Long-term anal continence and quality of life following postpartum anal sphincter injury.

OBJECTIVE: Anal incontinence occurs as a result of damage to pelvic floor and the anal sphincter. In women, vaginal delivery has been recognized as the primary cause. To date, figures quoted for overt third degree anal sphincter tear vary between 0% and 26.9% of all vaginal deliveries and the prevalence of anal incontinence following primary repair vary between 15% and 61%. Our aim was to analyse the long-term (minimum 10 years post primary repair) anorectal function and quality of life in a cohort of women who suffered a third degree tear (Group 1) and compare the results with a cohort of women who underwent an uncomplicated vaginal delivery (Group 2) or an elective caesarean delivery (Group 3). METHOD: In all, 107 patients who suffered a third degree tear between 1981 and 1993 were contacted with a validated questionnaire. The two control groups comprised of 125 patients in each category. Those who responded to the questionnaire were invited for anorectal physiology studies and endoanal ultrasound. RESULTS: Of the total number contacted, 54, 71 and 54 women from the three groups returned the completed questionnaire. In the three groups, a total of 28 (53%), 13 (19%) and six (11%) complained of anal incontinence (P < 0.0001) respectively. Comparison of quality of life scores between the groups showed a poorer quality of life in those who suffered a tear (P < 0.0001). In addition, in spite of primary repair, 13 (59%) patients in group 1 showed a persistent sphincter defect compared to one (4%) occult defect in Group 2 and none in Group 3. CONCLUSION: Our study indicates that long-term results of primary repair are not encouraging. It therefore emphasizes the importance of primary prevention and preventing further sphincter damage in those who have already suffered an injury (during subsequent deliveries).

Postoperative esophageal physiology studies may help to predict long-term symptoms following laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication is an established treatment for gastroesophageal reflux disease (GERD). Postoperative improvement in esophageal physiology can be indicative of successful surgery, but the degree to which it correlates with symptom control remains questionable. We have performed this study to assess the utility of postoperative esophageal physiology studies in predicting long-term symptomatic outcome. METHODS: Between August 1997 and August 2003, 145 patients with symptomatic GERD underwent laparoscopic Nissen fundoplication as part of a randomized trial. Four months after surgery patients were invited to have postoperative esophageal physiology studies. In November 2005, a postal questionnaire was sent to all patients in order to assess reflux symptomatology (DeMeester symptom score). RESULTS: Completed symptom questionnaires were returned by 108 patients (74%) after a median of 5.7 years postoperatively. Linear regression of manometry data showed a significant correlation between the level of postoperative neosphincter pressure either above or below the median and long-term scores for heartburn (p = 0.03), dysphagia (p = 0.02), regurgitation (p = 0.01), and total symptom score (p = 0.002). In contrast, there was no evidence of a significant correlation between results of postoperative esophageal pH studies and symptom scores. CONCLUSION: Postoperative physiology studies, particularly manometry, may be predictive of long-term symptoms following laparoscopic Nissen fundoplication.

HOW DO WORK HIERARCHIES AND STRICT DIVISIONS OF LABOUR IMPACT CARE WORKERS' EXPERIENCES OF HEALTH AND SAFETY? CASE STUDIESOF LONG TERM CARE IN TORONTO.

BACKGROUND: According to the Canadian Health Care Association (1), there are 2,577 long-term care ("LTC") facilities across Canada, with the largest proportion (33.4%) located in Ontario. Most studies focus on residents' health, with less attention paid to the health and safety experiences of staff. Given that the work performed in Ontario LTC facilities is very gendered, increasingly racialized, task-oriented, and with strict divisions of labour, this paper explores in what ways some of these factors impact workers' experiences of health and safety. OBJECTIVES: The study objectives included the following research question: How are work hierarchies and task orientation experienced by staff? DESIGN AND SETTING: This paper draws on data from rapid team-based ethnographies of the shifting division of labour in LTC due to use of informal carers in six non-profit LTC facilities located in Toronto, Ontario. METHODS: Our method involved conducting observations and key informant interviews (N=167) with registered nurses, registered practical nurses, personal support workers, dietary aides, recreation therapists, families, privately paid companions, students, and volunteers. Interviews were audio-recorded, transcribed verbatim, and thematically analyzed. For observations, researchers were paired and covered shifts between 7 a.m. and 11 p.m., as well as into the late night over six days, at each of the six sites. Detailed ethnographic field notes were written during and immediately following observational fieldwork. RESULTS: Our results indicate that employee stress is linked to the experiences of care work hierarchies, task orientation, and strict divisions of labour between and among various staff designations. CONCLUSION: Findings from this project confirm and extend current research that demonstrates there are challenging working conditions in LTC, which can result in occupational health and safety problems, as well as stress for individual workers.

