFT was performed, the rectovaginal fistula healed in 4 cases (44%). In the following 12 patients in whom an additional LFFT was performed, a similar healing rate was observed (50%). In conclusion, the outcome of transanal advancement flap repair of rectovaginal fistulas is poor. Addition of a labial fat flap transposition does not improve this outcome.

Adipose Tissue↗
PubMed2002

The perineorectal reflex The perineorectal reflex in health and obstructed defecation.

PURPOSE: Many females with obstructed defecation apply digital pressure on their perineum to facilitate defecation. This study investigated the impact of this maneuver on rectal tone. METHODS: Forty-five female patients with obstructed defecation were studied. Thirty-four patients (76 percent) regularly applied digital pressure on their perineum to facilitate defecation. Total colonic transit time was normal in 32 patients and prolonged in 13 patients. For comparison, 17 female controls were studied. With the subject in the left lateral position, a thin, "infinitely" compliant polyethylene bag was inserted into the rectum at 10 cm from the anal canal. Rectal tone was assessed by measuring variations in bag volume with a computer-controlled electromechanical air injection system. After an adaptation period of 15 minutes, digital pressure was applied to the anterior perineum by one of the authors (WRS). In a second recording session, the tonic response of the rectum to an evoked urge to defecate was examined. RESULTS: During the application of perineal pressure, all controls showed an increase in rectal tone (mean value, 52.8+/-19 percent). In the whole patient group, this response was significantly lower (mean value, 24.2+/-19 percent; P < 0.001). Eight of these patients (18 percent) showed no response at all. None of them applied perineal pressure. In the remaining 37 patients (72 percent), the perineorectal reflex was present but was significantly lower (mean value, 29.8+/-17 percent; P < 0.001). Thirty-four of these females (92 percent) stated that they applied perineal pressure on a regular basis to facilitate their defecation. All controls showed an increase in rectal tone during an evoked urge to defecate (mean value, 37.8+/-8 percent). In the patients, this response was significantly lower (16.7+/-6 percent). Eight of these patients showed no increase in rectal tone at all. These patients were the same patients in whom the perineorectal reflex was absent. Regarding the tonic response of the rectum to perineal pressure, no difference was found between patients with a normal colonic transit time and those with a prolonged colonic transit time. CONCLUSION: Digital pressure applied on the perineum results in an increase in rectal tone. This perineorectal reflex is present, although significantly lower, in the majority of females with obstructed defecation. This observation might explain why females with obstructed defecation frequently apply perineal pressure to facilitate defecation.

Adolescent↗
PubMed2002

Topical L-arginine gel lowers resting anal pressure: possible treatment for anal fissure.

PURPOSE: Exogenous nitric oxide donors, such as glyceryl trinitrate, have been used as treatment for anal fissures; however, headaches develop in 60 percent of patients. Nitric oxide produced from the cellular metabolism of L-arginine mediates relaxation of the internal anal sphincter. This study investigated whether topical L-arginine gel reduces maximum anal resting pressure in volunteers. METHOD: In a two-center study, volunteers received a single topical dose of L-arginine or placebo (Aquagel ). Anal manometry was performed for two hours after application of 400 mg of L-arginine gel or placebo gel to the anal verge in 25 volunteers. Side effects were recorded after single application and also after repeated dosing for three days. RESULTS: L-Arginine reduced maximum anal resting pressure by 46 percent from a median of 65 cm of water to a minimal value of 35 cm of water ( P< 0.001, Wilcoxon's signed-rank test). The difference between L-arginine and placebo using repeated-measures testing was significant at P< 0.005. No side effects occurred with either gel; in particular, no episodes of headache were recorded. CONCLUSION: Topical L-arginine gel significantly lowers maximum anal resting pressure; its onset of action is rapid, and duration is at least two hours ( P< 0.01). L-arginine may have therapeutic potential, but further evaluation is needed before it can be used as a possible alternative treatment for chronic anal fissure.

Administration, Topical↗
PubMed2001

[Gastrointestinal surgery and gastroenterology. XIII. Classification and diagnosis of perianal fistulas].

Intersphincteric abscesses due to inflammation of an anal gland are the origin of most perianal fistulas. Perianal fistulas are classified into four types. Intersphincteric and transsphincteric fistulas are the most common. The appropriate surgical treatment of perianal fistulas is dependent upon their correct classification. Despite new imaging-techniques, physical examination of the perianal region remains of paramount importance for the preoperative classification of perianal fistulas. At present, endoanal ultrasound with the injection of hydrogen peroxide into the fistulous tract, is advocated as the most suitable method for the preoperative imaging of perianal fistulas.

