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PubMed1997

Current techniques of assessing defecation dynamics.

The pathophysiology of defecation disorders is multifactorial. An ideal test should identify the underlying cause(s) and provide guidelines for treatment. Unfortunately, there is no such single test. But several techniques are available that could provide comprehensive information regarding the changes in defecation dynamics. Among these, anorectal manometry offers the most useful test for clinicians. Manometry may provide objective evidence for impaired rectal sensation, poor rectoanal coordination, weak anal sphincters or changes that support a diagnosis of obstructive defecation. Other tests such as the balloon expulsion test may serve as screening tools for patients with constipation. In a patient with fecal incontinence, anal endosonography may localize the sphincter defect and aid surgical reconstruction. The pudendal nerve latency test may provide a pathophysiological basis for a weak anal sphincter. Imaging techniques such as defecography may provide useful information regarding rectal prolapse or levator ani dysfunction. Ideally, the clinician should utilize these tests either to confirm a clinical suspicion or to provide new information that could aid management. This review provides an update regarding the various tests that are available for assessing defecation and provides some practical guidelines for performing manometry.

Anal Canal↗
PubMed1997

Treatment of dual urinary and fecal incontinence by implantation of two AMS 800 artificial sphincters. Case report.

We report the case of a 61-year-old woman with urinary and anal incontinence due to neurologic disease. An AMS 800 artificial sphincter was implanted first round the bladder neck with recovery of satisfactory urinary continence. Four months later, another AMS 800 artificial sphincter was implanted round the anal sphincter. Two revisional procedures had to be performed: replacement of the pump for mechanical failure, and replacement of the low-pressure balloon by a high-pressure one. Finally the patient has been almost completely continent with only occasional leakage of feces or liquid stools (follow-up 24 months after activation). Defecography shows total rectal evacuation and anorectal manometry records an anal closing pressure of 70 cm H2O. Dual implantation of artificial sphincters is possible for incontinence of neurological origin, provided bladder and rectal compliance are normal.

Anal Canal↗
PubMed2003

Anorectal motility in patients with achalasia of the esophagus: recognition of an esophago-rectal syndrome.

BACKGROUND: During my study of constipation, I encountered patients who had achalasia of the esophagus (AE) as well. The possibility of an existing relationship between the 2 conditions was studied. METHOD: Investigations to study the anorectal motility in 9 AE patients included: the intestinal transit time, anorectal manometry, rectoanal inhibitory reflex, defecography and electromyography (EMG) of external anal sphincter and levator ani muscle. Anorectal biopsy was done. The study comprised 8 healthy volunteers as controls. RESULTS: 6/9 AE patients had constipation presenting as strainodynia (excessive prolonged straining at stool). Rectocele was present in 4 of them. The 6 constipated patients showed significantly high rectal neck pressure (p < 0.05), absent rectoanal inhibitory reflex and aganglionosis in the anorectal biopsy. The EMG revealed diminished activity in 4 of the 6 constipated patients. The remaining 3 patients with AE had normal anorectal function. Heller's myotomy with Nissen's fundoplication improved the dysphagia, but not the constipation which was, however, relieved after performance of anorectal myectomy. CONCLUSION: The high incidence of constipation with AE postulates a relationship between the 2 conditions. Both have the same pathologic lesion which is aganglionosis. This study is preliminary and requires further studies on a larger number of patients.

Adult↗
PubMed2004

Preserving the superior rectal artery in laparoscopic sigmoid resection for complete rectal prolapse.

