Colectomy for slow-transit constipation: preoperative functional evaluation is important but not a guarantee for a successful outcome.

PURPOSE: This study was designed to assess the results of preoperative functional evaluation of patients with severe slow-transit constipation in relation to functional outcome. METHODS: Four hundred thirty-nine patients with chronic intractable constipation were evaluated by marker studies. Twenty-one patients underwent colectomy and ileorectal anastomosis for slow-transit constipation. Mean colorectal transit time was 156 hours (normal, <45 hours). Small-bowel transit time was normal in ten patients and delayed in five patients. Six were nonresponders. Morbidity was 33 percent. Small-bowel obstruction occurred in six patients; relaparotomy was done in four patients. Follow-up varied from 14 to 153 (mean, 62) months. RESULTS: After three months, defecation frequency was increased in all. Mean stool frequency improved from one bowel movement per 5.9 days to 2.8 times per day. Sixteen patients felt improved after surgery. Seventeen continued to experience abdominal pain, and 13 still used laxatives and enemas. Satisfaction rate was 76 percent (16 patients). After one year, defecation frequency was back at the preoperative level in five patients. An ileostomy was created in two more patients because of incontinence and persistent diarrhea. Eleven patients (52 percent) still felt improved. A relation between small-bowel function and functional results could not be demonstrated. CONCLUSIONS: Preoperative evaluation is important but not a guarantee for, successful outcome. Colectomy remains an ultimate option for patients with disabling slow-transit constipation, but patients should be informed that, despite an increased defecation frequency, abdominal symptoms might persist. Any promiscuous use of colectomy to treat constipation should be discouraged.

Transposition of the rectus abdominis muscle for complicated pouch and rectal fistulas.

PURPOSE: Operative repair for complicated pouch and rectal fistulas is often difficult. We present our experience with ten consecutive patients operated on for complicated pouch and rectal fistulas by transposition of the rectus abdominis muscle. METHODS: Ten patients with high and complex pouch and rectal fistulas were treated with the interposition of a vascularized rectus abdominis muscle flap. All patients received standard bowel preparation and antibiotics. All were diverted by a temporary ileostomy. RESULTS: Causes of fistulas included Crohn's disease (n = 3), previous rectal surgery (n = 5), anal atresia (n = 1), and sphincter repair (n = 1). Three patients had a third recurrence. The procedure was performed in combination with a plastic surgeon. All fistulas healed. No special postoperative care was required. There were no cosmetic or functional complaints caused by transposition of the rectus abdominis muscle. CONCLUSIONS: Transposition of the rectus abdominis muscle is a suitable technique in treatment of fistulas between the rectum or ileal pouch and the vagina or urinary system, with no obvious side effects and excellent clinical outcome.

Management of left-sided colonic obstruction by subtotal colectomy and ileocolic anastomosis.

OBJECTIVE: To assess complications and functional results of emergency subtotal colectomy with ileocolic anastomosis for acute left-sided colonic obstruction. DESIGN: Retrospective study. SETTING: University hospital, Netherlands. SUBJECTS: 37 patients with acute left-sided colonic obstruction. INTERVENTIONS: Emergency subtotal colectomy with immediate anastomosis (n = 20), Hartmann's procedure (n = 13) or double-loop transverse colostomy (n = 4). MAIN OUTCOME MEASURES: Mortality, morbidity, duration of hospital stay, frequency of defecation, and continence. RESULTS: Morbidity after subtotal colectomy was 10% (n = 2) and mortality 0. There was one anastomotic dehiscence that required a temporary ileostomy. Mean hospital stay was 15 days (range 10-31). All had adequate continence. After 6 weeks mean frequency of defecation was 3/24 hrs (range 2-6). 9 patients died within 2 years of metastatic disease. CONCLUSIONS: Subtotal colectomy with ileocolic anastomosis is a suitable procedure for treating left-sided colonic obstruction provided that pelvic floor function is adequate and a skilled surgeon is available.

Interobserver agreement in defecography--an international study.

BACKGROUND: Defecography is considered to be an essential investigation in the evaluation of functional anorectal disorders, but the agreement between observers from different clinical centers has never been evaluated. METHODS: 14 defecographic studies were selected aimed to cover the most relevant defecographic findings responsible for disordered defecation. Eight studies were considered unequivocal, but six were thought to be controversial. All were sent to the ten participants in Europe and the US (five proctosurgeons, three radiologists, two gastroenterologists). They evaluated the studies using a previously agreed upon questionnaire. Interobserver agreement was quantified by kappa statistics and by the proportions of positive and negative agreement as compared to chance agreement, respectively. RESULTS: Overall, only the completeness of rectal emptying and the presence of a rectocele achieved acceptable kappa values above 0.4. When restricting the evaluation to the studies considered to be unequivocal, agreement improved considerably and was moderate to good for all items describing the images (kappa 0.43-0.63). However, whether proctosurgery should be performed and whether defecography contributed to the management of the particular patient remained controversial with very low kappa. CONCLUSIONS: It is doubtful whether defecography contributes substantially to the management of patients with disordered defecation.

