Preoperative conditioning with oral carbohydrate loading and oral nutritional supplements can be combined with mechanical bowel preparation prior to elective colorectal resection.

OBJECTIVE: Preoperative conditioning with oral fluid and carbohydrate (CHO) loading allows the patient to undergo surgery in the fed state and is associated with reduced postoperative insulin resistance. Further benefit may accrue from oral nutritional supplements (ONS) to counteract the fasting associated with mechanical bowel preparation (MBP). In this study we assess the ability to prescribe, dispense and have patients comply with a protocol combining preoperative ONS and CHO/fluid loading during MBP. METHOD: One hundred and forty-seven patients undergoing elective left colonic or rectal resection were recruited to an Enhanced Recovery after Surgery (ERAS) programme. All patients were prescribed MBP (2 sachets Picolax). On the daytime prior to surgery, eligible patients were prescribed 2 x 200 ml of ONS (Fortijuice, Nutricia) and in the evening 800 ml oral CHO/fluid loading (Preop(R), Nutricia,). Patients were prescribed a further 400 ml of oral/CHO/fluid on the morning of surgery 2 h prior to induction of anaesthesia. Protocol compliance was audited prospectively. RESULTS: One hundred and forty-seven patients received MBP. Twenty-three patients were ineligible for oral CHO/fluid loading [diabetes (n = 22), allergy to lemon flavoured drinks (n = 1)]. Fourteen patients did not receive the preoperative CHO drinks due to failure to prescribe (n = 8) or dispense (n = 6). One hundred and ten patients were dispensed the combined ONS and CHO/fluid loading regimen, compliance rates were 83% with ONS, 80% with CHO/fluid loading and 74% with both. CONCLUSION: Approximately 74% of patients undergoing MBP can comply with preoperative conditioning with ONS and CHO/fluid loading. Prescription and dispensing requires close attention to detail.

Preliminary results of a multicentre trial of the electrically stimulated gracilis neoanal sphincter.

BACKGROUND: The electrically stimulated gracilis neoanal sphincter was initially developed to treat refractory incontinence. Good early results were reported from the two centres that pioneered the technique. The aim of this study was to assess the operation in a prospective multicentre setting. METHODS: The procedure was performed on 64 patients from seven centres worldwide and was performed in stages. All patients were evaluated clinically and manometrically before and after operation. RESULTS: There was a high incidence of infective and hardware-related complications. At a median of 10 months following closure of the defunctioning stoma 56 per cent had experienced a good functional result. The major functional problems comprised evacuatory difficulties experienced by 25 per cent. CONCLUSION: The technique is effective in treating otherwise refractory incontinence. It is, however, a complex procedure and the morbidity rate may be high, particularly during the learning curve, factors that necessitate careful patient selection. Presented to the Association of Surgeons of Great Britain and Ireland in Bournemouth, UK, April 1997 and the European Council of Coloproctology in Edinburgh, UK, June 1997; and published in abstract form as Br J Surg 1997; 88(Suppl): 39 and Int J Colorectal Dis 1997; 12: 144

Glutamine-supplemented total parenteral nutrition enhances T-lymphocyte response in surgical patients undergoing colorectal resection.

OBJECTIVE: The authors determined the effect of glutamine-supplementation of TPN on postoperative peripheral blood T-cell response and proinflammatory cytokine production in patients undergoing colorectal resection. SUMMARY BACKGROUND DATA: Several vital tissues, including the immune system, are very dependent on glutamine; however, this amino acid, which may be essential in conditions of stress, only now is becoming formulated suitably for incorporation into TPN. The effects of such supplementation on the immune function of stressed surgical patients is unknown. METHODS: Patients (n = 20) were randomized to receive conventional TPN (0.2 g nitrogen/kg/d) or an isonitrogenous/isocaloric regimen with 0.18 g of glutamine/kg/d from days 1 to 6 postoperatively. T-cell DNA synthesis and interleukin (IL)-2 production and peripheral blood mononuclear cell IL-6 and tumor necrosis factor (TNF) production were measured in vitro preoperatively and on days 1 and 6 postoperatively. RESULTS: T-cell DNA synthesis after 5 days of TPN was increased compared with preoperative values in the glutamine-supplemented group (median preoperative tritiated thymidine uptake: 78.3 x 10(3) cpm, day 6: 95.0 x 10(3) cpm, p < 0.05). There was no such increase in the control TPN group (preoperative: 89.0 x 10(3) cpm, day 6: 69.4 x 10(3) cpm, p > 0.05). Glutamine supplementation did not influence IL-2 production or the production of TNF or IL-6. CONCLUSIONS: Glutamine supplementation may be a method of enhancing T-cell function in the surgical patient receiving TPN.