Sigmoid resection is indicated in the treatment of complete rectal prolapse (CRP) in patients with prolonged colorectal transit time (CTT). Its use however has been limited due to fear of anastomotic leakage. This study challenges the current practice of dividing the mesorectum by prospectively evaluating the impact of sparing the superior rectal artery (SRA) on leak rates after laparoscopic sigmoid resection (LSR) for CRP. During 30 months data on 33 selected patients with CRP were prospectively collected. Three patients were withdrawn from the analysis, as they had neither resection nor anastomosis. Twenty-nine women and one man (median age 55 range 21-83 years) underwent LSR with preservation of SRA for a median CRP of 8 (3-15) cm. There were 20 ASA I and 10 ASA II patients. Ten patients had undergone previous surgery. Four patients complained of dyschezia, whereas incontinence was present in 26 patients. Anal ultrasound showed isolated internal sphincter defects in two patients. Four young adults (21-32 years) had normal CTT, whereas 26 older patients had a median CTT of 5 (4-6) days. Defecography demonstrated 10 enteroceles, two sigmoidoceles, and one rectal hernia through the levator ani muscle. Mortality was nil. Median operating room time was 180 (120-330) min, suprapubic incision length 5 (3-7) cm, estimated blood loss 150 (50-500) ml, specimen length 20 (12-45) cm, solid food resumption 3 (1-6) days, and length of stay 4.5 (2-7) days. Thirty-day complications were not related to anastomosing and occurred in 20% of the patients. Although the evidence provided by the present study suggests that sparing SRA has a favorable impact on anastomotic leak rates, these nonrandomized results need further evaluation. The division of the mesorectum at the rectosigmoid junction seems not necessary, and its sparing should therefore be considered as it may contain anastomotic leak rates.

Adult↗
PubMed2001

Circular stapling procedure for mucosal prolapse of the rectum associated with outlet obstruction.

The aim of this study was designed to investigate the outcome from using the new circular stapling device in the surgical treatment for mucosal prolapse of the rectum associated with outlet obstruction. The treatment consisted of resection of the mucosal prolapse through a transverse incision and resecting a suitable part of the mucosa between the rectum and the anal canal, using an HCS33 circular stapler. Eleven patients successfully underwent this operation without morbidity or mortality, and were assessed clinically and by rectoanal manometry and defecography pre- and post-operation. The mean operating time was 39 (range 22-49) min. The postoperative proctalgia and complications were mild, and the patients were discharged at 4 days after the operation. The pre-operative constipation was improved, and the patient's satisfaction was increased at one month after operation in comparison with the preoperative level. Rectoanal function test at 6 months after the operation demonstrated normalization of the maximum resting and squeezing pressures of the anal canal and rectal compliance to the normal levels. No patient has had recurrence of symptoms during the follow-up period. Our data suggest that this procedure may be a useful surgical treatment, as it causes little postoperative complication and enables early discharge of the patients. However, long-term outcomes of recurrence, continence, and constipation need to be evaluated in a more extended follow-up.

Female↗
PubMed1996

Prediction of genital prolapse after Burch colposuspension.

OBJECTIVE: The aim of this prospective observational study was to investigate the gynecological and defecographic features in women with stress urinary incontinence operated with Burch colposuspension in order to analyze if the findings could predict subsequent development of genital prolapse. SUBJECT: Twenty-one women with urodynamically proven genuine stress urinary incontinence were consecutively operated with the Burch colposuspension during 1991-1992. No concomitant prolapse repair surgery was performed. METHODS: All were carefully examined in the lithotomy position at rest and with the Valsalva maneuver. The pelvic floor laxity was graded semiquantitatively. The defecography and the clinical examination were done preoperatively and repeated one year postoperatively. RESULTS: The clinical examination revealed a significant progression of rectoceles (p = 0.003) after the colposuspension. The colposuspension cured a significant number of cystoceles (p = 0.035). Six women (29%) had subsequent corrective prolapse surgery median 2 years after the colposuspension. The defecographic measurements showed a significant increase of the recto-vaginal distance (RVD) following the operation (p = 0.020). At the postoperative measurement the group with subsequent prolapse surgery had a significantly larger RVD as compared to the group without further surgery (p = 0.004). The kappa reliability test showed poor agreement between the defecographic and clinical assessment of the rectoceles. CONCLUSION: We failed to find any clinical or defecographic characteristic which could predict the development of surgery-demanding genital prolapse following colposuspension. The colposuspension seemed to accelerate the deterioration of the pelvic floor. However, only a minority of the patients developed symptomatic genital prolapse demanding corrective surgery. We suggest that only women with symptomatic prolapse should be considered for concomitant corrective surgery at the time of the colposuspension.