Adult↗
PubMed2001

[Gastrointestinal surgery and gastroenterology. XII. Care of stoma patient].

A stoma nurse provides information, counselling and care to patients with gastrointestinal and urological conditions such as a stoma, incontinence, fistulas or an ileoanal anastomosis with a pouch. The stoma nurse will provide the patient and his or her partner with pre-operative information, post-operative counselling, practical care and instruction as well as check-ups at the outpatients' clinic. Careful selection of the most suitable collection device is highly important. This stoma care has a positive effect on the quality of life of a patient with a stoma. The most common complication is peristomal dermatitis which, in combination with care problems, may lead to social restrictions. Providing the patient's physical and psychological health is not in danger, the stoma care nurse can treat or control these complications, thereby avoiding the need for further surgery.

Enterostomy↗
PubMed2001

Anocutaneous advancement flap repair of transsphincteric fistulas.

PURPOSE: The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after anocutaneous advancement flap repair and to examine the impact of this procedure on fecal continence. METHODS: Between January 1997 and June 1999, 26 consecutive patients with a transsphincteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent anocutaneous advancement flap repair. There were six female patients, and the median age was 39 (range, 27-54) years. Twenty patients (77 percent) had previously undergone one or more prior attempts at repair. With the patient in the prone-jackknife position, the internal opening of the fistula was exposed using a Lone Star Retractor System, and the crypt-bearing tissue around the internal opening as well as the overlying anoderm was excised. An (inverted) U-shaped flap, including perianal skin and fat, was created. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the mucosa and underlying internal anal sphincter proximal to the closed internal opening. The median follow-up time was 25 months. Fecal continence was evaluated in 23 patients by means of a questionnaire. RESULTS: Anocutaneous advancement flap repair was successful in 12 patients (46 percent). Success was inversely correlated with the number of prior attempts. In patients who had undergone no or only one previous attempt at repair (n = 9), the healing rate was 78 percent. In patients with two or more previous repairs (n = 17) the healing rate was only 29 percent. In seven patients (30 percent) continence deteriorated after anocutaneous advancement flap repair. Eleven patients (48 percent) had a completely normal continence preoperatively. Two of these patients (18 percent) encountered soiling and incontinence for gas after the procedure, whereas two subjects (18 percent) complained of accidental bowel movements. Twelve patients (52 percent) presented with continence disturbances at the time of admission to our hospital. In this group, deterioration was observed in two patients (17 percent). CONCLUSION: The results of anocutaneous advancement flap repair in patients with no or only one previous attempt at repair are moderate. In patients who have undergone two or more previous attempts at repair the outcome is poor. Based on the relatively low healing rate and deterioration of continence, this procedure seems less suitable for high transsphincteric fistulas than transanal mucosal advancement flap repair.

Adult↗
PubMed2001

Circadian rhythm of rectal motor complexes.

PURPOSE: Prolonged rectal pressure recordings have revealed that the rectum exhibits typical bursts of regular pressure waves, also called rectal motor complexes. Although there is consensus regarding the characteristics of rectal motor complexes, their function is poorly understood. Furthermore, data regarding the circadian rhythm of these complexes are either lacking or conflicting. Therefore, we conducted a study to investigate the circadian rhythm of rectal motor complexes in fully ambulant subjects. Because a meal is a powerful and physiologic stimulus to elicit colonic pressure activity, we also studied the effect of a meal on these rectal motor complexes. METHODS: Prolonged ambulant anorectal pressure recordings were performed in 12 healthy volunteers (male:female ratio, 6:6; median age, 27 (range, 22-53) years). A total of 139 rectal motor complexes were observed in >300 hours of recording. RESULTS: All subjects exhibited rectal motor complexes during the daytime, whereas in five subjects, no rectal motor complexes were observed during sleep. The number of rectal motor complexes was significantly lower during sleep (diurnal vs. nocturnal, 8 vs. 1 per subject, P < 0.0001). Furthermore, the duration and peak amplitude of these nocturnal rectal motor complexes were significantly reduced. On the ambulant recordings, the subjects marked a total of 20 meals. During the first 2 hours after these meals, rectal motor complexes were noted in 65 percent of the cases. The postprandial frequency of rectal motor complexes was significantly higher than the overall frequency (2/hour vs. 0.4/hour, P = 0.004). CONCLUSIONS: These findings suggest that sleep results in a reduction of rectal motor activity, whereas a meal provides a stimulus for increased rectal motor activity in fully ambulant subjects.

