Recurrence rate after Delorme's procedure with simultaneous placement of a Thiersch suture.

Introduction Rectal prolapse is a debilitating condition usually affecting elderly women. The management is generally surgical but the optimal operation remains unclear. The recurrence rate after Delorme's procedure has been found to be similar to that for an abdominal approach. Thiersch sutures have been associated with high rates of complications and recurrence. The aim of this study was to compare the outcomes of Delorme's procedure with those of a combined Delorme-Thiersch procedure. Methods A retrospective case note review was performed of all patients who underwent Delorme's procedure for rectal prolapse between 2008 and 2014 in a single centre. Results Sixty-seven patients (63 women) underwent Delorme's procedure during the study period. The majority (85%) of patients were over 75 years old. Twelve patients had a Thiersch suture placed at the time of the procedure. The median length of stay was 3 days (range: 0-19 days). Postoperative bleeding requiring either transfusion or readmission occurred in five patients (7.5%) and two patients (3.0%) were readmitted with pain. There was no difference in the rate of complications regardless of whether a Thiersch suture had been placed. Recurrence occurred in 8.3% of those who had a Thiersch suture compared with 21.8% of those who did not (p=0.26). There was no difference in the median time to recurrence between the groups. Conclusions There was no increase in complications after placement of a Thiersch suture with Delorme's procedure. The rate of recurrence could potentially be decreased with this combined technique. Additional studies are required to investigate this further.

A single-centre experience of chemoradiotherapy for rectal cancer: is there potential for nonoperative management?

AIM: The aim of the study was to assess the outcome of patients who received chemoradiotherapy (CRT) for locally advanced rectal cancer, specifically those with complete clinical response (CCR) and who were then managed nonoperatively with a 'Watch and Wait' follow-up protocol. METHOD: A retrospective study was carried out of patients undergoing preoperative CRT for rectal cancer, conducted in a district general hospital managing rectal cancer through the multidisciplinary team process. RESULTS: Forty-nine patients received preoperative CRT over a 5-year period (2004-2009). Twelve (24%) were considered potentially to have had a complete response on MRI. Of these, six subsequently had clinical evidence of residual disease, leading to surgery (mean time to surgery, 24 weeks; range, 12-36 weeks). The remaining six had CCR, avoiding surgery (mean follow up, 26 months; range, 12-45 months), with all six patients disease free to date. A further six patients had complete pathological response (CPR) following surgery after comprehensive histopathological assessment of the specimen. CONCLUSION: In this consecutive series of patients with locally advanced rectal cancer treated with CRT, 12% demonstrated a CCR and have been actively managed conservatively, thereby avoiding surgery. With further improvements in diagnostic assessment of response to CRT, this figure may rise.

Treatment of resistant anal fissure with advancement anoplasty.

OBJECTIVE: The primary aim of this study was to assess the outcome of advancement anoplasty in the treatment of chronic anal fissure, resistant to conventional therapy. The secondary aim was to evaluate the anal resting pressure in these patients with resistant fissures. PATIENTS AND METHODS: Over a five-year period eight patients (2 male, median age 55 years, range 20-74) with resistant anal fissure were referred from 6 centres. They had endured symptoms for a median of 8 years (range 2-20) and had undergone a median of 2 previous surgical procedures (range 1-3), including lateral sphincterotomy and anal dilatation. Anorectal physiological testing was performed on all patients who then underwent advancement anoplasty. The outcome was analysed retrospectively. RESULTS: Pre-operative anorectal physiological testing showed a significantly lowered median maximal anal resting pressure of 42 mm H2O (range 12-72 mm H2O, normal range > 60 mm), P=0.03. All patients underwent advancement anoplasty. At a median of seven months follow-up (range 2-22) seven of eight patients had healed their fissure and were asymptomatic. The median healing time was four months (range 2-6). CONCLUSION: Patients with chronic anal fissure, resistant to conventional therapy, may be successfully treated by advancement anoplasty. Healing time however, may be prolonged. In this series patients had a decreased anal resting pressure rather than anal hypertonia.

On-line quantitative analysis of surface electromyography of the pelvic floor in patients with faecal incontinence.

BACKGROUND: Needle electromyography (EMG) remains the 'gold standard' for the assessment of external anal sphincter innervation. It is, however, an invasive and poorly tolerated technique. In this study a quantitative form of surface electromyography was compared with needle EMG of the external anal sphincter. METHODS: Invasive needle EMG to assess mean fibre density and neuromuscular jitter was compared directly with quantitative surface EMG in 37 patients with faecal incontinence and 12 age-matched controls. RESULTS: There was a significant positive correlation between mean fibre density on needle EMG and maximum turns rate on surface EMG (rs = 0.48 (95 per cent confidence interval 0.28-0.76), P = 0.003). Furthermore, surface EMG was able to discriminate between patients with normal neuromuscular jitter and those with increased jitter, a measure of progressive denervation and reinnervation, on the basis of reduced rectified mean surface signal (P = 0.02, Fisher's exact test). CONCLUSION: Quantitative surface EMG may potentially replace invasive needle EMG as the investigation of choice in the assessment of anal sphincter electrophysiology.

