Tissue-resident memory T cells are epigenetically cytotoxic with signs of exhaustion in human urinary bladder cancer.

Tissue-resident memory T (TRM ) cells are CD8+ T lymphocytes that reside in the tissues, including tumours. This T cell subset possesses a magnitude of cytotoxicity, but its epigenetic regulation has not been studied. Here, we investigate the impact of perforin DNA methylation in TRM cells and correlate it with their functional potential. Fifty-three urothelial urinary bladder cancer (UBC) patients were recruited prospectively. The DNA methylation status of the perforin gene (PRF1) locus in TRM cells was investigated by pyrosequencing. Flow cytometry with ViSNE analysis and in-vitro stimulation were used to evaluate TRM cell phenotypes. We discovered that tumour TRM cells have low DNA methylation in the PRF1 locus (32·9% methylation), which corresponds to increased numbers of perforin-expressing TRM cells. Surprisingly, programmed cell death 1 (PD-1) expression is high in tumour TRM cells, suggesting exhaustion. Following interleukin-15 and T cell receptor stimulation, perforin and T-bet expressions are enhanced, indicating that TRM cells from tumours are not terminally exhausted. Moreover, a high number of TRM cells infiltrating the tumours corresponds to lower tumour stage in patients. In conclusion, TRM cells from UBC tumours are epigenetically cytotoxic with signs of exhaustion. This finding identifies TRM cells as potential new targets for cancer immunotherapy.

Outcome of younger patients with acute diverticulitis.

BACKGROUND: There is controversy over whether patients presenting with a primary attack of acute diverticulitis at a younger age are more prone to complications and recurrence than older patients. METHODS: A review, including postal questionnaires, was undertaken of 234 patients who had a primary episode of acute diverticulitis. The diagnosis was confirmed by computed tomography (CT) and/or pathology report. The mean length of follow-up was 30 (range 16-45) months. RESULTS: In 58 patients aged 50 years or less no differences in fever or white blood cell count were found in comparison with findings in 176 patients aged above 50 years. The rate of severe diverticulitis observed with CT was lower in the younger patients (2 versus 11.9 per cent; P = 0.025). Surgical management during the first admission was undertaken less commonly in younger patients (2 versus 6.8 per cent; P = 0.271). Rates of subsequent events (recurrent diverticulitis and/or further surgery) during follow-up were higher in younger patients (25 versus 19.5 per cent), but this was not significant (P = 0.423). A type II error cannot be excluded. CONCLUSION: First episodes of acute diverticulitis were not more aggressive in patients aged 50 years or less. Recurrence rates were slightly higher than in older patients.

CT colonography versus colonoscopy in the follow-up of patients after diverticulitis - a prospective, comparative study.

AIM: To assess whether computed tomography colonography (CTC) is a viable alternative to colonoscopy or double contrast barium enema in the follow-up of patients after diverticulitis. MATERIAL AND METHODS: Fifty patients underwent CTC followed immediately by colonoscopy. Results were blinded to the examiners. Findings of diverticular disease and patient acceptance were evaluated. RESULTS: Bowel preparation and distension were good in the majority of CTC and colonoscopy examinations. Diverticular disease was found in 96% of patients at CTC and in 90% at colonoscopy. The rate of agreement between CTC and colonoscopy for diverticular findings in the sigmoid colon was good (kappa=0.64). No complications were seen. Patients found colonoscopy more uncomfortable (p<0.03), more painful (p<0.001), and more difficult (p<0.01) than CTC. Of the patients favouring one examination, 74% preferred CTC. CONCLUSION: CTC appears to have a better diagnostic potential for imaging of diverticular disease-specific findings, when compared with colonoscopy. Also, CTC was less uncomfortable and was preferred by a majority of patients. CTC seems to be a reasonable alternative in follow-up of patients with symptomatic diverticular disease.

Late adverse effects of short-course preoperative radiotherapy in rectal cancer.