Anismus: the cause of constipation? Results of investigation and treatment.

Anismus, or failure of the somatic sphincter apparatus to relax at defecation, has been implicated as a major contributor to the problem of obstructed defecation. Current diagnostic methods depend on laboratory measurements of attempted defecation and the most complex, dynamic proctography has been the mainstay of diagnosis. Using a new computerized ambulatory method of recording sphincter function in these patients at home, we report an 80% reduction in our diagnostic rate suggesting that conventional tests fail to accurately diagnose this condition, probably because they poorly represent the natural physiology of defecation. Treatment of this distressing condition is more complex and a variety of surgical and pharmacological measures have failed. Biofeedback retraining of anorectal function of these patients has been very successful and represents the management of choice.

Intra-operative air testing: an audit on rectal anastomosis.

Thirty three patients having an anastomosis to the rectum were studied prospectively to determine the usefulness of intra-operative air testing. The pelvis was filled with saline and the anastomosis was distended with air. Any leaks demonstrated were oversewn. A Gastrografin enema was performed on all the patients on the eighth postoperative day. Overall, there were 4 (12%) clinical leaks and 10 (30%) radiological leaks. In six patients with air leaks demonstrated at operation, two had a radiological leak, one of which presented clinically as well. We believe that in the other four patients a potential leak was probably avoided as a result of intra-operative air testing. This technique is simple, safe and effective and probably helps reduce leakage after colorectal anastomosis.

Anal sensation and the continence mechanism.

Thermal sensation is thought to be important in sensory discrimination between different substances. The aim of this study was to determine the thermal sensitivity in the anal canal in continent patients with hemorrhoids (N = 20), a group that has been reported to have a sensory deficit, and to compare the results with control subjects (N = 40) and patients with idiopathic fecal incontinence (IFI) (N = 22). Anal manometry was performed and sensation to mucosal electrostimulation and temperature change in the lower, middle, and upper zones of the anal canal assessed. Thermal sensation was impaired in the hemorrhoid group as compared with controls, but not to the same degree as in IFI (e.g., median thermal sensitivity in mid anal canal, control 0.9 degrees C, hemorrhoid 1.2 degrees C, IFI 2.0 degrees C, P less than .05 and less than .001, respectively). The correlation between the two tests of sensation was 0.54 (P less than .001) and the reproducibility of thermal sensory thresholds was 0.82 (P less than .001). In conclusion, patients with hemorrhoids have a mild anal sensory deficit, but continence in this group is likely to be augmented by other factors.

Flap-valve theory of anorectal continence.

The most important component of continence is considered to be the puborectalis muscle which is reputed to function by creating a flap-valve mechanism in which the anterior rectal wall occludes the upper and canal. To elucidate this, anal and rectal pressures were measured simultaneously together with external anal sphincter and puborectalis electromyogram and synchronously superimposed on an image intensifier displaying the rectum outlined by barium. We studied 13 subjects at rest, and during a Valsalva manoeuvre. There was a significant rise in rectal and sphincter pressures (P less than 0.005) and external sphincter and puborectalis EMG (P less than 0.005). In a further 13 patients Valsalva manoeuvres were performed during proctography alone. In all subjects the anterior rectal wall was always clearly separated from the upper sphincter despite a maximal effort and a rectum filled with sufficient liquid to produce a desire to defaecate. These findings question the flap-valve theory of continence and suggest the puborectalis functions by sphincteric occlusion of the anal canal.

Techniques in evacuation proctography in the diagnosis of intractable constipation and related disorders.

A technique of evacuation proctography using a simple barium and air mixture is described. The study can be easily combined with a barium enema examination. A series of 35 patients with intractable constipation have been studied and compared with 7 controls. Most of the abnormalities seen using more elaborate methods of defaecography were identified. Variants of rectal intussusception were found in 16 patients. Other diagnoses included rectocele, mucosal and full rectal prolapse, accentuation of puborectalis impression and solitary rectal ulcer. The technique should prove useful in the management of patients with disorders of defaecation.