Preoperative increase in neuromuscular jitter and outcome following surgery for faecal incontinence.

BACKGROUND: Long-term results of surgery for faecal incontinence remain disappointing. Previous studies have demonstrated that pudendal neuropathy may progress in incontinent patients managed either conservatively or operatively. This progression of pudendal neuropathy may underlie poor long-term results. METHODS: Measurement of neuromuscular jitter by single-fibre electromyography allows the stability of terminal motor axons and end-plates to be assessed before operation. An increase in jitter implies progressive denervation. RESULTS: In this study, patients with increased jitter before operation (n = 14) had significantly worse symptom scores (median (interquartile range (i.q.r)) 14 (9-18) versus 3 (2-8), P = 0.007) and lower squeeze pressures (median (i.q.r.) 23 (21-36) versus 53 (46-60) mmHg, P = 0.015) at 6-month follow-up compared with those with normal jitter before operation (n = 22). CONCLUSION: This study implies that the poor results of surgery are related to progressive denervation and that this may be assessed before operation.

The effect of sampling frequency on chemical parameters in acid-sensitive streams.

We assessed the effects of different simulated sampling regimes (weekly, fortnightly, monthly and bimonthly) on parameters describing the water chemistry of 72 streams in acid-sensitive areas of Wales. For pH, sulphate, total hardness and aluminium, reduced sampling frequency had no discernible or systematic effect on the apparent annual mean chemistry relative to the values derived from weekly data. Standard deviations and coefficients of variation were either unaffected, or were reduced. However, sampling frequency had a moderate effect on mean pH when the data were separated into seasons: winter mean pH increased on average by 0.13 units and summer means decreased on average by 0.12 units, when using bimonthly data relative to weekly. Extreme values were detected less effectively at lower sampling frequencies, significantly altering the intercept and/or the slope of the strong relationships between the means and minimum pH or maximum Al. These effects almost certainly reflect the exclusion of extreme events (summer drought and winter floods) from low sample frequencies and reveal limitations in the use of mean values from periodic sampling programmes for summarising some aspects of site chemistry. Nevertheless, previously established relationships between mean stream chemistry, land use and stream biology were still strong at all sampling frequencies. Clear recommendations about the needs to fully parameterise episodic fluctuations depend on unanswered questions about: (i) whether biota respond to mean or episodic chemical conditions and (ii) whether baseflow chemistry, episodic fluctuations, or some combination of these, will best reflect trends in acidification.

Urge incontinence of faeces is a marker of severe external anal sphincter dysfunction.

A proportion of patients with faecal incontinence experience debilitating urgency of defaecation and urge incontinence. This study prospectively assessed 56 faecally incontinent patients by means of standard interview, physical examination and anorectal physiology. Patients with urge incontinence, when compared with those without urge incontinence, were symptomatically worse, had had more vaginal deliveries and had more bowel actions each day. Physiological tests included anal manometry, anal electrosensitivity, pudendal nerve terminal motor latency and a standard proctometrogram. The only physiological differences between the groups were a reduction in voluntary squeeze pressure (median (interquartile range (i.q.r.)) 43 (26-67) versus 67 (45-122) mmHg, P = 0.01) and a smaller percentage change in pressure-volume, an integral of sphincter length and squeeze (median (i.q.r.) 43.5 (0-289) versus 247 (71-455), P = 0.02), in those with urgency. The authors conclude that urge incontinence is associated with impairment of the striated musculature of the anal sphincter complex.

What is the relationship between perineal descent and anal mucosal electrosensitivity?

PURPOSE: Perineal descent is found in many patients with anorectal disorders. There is now substantial evidence against perineal descent causing damage to the motor axons in the pudendal nerves, but the sensory sequelae of perineal descent have been neglected. The purpose of this study was to establish the relationship between perineal descent and anal sensation. METHODS: Perineal position was determined in relation to the bony pelvis by means of defecating proctography. Anal mucosal electrosensitivity was determined by using a constant current generator. RESULTS: This study demonstrated significant correlations between perineal position at rest and sensitivity in each third of the anal canal in the study group overall. In women studied alone, there were significant correlations between perineal position at rest and at squeeze and anal mucosal electrosensitivity in each third of the anal canal. CONCLUSIONS: We propose that perineal descent traumatizes the pudendal nerves, damaging the large diameter sensory axons. This may be a precursor of motor axon damage or may correlate with the global pelvic sensory loss found in patients with perineal descent and fecal incontinence.