BACKGROUND: Preoperative radiotherapy improves local control and survival in rectal cancer, but there are few reports on long-term morbidity. The aims of this study were to compare long-term morbidity and quality of life in patients undergoing rectal cancer surgery with or without preoperative radiotherapy. METHODS: A total of 252 patients, randomized within the two Stockholm trials on preoperative radiotherapy in rectal cancer, were alive at a mean of 15 years after surgery. Some 139 of these patients were available for follow-up by questionnaires and clinical examination. Questionnaires regarding medical history and quality of life were completed by all patients. All patients had a clinical examination, and those without a stoma underwent rigid sigmoidoscopy. RESULTS: Overall, patients who had preoperative radiotherapy experienced significantly more late complications than those who did not (69 versus 43 per cent; P = 0.002). This morbidity consisted mainly of cardiovascular disease (35 versus 19 per cent; P = 0.032), faecal incontinence (12 of 21 versus 11 of 42 patients having anterior resection; P = 0.013) and urinary incontinence (45 versus 27 per cent; P = 0.023). No significant differences between groups were found for hip or pelvic fractures, small bowel obstruction or global quality of life. CONCLUSION: Preoperative short-course, high-dose radiotherapy in patients with rectal cancer increases the risk of anal and urinary dysfunction, and may lead to increased cardiovascular morbidity, at long-term follow-up.

Improved analgesia with clonidine when added to local anesthetic during combined spinal-epidural anesthesia for hip arthroplasty: a double-blind, randomized and placebo-controlled study.

BACKGROUND: The perioperative effects of intrathecal and epidural clonidine combined with local anesthetic were evaluated in 60 patients undergoing hip arthroplasty. METHODS: This was a double-blinded study and the patients were randomized into three groups, with 20 patients in each group. All patients received spinal anesthesia with 17.5 mg of plain bupivacaine with 15 microg of clonidine (Group BC-RC) or without clonidine (Groups B-R and B-RC). Postoperatively, epidural infusion was administered in the following way: Group B-R-ropivacaine 4 mg h(-1); Groups B-RC and BC-RC: ropivacaine 4 mg h(-1) and clonidine 40 microg h(-1). Sensory block was assessed with light touch, pinprick, transcutaneous electrical stimulation at T12 and L2 dermatomes, and perception of thermal stimuli. RESULTS: The maximal upper level of sensory block measured by pin-prick (T6-T7) did not differ between the groups while the partial sensory block for cold and warmth were increased two dermatomes above pin-prick level in the group with intrathecal clonidine compared to the other two groups (P < 0.05). Duration of anesthesia, analgesia and motor block were longer in Group BC-RC compared to Groups B-R and B-RC (P < 0.02). Postoperatively, both VAS score on movement and PCA-morphine consumption were higher in Group B-R than in Groups B-RC and BC-RC (P < 0.01). The arterial pressure and heart rate in Groups B-RC and BC-RC were significantly lower than in Group B-R at 10-24 and 15-24 h, respectively, after spinal injection. CONCLUSION: Low-dose intrathecal clonidine provided a better quality of anesthesia and longer-lasting analgesia. Epidural clonidine-ropivacaine infusion resulted in improved postoperative analgesia but was associated with a moderate decrease in blood pressure.

Intrathecal and oral clonidine as prophylaxis for postoperative alcohol withdrawal syndrome: a randomized double-blinded study.

