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PubMed2004

Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles.

BACKGROUND: The aim of the study was to compare the results in 95 patients randomly allocated to undergo either stapled or open hemorrhoidectomy using Ligasure. METHODS: Ninety-five patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open using Ligasure (45 patients). Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique by using Ligasure. Postoperative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and an 18 (12-24) month median telephone follow-up were obtained in all patients. RESULTS: Operation time for open hemorrhoidectomy using Ligasure was shorter [median 13 (range 9.2-16.1) min vs 15 (range 8-17) minutes, p < 0.05]. Median range of VAS score in the stapled group were significantly lower [VAS score after 8 h: 3 (2-6) vs 5 (3-8), p < 0.01; VAS score after first defecation: 5 (3-8) vs 7 (3-9), p < 0.001. The stapled hemorrhoidectomy was associated with an increased incidence of intraoperative bleeding in 18 cases (36%) vs four cases (8.8%) of the Ligasure group. There were three cases (6%) from the stapled group with recurrence of the hemorrhoids and none from the open technique. CONCLUSIONS: Hemorrhoidectomy with a circular stapler device is easy to perform, but one more line of clips must be added to the device to avoid intraoperative bleeding from the cut line. Hemorrhoidectomy performed using Ligasure is more painful postoperatively but is a more radical operation.

Digestive System Surgical Procedures↗
PubMed2005

Flavonoids to reduce bleeding and pain after stapled hemorrhoidopexy: a randomized controlled trial.

INTRODUCTION: Control of postoperative symptoms is of paramount importance in ambulatory surgery. This trial was conducted to evaluate whether a micronized purified flavonoid fraction (MPFF) (Detralex((R))) reduces postoperative bleeding, pain and consumption of analgesics after ambulatory stapled hemorrhoidopexy, as reported in trials after classic hemorrhoidectomy. Phlebotropic activity, protective effect on the capillaries and anti-inflammatory properties of this drug have been reported in several studies. METHODS: Sixty-three patients with third-degree hemorrhoids had ambulatory stapled hemorrhoidopexy under spinal anesthesia in the period of one year. The patients were randomized, with 30 receiving Detralex 500 mg (2 tablets 3 times daily for 5 days after the operation) and 33 forming the control group. The patients were asked to daily self-assess the presence of blood on defecation, degree of pain and consumption of analgesics for the first week after the operation. RESULTS: There was no significant difference between the two groups in duration of presence of blood, degree of pain or analgesics requirement. No major complications, such as bleeding requiring transfusion or hospitalization, sepsis, anal stenosis or urgent defecation, were noted in the follow-up period. There were no side effects from Detralex treatment. DISCUSSION: In our study we could not demonstrate any positive effect of prescribing flavonoids after stapler hemorrhoidopexy. This procedure may not be sufficiently aggressive and is associated with too few postoperative complications to show any protective influence of flavonoids.

Analgesics↗
PubMed2006

Dynamic pelvic three-dimensional computed tomography for investigation of pelvic abnormalities in patients with rectocele and rectal prolapse.

BACKGROUND: Dynamic three-dimensional computed tomography (D-3DCT: high-speed helical scanning during defecation) was used for morphological evaluation of intrapelvic structures in patients with rectal prolapse and rectocele. METHODS: Twenty-five patients with rectal prolapse or rectocele diagnosed by conventional defecography (CD) or clinical findings were additionally investigated with D-3DCT. D-3DCT images were acquired using a multislice CT system with a 16-row detector during simulated defecation. Helical scanning was performed with a slice thickness of 1 mm, a helical pitch of 15 s/rotation, and a table movement speed of 35 mm/s. The contrast medium, 100 ml of iopamidol (370 mg/ml), was injected at a rate of 2.5 ml/s to enhance contrast with other structures, and scan start was triggered by using a function for automatically determining the optimal scan timing. RESULTS: Among the eight patients with rectocele, additional intrapelvic disorders were diagnosed in five (enterocele, 4; cystocele, 1; and uterine prolapse, 1) with D-3DCT. In the 17 patients with rectal prolapse, concomitant intrapelvic disorders were found in six (intussusception, 3; cystocele, 2; uterine prolapse, 2; rectocele, 1; and vaginal prolapse, 1). CONCLUSIONS: D-3DCT can be a useful diagnostic tool for investigation of pelvic pathology in patients with rectocele and rectal prolapse.