Surgical treatment of symptomatic rectosigmoid endometriosis.

OBJECTIVE: To assess the results of surgical treatment of symptomatic intestinal endometriosis. DESIGN: Retrospective study. SETTING: University hospital, The Netherlands. SUBJECTS: 14 patients in whom medical treatment had failed. INTERVENTIONS: Hysterectomy (n = 5), salpingo-oophorectomy (n = 8, bilateral in 5), posterior vaginal wall excision (n = 14), and partial resection (n = 6) or anterior wedge excision (n = 8) of the rectum. MAIN OUTCOME MEASURES: Blood loss, operating time, morbidity, and relief of symptoms. RESULTS: 9 patients became symptom free (64%), 5 of whom developed postmenopausal symptoms later on. 2 had unrelated vague abdominal symptoms and 3 more could not be assessed because they underwent in vitro fertilisation and developed stimulation-related abdominal symptoms. All were content with the operative results. CONCLUSIONS: Operations for rectosigmoid endometriosis are technically difficult with a long operating time and considerable blood loss, but they are successful in relieving symptoms when conservative treatment has failed.

Plasma cholecystokinin levels and gallbladder volumes after proctocolectomy with ileal pouch-anal anastomosis.

BACKGROUND: The colon and rectum contain regulatory peptides in mucosal endocrine cells, which suggests a hormonal role. In animal studies colectomy leads to increased plasma levels of cholecystokinin. Little is known about the effects of proctocolectomy with ileal pouch-anal anastomosis on the release of cholecystokinin in human beings. Therefore we studied the effects of this procedure on fasting, postprandial, and bombesin-stimulated plasma cholecystokinin levels and gallbladder volumes. METHODS: Ten patients who had undergone proctocolectomy with ileal pouch-anal anastomosis and 12 healthy volunteers participated in the study. Fasting and postprandial plasma cholecystokinin levels and gallbladder volumes were studied for 3 hours at 15-minute intervals. In a second experiment plasma cholecystokinin levels were measured before and during intravenous administration of bombesin in six patients with ileal pouch and five healthy volunteers. RESULTS: Fasting plasma cholecystokinin levels were higher (p < 0.05) in patients with ileal pouch-anal anastomosis (2.6 +/- 0.3 pmol/L) compared with controls (1.7 +/- 0.2 pmol/L). Integrated postprandial plasma cholecystokinin levels were also distinctly higher (p < 0.01) in patients (978 +/- 126 pmol/L.180 min) than in controls (588 +/- 60 pmol/L.180 min). Mean fasting gallbladder volume was significantly (p < 0.01) decreased in patients with ileal pouch-anal anastomosis (18 +/- 2 ml) compared with controls (28 +/- 2 ml). Postprandial gallbladder emptying as measured by percentage change was similar in both groups. After infusion of bombesin, integrated plasma cholecystokinin responses were higher (p < 0.05) in patients (161 +/- 20 pmol/L.20 min) than in controls (90 +/- 12 pmol/L.20 min). CONCLUSIONS: Fasting, postprandial, and bombesin-stimulated plasma cholecystokinin levels are elevated in patients with ileal pouch-anal anastomosis compared with controls. Fasting gallbladder volume is decreased after ileal pouch-anal anastomosis. These findings suggest that the colon contains a factor that inhibits the release of cholecystokinin.

Continence disorders after anal fistulotomy.

PURPOSE: This study was designed to detect factors that predict the occurrence of continence disorders after anal fistulotomy. METHODS: A retrospective study of the charts of 312 patients was undertaken. A questionnaire was sent to all patients, with a response rate of 90 percent. RESULTS: Minor continence disorders occurred in 73 patients, incontinence did not occur. Multivariate analysis (chi-squared test) was performed showing that extensions (P = 0.008), location (P = 0.03), and level (P = 0.029) of the anal opening appeared to be independent factors. CONCLUSION: Patients with high openings, posterior openings, or fistula extensions are at risk to develop continence disorders after anal fistulotomy.