UNLABELLED: In this study, we evaluated the effect of intrathecal and oral clonidine as supplements to spinal anesthesia with lidocaine in patients at risk of postoperative alcohol withdrawal syndrome (AWS). We hypothesized that clonidine would have a prophylactic effect on postoperative AWS. Forty-five alcohol-dependent patients (daily ethanol intake >60 g) scheduled for transurethral resection of the prostate were double-blindly randomized into three groups. All patients received hyperbaric lidocaine 100 mg intrathecally. The diazepam group (DiazG) was premedicated with diazepam 10 mg orally; the intrathecal clonidine group (Clon(i/t)G) received a placebo (saline) tablet and clonidine 150 microg intrathecally; and the oral clonidine group (Clon(p/o)G) received clonidine 150 microg orally. For patients diagnosed with AWS, the Clinical Institute Withdrawal Assessment for Alcohol, revised scale, was used. Twelve patients in the DiazG had symptoms of AWS, compared with two in the Clon(i/t)G and one in the Clon(p/o)G. The median Clinical Institute Withdrawal Assessment for Alcohol, revised scale, score was 12 in the DiazG versus 1 in the clonidine-treated groups. Two patients in the DiazG had severe delirium. Patients receiving oral clonidine had a slightly decreased mean arterial blood pressure 6-12 h after spinal anesthesia (P < 0.05); patients in the DiazG had a hyperdynamic circulatory reaction 24-72 h after surgery. In conclusion, preoperative clonidine 150 microg, intrathecally or orally, prevented significant postoperative AWS in ethanol-dependent patients. IMPLICATIONS: In this randomized, double-blinded study, clonidine 150 microg both intrathecally and orally prevented postoperative alcohol-withdrawal symptoms in alcohol-dependent men. The effect was superior to that with a single dose of diazepam 10 mg orally.

Clonidine combined with small-dose bupivacaine during spinal anesthesia for inguinal herniorrhaphy: a randomized double-blinded study.

UNLABELLED: The aim of this randomized double-blinded study was to see whether the addition of small-dose clonidine to small-dose bupivacaine for spinal anesthesia prolonged the duration of postoperative analgesia and also provided a sufficient block duration that would be adequate for inguinal herniorrhaphy. We randomized 45 patients to 3 groups receiving intrathecal hyperbaric bupivacaine 6 mg combined with saline (Group B), clonidine 15 micro g (Group BC15), or clonidine 30 micro g (Group BC30); all solutions were diluted with saline to 3 mL. The sensory block level was insufficient for surgery in five patients in Group B, and these patients were given general anesthesia. Patients in Groups BC15 and BC30 had a significantly higher spread of analgesia (two to four dermatomes) than those in Group B. Two-segment regression, return of S1 sensation, and regression of motor block were significantly longer in Group BC30 than in Group B. The addition of clonidine 15 and 30 micro g to bupivacaine prolonged time to first analgesic request and decreased postoperative pain with minimal risk of hypotension. We conclude that clonidine 15 micro g with bupivacaine 6 mg produced an effective spinal anesthesia and recommend this dose for inguinal herniorrhaphy, because it did not prolong the motor block. IMPLICATIONS: The addition of clonidine 15 micro g to 6 mg of hyperbaric bupivacaine increases the spread of analgesia, prolongs the time to first analgesic request, and decreases postoperative pain, compared with bupivacaine alone, during inguinal herniorrhaphy under spinal anesthesia.

Low-dose bupivacaine plus fentanyl for spinal anesthesia during ambulatory inguinal herniorrhaphy: a comparison between 6 mg and 7. 5 mg of bupivacaine.

BACKGROUND: Inguinal herniorrhaphy is commonly performed as an outpatient procedure. Spinal anesthesia offers some advantages over general anesthesia in this setting. METHODS: Forty patients were randomly divided into two groups according to a double-blind protocol: Group L had spinal anesthesia with bupivacaine 6.0 mg and Group H with bupivacaine 7.5 mg; in both groups, fentanyl 25 micro g was added to the spinal anesthetic. The sensory block was measured by 'pin-prick' and the motor block was evaluated by a modified Bromage scale. RESULTS: No differences were seen in the spread, duration and regression of sensory block between the groups on the operated side. A greater number of patients required analgesics during the operation in Group L (6) compared with Group H (1) (P<0.05). The return of the modified Bromage scale to grade 0 was earlier in Group L than in Group H (P<0.05) but the time to mobilization and discharge was similar. Seven patients (17%) needed to be catheterized and two had the catheter retained overnight. Times to home discharge (median) were 350 and 445 min, respectively, in Groups L and H. Postoperatively and during the first week, visual analog pain scores, analgesic requirements and side-effects were similar between the groups. In Group H, 95% of the patients and in Group L 85% would have the same anesthetic again if operated upon for a similar procedure. CONCLUSIONS: Spinal anesthesia with bupivacaine 7.5 mg and fentanyl offers an alternative to general or local anesthesia for ambulatory inguinal herniorrhaphy. However, the long discharge times and risk for urinary retention restrict its routine use in all patients.

