Postanal repair--do the long-term results justify the procedure?

OBJECTIVE: Early outcomes after postanal repair (PAR) demonstrated excellent results but subsequent reports showed an ever declining success rate in maintaining continence. The aim of this study was to document long-term continence after PAR and relate this to patient satisfaction and quality of life. METHOD: Patients with neurogenic incontinence who underwent PAR from 1986 to 2002 were interviewed by telephone, utilizing a questionnaire which assessed continence, patient satisfaction, overall improvement, and quality of life. RESULTS: One-hundred one patients from four surgeons were identified. Fifty-four patients were excluded because of loss to follow-up. Three had a stoma (two for incontinence), four had undergone a graciloplasty, leaving 57 patients (F = 53), mean duration of follow-up of 9.1 years (2.2-18.7 years). Mean CCS was 11.7 (SD 7.4). 26% (n = 15) scored none to minimal incontinence (CCS 0-5), 26% moderate (CCS 6-12), and 48% (n = 27) severe incontinence (CCS 13-24). 79% (n = 45) were satisfied with the outcome. A low CCS significantly correlated with good patient satisfaction, and was influenced by high QOL score (P < 0.0001). A high CCS significantly correlated with high bowel frequency (P = 0.0007). A favourable CCS was associated with a good QOL, a shorter duration of follow-up, and being able to distinguish flatus and stool. CONCLUSIONS: In patients with neurogenic faecal incontinence selected following anorectal physiology studies, PAR remains a useful treatment. It is associated with low morbidity and results in a satisfactory long-term subjective outcome, despite the fact that many patients have a high incontinence score.

Rigid sigmoidoscopy: a potential hazard for cross-contamination.

BACKGROUND: Rigid sigmoidoscopy using a disposable or nondisposable sigmoidoscope is a common outpatient procedure. It has been assumed that the nondisposable bellows and light head of the sigmoidoscope remain free from enteric organisms so that the procedure is sterile if a disposable or nondisposable (metal) sigmoidoscope shaft is used. The aim of this study was to identify the presence of organisms within the bellows or light head of the sigmoidoscope. METHODS: Of 21 patients undergoing rigid sigmoidoscopy with a disposable instrument, bacterial cultures were taken from the inside of sterile Jackson-Pratt bulbs in 12 patients, with the bulbs being used to simulate the nondisposable insufflation bellows. In an additional nine patients, swabs were taken for culture from the inside of the nondisposable light head. RESULTS: Enteric gram-negative Escherichia coli and mixed anaerobic organisms were cultured from the Jackson-Pratt bulbs in two cases, and gram-positive organisms were cultured in another case. Gram-negative organisms, including Bacillus, Proteus mirabilis, Klebsiella, and Enterococcus faecalis, were cultured from the inside of the light head in two cases. CONCLUSION: Sigmoidoscopy using a disposable instrument is not a sterile procedure and may pose a risk of patient-to-patient cross-contamination by potentially harboring organisms in the bellows or light head.

Anal fistula: Levovist-enhanced endoanal ultrasound: a pilot study.

PURPOSE: The aim of the study was to investigate the usefulness of the contrast agent Levovist in ultrasound assessment of anal fistula. METHODS: Fifteen patients (11 females, mean age 46) with a diagnosis of anal fistula were assessed by physical examination, conventional ultrasound, Levovist-enhanced ultrasound, and surgery. Levovist was injected a cannula into the fistula. The results of physical examination, conventional ultrasound and Levovist-enhanced ultrasound were compared with surgical findings as criterion standard. RESULTS: At physical examination, three intersphincteric fistulas and two sinuses were diagnosed. Using conventional ultrasound, five intersphincteric and five transsphincteric fistulas were found; four fistulas and one sinus were not detected. Levovist-enhanced ultrasound revealed one sinus, five intersphincteric, seven transsphincteric, and one extrasphincteric fistulas; only one fistula was not detected. At surgery, three intersphincteric, seven transsphincteric, and two sinuses were found; however, the extrasphincteric fistula detected by Levovist was missed. Compared with physical examination, Levovist-enhanced ultrasound and surgery were significantly favorable in the diagnosis of anal fistula (P < 0.05 in chi-squared test and Fisher's exact probability test). The concordance rate of surgery with conventional ultrasound was 69 percent (9/13) and with Levovist-enhanced ultrasound was 77 percent (10/13). However, because the extrasphincteric fistula was missed at surgery, the accuracy of Levovist-enhanced ultrasound was in fact 85 percent (11/13) if surgical finding was not used as the standard. The internal opening was detected at physical examination in 2 patients (13 percent), with conventional ultrasound in 4 patients (27 percent), with Levovist-enhanced ultrasound in 9 patients (60 percent) and during surgery in 11 patients (85 percent). Consistently, Levovist-enhanced ultrasound and surgery were significantly better than physical examination in the diagnosis of internal opening (P < 0.05). One secondary extension and two sphincter defects were detected by both types of ultrasound. The extension was not confirmed during surgery. No patients developed recurrence or nonhealing of wound. One patient developed incontinence to flatus and one developed a perianal hematoma. CONCLUSION: Levovist-enhanced ultrasound is better at assessing anal fistula than physical examination and conventional ultrasound. However, a future trial comparing Levovist, hydrogen peroxide, and magnetic resonance imaging is needed to establish which is the most cost-effective preoperative imaging technique to use.

Hyperplastic polyposis of the colon and rectum.