Defecation↗
PubMed1996

Iron deficiency anemia, backache, and abdominal pain attacks during sexual intercourse in a 42-year-old woman.

BACKGROUND: Gastrointestinal bleeding is a common diagnostic problem. We describe here a 42-year-old woman who had iron deficiency anemia that went undiagnosed for 8 years. SYMPTOMS AND RESULTS: She had a 'blood spray' when crouching, backache, and abdominal pain attacks during sexual intercourse. Defecography, but neither clinical examination nor endoscopy, demonstrated abnormal mobility of the rectal mucosa associated with other pelvic floor abnormalities. THERAPY: After rectopexy, the bleeding stopped, and the blood values normalized.

Abdominal Pain↗
PubMed1996

Colectomy for severe slow-transit constipation in strictly selected patients.

BACKGROUND: Colectomy for severe constipation has in up to 25% of patients given unsatisfactory results. Failure to cure constipation is in most patients due to rectal dysfunction. The aim of the present study was to evaluate the effect of colectomy in a group of patients who fulfil all the criteria which, with our present knowledge, should predict a favourable result. METHODS: Twelve patients with long-standing severe constipation incurable by dietary regulation and medical treatment with demonstrable slow-transit constipation and normal rectal function entered the study. RESULTS: Ten patients were relieved of their constipation. Two patients continued to be constipated after subtotal colectomy. One had a very highly compliant rectum (preoperatively) with a maximal tolerable volume of 700 ml but normal emptying at defecography and normal emptying of viscous fluid. The patient was subsequently treated with proctectomy and ileo-pouch-anal anastomosis with satisfactory result. One patient with opioid abuse due to abdominal pain was improved by the operation but was still constipated. The opioid abuse continued, however, after the operation owing to continuing abdominal pain. A further three patients complained of abdominal pain, and two developed diarrhoea, one of whom became incontinent. CONCLUSION: Subtotal or segmental colectomy should be considered in a small number of patients with severe constipation provided strict criteria are fulfilled. Excessively high rectal volume tolerability may in spite of normal emptying capacity indicate the risk of development of rectal inertia postoperatively and may be a contraindication for surgery.

Adult↗
PubMed1990

Intussusception of the rectum and the solitary ulcer syndrome.

A general review is given of the intussusception of the rectum, the paradoxical contraction of the pelvic floor syndrome and of the solitary ulcer syndrome. The latter is in most cases a symptom of the other two as is the descending perineum syndrome. The conditions are diagnosed by defecography, proctosigmoidoscopy and EMG. The etiologies are unknown. The treatment is either conservative or operative.

Adult↗
PubMed2003

Prospective study of biofeedback retraining in patients with chronic idiopathic functional constipation.

AIM: To determine the efficacy and long-term outcome of biofeedback treatment for chronic idiopathic constipation and to compare the efficacy of two modes of biofeedback (EMG-based and manometry-based biofeedback). METHODS: Fifty consecutive contactable patients included 8 cases of slow transit constipation, 36 cases of anorectic outlet obstruction and 6 cases of mixed constipation. Two modes of biofeedback were used for these 50 patients, 30 of whom had EMG-based biofeedback, and 20 had manometry-based biofeedback. Before treatment, a consultation and physical examination were done for all the patients, related information such as bowel function and gut transit time was documented, psychological test (symptom checklist 90, SCL90) and anorectic physiological test and defecography were applied. After biofeedback management, all the patients were followed up. The Student's t-test, chi-squared test and Logistic regression were used for statistical analysis. RESULTS: The period of following up ranged from 12 to 24 months (Median 18 months). 70 % of patients felt that biofeedback was helpful, and 62.5 % of patients with constipation were improved. Clinical manifestations including straining, abdominal pain, bloating, were relieved, and less oral laxative was used. Spontaneous bowel frequency and psychological state were improved significantly after treatment. Patients with slow and normal transit, and those with and without paradoxical contraction of the anal sphincter on straining, benefited equally from the treatment. The psychological status rather than anorectal test could predict outcome. The efficacy of the two modes of biofeedback was similar without side effects. CONCLUSION: This study suggests that biofeedback has a long-term effect with no side effects, for the majority of patients with chronic idiopathic constipation unresponsive to traditional treatment. Pelvic floor abnormalities and transit time should not be the selection criteria for treatment.