Postoperative pain relief following intrathecal bupivacaine combined with intrathecal or oral clonidine.

BACKGROUND: The purpose of the present study was to evaluate the postoperative analgesic and adverse effects of equal doses of oral or intrathecal clonidine in spinal anaesthesia with bupivacaine plain. METHODS: Forty-five ASA I-III orthopaedic patients scheduled for osteosynthesis of a traumatic femur fracture were randomised in a double-blind fashion to one of 3 groups. Patients received 15 mg of plain bupivacaine intrathecally (group B) or an intrathecal mixture of bupivacaine 15 mg and clonidine 150 mg (group CIT). In group CPO oral clonidine 150 mg was administered 60 min before intrathecal injection of bupivacaine 15 mg. RESULTS: Oral and intrathecal clonidine prolonged the time until the first request for analgesics, 313 +/- 29 and 337 +/- 29 min, respectively, vs. 236 +/- 27 min in group B (P < 0.01). The total 24- h PCA morphine dose was significantly lower in group CIT(19.3 +/- 1.3 mg) compared to groups B and CPO(33.4 +/- 2.0 and 31.2 +/- 3.1 mg). MAP was decreased significantly during the first hour after intrathecal clonidine(14%) and during the first 5 h after oral clonidine(14-19%). HR decreased in CIT during the 5th and 6th postoperative hours(7-9%) and during the first 2 h(9%) in CPO (P < 0.01). The degree of sedation was more pronounced in group CPO during the first 3 h. Four patients had pruritus in group B. CONCLUSIONS: Addition of intrathecal clonidine prolonged analgesia and decreased morphine consumption postoperatively more than oral clonidine. Hypotension was more pronounced after oral than after intrathecal clonidine. Intrathecal clonidine is therefore recommended.

Cystodefecoperitoneography in patients with genital prolapse.

The aim of the study was to prospectively evaluate pre- and postoperative findings of cystodefecoperitoneography (CDP) and to correlate the findings to the clinical examination in patients with genital prolapse. Twenty-five female patients were investigated both pre- and postoperatively with a standardized questionnaire, clinical examination and CDP, including contrast medium in the rectum, vagina, bladder, small bowel and peritoneal cavity. At preoperative clinical examination a rectocele was diagnosed in 24 patients, a cystocele in 7 and an enterocele in 2. At the preoperative CDP a rectocele was diagnosed in 21 patients, a cystocele in 22 patients and a peritoneocele in 9, of which six contained small bowel (i.e. an enterocele). Surgery was performed according to the clinical findings. At the postoperative clinical examination no rectocele was diagnosed, a cystocele was diagnosed in 3 patients and an enterocele in 1. Postoperative CDP showed a rectocele in 4 patients, a cystocele in 24 and a peritoneocele in 7 patients, of which three contained small bowel (i.e. an enterocele). CDP may complement the clinical assessment of patients with genital prolapse, in particular to confirm or detect defects involving the posterior compartment. The radiologic definition of cystocele needs further evaluation.

A systematic review of the peripheral analgesic effects of intraarticular morphine.

