Does drinking coffee reduce the risk of colorectal cancer? A qualitative umbrella review of systematic reviews.

PURPOSE: Coffee drinking has been linked to many positive health effects, including reduced risk of some cancers. The present study aimed to provide an overview of the collective evidence on the association between coffee consumption and risk of colorectal cancer (CRC) through an umbrella review of the published systematic reviews. METHODS: This PRISMA-compliant systematic review of systematic reviews assessed the association between coffee drinking and the risk of CRC. An umbrella review approach was followed in a qualitative narrative manner. The quality of included reviews was assessed by the AMSTAR 2 checklist. The main outcome was the association between coffee drinking and CRC and colon and rectal cancer separately. RESULTS: Fourteen systematic reviews were included in this umbrella review. Coffee drinking was associated with a significant reduction in the risk of CRC according to five reviews (11-24%), colon cancer according to two reviews (9-21%), and rectal cancer according to one review (25%). One review reported a significant risk reduction of CRC by 7% with drinking six or more cups of coffee per day and another review reported a significant risk reduction of 8% with five cups per day reaching 12% with six cups per day. Decaffeinated coffee was associated with a significant risk reduction according to three reviews. CONCLUSION: The evidence supporting caffeinated coffee as associated with a reduced risk of CRC is inconsistent. Dose-dependent relation analysis suggests that the protective effect of coffee drinking against CRC is evident with the consumption of five or more cups per day.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer.

BACKGROUND: Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment. METHODS: This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications. RESULTS: This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008). CONCLUSIONS: Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Biological therapy prior to repeat ileocolic resection in Crohn's disease can reduce the postoperative complication rate.

BACKGROUND: The aim of this study was to assess the effect of preoperative biologic therapy on the surgical outcome of Crohn's disease (CD) patients undergoing repeat ileocolic resection. METHODS: This was a retrospective analysis of all CD patients who underwent repeat ileocolic resection at Cleveland Clinic Florida between January 2011 and April 2021. Patients were divided into two groups: treatment biologic therapy prior to surgery and controls. RESULTS: Sixty-five patients (31males, median age 54 [range 23-82] years) were included in the study. Twenty nine (44.6%) were treated with biologic therapy prior to repeat ileocolic resection. No demographic differences were found between the biologic therapy and control groups. In addition, no differences were found in mean time from index ileocolic resection (p = 0.9), indication for surgery (p = 0.11), and preoperative albumin (p = 0.69). The majority of patients (57; 87.7%) were operated on laparoscopically, and mean overall operation time was 225 (SD 49.27) min. Overall, the postoperative complication rate was 43.1% (28 patients) and median length of stay was 5 (range 2-21) days. Postoperative complications were more common in the control group, compared to the biologic therapy group (55.6 vs 27.5%; p = 0.04). Conversion rate (35.7 vs 20.7%; p = 0.24), operation time (223 vs 219 min; p = 0.75), length of stay (5.2 vs 5.9 days; p = 0.4), and readmission (16.6 vs 11.1%; p = 0.72) were similar between the two groups. Multivariate analysis of risk factors for postoperative complications showed that biologic treatment was correlated with a lower risk (HR -0.28, CI 95% -0.5596 to -0.01898, p = 0.03). CONCLUSIONS: Patients treated with biologic therapy for CD who underwent repeat ileocolic resection had fewer postoperative complications.

Use of indocyanine green fluorescence angiography during ileal J-pouch surgery requiring lengthening maneuvers.

BACKGROUND: The purpose of this study was to review whether routine usage of indocyanine green (ICG) perfusion assessment during complex ileal J-pouch surgery requiring lengthening maneuvers reduces ischemic complications. METHODS: Retrospective chart review of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) who underwent ileal pouch-anal anastomosis (IPAA) surgery with lengthening maneuvers and intraoperative ICG assessment between January 2015 and January 2021. All patients underwent a double stapled anastomosis and were temporarily diverted. All patients underwent laparoscopic and trans-anal ICG assessment of their J-pouch and anastomosis. All J-pouches were evaluated 6 weeks after surgery via contrast enema and pouchoscopy. RESULTS: One hundred fifty eight patients underwent ileal J-pouch surgery during the study period. Sixteen patients (10%) underwent lengthening maneuvers and intra-operative ICG assessment. Twelve patients underwent surgery for UC and 4 for FAP. Median age was 40.3 years and average body mass index was 24.9 kg/m2. Twelve patients underwent a two-stage procedure and the remaining underwent a three-stage procedure. 93.7% of cases were completed laparoscopically (15/16). All patients underwent scoring of the peritoneum and 43% (7/16) underwent division of the ileocolic or intermediate mesenteric vessels. There was no mortality or pouch ischemia and the leak rate was 12.5%. All patients underwent reversal after an average of 18 ± 7 weeks. CONCLUSION: ICG perfusion assessment appears to be of utility in complex IPAA surgery requiring lengthening maneuvers. Its application may be associated with reduced J-pouch ischemia and leak rate in this unique setting.