Adult↗
PubMed2001

Rectal sensory perception in females with obstructed defecation.

PURPOSE: Parasympathetic afferent nerves are thought to mediate rectal filling sensations. The role of sympathetic afferent nerves in the mediation of these sensations is unclear. Sympathetic nerves have been reported to mediate nonspecific sensations in the pelvis or lower abdomen in patients with blocked parasympathetic afferent supply. It has been reported that the parasympathetic afferent nerves are stimulated by both slow ramp (cumulative) and fast phasic (intermittent) distention of the rectum, whereas the sympathetic afferent nerves are only stimulated by fast phasic distention. Therefore, it might be useful to use the two distention protocols to differentiate between a parasympathetic and sympathetic afferent deficit. METHODS: Sixty control subjects (9 males; median age, 48 (range, 20-70) years) and 100 female patients (median age, 50 (range, 18-75) years) with obstructed defecation entered the study. Rectal sensory perception was assessed with an "infinitely" compliant polyethylene bag and a computer-controlled air-injection system. This bag was inserted into the rectum and inflated with air to selected pressure levels according to two different distention protocols (fast phasic and slow ramp). The distending pressures needed to evoke rectal filling sensations, first sensation of content in the rectum, and earliest urge to defecate were noted, as was the maximum tolerable volume. RESULTS: In all control subjects, rectal filling sensations could be evoked. Twenty-one patients (21 percent) experienced no sensation at all in the pressure range between 0 and 65 mmHg during either slow ramp or fast phasic distention. The pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients with obstructed defecation (P < 0.001). In each subject, the pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were always the same, regardless of the type of distention. CONCLUSION: Rectal sensory perception is blunted or absent in the majority of patients with obstructed defecation. The observation that this abnormality can be detected by both distention protocols suggests that the parasympathetic afferent nerves are deficient. Because none of the patients experienced a nonspecific sensation in the pelvis or lower abdomen during fast phasic distention, it might be suggested that the sympathetic afferents are also deficient. This finding implies that it is not worthwhile to use different distention protocols in patients with obstructed defecation.

Adult↗
PubMed2001

Rectal compliance in females with obstructed defecation.

PURPOSE: This study was designed to investigate whether rectal compliance is altered in females with obstructed defecation. METHODS: Eighty female patients with obstructed defecation and 60 control subjects were studied. Rectal compliance was measured with an "infinitely compliant" polyethylene bag. This bag was inserted in the rectum and inflated with air to selected pressure plateaus (range, 0-60 mmHg; cumulative steps of 2 mmHg with a duration of ten seconds) using a computer-controlled electromechanical barostat system. Volume changes at the levels of distending pressures were recorded. The distending pressures, needed to evoke first sensation of content in the rectum, earliest urge to defecate, and the maximum tolerable volume were noted. RESULTS: In all cases, the compliance curve had a characteristic triphasic (S-shaped) form. The mean compliance curve obtained from the patients was identical to that of the controls. However, the course of the compliance curve fell above the normal range (mean + 2 SD) in 14 patients. In ten (71 percent) of these patients, a large rectocele was seen at evacuation proctography. Such a rectocele was observed in only five patients (7.6 percent) with a normal compliance curve (P < 0.001). Eighty percent of the controls experienced earliest urge to defecate during the second phase of the curve. In 75 percent of the patients, this occurred in the third phase. The mean pressure threshold for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients compared with control subjects. Ten of the patients experienced no sensation at all in the pressure range between 0 and 60 mmHg. CONCLUSION: In females with obstructed defecation, the compliance of the rectal wall is normal.

Adolescent↗
PubMed2001

The gastrorectal reflex in women with obstructed defecation.