The analgesic effects of intraarticular morphine are controversial. To systematically evaluate the effects, we performed a review of the literature and a metaanalysis of the peripheral effects of morphine injected intraarticularly. Research databases were searched to identify articles in which peripheral analgesic effects of morphine were studied in patients undergoing arthroscopic knee procedures under local, regional, or general anesthesia. The review was performed on three issues: does morphine injected intraarticularly produce analgesia, is it a dose-dependent effect, and, if so, is the effect systemic or mediated via peripheral opioid receptors? Visual analog score (VAS) and analgesic consumption were studied during the early phase (0-2 h), intermediate phase (2-6 h), and late phase (6-24 h) postoperatively after injection of morphine intraarticularly. Metaanalysis of these effect variables was performed by the weighted-analysis technique, and the essential homogeneity assumption was tested by the chi(2) test. Forty-five articles could be identified in which the effects of morphine were studied in a prospective, randomized manner, and 32 of these studies included a placebo control. Pooled analyses of data from 19 studies suitable for metaanalysis showed an improvement in analgesia after morphine compared with placebo in the order of 12-17 mm on the VAS during all three phases of treatment. Studies with high quality scores showed somewhat smaller improvements. Total analgesic consumption could not be analyzed statistically, but the number of studies showing decreased analgesic consumption or no differences between groups was identical (six and six). No clear dose-response effect was seen when VAS was used as a measure of pain, but it was seen when area under the curve was used as a measure of pain. A systemic effect of peripherally-injected morphine was not possible to exclude because of the very limited data available. We conclude from this metaanalysis that intraarticularly administered morphine has a definite but mild analgesic effect. It may be dose dependent, and a systemic effect cannot be completely excluded.

Durability of success after rectocele repair.

The purpose of the study was to determine the durability of success after rectocele repair and to evaluate parameters that might influence long-term results. Twenty-five patients with rectocele were prospectively evaluated both clinically and physiologically. Follow-up was performed twice, at 1 and 5.1 years postoperatively. Twenty-four patients had a long-term follow-up; 21/23 patients (91%) with preoperative symptoms of rectal emptying difficulty reported improvement of their symptoms and 9 of 12 (75%) with preoperative symptoms of pelvic heaviness reported relief at long-term follow-up. All 5 patients with preoperative pathologic transit study had various degrees of rectal emptying difficulty at long-term follow-up. Three of 5 patients with preoperative paradoxical sphincter reaction (PSR) at electromyography (EMG) reported improvement of the symptoms of rectal emptying difficulty at long-term follow-up. Surgery for rectocele is associated with improved symptoms in a majority of patients which are sustained long term. Patients with pathologic transit study may have a less favorable symptomatic outcome. The clinical significance of PSR needs further study.

Necrotizing fasciitis and toxic shock-like syndrome caused by group B streptococcus.

A recent increase in reports of necrotizing fasciitis resulting from group B streptococcus has alerted physicians to a possible concomitant increase of toxic shock-like syndrome. We report the second case of group B streptococcus causing necrotizing fasciitis and toxic shock-like syndrome. A black woman, aged 52 years, with newly diagnosed diabetes mellitus had necrotizing fasciitis type II of the left groin. Hypotension, elevated bilirubin and liver enzymes, and adult respiratory distress syndrome rapidly developed. Because group B streptococcus was isolated from a normally sterile site, the patient's condition met the criteria for toxic shock-like syndrome. Extensive surgical debridement, hyperbaric oxygen therapy, and intravenous antibiotic therapy (including clindamycin) were required for complete recovery. The antitoxin effects of hyperbaric oxygen therapy and clindamycin should be further investigated for the treatment of such patients.

The combined spinal-epidural technique.