Intraoperative tissue oximetry in the human gastrointestinal tract.

Tissue oxygen tension was measured using a modified Clark oxygen electrode in the gastrointestinal tract of 33 patients undergoing laparatomy. The electrode, which incorporated a thermistor, had a linear response to oxygen tension (r = 0.995, p less than 0.001). The patients were all maintained on an inspired oxygen concentration of 33 +/- 3% and had a mean arterial oxygen tension (PaO2) of 124.9 +/- 31.9 mm Hg. Tissue oxygen tension measurements (mm Hg, mean +/- SD) were recorded from the serosal surfaces of the stomach (46.3 +/- 15.4), mid-ileum (36 +/- 9.7), terminal ileum (33.5 +/- 11.5), cecum (30.3 +/- 7.4), transverse colon (38.5 +/- 10), descending colon (29.3 +/- 11), and sigmoid colon (39.2 +/- 7.7) and tended to increase with increasing PaO2 (r = 0.70, p less than 0.001). Arterial occlusion resulted in a gradual decrease in tissue oxygen tension. It is concluded that intraoperative tissue oxygen tension measurement is feasible, and that the technique may have clinical applications in the assessment of intestinal viability.

Comparison of vector symmetry index and endoanal ultrasonography in the diagnosis of anal sphincter disruption.

BACKGROUND: Anal pressure vectography is an anorectal physiology study that evaluates the radial pressures in the anal canal from which a symmetry index that indicates the anatomical integrity of the anal sphincter can be calculated. However, there are conflicting opinions of its validity. Since endoanal ultrasonography (EAUS) has been recognized as the gold standard for detecting anal sphincter disruption, the aim of this pilot study was to observe whether a vector symmetry index (VSI) determined at the level of injury shown in EAUS has a better sensitivity than the overall VSI in detecting anal sphincter disruption. METHODS: A group of 11 women in whom EAUS had shown defects in both the internal and the external anal sphincters underwent anorectal manometry using a water-perfused vector manometry catheter, and the overall VSI and the VSI at the level of sphincter disruption (shown on EAUS) were calculated. RESULTS: Overall VSI at rest indicated internal sphincter injury in 7 women (64%) but the VSI at the level of disruption indicated internal sphincter injury in all 11 women (100%, p=0.0137). Similarly, the overall VSI at squeeze indicated external sphincter injury in 6 women (55%), but the VSI at the level of disruption indicated external sphincter injury in 10 women (91%, p=0.0049). CONCLUSIONS: Our pilot study showed that EAUS and VSI are equally sensitive in diagnosing a localized anal sphincter defect, provided a segment-for-segment comparison is carried out.

Randomized clinical trial of laparoscopic Nissen fundoplication compared with proton-pump inhibitors for treatment of chronic gastro-oesophageal reflux.

BACKGROUND: Both laparoscopic Nissen fundoplication (LNF) and proton-pump inhibitor (PPI) therapy are established in the treatment of gastro-oesophageal reflux disease (GORD). The aim of this study was to compare these two treatments in a randomized clinical trial. METHODS: Between July 1997 and August 2001, 340 patients with a history of GORD for at least 6 months were investigated by endoscopy, 24-h pH monitoring and manometry. Of these, 217 were randomized, 109 to LNF and 108 to PPI therapy. The two groups were well matched for age, sex, weight and severity of reflux. Twenty-four-hour pH monitoring and manometry were performed 3 months after treatment, and quality of life was assessed in both groups using the Psychological General Well-being Index and the Gastrointestinal Symptom Rating Scale at 3 and 12 months after treatment. RESULTS: At 3 months there was an improvement in lower oesophageal sphincter pressure from 6.3 to 17.2 mmHg in the LNF group but no change in the PPI group (8.1 and 7.9 mmHg before and after treatment respectively) (P < 0.001). The mean DeMeester acid exposure score improved from 42.7 to 8.6 (P < 0.001) in the LNF group and from 36.9 to 17.7 in the PPI group (P < 0.001). The mean gastrointestinal symptom and general well-being scores improved from 31.7 and 95.4 respectively before treatment to 37.0 and 106.2 at 12 months after LNF, compared with changes from 34.3 and 98.5 to 35.0 and 100.4 respectively in the PPI group. The differences in both of these scores were significant between the two groups at 12 months (P = 0.003). CONCLUSION: LNF leads to significantly less acid exposure of the lower oesophagus at 3 months and significantly greater improvements in both gastrointestinal and general well-being after 12 months compared with PPI treatment.