Adolescent↗
PubMed1997

[Problems with continence after deep pelvic anastomoses in rectal carcinoma].

Based on the complex evaluation of the continence by anorectal manometry, EMG examination of sphincters, transrectal sonography, defecography and Colonic Transit Time examination, the analysis of the group of 15 patients partially incontinent after operation of carcinoma of the lower part of the rectum has been done. In these patients the deep pelvic anastomosis or coloanal anastomosis was performed. In none of the patients any serious organic damage of sphincters was manifested, the causes were dominantly extrasphincteric and functional, solvable well by conservative methods.

Anastomosis, Surgical↗
PubMed1999

Antegrade continence enema for the treatment of fecal incontinence in adults: use of gastric tube for catheterizable access to the descending colon.

PURPOSE: We describe the use of a gastric segment in performing the antegrade continence enema procedure in patients with refractory fecal incontinence. MATERIALS AND METHODS: The antegrade continence enema procedure was performed in 4 women and 3 men with refractory neurogenic fecal incontinence. Preoperative evaluation included defecography and anorectal manometry. Operative technique involves tunneling a 10 cm. segment of tubularized stomach isolated along the greater curve with preservation of the right gastroepiploic vessels through the anterior tenia of the colon just distal to the splenic flexure. After the stoma is mature the patient passes a catheter and runs 1 to 2 l. warm tap water through it while seated on the toilet. Digital stimulation may be required to initiate bowel emptying and irrigation is continued until clear. RESULTS: Creation of a nonrefluxing catheterizable gastric tube to the descending colon was successful in all 7 patients. At a mean postoperative followup of 22.4 months all patients are continent and use antegrade continence enema irrigation every other day on average. One patient required early revision because of stomal stenosis. Special measures include application of a generic antacid tablet to the stoma and use of a skin barrier. CONCLUSIONS: Catheterizable access to the descending colon for the antegrade continence enema procedure more closely approximates normal defecation patterns by emptying ("unloading") the left side of the colon. The stomach is a suitable option in close proximity for this purpose and is especially advantageous when the appendix is not available. The antegrade continence enema procedure using a gastric segment can be safely and effectively performed, and is well suited for use by reconstructive surgeons who are familiar with the Mitrofanoff principle.

Adult↗
PubMed1999

[Diagnostic evaluation of the rectum and pelvic floor in chronic constipation].

In outlet constipation an exact diagnostic evaluation is always necessary because of the different etiologies, multiple combinations in primary and secondary lesions and the number of therapeutic alternatives. Basic diagnostics start with the very important, structured evaluation of the patient's history, colorectal examination including inspection, palpation, procto-, recto-, sigmoidoscopy and anorectal manometry. Depending on the results of this primary evaluation the following methods are indicated: neurophysiologic evaluation (basic neurological examination, EMG, PNTML), defecography ev. including colon contrast enema and gastrointestinal transit time studies. If the complete problem could not be ruled out till that point, the following examinations might be helpful: dynamic pelvic floor MRI, anorectal endosonography, rectal motility studies, fecoflowmetry, colonoscopy, urological und gynecological examinations.

Adult↗
PubMed2000

Fecal incontinence: a clinical approach.