Adult↗
PubMed2006

Function preservation in rectal cancer surgery.

When total mesorectal excision (TME) is accurately performed, dysfunction, theoretically, does not occur. However, there are differences among individuals in the running patterns and the volumes of nerve fibers, and if obesity or a narrow pelvis is present, nerve identification is difficult. Currently, the rate of urinary dysfunction after rectal surgery ranges from 33% to 70%. Many factors other than nerve preservation play a role in minor incontinence. Male sexual function shows impotence rates ranging from 20% to 46%, while 20%-60% of potent patients are unable to ejaculate. In women, information on sexual function is not easily obtained, and there are more unknown aspects than in men. As urinary, sexual, and defecation dysfunction due to adjuvant radiotherapy have been reported to occur at a high frequency, the creation of a protocol that enables analysis of long-term functional outcome will be essential for future clinical trials. In the treatment of rectal cancer, surgeon-related factors are extremely important, not only in achieving local control but also in preserving function. This article reviews findings from recent studies investigating urinary, sexual, and defecation dysfunction after rectal cancer surgery and discusses questions to be studied in the future.

Digestive System Surgical Procedures↗
PubMed2003

Complications and results after stapled haemorrhoidopexy as a day surgical procedure.

BACKGROUND: The aim of this report is to describe our experience with stapled haemorrhoidopexy as a day surgery procedure. METHODS: From January 2000 to January 2003, a total of 214 patients with third- and fourth-degree haemorrhoids underwent stapled haemorrhoidopexy under spinal anaesthesia. We analysed early postoperative complications and long-term results. Patients were followed for 4-36 months (mean, 22 months). Only 3 patients (1%) were hospitalised. The long-term complications were analysed by means of a mailed questionnaire. RESULTS: Minor bleeding at wiping after defecation was observed by 9% of patients and minor haemorrhoidal prolapse by 8% of patients. Pain after defecation was reported by 6% of patients and anal stenosis occurred in 2% of them. Faecal urgency was reported by 3% of patients with previously unknown incontinence problems. CONCLUSION: According to our experience, stapled haemorrhoidopexy can be safely performed as a day surgery procedure.

Ambulatory Surgical Procedures↗
PubMed2001

Which surgical approach for rectocele? A multicentric report from Italian coloproctologists.

The most effective surgical technique for rectocele has not yet been clearly established. A retrospective multicentric study was carried out to compare the long-term results of 3 endorectal techniques (Block, Sarles and stapled) and the perineal levatorplasty, alone and in association, in a series of patients with symptomatic rectocele. From January 1992 to December 1999, 2212 patients with defecation disorders were referred to 5 Italian coloproctology units. An anterior rectocele was clinically diagnosed in 1045 patients and confirmed with defecography. On the basis of clinical and radiological parameters, 317 patients (312 women; mean age, 52.4+/-20.1 years) were selected for surgery. Group 1 consisted of 141 patients (136 women; mean age, 50.4+/-18.8 years) who were submitted to endorectal operations. Group 2 consisted of 126 women (mean age, 52.5+/-19.7 years) who received perineal levatorplasty. Finally, 50 women (mean age, 54.3+/-21.9 years) in Group 3 received endorectal operations associated with perineal levatorplasty. A total of 269 patients were followed postoperatively (mean period, 24.2+/-3.1 months, 27.5+/-5.4 months and, 22.8+/-2.8 months, respectively) with the same questionnaire and clinical examination. Three months after surgery, a defecography examination and anorectal manometry were performed in 136 and 132 patients, respectively. Operative time, hospital stay and time to return to work were significantly higher in Group 3 (p<0.001). There was one death in Group 3 due to severe sepsis. Main postoperative complications were: in Group 1, hemorrhage (7.8%, all Sarles), dehiscence of the endorectal suture (5.0%, all Block), distal rectal stenosis (2.1%, 1 stapled, 2 block), and rectovaginal fistula (1.4%, all Sarles); in Group 2, delayed healing of the perineal wound (16.4%); in Group 3 delayed healing of the perineal wound (22.0%), hemorrhage (6%, all Sarles), dehiscence (4.0%), stenosis (2.0%). 17.3% of patients of Group 2 and 22.5% of Group 3 complained of dyspareunia. Postoperative defecography showed a complete absence of the rectocele in 44.1% of patients and reduction of size in the others, without significant differences among the three groups. Manometric pattern was not significantly modified by surgery. Significant symptoms recurred in 5.9% of the patients in Group 1, 6.4% in Group 2, and 5.0% in Group 3. Perineal levatorplasty did not significantly improve obstructed defecation, as it did not allow to excise the rectal mucosal prolapse, and was followed by an high incidence of delayed healing of the perineal wound and dyspareunia. Sarles procedure achieved better control of mucosal prolapse but carried a higher complication rate compared to the others. The association of the perineal levatorplasty with an endorectal technique required significantly longer operative time, and led to a longer hospital stay and time to return to work. In conclusion, the investigated techniques showed different patterns of postoperative complications: bleeding after Sarles, dehiscence after Block, dyspareunia after perineoplasty and fatal gangrene after stapled, but non of them showed a clear superiority over the others in term of clinical or functional results 2 years after surgery.