Sacral neuromodulation for fecal incontinence in Latin America: initial results of a multicenter study.

BACKGROUND: Sacral neuromodulation (SNM) is a widely used therapeutic option for fecal incontinence (FI). Larger series are mainly from Western countries, while few reports address the results of SNM in less developed or less wealthy countries. The aim of the present study was to evaluate the efficacy of SNM in patients with FI in Latin America. METHODS: A retrospective study was conducted on patients with FI who had SNM between 2009 and 2016 at 15 specialized colorectal surgery centers in Latin America. Main outcomes measures were functional outcomes, postoperative complications, requirement of revisional surgery, and requirement of device removal. All patients had failed conservative management and had clinical assessment including recording of the validated Cleveland Clinic Florida Fecal Incontinence Score (CCF-FIS) and, when available, anal manometry and endoanal ultrasound. Patients were followed up for a median of 36.7 (1-84) months. RESULTS: One hundred and thirty-one patients [119 females, median age of 62.2 (range 19-87) years] were included. The most common etiology of FI was obstetric injury (n = 60; 45.8%). After successful test lead implantation, the stimulator was permanently placed in 129 patients (98.5%). One patient failed to respond in the test phase and one patient did not proceed to permanent implantation for insurance reasons. Nineteen patients (14.7%) had 19 complications including infection (n = 5, 3.8%), persistent implant site pain (n = 5, 3.8%), generator/lead dislodgment (n = 5, 3.8%), malfunctioning device (n = 3, 2.3%), and hematoma (n = 1, 0.7%). Reimplantation after the first and second stages was necessary in 2 (1.5%) and 3 patients (2.3%), respectively. The device removal rate was 2.2%. At a median follow-up of 36.7 (range 1-84) months, the CCF-FIS significantly improved from a preoperative baseline of 15.9 ± 2.98 to 5.2 ± 3.92 (95%CI: 15.46 vs 4.43; p < 0.0001). Overall, 90% of patients rated their improvement as "significant". CONCLUSIONS: Sacral nerve stimulation for FI is safe and efficient, even in less wealthy or less developed countries.

Faecal incontinence in patients with a sphincter defect: comparison of sphincteroplasty and sacral nerve stimulation.

AIM: Sphincteroplasty (SP) is used to treat faecal incontinence (FI) in patients with a sphincter defect. Although sacral nerve stimulation (SNS) is used in patients, its outcome in patients with a sphincter defect has not been definitively evaluated. We compared the results of SP and SNS for FI associated with a sphincter defect. METHOD: Patients treated by SNS or SP for FI with an associated sphincter defect were retrospectively identified from an Institutional Review Board approved prospective database. Patients with ultrasound evidence of a sphincter defect were matched by age, gender and body mass index. The main outcome measure was change in the Cleveland Clinic Florida Faecal Incontinence Score (CCF-FIS). RESULTS: Twenty-six female patients with a sphincter defect were included in the study. The 13 patients in each group were similar for age, body mass index, initial CCF-FIS and the duration of follow-up. No differences were observed in parity (P = 1.00), the rate of concomitant urinary incontinence (P = 0.62) or early postoperative complications. Within-group analysis showed a significant reduction of the CCF-FIS among patients having SNS (15.9-8.4; P = 0.003) but not SP (16.9-12.9; P = 0.078). There was a trend towards a more significant improvement in CCF-FIS in the SNS than in the SP group (post-treatment CCF-FIS 8.4 vs 12.9, P = 0.06). Net improvement in CCF-FIS was not significantly different between the groups (P = 0.06). CONCLUSION: Significant improvement in CCF-FIS was observed in patients treated with SNS but not SP patients. A trend towards better results was seen with SNS.