Epidural and spinal blocks are well-accepted regional techniques, but they have several disadvantages. The CSE technique can reduce or eliminate the risks of these disadvantages. CSE block combines the rapidity, density, and reliability of the subarachnoid block with the flexibility of continuous epidural block to extend duration of analgesia. The CSE technique is used routinely at many institutions, particularly for major orthopedic surgery and in obstetrics. It has been used in tens of thousands of patients without any reports of major problems. Although at first sight the CSE technique appears to be more complicated than epidural or spinal block alone, intrathecal drug administration and siting of the epidural catheter are both enhanced by the combined, single-space, needle-through-needle method. Concerns about the epidural catheter entering the theca via the small puncture hole are now considered to be unfounded, but as with all epidural catheter techniques, vigilant monitoring of the patient during and after any injection is paramount. CSE is an effective way to reduce the total drug dosage required for anesthesia or analgesia. The intrathecal injection achieves rapid onset with minimal doses of local anesthetics and opioids, and the block can be prolonged with low-dose epidural maintenance administration. In addition, the sequential CSE method can be used to extend the dermatomal block with minimal additional drugs or even saline. Reduction in total drug dosage has made truly selective blockade possible. Many studies have confirmed that low-dose CSE with local anesthetic and opioid, or low-dose epidural block alone, will provide effective analgesia with minimal motor and proprioceptive block. Such neurologic selective blockade has made it possible for most patients to walk and bear down normally in labor or postoperatively. There remains concern about the risk of infection being increased when the CSE technique is used in place of epidural block alone. Despite a recent flurry of reports of meningitis with CSE procedures, there is no evidence the CSE block is more hazardous than epidural or subarachnoid block alone. Arguably, the single-space, needle-through-needle CSE technique will continue to improve with new needle designs and other advances to improve further the success rate and reduce complications, such as neurotrauma, PDPH, and infection. Over the past decade it has become clear that the CSE technique is a significant advance in regional blockade.

Long-term results and functional outcome after Ripstein rectopexy.

PURPOSE: The aim of this study was to evaluate operative mortality, morbidity, and functional results after Ripstein rectopexy for rectal prolapse and internal rectal intussusception. METHODS: Sixty-nine patients with rectal prolapse and 43 with internal rectal intussusception were included. All patient records were studied and complications registered. Long-term follow-up was possible in 105 patients and performed by clinical examination and standardized interview, telephone interview, or patient records. Seventy-six patients were prospectively evaluated, comparing bowel function before and after rectopexy. RESULTS: There was no operative mortality. Operative morbidity was 33 percent, and most complications were minor. Severe early complications included one large-bowel obstruction and one transient ureteric stenosis. Median time of follow-up was seven years in patients with rectal prolapse and 5.4 years in patients with internal rectal intussusception. Late complications included two rectovaginal fistulas and one lethal sigmoid fecaloma. Five patients underwent subtotal colectomy for severe constipation. There was one recurrent prolapse (1.6 percent). Functional evaluation showed that incontinence improved (P = 0.049), whereas the number of bowel movements per week decreased (P < 0.001). Frequency of emptying difficulties did not change significantly in patients with rectal prolapse but increased in patients with internal rectal intussusception (P = 0.038). CONCLUSION: Ripstein rectopexy can be performed with low mortality and recurrence rate, but with a high early complication rate. There were also some serious late complications. Continence was improved, although increased constipation was a problem in some patients, especially among those with internal rectal intussusception.

Anal sphincter tears at vaginal delivery: risk factors and clinical outcome of primary repair.

OBJECTIVE: To determine risk factors for obstetric anal sphincter tears and to evaluate symptomatic outcome of primary repair. METHODS: Obstetric-procedure, maternal, and fetal data were registered in 845 consecutive vaginally delivered women. Risk factors for anal sphincter tears were calculated by multiple logistic regression. All 808 Swedish-speaking women who delivered vaginally were included in a questionnaire study regarding anal incontinence in relation to the delivery. Questionnaires were distributed within the first few days postpartum, and at 5 and 9 months postpartum. RESULTS: Six percent of the women had a clinically detected sphincter tear at delivery. Sphincter tears were associated with nulliparity (odds ratio [OR] 9.8, 95% confidence interval [CI] 3.6, 26.2), postmaturity (OR 2.5, 95% CI 1.0, 6.2), fundal pressure (OR 4.6 95% CI 2.3, 7.9), midline episiotomy (OR 5.5 95% CI 1.4,18.7), and fetal weight in intervals of 250 g (OR 1.3 95% CI 1.1, 1.6). Fifty-four percent of women with repaired sphincter tears suffered from fecal or gas incontinence or both at 5 months and 41% at 9 months. Most of the symptoms were infrequent and mild. CONCLUSION: Several risk factors for sphincter tear were identified. Sphincter tear at vaginal delivery is a serious complication, and it is frequently associated with anal incontinence. Special attention should be directed toward risk factors for this complication. Symptoms of anal incontinence should explicitly be sought at follow-up after delivery.