A versatile light microscope heating stage for biological temperatures.

A light microscope heating stage suitable for biological temperatures is described. A novel feature of the design is the use of cupro-nickel foil heaters (0.1 mm thick). With a temperature sensor mounted on the slide clip and a temperature controller unit, this apparatus maintains a temperature of 310 K with a precision of 0.1 K. The apparatus is inexpensive, reliable, not confined to use with one microscope and does not interfere significantly with the stage movement or optical alignment.

Colonic anastomotic healing and oxygen tension.

Using a Clark oxygen electrode and a 133Xe clearance technique, tissue oxygen tension (T02) and blood flow have been determined in the small and large bowel of a rabbit experimental model. The predictive value of perianastomotic T02 in colonic anastomoses was determined, healing being assessed by leakage rate, tensile strength and hydroxyproline content. The effect of suture technique on colonic perianastomotic T02 has also been studied. Colonic and small intestinal T02 correlated with blood flow (r = 0.93). Basal colonic blood flow and oxygen tension were significantly lower than in the small intestine (P less than 0.01). Interrupted and continuous suture techniques decreased colonic perianastomotic T02, although mean T02 in the continuous group was significantly lower than in the interrupted group (P less than 0.01). The leakage rate was 10 per cent (1/10) for anastomoses constructed with a perianastomotic T02 above 55 mmHg compared with 100 per cent (10/10) if less than 25 mmHg (P less than 0.001). Perianastomotic T02 correlated with breaking energy (P less than 0.001), breaking strength (P less than 0.01) and hydroxyproline content (P less than 0.05).

Tissue oxygen tension as a predictor of colonic anastomotic healing.

Inadequate blood flow causing tissue hypoxia can result in failure of anastomotic healing. Tissue oxygen tension (ptO2) measurement has been used to predict anastomotic leakage in animals, but its use in humans has not been described previously. A Clark-type oxygen electrode was used to measure ptO2 on the colon of 50 patients undergoing colonic resection and anastomosis. Baseline ptO2 levels were lowest on the descending colon (31.8 +/- 7.4 mmHg, mean +/- SD) and tended to increase at all sites with increasing arterial paO2 (r greater than .76, P less than .001). Perianastomotic ptO2 levels were predictive of subsequent anastomotic leakage when they were less than either 20 mmHg; 50 percent of the preresection ptO2; 15 percent of the arterial paO2; or 40 percent of the ptO2 at a control site (ileum). It is concluded that perioperative ptO2 measurements are of value in the prediction of anastomotic leakage.

A long-term clinical review of patients with oesophageal pain.

Oesophageal and cardiac chest pain are often difficult to distinguish on clinical grounds. The clinical course of 32 patients with recurrent chest pain due to oesophageal dysmotility has recently been assessed by questionnaire 9 years after diagnosis. Twenty-six of the 27 who replied continued to have pain, but despite this there was a significant reduction in the number of hospital admissions associated with chest pain. Repeat oesophageal manometry in nine showed that the disturbance in motility persisted. Three had died, one of them from a myocardial infarction; two patients could not be traced.

Oxygenation in the stomach and the effect of truncal vagotomy.

A Clark polarographic oxygen electrode allowed detailed mapping of tissue oxygen (PtO2) levels on the anterior surface of the stomach in five patients undergoing cholecystectomy. No significant difference in mean PtO2 was detectable between greater and lesser curvatures. A significant difference in mean PtO2 was detected between the body of the stomach and the pylorus (Mann-Whitney, P less than 0.01). The effect of truncal vagotomy on PtO2 was evaluated in six patients undergoing this procedure for duodenal ulceration. Mean postvagotomy stomach PtO2 levels (46 +/- 12 mmHg) were significantly lower (Wilcoxon test, P less than 0.001) than prevagotomy levels (59 +/- 14 mmHg). Truncal vagotomy did not have any significant effect on small intestinal PtO2. This work provides the first objective evidence of the relatively diminished tissue oxygenation in the gastric antrum and pyloric region, and confirms blood flow studies of the effects of vagotomy.