This study evaluated the tonic response of the rectum to a meal in women with obstructed defecation. Fifteen control subjects and 60 women with obstructed defecation were studied. Total colonic transit time was normal in 30 patients (group I) and prolonged in the other 30 (group II). After over-night fasting an "infinitely compliant" polyethylene bag was inserted into the rectum. Rectal tone was assessed by measuring variations in bag volume with a computerized electromechanical air injection system. After an adaptation period of 30 min all subjects consumed a 450-kcal liquid meal. Postprandial recordings were continued for 3 h. In a second recording session we investigated the tonic response of the rectum to an evoked urge to defecate. In a third session rectal sensory perception was assessed. Following the meal all controls showed an increase in rectal tone (mean 74.8 +/- 17%). Patients in whom colonic transit time was normal showed a similar tonic response. In group II the increase in rectal tone was significantly lower (mean 27.8 +/- 10%; P < 0.001). Three patients of this group showed no response to a meal at all. All controls showed an increase in rectal tone during an evoked urge to defecate (mean 39.2 +/- 9%). In both groups this tonic response was absent or significantly blunted (mean 15.3 +/- 6% and 16.4 +/- 5%, respectively; P < 0.001). In both groups rectal sensory perception was significantly impaired. In conclusion, patients with obstructed defecation in whom colonic transit time is normal have an intact gastrorectal reflex. The increase in rectal tone after a meal is absent or blunted in patients with obstructed defecation in whom transit time is prolonged. The tonic response of the rectum to an evoked urge to defecate as well as rectal sensory perception are significantly impaired both in patients with a normal and in those with a prolonged transit time.

Adolescent↗
PubMed2000

Analysis of patients with poor outcome of rectocele repair.

PURPOSE: The aim of the present study was to analyze the prognostic value of clinical data and physiologic tests in patients undergoing rectocele repair for obstructed defecation. METHODS: Between 1988 and 1996, 89 consecutive female patients with obstructed defecation caused by a rectocele were enrolled in the study. Median age at time of presentation was 55 (range, 35-81) years. All patients underwent a combined transvaginal and transanal rectocele repair. End evaluation to assess long-term results was performed by an independent observer after a median duration of follow up of 52 (range, 12-92) months. The presence of the following five symptoms was evaluated: prolonged and unsuccessful straining at stool, feelings of incomplete evacuation, manual assistance during defecation, false urge to defecate, and a stool frequency of less than three times per week. When none or just one of these symptoms was present, outcome of rectocele repair was considered successful. The outcome was considered as a failure when two or more of these symptoms were recorded. Furthermore, all patients were asked to score the outcome of their operations as excellent, good, moderate, or poor. Clinical data and the results of physiologic tests obtained in patients with a poor outcome of surgery were compared with those obtained in patients with a successful outcome. RESULTS: Objective outcome of rectocele repair, based on the presence of symptoms, was found to be successful in 63 (71 percent) patients. Sixty-one patients considered outcome of surgery excellent or good (69 percent). Graded subjective outcomes between the two groups showed significantly better grades in cases of success. Duration of symptoms, number of symptoms, age, parity, and previous hysterectomy had no influence on the final outcome of surgery. Defecographic parameters, such as size of the rectocele, barium trapping in the rectocele, poor rectal evacuation, or intussusception, had no prognostic value. Signs of anismus based on defecography, electromyography, and balloon-expulsion studies did not influence outcome of surgery. The presence of symptoms such as defecation frequency, manual assistance, severe straining, false urge to defecate, or feelings of incomplete evacuation had no impact on the outcome. However, in patients without a daily urge to defecate or with a stool frequency of less than once per week, results of rectocele repair were significantly worse than in patients with a daily urge to defecate or a defecation frequency of more than once per week or both. In 14 of 26 patients with a poor outcome, colonic transit studies were performed. A delayed passage was observed throughout the entire colon in seven patients, in the left part of the colon and the rectosigmoid colon in four patients, and in the rectosigmoid colon in one patient. In two patients colonic transit was normal. CONCLUSIONS: Combined transvaginal and transanal rectocele repair is beneficial for the majority of patients with obstructed defecation. In patients without a daily urge to defecate or a stool frequency of less than once per week, indicating colonic malfunctioning, the outcome of rectocele repair seems to be poor.

Adult↗
PubMed2000

Treatment of acute strangulated internal hemorrhoids by topical application of isosorbide dinitrate ointment.

Exogenous nitric oxide has been shown useful in decreasing the internal anal sphincter tone. This study investigated the role of isosorbide dinitrate in the treatment of patients with acute strangulated internal hemorrhoids, thereby avoiding the risk of continence disturbances following conventional surgical treatment. Four male patients (median age 35 years, range 30-42) with acute strangulated hemorrhoids were treated with 1% isosorbide dinitrate. The ointment was applied to the anoderm. This application was repeated every 3 h during daytime for 2 weeks. Significant pain relief was achieved within 1 day, while transient mild headache was experienced during the first 2 days. Within 1 week the hemorrhoids became reducible. Thereafter the hemorrhoids could be treated adequately by rubber band ligation. The alternative treatment of patients with acute strangulation of prolapsed internal hemorrhoids is effective. This nonsurgical, i.e., reversible reduction of sphincter tone is an attractive alternative.

Acute Disease↗