Adult↗
PubMed2004

Effect of hysterectomy on bowel function.

PURPOSE: Hysterectomy is the most common major gynecologic procedure. Unwanted postoperative effects on bowel function are a topic of recent debate. The aim of the present study was to prospectively evaluate the influence of hysterectomy on bowel function. METHODS: One hundred and twenty consecutive patients undergoing hysterectomy for benign conditions answered a questionnaire covering bowel habits and symptoms preoperatively and at 6 and 12 months postoperatively. Forty-four patients underwent vaginal hysterectomy and 76 underwent abdominal hysterectomy. Concomitant bilateral salpingo-oopherectomy was performed in 17 patients. RESULTS: After abdominal hysterectomy, patients reported increased symptoms of gas incontinence, urge to defecate, and inability to distinguish between gas and feces ( P < 0.05). There was a tendency of increased fecal incontinence. Subgroup analysis indicated that concomitant bilateral salpingo-oopherectomy resulted in an increased risk of fecal incontinence. No significant changes were detected in symptoms associated with constipation. Mean defecation frequency increased and the frequency of pelvic heaviness symptoms was reduced. After vaginal hysterectomy, there was no increased frequency of incontinence or constipation symptoms. The frequency of pelvic heaviness symptoms was reduced. CONCLUSIONS: Patients undergoing abdominal hysterectomy may run an increased risk for developing mild to moderate anal incontinence postoperatively and this risk is increased by simultaneous bilateral salpingo-oopherectomy. An increased risk of anal incontience symptoms could not be identified in patients undergoing vaginal hysterectomy. Our study does not support the assumption that hysterectomy is associated with de novo or deteriorating constipation.

Abdomen↗
PubMed2004

Functional constipation with impaired rectal sensation improved by electrical stimulation therapy: report of a case.

Patients with intractable constipation often complain of social, physical, and psychologic stress. Recently, biofeedback therapy has been widely used for the management of intractable constipation, particularly in cases of constipation associated with pelvic floor dyssynergia. However, some constipated patients often complain of absent or diminished sense of wanting to defecate. It is unclear whether impaired rectal sensation is a cause or outcome of constipation and what specific treatment is available for these patients. We treated a 25-year-old female patient who complained of intractable constipation for ten years. Colon transit time study and defecography showed nonspecific findings. Her anorectal manometric findings were within normal ranges with the exception of impaired rectal sensation. Rectal sensory threshold volumes for desire and urge to defecate and maximal tolerated volume were greatly increased. She was treated by electric stimulation therapy for the purpose of improving impaired rectal sensory function. After 14 sessions of electric stimulation therapy, her constipated symptoms improved dramatically. Furthermore, the desire and urge threshold volumes were remarkably decreased. We report this case of constipation with impaired rectal sensation possibly treated by electric stimulation therapy.

Adult↗
PubMed2004

Outcome after transperineal mesh repair of rectocele: a case series.