Sacral neuromodulation for the treatment of faecal incontinence following proctectomy.

AIM: This study assessed the effectiveness of sacral neuromodulation (SNM) for faecal incontinence (FI) following proctectomy with colorectal or coloanal anastomosis. METHODS: An Institutional Review Board (IRB)-approved database identified patients treated for FI following proctectomy (SNM-P) for benign or malignant disease, who were matched 1:1 according to preoperative Cleveland Clinic Florida Faecal Incontinence Scores (CCF-FIS) with patients without proctectomy (SNM-NP). Primary outcome was change in CCF-FIS. RESULTS: Twelve patients (seven women) were in the SNM-P group and 12 (all women) were in the SNM-NP group. In the SNM-P group, six patients underwent proctectomy for low rectal cancer and five received neoadjuvant chemoradiation. Five patients had handsewn anastomosis, and one had stapled coloanal anastomosis. One lead explantation occurred after a failed 2-week SNM percutaneous trial. Six patients underwent proctectomy for benign conditions. Within-group analyses revealed significant improvement in CCF-FIS in the SNM-P group (reduction from a score of 18 to a score of 14; P = 0.02), which was more profound for benign disease (reduction from 14.5 to 8.5) than for rectal cancer (reduction from 19.5 to 15). SNM was explanted in 66% and 33% of patients after proctectomy for malignant and benign conditions, respectively. In the SNM-NP group, 41% underwent overlapping sphincteroplasty. One patient received chemoradiation for anal cancer. Within-group analysis for the SNM-NP group showed significant improvement in CCF-FIS (a reduction from 17.5 to 4.0; P = 0.003). There was significant improvement in CCF-FIS in patients without previous proctectomy (mean delta CCF-FIS: 11.1 vs 4.7; P = 0.011). Analysis of covariance (ANCOVA) reaffirmed that controls outperformed proctectomy patients (P = 0.006). CONCLUSION: SNM for FI after proctectomy appears less effective than SNM in patients without proctectomy, with high device explantation rates, particularly after neoadjuvant chemoradiation and proctectomy for low rectal cancer.

What is the best option for failed sphincter repair?

AIM: This study aimed to evaluate the outcome of various procedures for patients with fecal incontinence following failed sphincteroplasty. METHOD: Patients who underwent surgery for failed sphincteroplasty from January 2000 to June 2011 [corrected] were identified. They were assessed using the Fecal Incontinence Quality of Life (FIQoL) scale and the Cleveland Clinic Florida-Wexner Fecal Incontinence Score (CCFFIS). RESULTS: Fifty-nine patients [97% females; median age 52 (25-81) years] were identified. They underwent either repeat sphincteroplasty (RS; n = 33), artificial bowel sphincter (ABS; n = 11) or sacral nerve stimulation (SNS; n = 15). The median follow-up was 31 (3-138) months. The RS group had a significantly wider external sphincter defect and had undergone fewer previous sphincteroplasties. The most common complication was infection. The incidence of complications was significantly higher after ABS (73%) compared with RS (24%) and SNS (33%) (P = 0.01). Seventeen (29%) patients required re-operation for complications or failure, with a lower rate in the RS group (P = 0.004). There was no difference in the rates of device removal after ABS or SNS. Ten (17%) patients underwent further surgery or re-implantation of the device with no difference between the groups. At follow-up, five (45%) ABS and 10 (67%) SNS patients retained a functioning device (P = 0.4). The mean postoperative CCFFIS decreased from 17.5 to 11.5 in the RS group, from 18.7 to 8.6 in the ABS group, and from 17.6 to 9.1 in the SNS group (P ≤ 0.02 for all). There were no differences in the improvement of CCFFIS or FIQoL scores among groups. CONCLUSION: RS, ABS and SNS are associated with similar improvements in continence after failed sphincteroplasty. Due to increased complications and re-operation with ABS and SNS, RS may be the first step in managing these patients.

Effects of radiotherapy on different histopathological types of rectal carcinoma.