The significance of multiple hyperplastic polyps in relation to the risk of colon cancer is unknown although recent investigation suggests a causative link. We have prospectively identified a small but distinct group of patients that also suggests an association. These patients have either numerous (usually more than twenty, in sites other than the rectosigmoid alone) or large (greater than 1 cm) hyperplastic polyps, in association with either adenomatous polyps, polyps of mixed pathology or carcinoma of the colon and rectum. Additionally, there is frequently a first or second degree family history of colorectal carcinoma.

Tailored lateral sphincterotomy for anal fissure.

PURPOSE: Most surgical texts describe the length of division of the internal sphincter during closed lateral sphincterotomy as "to just above the dentate line," resulting in significant rates of incontinence. This study reviews our experience using a "tailored" lateral sphincterotomy by selecting the height of sphincter to be divided with the aim of preserving more sphincter. METHODS: From 1976 to March 1996, the files of 440 patients who had sphincterotomies were reviewed by an independent research assistant. After exclusions, a residual group of 352 patients had undergone tailored left lateral sphincterotomy for chronic anal fissure that had failed conservative treatment or for acute anal fissure requiring surgical intervention. RESULTS: A total of 287 patients from the group who had tailored left lateral sphincterotomy returned for review (81.5 percent). Of these, four complained of imperfect control of flatus (1.4 percent), one of minor staining (0.35 percent), and two of urgency (0.7 percent). None had incontinence of feces or leakage of stool. Five patients had repeat sphincterotomies, four for recurrence and one for a persistent fissure. CONCLUSION: The technique of tailored lateral sphincterotomy is safe, effective, and preserves more anal sphincter. It might be argued that a controlled trial comparing tailored sphincterotomy with the standard height of incision (with preprocedure and postprocedure manometry) should be performed, but the clinically significant reduction in incontinence rates using the tailored approach would seem to support its use.

Campylobacter jejuni enterocolitis causing peritonitis, ileitis and intestinal obstruction.

Patients with Campylobacter enterocolitis may come to laparotomy due to the severity of abdominal symptoms and signs, although only two patients with intestinal inflammation have been described and in neither was the histopathology documented. A case of a 52-year-old male who had a typical diarrhoeal illness of Campylobacter enterocolitis diagnosed on stool culture is reported. Despite appropriate treatment he developed signs and symptoms consistent with small intestinal obstruction. Laparotomy revealed peritonitis and thickened distal ileum with transmural inflammatory changes on histopathology. These changes were shown to have completely resolved at a second laparotomy, required for persistent obstruction due to adhesions. Recurrent adhesions culminated in a third laparotomy. The clinical, operative and histopathological findings may be confused with Crohn's disease.

Logical clinical decisions in the investigation and management of non-urgent rectal bleeding.

The benefits of assessment for non-urgent rectal bleeding derive from a combination of yield, risk factors, cost and patient comfort. Prospective studies have been completed which assign patients to investigative and management programmes based on graded bleeding patterns, the yield and true extent of flexible sigmoidoscopy and the safety and efficacy of immediate anorectal management. Between 1986 and 1989, 2268 new patients with bleeding were categorised by symptom grouping and entered into programmes of investigation and management. Flexible sigmoidoscopy (n = 936) eliminated or identified proximal bleeding in most (n = 882; 94.23%) and was confirmed to be generally specific for sigmoid assessment by "blinded" image intensifier confirmation of the level reached. No cancers are known to have been missed by clinical categorisation of patients. Between 1985 and 1988, 2112 patients underwent immediate sclerotherapy and triple banding for haemorrhoids, Significant secondary bleeding occurred in 9 patients (0.43%) and moderate to severe pain in 45 (2.13%) No deaths occurred. Further therapy to residual mucosal pedicles was required in 234 patients (11.08%) at one month, in 135 (6.39%) at a further month, and 67 patients (3.18%) subsequently. Careful clinical assessment, immediate investigation and management of the majority of anorectal disease in an ambulatory setting has been shown to be safe, highly cost efficient and relatively comfortable.

Splenic artery--pancreatic duct fistula.

The difficulties of diagnosis are detailed in a patient presenting with unexplained recurrent severe rectal bleeding due to a fistula between the splenic artery and the pancreatic duct. A review of the condition is presented together with a description of the proposed aetiological factors. The importance of angiographic assessment in the diagnosis and subsequent management of bleeding unexplained by conventional investigations in emphasized. Resection of the aneurysm with distal pancreatectomy and splenectomy is curative.

Bowel preparation with mannitol.

Orally administered mannitol has been used for colonic preparation before operations, for colonoscopy, and before barium enema X-ray examinations. It is quick, effective, comfortable, safe, and cheap. The metabolic effects have been evaluated and found to be minimal, and recommendations for the use of orally administered mannitol are given.

Fibrinolytic activity of carcinoma of the colorectum.

Twenty patients with carcinoma, mostly of the colorectum, and five without malignant tumors who were used as controls, have been investigated to elucidate the relationship between tumor fibrinolytic activity and the release of circulating malignant cells. The nature of the tumor fibrinolytic activity has been considered. The most significant fibrinolytic activity was seen in blood draining from the tumors and was evident in 80 per cent. Circulating malignant cells were recovered from half the patients, and in those with significant blood fibrinolysis, recovery from the draining vein reached 89 per cent. The most undifferentiated tumors appeared to be more active and released more cells. Fibrinolytic activity of tumor tissue derives from inflammatory cells, dead tumor cells, avascular areas of the tumor and vascular endothelium and is probably proteolytic as well as purely fibrinolytic.