PURPOSE: This study was designed to establish the safety and efficacy of transperineal mesh repair in patients with obstructed defecation caused by rectocele. METHODS: Between 1998 and 2002, 24 consecutive females with symptomatic rectocele were retrospectively reviewed after mesh repair of rectocele. Two patients had inadvertent rectal perforation during operation and had no mesh implantation. Of the remaining 22 patients, 14 had a prolene mesh implanted, and 8 had a Vipro II mesh implanted. Median age at the time of presentation was 55 (range, 28-66) years. Patients were selected for operation based on clinical and evacuation proctogram findings. All patients complained of incomplete rectal evacuation, and the majority complained of excessive straining, constipation, and the need for vaginal/perineal digital pressure to aid defecation. Patients were followed up in clinic at six weeks, and a telephone questionnaire was performed at a median time of 12.5 (range, 3-47) months. Functional/objective outcomes were assessed for the following five symptoms preoperatively and postoperatively: excessive straining, incomplete evacuation, perineal/vaginal digital pressure, vaginal bulging, and constipation (always, usually, occasionally, never). Subjective outcomes were assessed as excellent, good, moderate, or poor. In addition, patients were asked about preexisting and postoperative dyspareunia. RESULTS: Objective outcomes based on symptoms showed an improvement in two or more symptoms in 20 patients (91 percent). For all symptoms, there was a significant reduction in mean values after repair. Subjective outcomes showed that 17 patients (77 percent) had a moderate/good/excellent result. Patients with abnormal preoperative colonic transit marker studies did as well as those who had no transit studies performed or those who had normal studies. Patients who did not vaginally digitate did as well as those who did not digitate. Only one patient complained of new onset dyspareunia. Two patients with sphincter defects on endoanal ultrasound had a sphincteroplasty performed (1 prerectocele repair and 1 at the same time). There were two superficial wound infections and one deep infection. All infections responded to antibiotic therapy. No mesh has been removed. Semiabsorbable mesh repair was superior to nonabsorbable mesh repair. CONCLUSIONS: Transperineal mesh repair of symptomatic rectocele is a safe technique that avoids the anal dilation and sphincter injury associated with endorectal repair. Objective and subjective results are good in the majority of patients, although a longer follow-up is required to confirm no deterioration.

Adult↗
PubMed2005

Laparoscopic or transanal repair of rectocele? A retrospective matched cohort study.

PURPOSE: The aim of the study was to analyze the functional and physiologic outcome of patients undergoing laparoscopic rectocele repair compared to a matched cohort undergoing transanal repair. METHODS: Forty patients with a rectocele who had undergone laparoscopic pelvic floor repair by a laparoscopic gynecologist were matched for age and rectocele size with 40 patients who had undergone a transanal repair by a colorectal surgeon. All patients had clinical evidence of a symptomatic rectocele. All patients were assessed postoperatively with a quality of life (SF-36) score, a modified St. Mark's continence score, a urinary dysfunction score, a Watt's sexual dysfunction score, and a linear analog patient satisfaction score. Fifteen patients in each group had also undergone preoperative and postoperative anal manometry. RESULTS: At 44 months median follow-up, the transanal approach resulted in significantly more patients reporting bowel symptom alleviation (P < 0.002) and higher patient satisfaction (P < 0.003). The bowel symptom improvement was also sustained over a significantly longer period (P < 0.03). Only 11 patients (28 percent) in the laparoscopic group reported more than 50 percent improvement in their bowel symptoms compared to 25 patients (63 percent) in the transanal group. On univariate analysis of 50 percent bowel symptom improvement, a larger rectocele (P < 0.009), transanal repair (P < 0.02), and presenting with obstructive defecation rather than fecal incontinence (P < 0.03) were statistically significant. Rectocele size (P < 0.012) and treatment cohort (P < 0.006) remained significant on multivariate analysis. Postoperatively, bowel symptom alleviation correlated with patient satisfaction in both groups (P < 0.015). Although not statistically significant, five patients (13 percent) in the transanal group developed postoperative fecal incontinence, which was associated with a low maximum anal resting pressure preoperatively that was further diminished postoperatively (P > 0.06). Only one patient (3 percent) in the laparoscopic group reported a decline in fecal continence, but four patients (10 percent) reported worsening of their symptoms of obstructed defecation. Postoperative dyspareunia was reported by 24 patients in total (30 percent), with significantly more in the transanal group (P > 0.05). CONCLUSIONS: The transanal repair results in a statistically greater alleviation of bowel symptoms and greater patient satisfaction scores. However, this approach may have a greater degree of functional co-morbidity than the laparoscopic rectocele repair.

Adult↗
PubMed2002

Combined perineal and endorectal repair of rectocele by circular stapler: a novel surgical technique.