"Fecal incontinence" is defined as the involuntary loss of stool at any time of life after toilet training. It is a socially and psychologically devastating condition for patients and their families, and a topic which both patients and physicians are reluctant to approach. Although the true prevalence of fecal incontinence is unknown, studies have reported it to be as high as 2. 2% in the general population, with significantly higher rates among nursing home residents and hospitalized elderly. Risk factors include advancing age, female gender and multiparity. An understanding of pelvic floor anatomy and physiology is required to appreciate how diverse medical conditions can affect mechanisms involved in normal continence. The rectum serves as a storage reservoir until elimination can take place at a socially acceptable time and place. The pelvic floor muscles help to regulate the defecatory process and maintain continence. These muscles include the internal anal sphincter, the external anal sphincter and the puborectalis muscle. Each muscle contributes to normal continence, although the relative importance of each is controversial. Neurologic integrity and sensation are also key factors. Conditions associated with fecal incontinence include diarrheal states, fecal impaction, idiopathic neurologic injury, surgical and obstetric injury, pelvic trauma, collagen vascular disease, and neurologic impairment related to stroke, diabetes, or multiple sclerosis. Evaluation of the patient with fecal incontinence includes a directed history and physical examination, with particular attention paid to integrity of the perineum and rectum, and a complete neurologic evaluation. Diagnostic tools such as stool studies, anorectal manometry, defecography, electromyography, pudendal nerve conduction, and endoanal ultrasound may be employed in an outpatient setting. Fecal incontinence may be treated conservatively by employing such methods as dietary restriction, stool bulking agents, and biofeedback. Surgery may be the best option for cases refractory to medical treatment, or for those patients with rectocele or obstetrical injury. In this article, we review the presentation, epidemiology, pathophysiology, and etiology of fecal incontinence. Evaluation, including key components of directed history and physical examination, and the appropriate use of diagnostic studies and indications for treatment options are also addressed.

Defecation↗
PubMed1998

[Dynamic graciloplasty in the treatment of severe fecal incontinence--2 case reports].

Severe fecal incontinence is a serious problem not only for the patient whose quality of life is diminished, but also for the surgeon, who sometimes has difficulties how to manage all the aspects of this complicated condition. Conservative treatment is often ineffective, while operative sphincter repair is feasible only when anal sphincter is relatively functional and conserved. Dynamic graciloplasty is a method where functional anal neosphincter is constructed by transposing m. gracilis and wrapping it around the anal canal with subsequent implantation of electric neurostimulator and electrodes. Relatively good continence can be achieved with this technique, especially in-patients where all other therapeutic options failed. We present two patients, 25 and 21 years old, operated on our department, both suffered from severe fecal incontinence from the time they were born. They were interviewed, underwent a physical examination and evaluated by anal manometry, defecography and electromyography. Severe fecal incontinence was revealed (18 and 20, according to the Continence grading scale). In both cases, Gamma graciloplasty was performed. At first patient, implantation of the neurostimulator was performed 8 months after graciloplasty, while in second case, both graciloplasty and implantation of the electrodes with neurostimulator were performed at the same time. Postoperative recovery was uneventful in both cases. There was minor infection of the perineal wound in one patient. Electrostimulation training program was started on 9th postoperative day in both cases. Functional results were revealed by questionnaire and anal manometry. The quality of life was significantly improved in both cases, with good continence and psychological recovery. Anal manometry revealed increased anal contraction pressure comparing with preoperative basal and squeeze pressures. Dynamic graciloplasty is a relatively new; high specialized method in treatment of intractable, fecal incontinence. It is safe and reliable procedure in hands of an well-experienced surgeon, if well indicated and performed.

Adult↗
PubMed2001

[Quality of life, symptoms of dyschezia, and anatomy after correction of rectal motility disorder].

AIM OF THE STUDY: To evaluate the quality of life of patients suffering from dyschezia and its correlation with symptomatic complaints and anatomical abnormalities, before and after elective surgery for rectal static disorder. PATIENTS AND METHODS: A prospective study was conducted using a general quality of life questionnaire (SF36) and a constipation specific score (PAC-QoL), a dyschezia symptom score, and defecography. RESULTS: Thirty-eight female dyschesic patients (mean age 54 years) underwent surgery for rectocele with (n=16) or without (n=14) internal rectal prolapse, an isolated internal rectal prolapse (n=3), or a total rectal prolapse (n=5). Preoperative quality of life was low, correlated with the intensity of dyschezia. Seven months after surgery, quality of life and dyschezia improved independently of the amplitude of the anatomical correction. More items improved in the constipation specific score than on the quality of life questionnaire; they were correlated with the course of dyschezia symptoms. Neither incontinence nor irritable bowel syndrome affected evolution of the symptoms. CONCLUSION: Surgery improved initially low quality of life and symptomatic complaints in patients with dyschezia and a rectal static disorder, independently of anatomic repair. Differences in changes observed in the PAC-QoL and SF36 suggest different fields of application.