BACKGROUND: Down staging by pre-operative chemoradiotherapy is currently considered part of the standard therapeutic approach to rectal carcinoma. The aim of this study was to assess the response to chemoradiotherapy of different histopathological types of rectal carcinoma with emphasis on the mucinous variant. METHOD: Between 1997 and 2002, 71 patients who received pre-operative chemoradiotherapy followed by surgery for rectal carcinoma were enrolled in the study. Staging of the rectal carcinoma was performed according to transrectal ultrasound findings (TN score) prior to the chemoradiotherapy. The chemoradiotherapy was followed by radical resection with mesorectal excision. All surgical specimens were examined by a single pathologist (MB). Pathological TN staging was assessed and tumour regression was graded according to a standard method (TRG1, complete response - TRG5 no response). Tumours were classified as mucinous or nonmucinous according to pre- and post-operative biopsy and specimen histopathological types. TN score change and TRG differences between groups were assessed. RESULTS: Tumour regression was seen after chemoradiotherapy in 94.4% of the patients, while in 5.6% of the patients no response was found. The change in TN score and TRG were correlated. Higher TRG was associated with a smaller decrease in TN staging. TRG was significantly lower in the nonmucinous compared to the mucinous group and the decrease in TN grade was significantly larger in the nonmucinous group. CONCLUSION: Mucinous carcinoma was associated with a lower response to pre-operative chemo-radiotherapy in this group of rectal carcinoma patients. Further studies are needed to determine its prognostic value.

Biofeedback therapy for rectal intussusception.

BACKGROUND: Surgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception. METHODS: We retrospectively evaluated the results of electromyography (EMG)-based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder. RESULTS: A total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean+/-SD) was 2.0+/-6.8 before and 4.1+/-4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8+/-3.5 before to 1.5+/-2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty-three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were constipated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0+/-0.7 before to 0.07+/-0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1+/-4.2 before to 4.6+/-3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. CONCLUSIONS: Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

Recurrence rates at minimum five-year follow-up: laparoscopic versus open sigmoid resection for uncomplicated diverticulitis.

The aim of the study was to compare the impact of surgical access to sigmoid resection on recurrence rates in patients with uncomplicated diverticulitis of the sigmoid (UDS) at a minimum follow-up of five years. Recurrence after surgery was defined as left lower quadrant pain, fever and leucocytosis with consistent CT and enema findings on admission and at 6 weeks, respectively. Outcome measures included splenic flexure mobilization, specimen length, inflammation at proximal resection margin and presence of teniae coli at distal resection margin. Seventy-nine patients undergoing laparoscopic sigmoid resection (LSR) were compared with 79 matched controls with open sigmoid resection (OSR) operated on at two institutions during the same period. Patients were well matched for age, gender, body mass index, ASA grading and symptoms duration, but not for follow-up length (81.9 vs. 86.9 months, p = 0.046). The rate of splenic flexure mobilization (19 vs. 41, p 0.001), specimen length (16.1 vs. 18.3 cm, p = 0.048), presence of inflammation at proximal resection margin (21 vs. 4, p 0.001), and presence of teniae coli at distal resection margin (4 vs. 53, p 0.001). Three LSR patients and 7 OSR patients had one recurrence (p = 0.19). There were no significant differences in rates of flexure mobilization, specimen length, and rates of inflammation present at proximal resection margin in 10 recurring and 145 non-recurring patients. The rate of teniae coli present at distal resection margin was significantly increased in recurring patients (7 vs. 43, p = 0.03). Surgical access to sigmoid resection for UDS is unlikely to have an impact on recurrence rates provided that the oral bowel end is anastomosed to the proximal rectum rather than to the distal sigmoid.

Electrolyte profiles within the ileoanal pouch: measurement by an in vivo equilibrium dialysis technique.