PURPOSE: The aim of this study was to present a new technique for treatment of disabling rectocele when associated with internal mucosal prolapse or hemorrhoids using a 33-mm circular stapler. METHODS: Eight female patients complaining of obstructed defecation because of distention rectocele associated with internal mucosal prolapse or hemorrhoids and perineal descent entered the study. The rectovaginal septum was opened by diathermy up to the end of the rectal wall weakness. The perineal wound and the anus were held open by a self-retractor. Using a transparent anoscope (PPH 01 system), 2 mucosal pursestrings were prepared 5 and 8 to 9 cm distant from the dentate line. Posteriorly, only the submucosa was included in the pursestring; anteriorly, it included the rectal wall, which was kept separate from the vaginal wall. A transanal 33-mm circular stapler was then used to close the rectocele and treat the mucosal prolapse. Before closing the perineum a levatorplasty was fashioned. RESULTS: One patient had a vaginal tear during dissection of the septum, which healed spontaneously in one month. No other complications were recorded. Postoperative defecography showed correction of the rectocele and the posterior rectal prolapse in all patients. In two of them, a small lateral diverticulum could be seen, although this was asymptomatic. After a median follow-up of 12 months, all had significantly improved defecation (chronic constipation score dropped from 14.3 to 5, P < 0.04). CONCLUSION: Combined perineal and endorectal stapler repair of rectocele may be a useful new surgical tool for correcting distention rectocele associated with mucosal prolapse or hemorrhoids and perineal descent in selected patients. A longer follow-up on a larger number of patients is needed to confirm these preliminary results.

Adult↗
PubMed2002

Clinical effects of preoperative radiation therapy on anorectal function after proctectomy and colonic J-pouch-anal anastomosis.

PURPOSE: Preoperative radiotherapy is increasingly used for certain rectal cancers, although some evidence suggests that it may adversely affect anorectal function. Reconstruction with a colonic J-pouch-anal anastomosis after complete proctectomy is thought to improve function, but few published data on pouch function after radiation exists. The aim of our study was to compare long-term bowel habits in patients receiving preoperative radiation for rectal cancer followed by colonic J-pouch-anal anastomosis with those of patients having similar rectal cancer surgery without radiation. METHODS: Patients (n = 125) having undergone colonic J-pouch-anal anastomosis for rectal cancer, of whom 28 had preoperative radiotherapy and 97 did not, responded to a detailed questionnaire about their bowel habits at least 12 months after surgery, with a mean (+/- standard deviation) interval of 64 (+/-42) months. Radiation was administered preoperatively as a short (25 Gy over 5 days, n = 22) or long (45 Gy over 4 weeks, n = 6) course. All patients had colonic J-pouch-anal anastomosis with manual anastomosis at or immediately above the dentate line. RESULTS: Except for tumor stage, no preoperative difference was observed between the two groups. The number of bowel movements per 24 hours in patients with and without radiation was 1.8 (+/-0.8) and 1.8 (+/-1.5), respectively (P> 0.05). In the irradiated group, diarrhea (39 vs.13 percent, P= 0.005) and nocturnal defecation (36 vs.15 percent, P= 0.03) were more frequent than in the nonirradiated group. No other significant difference existed between groups with regard to stool clustering, use of protective pads, ability to defer evacuation >15 minutes, ability to evacuate the bowel within 30 minutes, incontinence score, use of medications, or dietary restriction. CONCLUSION: Preoperative radiotherapy followed by proctectomy and colonic J-pouch-anal anastomosis significantly increased nocturnal defecation frequency and diarrhea compared with similar nonirradiated patients but had no influence on the other bowel-habit parameters studied.

Aged↗
PubMed2005

Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study.

PURPOSE: This study was designed to evaluate rectocele repair using collagen mesh. METHODS: 32 female patients underwent surgical repair using collagen mesh. Outcome was assessed in 29 patients and preoperative assessment included standardized questionnaire, clinical examination, and defecography. At the six-month follow-up, patients answered a standardized questionnaire and underwent clinical examination. At the 12-month follow-up, patients answered a standardized questionnaire, underwent clinical examination, and defecography. RESULTS: Preoperatively, 26 patients had a Stage II and 3 patients had a Stage III rectocele. At the 6-month follow-up, five patients had rectocele > or = Stage II (P < 0.001) and at the 12-month follow-up, seven patients had rectocele > or = Stage II (P < 0.001) at clinical examination. At the preoperative defecography, all patients presented a rectocele. At the 12-month defecography, 14 patients had no rectocele (P < 0.001) and 15 had a rectocele. At the six-month follow-up, there was a significant decrease in rectal emptying difficulties, need of digital support of the posterior vaginal wall at defecation, and defecation frequency. At the 12-month follow-up, symptom improvement remained, but was less pronounced. CONCLUSIONS: Rectocele repair using collagen mesh improved anatomic support, but there is a substantial risk for recurrence with unsatisfactory anatomic and functional outcome one year after surgery. Rectocele repair using mesh was not associated with an increased risk of dyspareunia. Rectocele repair using biomaterial mesh reinforcement needs further evaluation before adopted into clinical practice.