Spatial patterns concentrations in upland Wales in relation to catchment forest cover and forest age.

Data on nitrate nitrogen were collected weekly during 1984 from 136 sites on streams in upland Wales. Mean nitrate concentrations in summer (0.02 to 1.5 mg litre(-1)) were significantly lower (P<0.001) than in winter (0.02 to 1.26 mg litre(-1)), particularly at sites with mature conifers (>30 years old). Mean concentrations increased significantly with the average age of conifers on each catchment (P<0.001), and with increasing areal cover by trees over 30 years old (P<0.001). Nitrate concentrations increased significantly with stream total hardness (P<0.001), possibly reflecting nitrogen mineralisation in soils of higher base status. Concentrations also increased with stream chloride (P<0.001), which is predominantly atmospherically derived, implying that increased nitrate occurred where general atmospheric inputs of solutes were increased. After accounting for variation in hardness, residual nitrate concentrations still increased with the average age of the conifers (P<0.001), and with catchment cover by mature trees (P<0.001). We infer that some additional nitrate under older conifers is thus independent of catchment sources associated with increasing hardness. Two possibilities are increased inputs and decreased retention of nitrogen within the ecosystem of maturing conifer forest. Residual nitrate after accounting for variations in chloride also increased significantly with conifer age (P<0.01) and cover (P<0.01), a pattern implying that some sources of nitrate may also be independent of increased sea-salt deposition. We allude to the possibility that additional nitrogen deposition adds to nitrogen throughputs from maturing forests, and we discuss the potential ecological role of additional nitrogen in runoff.

Acid waters in upland Wales: causes, effects and remedies.

Although situated on the western seaboard of the UK, and hence in the path of predominantly maritime air masses arriving directly from the Atlantic, Wales receives acidic deposition when winds are from the east. In conjunction with the highly base-poor rocks and soils found in the region, significant acidification of surface waters has occurred. Extensive afforestation in the Welsh uplands in the last 40 years has exacerbated acidification effects by elevating the loading of acidic anions received by catchments, thus increasing the concentrations of aluminium in watercourses. In considering possible remedial strategies, results of liming investigations from the Llyn Brianne Project in mid-Wales are presented. These studies have mainly involved liming small streams by a variety of catchment liming techniques. The most effective catchment treatments were those where finely ground CaCO3 was applied to the hydrological source areas at rates of up to 25 tonnes ha(-1). Possible drawbacks with such liming are discussed, although it is emphasized that liming is likely to be a component of any remedial strategy in the next 30 years until emissions reductions greater than those proposed in the forthcoming EC Directive are implemented.

Restoring acidified streams in upland Wales: a modelling comparison of the chemical and biological effects of liming and reduced sulphate deposition.

Increasing emphasis is being placed on the restoration of surface waters which have been affected by acidification. Amongst the possible strategies are management of the causes, by reducing acidic deposition, and management of the symptoms, by treating affected areas with basic material such as limestone. In few cases have there been comparisons of the likely effect of these two strategies on surface water chemistry and ecology, although there is widespread belief that the two are similar in outcome. At present, only a modelling approach permits such a comparison. This paper describes chemical and biological responses of three Welsh streams whose catchments were limed experimentally in 1987-1988 as part of the Llyn Brianne project. Actual changes are compared with simulated changes which occur following reduced acid deposition according to the hydrochemical model, MAGIC (Model of Acidification of Groundwaters in Catchments). The results indicate that liming and 90% reduction in sulphate deposition reduce concentrations of toxic aluminium to similar levels. However, calcium concentrations and pH were increased by liming to values which were high by comparison with conditions simulated at low acid deposition, either in the past or future. Trout density increased in two of the streams following liming to levels similar to those simulated under low acid deposition. By contrast, the aquatic invertebrate fauna changed after liming so that streams acquired species typical of higher calcium concentrations than those simulated under low acid deposition. Species characteristic of 'soft water' communities were apparently lost, although more data are required to separate treatment effects from random change in the longer term. The 'soft water' community also declined in the model as a result of acidification, indicating that both liming and acid deposition resulted in a different faunal community from that prior to acidification. The results support those who conclude that liming is suitable for the restoration or protection of a fishery, but indicate that there may be other ramifications, for example to conservation, which must be considered when liming is implemented. However, the simulation of biological conditions under low acid deposition involves extrapolation from the initial data base. Further data are now required to assess empirically the likely biological character of British streams which have low base cation concentrations unaffected by acid deposition.