Adolescent↗
PubMed2000

The role of overlapping sphincteroplasty in traumatic fecal incontinence.

Fecal incontinence is one of the most distressing conditions. Even there is a great variety of etiologic factors, they can be systematized in two main categories; fecal incontinence with normal and fecal incontinence with abnormal function of pelvic floor muscles. The latter is more interesting for surgeons since this category includes the great majority of surgically caused and surgically correctable fecal incontinences. Disruption of the anal sphincter caused by obstetric injury, anorectal operations or external trauma is the commonest cause of fecal incontinence. In the period 1990-1999, 53 patients with fecal incontinence caused by sphincter injury were treated on the third department for colorectal surgery, First Surgical Clinic. There were 43 females and 10 males with a mean age of 36.1 years (range 18-64). Causes of fecal incontinence were: obstetric trauma 38 patients. (71%), fistulotomy 9 (17%), war injuries 3 (6%) and nonspecific 3 (6%). The severity of incontinence was graded by Browning--Parks's classification. There were no patients in group A and B, in group C were 11 patients and in D group 37 patients. Wexner score system was also utilized preoperatively and postoperatively to determine continence function more precisely. Clinical exam, anoscopy and special investigations, such as anal manometry, EMG and defecography were carried out in all cases. Period between injury and repair was between 6 months and 20 years. Severe pudendal neuropathy was present in 17 patients. Five patients had oostomies performed at the time of injury. In three cases was present traumatic cloaca and in one case rectovaginal fistula. Overlapping sphincter repair technique was carried out in all cases. Full bowel preparation and antibiotics were prescribed. Anterior sphincteroplasty was performed in 39 cases, lateral in 7, posterior in 3 and anterior sphincteroplasty + posterior plication of puborectalis (Parks operation) in 4 patients. Protective colostomy was not performed in any case. The outcome of the procedure was considered as excellent, good, fair and poor (excellent when full control of solid and liquid stool and flatus was achieved, good when there was continence to feces but not to flatus, fair when patients could control only solid feces and poor when only partial control of solid feces was obtained). The overall functional results were as follows: Excellent in 25 patients (47.2%), good in 12 (22.7%), fair in 11 (20.7%) and poor in 5 (9.4%). Wound infection occurred in 9 (16.9%) patients, leading to disruption of sutures in three patients with consequent poor results. Two of them were reoperated. The duration of follow-up was from 5 to 60 months. We conclude that an overlapping sphincteroplasty is a method of choice in treating fecal incontinence caused by trauma. The best results are achieved with anterior sphincteroplasty. Results of posterior sphincteroplasty were disappointing. If present, pudendal neuropathy directly influences the outcome of sphincteroplasty. Manometric studies correlate with the clinical outcome.

Adolescent↗
PubMed1999

[Diagnosis and surgical treatment of idiopathic slow transit constipation].

OBJECTIVE: To investigate the pathogenesis, the diagnostic criteria, and the therapeutic method of idiopathic slow transit constipation. METHODS: History recording, bowel transit, anorectal dynamic, electromyography of the pelvic floor and defecography were performed before subtotal or total colectomy for severe constipation resistant to conservative treatment. RESULTS: The natural stool frequency was decreased and the time of bowel transit was delayed. The rectal sensation and the ability to reflect inhibition of the pelvic floor when attempting to defecate were damaged significantly compared with normal controls. pathological findings showed that the argyrophilic neurons in the myentenic and submucous plexus reduced quantitatively. All the patients were followed up for an average of 32.2 months. Satisfactory functional outcome was obtained in 91.8% of the patients receiving the operation. CONCLUSIONS: The severe damage colon transit function is due to the impairement of the myentenic and submucous plexus of the colon. It causes vary. The diagnosis of the disease is dependent on the typical clinic features and the bowel transit test. The symptoms of constipation could be relieved effectively by removal of the pathologic colon.

Adolescent↗