Adult↗
PubMed2006

Rectal volume tolerability and anal pressures in patients with fecal incontinence treated with sacral nerve stimulation.

PURPOSE: Sacral nerve stimulation has proven to be a promising treatment for fecal incontinence when conventional treatment modalities have failed. There have been several hypotheses concerning the mode of action of sacral nerve stimulation, but the mechanism is still unclear. This study was designed to evaluate the results of rectal volume tolerability, rectal pressure-volume curves, and anal pressures before and six months after permanent sacral nerve stimulation and to investigate the mode of action of sacral nerve stimulation. METHODS: Twenty-nine patients with incontinence (male/female ratio = 6/23; median age, 58 (range, 29-79) years) underwent implantation of a permanent sacral electrode and neurostimulator after a positive percutaneous nerve evaluation test. Wexner incontinence score, rectal distention with thresholds for "first sensation," "desire to defecate," and "maximal tolerable volume," rectal pressure-volume curves, anal resting pressure, and maximum squeeze pressure were evaluated at baseline and at six months follow-up. RESULTS: Median Wexner incontinence score decreased from 16 (range, 6-20) to 4 (range, 0-12; P < 0. 0001). Median "first sensation" increased from 43 (range, 16-230) ml to 62 (range, 4-186) ml (P = 0.1), median "desire to defecate" from 70 (range, 30-443) ml to 98 (range, 30-327) ml (P = 0.011), and median "maximal tolerable volume" from 130 (range, 68-667) ml to 166 (range, 74-578) ml (P = 0.031). Rectal pressure-volume curves showed a significant increase in rectal capacity (P < 0.0001). The anal resting pressure increased significantly from 31 (range, 0-109) cm H(2)O to 38 (range, 0-111) cm H(2)O (P = 0.045). No significant increase in maximum squeeze pressure was observed. CONCLUSIONS: For patients with fecal incontinence successfully treated with sacral nerve stimulation, there was a significant increase in rectal volume tolerability and rectal capacity. A significant increase in anal resting pressure, but not in maximum squeeze pressure, was found. We suggest that sacral nerve stimulation causes neuromodulation at spinal level.

Adult↗
PubMed2007

Functional results of laparoscopic resection rectopexy for symptomatic rectal intussusception.

PURPOSE: This study was designed to assess the role of laparoscopic resection rectopexy for symptomatic rectal intussusception in patients who failed medical treatment. The functional outcomes of laparoscopic resection rectopexy were evaluated. METHODS: Patients who underwent laparoscopic resection rectopexy for rectal intussusception between July 1998 and November 2004 were identified. All patients with obstructed defecation failing medical treatment were included. Data were prospectively collected for the perioperative period. A follow-up questionnaire was used to assess functional outcome. RESULTS: Between 1998 and 2004, a total of 56 patients (53 females (95 percent); age range, 23-83 years) underwent laparoscopic resection rectopexy for rectal intussusception. The median operative time was 123 minutes. Morbidity was 7 percent, and there was no mortality. Fifty-two patients were available for follow-up, and of these 33 (63 percent) reported an overall improvement in their function after surgery. Of 28 patients suffering constipation, 15 (53 percent) reported an improvement in bowel frequency. Sixty-seven percent of patients incontinent before surgery improved. Symptoms of incomplete evacuation resolved in 38 percent of affected patients. Thirty-six percent of patients needing to strain at stool did not have this problem after surgery. Median follow-up was 44 (range, 15-92) months. CONCLUSIONS: The management of patients with rectal intussusception and obstructed defecation failing medical treatment is challenging. Laparoscopic resection rectopexy is an option that might offer symptomatic relief and improved function. Further studies are required to define the selection criteria to optimize the outcome in this patient group.

Adult↗
PubMed2003

Treatment of Fecal Incontinence.

