Squamous cell carcinoma of the rectum in ulcerative colitis: case report and review of the literature.

The majority of colorectal carcinomas diagnosed are adenocarcinomas. Squamous cell carcinomas (SCC) of the rectum are rare tumors, and were reported as rare complication of inflammatory bowel disease. Surgery is the most effective therapy; and adjuvant chemotherapy and radiotherapy should also be considered. We report two cases of ulcerative colitis-associated SCC of the rectum. The lesions were treated with chemoradiotherapy with complete response.

New surgical options for fecal incontinence in patients with imperforate anus.

INTRODUCTION: Anorectal malformations are among the various etiologic factors causing fecal incontinence. Patients with imperforate anus are difficult to treat, specifically those with high lesions. The artificial bowel sphincter and electrically stimulated gracilis neosphincter are two relatively new techniques that have been used for the treatment of patients with severe refractory fecal incontinence. The aim of this study was to evaluate the results of these technologies in the treatment of patients with chronic fecal incontinence due to imperforate anus. METHODS: All patients with imperforate anus who had fecal incontinence and underwent either the artificial bowel sphincter procedure or the gracilis neosphincter procedure between February 1995 and December 2000 were evaluated. Preoperative and postoperative incontinence score (Cleveland Clinic Florida Incontinence Score; 0 = perfect continence; 20 = complete incontinence), quality of life, (Fecal Incontinence Quality of Life Scale, 29 items forming 4 scales), and manometric sphincter pressure results were compared. RESULTS: Eleven patients had artificial bowel sphincter and five had the gracilis neosphincter (one nonstimulated) procedure. There were 11 males and 5 females of a mean age of 25.3 (range, 15-45) years. The mean follow-up time was 1.7 years (5 months to 5.7 years). Eight (50 percent) complications occurred in six patients, including three with fecal impaction (all artificial bowel sphincter), three with device migration (two gracilis neosphincter, one artificial bowel sphincter), and two patients with concomitant wound infection (one gracilis neosphincter, one artificial bowel sphincter); no patients had the devices explanted. Fourteen patients had manometric data (10 artificial bowel sphincter and 4 gracilis neosphincter) available. The overall incontinence score decreased from a preoperative mean of 18.5 to a postoperative mean of 7.5 in the artificial bowel sphincter group (P < 0.01) and from 17.4 to 9.4 in the gracilis neosphincter group (P = 0.06). All four Fecal Incontinence Quality of Life scales increased in both the artificial bowel sphincter (lifestyle and depression/self-perception, P = 0.02; coping/behavior and embarrassment, P = 0.03) and the gracilis neosphincter (lifestyle and coping, P = 0.06; depression and embarrassment, P = 0.05) patients. As well, the mean resting and squeeze pressures increased with both techniques (artificial bowel sphincter: P = 0.008 and P = 0.02, respectively; gracilis neosphincter: P = 0.4 and P = 0.1, respectively). All results were statistically significant in the artificial bowel sphincter group. CONCLUSIONS: Artificial bowel sphincter and gracilis neosphincter are efficient methods to treat patients with imperforate anus. These techniques should be considered for patients with imperforate anus and severe fecal incontinence.

Recovery of the rectoanal inhibitory reflex after restorative proctocolectomy: does it correlate with nocturnal continence?

PURPOSE: The rectoanal inhibitory reflex has an important role in fecal sampling and discrimination of rectal contents. The aim of this study was to determine the significance of rectoanal inhibitory reflex after restorative proctocolectomy with ileal pouch-anal anastomosis for mucosal ulcerative colitis. METHODS: The medical records of 345 patients who underwent ileal pouch-anal anastomosis from September 1988 to May 1999 were retrospectively reviewed. One hundred patients who underwent double-stapled ileal pouch-anal anastomosis and had anorectal physiology testing within 3 months before surgery as well as after ileostomy closure (mean, 23.1; range, 3-77 months) were analyzed. Anorectal physiology testing included detecting the presence of the rectoanal inhibitory reflex, sensory threshold volume, and rectal or pouch capacity and compliance. Parameters to determine incontinence included daytime and nocturnal bowel movement frequency, nocturnal spotting, status of continence for solid or liquid stool, gas, use of pads, and lifestyle alteration were surveyed in 62 of the 100 patients at a mean of 3.9 (range, 1-9.1) years to determine the incontinence score. RESULTS: Whereas the rectoanal inhibitory reflex was noted in 96 (96 percent) patients before surgery, it was found in only 53 (53 percent) after ileostomy closure (P < 0.0001). Incontinence status data was available in only 62 of the 100 patients (32 RAIR-positive; 30 RAIR-negative). There were no significant differences between the rectoanal inhibitory reflex-positive and the rectoanal inhibitory reflex-negative groups relative to the interval between surgery and manometry (22 vs 25 months), postoperative threshold sensation volume (32 vs 31 ml), postoperative compliance (19 vs 12 cm H(2)O/ml), postoperative capacity (85 66 ml), daytime/nighttime stool frequency (6.2/2 vs 5.5/1.5), or postoperative incontinence score (3.9 vs 1.8). However, there were significant differences relative to the incidence of nocturnal soiling (12/30 (40 percent) 23/32 (72 percent), P = 0.0012) favoring the presence of the rectoanal inhibitory reflex. CONCLUSION: Preservation of the rectoanal inhibitory reflex correlated with a decrease in the incidence of nocturnal soiling after double-stapled ileoanal reservoir construction.

Long-term efficacy of dynamic graciloplasty for fecal incontinence.

PURPOSE: 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 dynamic graciloplasty. The aim of this study was to review the long-term efficacy data. METHODS: Success was defined as a greater than 50 percent decrease in the frequency of incontinent episodes. Measured physiologic parameters included enema retention time and the difference in resting and squeezing pressures with and without stimulation. Measured quality-of-life parameters included the Medical Outcomes Study Short Form 36 Health Status Questionnaire, a Fecal Incontinence TyPE Specification, the Zung Self-Rating Depression Scale, the "state" portion of the State-Trait Anxiety Inventory, and the Visual Analog Scale, which were administered at baseline and through follow-up. Independent monitors collected data as part of a multicenter trial for patients who underwent dynamic graciloplasty from May 1993 to November 1999. RESULTS: There were 129 patients entered in the study, 115 of whom met eligibility criteria and were included in the efficacy outcome analysis. Twenty-seven patients entered the study with a preexisting functioning stoma; the remaining 88 patients did not have a functioning stoma at the time of enrollment. Success was achieved in 62 percent of nonstoma patients at 12 months; these results were sustained at 18-month and 24-month follow-up assessments (55 and 56 percent, respectively). The success rate in the stoma patients increased from 37.5 percent (9 of 24 patients) at 12 months to 62 percent (13 of 21 patients) at 18 months and was 43 percent at 24 months (9 of 21 patients), which reflects the increased number of patients whose stomas were closed. Although the measured physiologic continence parameters generally improved, these changes did not correlate with continence outcome. The group of patients (stoma and nonstoma) who underwent dynamic graciloplasty showed statistically significant improvements in quality of life as measured by Medical Outcomes Study Short Form 36 physical function (P = 0.006) and social functioning (P = 0.02) assessment. CONCLUSIONS: Dynamic graciloplasty was successful in the majority of patients with end-stage fecal incontinence. This result was usually achieved by 12 months after surgery in patients who did not have stomas and by 18 months in patients who had stomas at the time of dynamic graciloplasty surgery. These various improvements conferred by dynamic graciloplasty persisted during the two-year follow-up.