Vector volume analysis of the lower esophageal sphincter in achalasia and the effect of balloon dilation.

Assessment of the effect of balloon dilation of the lower esophageal sphincter in achalasia currently relies on symptom scores, radiologic studies, or manometry. We have used vector volume analysis which constructs a three-dimensional (3D) pressure profile to examine the effects of balloon dilation on the sphincter. Studies were performed in 26 normal subjects and in 11 patients with achalasia in whom vector volume was determined before and/or after balloon dilation. Vector volume analysis was performed using a multilumen manometry catheter with eight side-reading ports. The catheter was withdrawn through the sphincter using a continuous pull-through technique. A 3D pressure profile was constructed. Vector volume of the lower esophageal sphincter shows a marked radial and linear asymmetry in normal subjects. 3D pressure profiles showed a symmetrical increase in lower esophageal sphincter pressure in untreated achalasia. Mean vector volumes pre and postdilation fell from 254 to 88 cm3 respectively. This was associated with a fall in the mean radial symmetry index from 0.83 to 0.76. Improvement in dysphagia occurred in those patients in whom pressure fell to 15 mmHg or below in at least three adjacent segments. This technique may be a useful tool in the assessment of patients with achalasia and postdilation results may help to predict the long-term outcome of treatment.

Determination of a critical level of tissue oxygenation in acute intestinal ischaemia.

Tissue oxygen tension (PtO2) was measured using a miniaturised polarographic oxygen electrode in 134 segments of rat small intestine of varying degrees of ischaemia. Without knowledge of the PtO2 levels, the viability of each segment was scored using clinical parameters and tissue damage scored by independent histological examination. Histologically non-viable bowel had significantly impaired tissue oxygenation when compared with viable bowel (t test, p less than 0.001). Marked degrees of tissue hypoxia were frequently tolerated before major histological damage became apparent, a critical PtO2 level of 1.9 mmHg being identified. The overall accuracy rate of PtO2 measurement in the operative prediction of intestinal viability was 92.5%, which contrasts with a rate of only 57.7% for clinical criteria alone.

Anorectal physiological testing in defecatory disorders: a prospective study.

A prospective study of anorectal physiological testing in 26 patients with obstructed defecation and 20 patients with faecal incontinence was performed. There were overlaps in individual test parameters between the two groups of patients. However, patients with severely blunted rectal sensation (maximum tolerated volume > 300 mL) and anismus were more likely to have obstructed defecation. Patients with very low anal canal pressures, a short (< 2.0 cm) anal canal, bilaterally prolonged (> 2.1 ms) pudendal nerve terminal motor latency and a grossly distorted and canal (vector symmetry index < or = to 0.75) were more likely to have faecal incontinence. Thus, patterns of anorectal physiological test results together with clinical evaluation, rather than individual test measurements, are more valuable in defining the underlying defecatory disorders and providing guidance on therapy.

High tie of the inferior mesenteric artery in distal colorectal resections--a safe vascular procedure.

Division of the inferior mesenteric artery flush with the aorta (high tie) allows a tension-free anastomosis in distal colorectal resections but may also diminish the blood supply. Tissue oxygen tension was measured proximal to the resection margin before and after either low or high division of the inferior mesenteric artery in 62 patients undergoing elective colorectal resections. Oxygenation was maintained or improved when the transverse (median change after vs before resection for low tie +9 mmHg (P < 0.05), high tie +8 mmHg (P = 0.3)) and descending colon (low tie +7 mmHg (p < 0.01), high tie +1 mmHg (p = 0.67)) were used for the anastomosis but diminished for sigmoid anastomoses (low tie -4 mmHg (P = 0.42), high tie -9 mmHg (P < 0.05)). Change in oxygenation was significantly affected by location of proximal resection site but not by choice of high or low tie. These results suggest that the marginal artery provides a more than adequate vascular supply to the transverse and descending colon, but that the sigmoid colon is not suitable for anastomosis. We conclude that the sigmoid colon be sacrificed and there should be no hesitation in performing a high tie to avoid tension in low pelvic anastomoses.