Fecal incontinence is a symptom of many disorders that can affect the nerves and muscles controlling defecation; it is not just due to exceptionally voluminous diarrhea. Underlying problems should be identified and treated, because that may improve incontinence. If treatment of the underlying problem does not correct incontinence, several approaches can be employed successfully. General approaches include stimulation of defecation at intervals to empty the rectum under supervised conditions; treatment of diarrhea, if present; addressing coexisting psychologic problems, such as depression; use of continence aids, such as adult diapers; and perineal skin care to prevent skin breakdown. Drug therapy includes use of constipating drugs, such as loperamide or diphenoxylate, that can impede the gastrocolic reflex, thereby limiting rectal filling and the likelihood of incontinence. Biofeedback training is useful in patients with some ability to sense rectal distention and to contract the external anal sphincter; instrumental learning using manometric or electromyographic biofeedback can be used to reinforce the rectoanal contractile response to rectal distention. Improvement in continence has been noted in up to 70% of suitable candidates with a single biofeedback training session. Patients with external anal sphincter disruption due to childbirth injury or other trauma may benefit from direct external anal sphincter repair (sphincteroplasty). In others, tightening up the anal canal by encirclement with nonabsorbable mesh (Thiersch procedure), perianal injection of fat, collagen, or synthetic gel, or radiofrequency electrical energy (Stretta procedure) may provide some palliation. Creation of a new sphincter mechanism by muscle transposition and encirclement of the anal canal is another approach that has been improved by use of electrical stimulators to keep the neosphincter contracted. Artificial anal sphincters patterned after artificial urinary sphincters have met with some success, but local infection remains problematic. When all else fails, fecal diversion (ileostomy, colostomy) can be effective in rehabilitating patients.

Journal Article↗
PubMed2004

An outbreak of norovirus gastroenteritis on an Israeli military base.

BACKGROUND: Noroviruses (NVs) are a predominant cause of viral gastroenteritis outbreaks, but they are difficult to identify because they cannot be cultivated in cell culture. Therefore, reverse-transcriptase polymerase chain reaction (RT-PCR) assays are widely used in the testing of clinical stool specimens for NV. However, testing of perianal swabs in the context of an outbreak is considered to be an insensitive method for identification of NV using the RT-PCR technique. An outbreak of acute gastroenteritis involving 159 soldiers on a training base of the Israel Defense Force in December 1999 allowed us to evaluate this identification method. PATIENTS AND METHODS: An epidemiologic investigation, a sanitation survey and a case-control study of exposure to different food items served up to 48 h preceding the outbreak were conducted. Stool samples in the form of post-defecation perianal swabs were collected from 24 ill personnel and three non-ill food handlers. Swabs were tested for the presence of NV by RT-PCR assay. RESULTS: Epidemiologic data were consistent with a pointsource food-borne outbreak which was associated with consumption of fresh vegetable salad in the base mess hall (OR = 4.38, 95% CI 1.51-13.35). Both epidemiologic and clinical features were suggestive of gastroenteritis caused by NV, and upon laboratory analysis perianal swabs from four of 24 cases were positive for NV. CONCLUSION: The combination of practical specimen collection with perianal post-defecation swabs, and the utilization of a molecular epidemiology approach, can simplify the rapid identification of outbreaks caused by NVs.

Adult↗
PubMed1991

Effects of atipamezole, a novel alpha 2-adrenoceptor antagonist, in open-field, plus-maze, two compartment exploratory, and forced swimming tests in the rat.

The behavioral effects of atipamezole (0.5-4.5 mg/kg), a new and highly selective alpha 2-adrenoceptor antagonist, were studied in four behavioral models: open-field, elevated plus-maze, two compartment exploratory test and forced swimming test. Atipamezole (1.5 and 4.5 mg/kg) produced a dose-dependent suppression of locomotor activity in the open field test. In the two compartment exploratory test, the same doses of atipamezole decreased locomotor activity in a 5 min test but not in a 10 min test. The numbers of transitions between the compartments were not significantly affected by atipamezole. Doses of 0.5-4.5 mg/kg did not significantly change the time spent in the open arms or the total number of arm entries in the plus-maze, and doses of 1.5 and 4.5 mg/kg decreased defecation marginally. Vocalization during the forced swimming test was increased by atipamezole (1.5 mg/kg) but the duration of immobility was not increased over the dose range (0.5-1.5 mg/kg) of atipamezole used. Our results suggest that, in the rat, atipamezole decreases motor activity in the early phase of the exploration of new surroundings. In the doses used, atipamezole may suppress defecation and increase vocalization in rats.

Adrenergic alpha-Antagonists↗