BACKGROUND: Patients with an ileoanal pouch have high rates of fluid and electrolyte loss. These improve with pouch adaptation. There is limited information concerning secretion and absorption in the stable ileoanal pouch. A new method to measure and characterize electrolytes in the ileoanal pouch is described. METHODS: Following an in vitro study, nine patients with a stable ileoanal pouch had consecutive placement of dialysis bags consisting of a semi-permeable membrane containing 5 ml of 10% dextran in normal saline into the ileoanal pouch. These were left in place for 15, 30, 60, and 120 min. After determining that 60 min was the optimal timing for measurement of electrolyte concentrations, 12 normal volunteers underwent a similar in vivo dialysis study with dialysis bags withdrawn at 60 min. Sodium, chloride, potassium, phosphorus, calcium and magnesium concentrations in the dialysis bags were compared between the two groups. RESULTS: In the in vitro and in vivo studies, the measured electrolytes reached equilibrium within 60 min. Statistically significant differences between sodium concentrations (160.9 +/- 30.2 vs. 116.8 +/- 13.8 mmol/l, respectively) and phosphorus concentrations (6.8 +/- 5.2 vs. 1.8 +/- 0.7 mg/dl, respectively) at 60 min in ileoanal pouch patients and volunteers were found (p<0.001). There were no statistical differences in the other measured electrolytes between the two groups. CONCLUSION: An in vivo dialysis technique is described for measuring electrolyte concentrations within the ileoanal pouch. Differences in sodium and phosphate concentrations may reflect incomplete adaptation of the ileoanal pouch, and are a potential explanation for increased stool frequency in these patients.

Bowel preparation for colorectal surgery.

PURPOSE: The aim of this study was to assess recent literature regarding bowel preparation for colonoscopy and surgery. METHODS: The study was conducted by an Index Medicus English-language search of articles relevant to both oral mechanical and parenteral and oral antibiotic preparation for elective colorectal surgery and mechanical bowel preparation for colonoscopy. The study period was from 1975 to 2000. In addition, studies of elective colorectal surgery without mechanical bowel preparation were also considered. RESULTS: Although several recent prospective, randomized trials have suggested that elective colorectal surgery can be safely performed without any mechanical bowel preparation, mechanical bowel preparation remains the standard of care, at least in North America at the present time. A recent survey of the members of The American Society of Colon and Rectal Surgeons revealed that the majority currently use sodium phosphate for bowel preparation and use a dual oral antibiotic regimen before elective colorectal surgery, combined with two doses of parenteral antibiotics. Although some of the use patterns are based on prospective, randomized study, others seem founded strictly on habit and theory. CONCLUSIONS: The current methods of bowel cleansing for both colonoscopy and surgery include sodium phosphate and polyethylene glycol; colorectal surgeons practicing in North America currently prefer sodium phosphate. Additional preparation for colorectal surgery includes perioperative parenteral antibiotics and, to a slightly lesser degree, preoperative oral antibiotic preparation. Although some recent prospective, randomized studies have suggested that omission of mechanical bowel preparation for elective colorectal surgery is not only feasible but potentially preferable, caution is recommended before routinely omitting these widely practiced measures, because data to support such routine omission are limited.

Outcome and management of patients with large rectoanal intussusception.

OBJECTIVES: Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome. METHODS: Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception > or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse. RESULTS: Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12-118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37-91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0-5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group 1 (8.1+/-2.8 vs 0.8+/-0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7+/-4.2 to 1.1+/-5.4 vs 1.4+/-2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse. CONCLUSIONS: This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.

Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction.

PURPOSE: The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS: From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent). RESULTS: Whereas 65 patients failed to complete the course of biofeedback therapy, 108 (62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5 (8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P = not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION: Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

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

Prospective, randomized trial comparing four biofeedback techniques for patients with constipation.

PURPOSE: The aim of this study was to compare four methods of biofeedback for patients with constipation. METHODS: Thirty-six patients were prospectively, randomly assigned to one of four protocols: 1) outpatient intra-anal electromyographic biofeedback training; 2) electromyographic biofeedback training plus intrarectal balloon training; 3) electromyographic biofeedback training plus home training; or 4) electromyographic biofeedback training, balloon training, and home training. All 36 patients received weekly one-hour outpatient biofeedback training. Success was measured by increased unassisted bowel movements and reduction in cathartic use. In all instances patients maintained a daily log in which documentation was maintained regarding each bowel evacuation and the need for any cathartics. RESULTS; There was a statistically significant increase in unassisted bowel movements for Groups 1, 2, and 4 (P < 0.05) and a reduction in the use of cathartics in Groups 1, 2, and 3 (P < 0.05). CONCLUSION: There was a significant improvement in outcome after all four treatment protocols for constipation; however, no significant difference was found among the treatments. Therefore, electromyographic biofeedback training alone is as effective as with the addition of balloon training, home training, or both.

Stimulated graciloplasty for treatment of intractable fecal incontinence: critical influence of the method of stimulation.