Whole gut transit is prolonged after Ripstein rectopexy.

OBJECTIVE: To find out if there are changes in transit time after Ripstein rectopexy and whether measurement of whole gut transit time preoperatively can predict postoperative constipation. DESIGN: Prospective open study. SETTING: Teaching hospital, Sweden. SUBJECTS: 30 patients undergoing Ripstein rectopexy for rectal prolapse (n = 17) or internal rectal intussusception (n = 13). METHODS: Whole-gut transit studies and recording of symptoms of constipation preoperatively and postoperatively. MAIN OUTCOME MEASURES: Constipation and retention of markers. RESULTS: Significantly more markers were retained in postoperative compared with preoperative transit studies (p < 0.001). Constipation mainly presented as emptying difficulties and there was no increase in the total number of patients who reported emptying difficulties postoperatively. There was a weak but significant correlation between retention of markers preoperatively and postoperative emptying difficulties (p < 0.05). CONCLUSION: Whole gut transit was prolonged after Ripstein rectopexy. Preoperative retention of markers indicated an increased risk of postoperative constipation.

Electromyography of the external anal sphincter: comparison between needle and surface electrodes.

PURPOSE: Electromyography of the external anal sphincter is frequently used when investigating patients with defecation disorders. Investigations are often performed using an invasive technique by perineal insertion of a needle or wire electrode. The aim of the present study was to investigate whether surface electromyography, with electrodes applied to the perineal skin, is a reliable method in the diagnosis of paradoxical anal sphincter reaction. METHODS: Seventy-one patients with defecation disorders participated in the present study. They were investigated with electromyography of the external anal sphincter using surface and needle electrodes. RESULTS: In 65 of 71 (92 percent) patients the electromyography recording showed the same result during straining using surface electrodes when compared with needle electrodes. Twenty-two of these 65 patients had paradoxical anal sphincter reaction, and 43 patients had decreased electromyography activity. In 6 of 71 (8 percent) patients the electromyography recording showed a different pattern during straining using surface electrodes when compared with needle electrodes. CONCLUSION: The present study demonstrates a good correlation between surface electrodes applied to the perineal skin and concentric needle electrodes in the diagnosis of paradoxical anal sphincter reaction. Noninvasive electromyography recordings of the external anal sphincter are often preferred in the diagnosis of paradoxical anal sphincter reaction.

Preoperative electrophysiologic assessment cannot predict continence after rectopexy.

PURPOSE: The aim of this study was to evaluate preoperative electrophysiologic assessment for prediction of anal continence after rectopexy. METHODS: Forty-three patients with rectal prolapse (n = 26) or internal rectal intussusception (n = 17) underwent concentric-needle electromyography, fiber density determination by single-fiber electromyography of the external anal sphincter, and pudendal nerve terminal motor latency evaluation before Ripstein rectopexy. A detailed history was obtained from each patient preoperatively and postoperatively. RESULTS: Anal continence was improved after rectopexy, both in patients with rectal prolapse (P = 0.06) and in those with internal rectal intussusception (P = 0.003). Abnormal results were registered in one or several aspects of the electrophysiologic assessment in 31 (72 percent) of the patients. However, functional outcome with respect to continence was not predicted by preoperative electromyography or pudendal nerve terminal motor latency assessment results. CONCLUSION: Electrophysiologic examinations in the preoperative assessment of patients with rectal prolapse and internal rectal intussusception do not predict continence after the Ripstein rectopexy. The routine use of electrophysiologic assessment requires further definition.