INTRODUCTION: Patients with end-stage fecal incontinence, in whom all standard medical and surgical treatment has failed or is not expected to be effective, can be treated by stimulated graciloplasty. The aim of the present study was to assess the efficacy of stimulated graciloplasty by both direct nerve and intramuscular perineural stimulation techniques and to evaluate various parameters relative to outcome. METHODS: A prospective analysis of all patients who underwent this procedure was undertaken. All patients were preoperatively investigated by anal manometry, electromyography, pudendal nerve terminal motor latency assessment, endoanal ultrasound, and an enema retention test. They were further assessed with an incontinence scoring system and a Quality of Life Questionnaire. Postoperative evaluation included anorectal manometry, incontinence score registry, and a Quality of Life Questionnaire. In our initial experience the stimulation system electrodes were fixed directly to the nerve (direct nerve stimulation graciloplasty); later in the study the stimulation system electrodes were fixed intramuscularly close to the nerve branches (intramuscular perineural stimulation graciloplasty). RESULTS: From May 1993 to February 1998, 27 patients underwent 33 gracilis transpositions for fecal incontinence, 30 of which were stimulated. Six of the patients with direct nerve stimulation graciloplasty eventually had the direct nerve stimulator removed and replaced with an intramuscular electrode stimulator. After an mean follow-up (until the time of exit from study) of 12.5 (range, 1-23) months for direct nerve stimulation graciloplasty and 21 (range, 8-27) months for intramuscular perineural stimulation graciloplasty, 13 graciloplasties (43 percent) were successful. There was no correlation between outcome of surgery and age, duration or cause of symptoms, body habitus, manometric or electromyographic parameters, prior sphincter repair, the presence of a pre-existing stoma, or any immediate postoperative complications. However, the number of patients with intramuscular perineural stimulation graciloplasty who had a successful outcome (continent, 69 percent; improved but not fully continent, 23 percent; incontinent, 8 percent) was significantly higher than patients with direct nerve stimulation graciloplasty (improved but not fully continent, 10 percent; incontinent, 90 percent). CONCLUSION: The success of stimulated graciloplasty is dependent on the method of nerve stimulation, whereas surprisingly, none of the many other factors assessed influenced outcome.

How well can surgeons perform colonoscopy?

BACKGROUND: Little recent data exist relative to the efficacy or postprocedural complications of surgeons performing diagnostic or therapeutic colonoscopy. Therefore, the aim of this study was to retrospectively assess the outcome of colonoscopy performed by surgeons. METHODS: The charts of 2,069 patients who underwent colonoscopy between January 1992 and April 1995 by one of four surgeons at one of two centers were reviewed. Parameters included demographics, indications, procedures and findings, pathology, major complications, length of procedures and dosage of medication. RESULTS: 2,069 colonoscopies were performed for the following indications: 877 polyp surveillance, 509 cancer surveillance, 287 rectal bleeding, 282 family history of colon cancer, 127 change in bowel habits, 112 polyps found by flexible sigmoidoscope or barium enema, 92 inflammatory bowel disease, 48 preoperation, and 58 other indications. Some patients had more than one indication. The cecum could not be intubated in 73 cases (3.5%) due to narrowing and stricture [33] redundancy [18], poor preparation [14], and other miscellaneous conditions [8]. The average procedure time in the 1, 023 cases in which it was measured was 34.7 min. Average sedation doses were 2.1 mg of midazolam and 75.2 mg of meperedine in these same cases. The 2,069 colonoscopies included 1,878 biopsies, 353 polypectomies, and 139 other procedures. Some patients had multiple therapeutic interventions. Findings included 2,107 polyps, the pathology of which included 907 tubular; 62 tubulovillous and 41 villous adenomas, 325 hyperplastic polyps, and 68 carcinomas. There were five major complications after polypectomies (0.2%) including two cases of bleeding and three perforations. The two patients with bleeding were admitted to hospital, one for observation for 2 days and the other for colonoscopy, coagulation, and transfusion of 3 units of blood. Of the three patients with perforation, one underwent hospitalization for intravenous antibiotics and the other two for surgery (0.01%). Surgery included one resection with primary closure of the sigmoid perforation and one colostomy. CONCLUSIONS: This study confirms the observation that colonoscopy performed by surgeons is safe and rapid whether performed as a therapeutic or as a diagnostic procedure.