Biofeedback treatment of constipation: a comparison of two methods.

OBJECTIVES: Our purpose in this study was to determine whether, with balloon feedback treatment, one can obtain results similar to those achieved with electromyographic (EMG) feedback treatment, in patients with a functional outlet obstruction (spastic pelvic floor syndrome). METHODS: In a randomized controlled study, 11 patients received EMG biofeedback and nine patients received balloon feedback. Treatment outcome was assessed by standard EMG during straining, constipation score, and a standard diary with details about complaints. RESULTS: Using change scores (posttreatment score minus pretreatment score), we found significantly greater positive changes for EMG feedback at posttreatment and at follow-up. When criteria for good clinical outcome were used, eight of 11 patients treated with EMG feedback appeared to be improved, against two of nine patients treated with balloon feedback. Type of feedback was the only difference between the groups. CONCLUSIONS: Alteration of the EMG pattern leads to lessening of complaints, which means that pelvic floor contraction during straining indeed is the cause of the constipation. The results suggest that EMG feedback is more effective than balloon feedback in treating spastic pelvic floor syndrome.

Effect of electrostimulation on sphincter function in neurogenic fecal continence.

PURPOSE: This study was designed to examine the effects of electrostimulation on sphincter function. METHODS: Electric stimulation was performed twice a day for 30 minutes over a 12-week period on 10 patients with neurogenic fecal incontinence. Anal manometry was repeated after 6 and 12 weeks. RESULTS: Two patients experienced some improvement. Mean resting pressure was increased by 0.6 (-5.8 to +5.3) kPa and mean squeezing pressure by 0.3 (-1.6 to +2.6) kPa. All values remained below continent levels. An increase in squeezing pressure after both 6 and 12 weeks was recorded in only one patient. CONCLUSION: Electrostimulation does not improve internal or external sphincter function. There is no indication that it will do so in the long term either.

Treatment of complete rectal prolapse: to narrow, to wrap, to suspend, to fix, to encircle, to plicate or to resect?

Selection of the best surgical procedure for the treatment of complete rectal prolapse is difficult amid the many different techniques for which excellent results are reported. A critical review is given. It is concluded that any surgical procedure with rectal mobilization and fixation as a standard maneuver will lead to a recurrence rate of 2% to 4%. Advocacy of additional maneuvers to make the procedure easier is acceptable if it does not lead to a higher complication rate. But to obtain a better result its benefit has to be proven, either by a large prospective double-blind study, or by tests from the colorectal laboratory. New surgical techniques for rectal prolapse should therefore be based, not only on a low recurrence and complication rate, but also on tests that evaluate the effect of the procedure on fecal continence.

Assessment and treatment of obstructed defecation.

Defecation may be considered as "the last taboo". The inability to defecate, or to achieve it only by digital evacuation, has never been a popular topic among patients and doctors. The extensive development of tests in laboratories studying colorectal disorders during recent years, however, has made it possible to study the different parts of the mechanism for maintaining continence. Since constipation is a disorder of this mechanism, namely a disorder of rectal evacuation, application of these tests on constipated patients is logical. Certainly surgery, either colectomy or sphincter division, is not the solution, nor is the injection of muscle weakening solutions. Biofeedback, however, seems to be a logical treatment. Development of new functional tests and strategies is needed to enable a better understanding of the problem. Collaboration between surgeon and psychologist has proved valuable and is recommended.

Disorders of impaired fecal control. A clinical and manometric study.

Two hundred eight patients with retention disorders have been studied. Most frequent causes were idiopathic (107), iatrogenic (57), and obstetric (33). Twenty-five patients experienced soiling, 31 had insufficient function, and 152 complained of incontinence. Seventy percent of patients with idiopathic incontinence did not experience urge, compared with 38 percent with iatrogenic and only 3 percent with obstetric incontinence. The incidence of prolapse was 58 percent in patients with idiopathic incontinence, 20 percent in patients with iatrogenic incontinence, and only 3 percent in patients with obstetric incontinence. The authors conclude that the function of the puborectalis sling is to create the anorectal angle to evoke the feeling of urge and to support intra-abdominal contents and, furthermore, that fecal incontinence after anorectal surgery was likely caused by denervation. Anal resting and squeeze pressures varied widely. There was a huge overlap in the different groups. Mean resting and squeeze pressures were 9.5 kPa and 9.4 kPa, respectively, in controls, 4.8 kPa and 10.3 kPa, respectively, in the soiling group, 7.1 and 6.1 kPa, respectively, in the insufficient group, and 5.1 and 2.7 kPa, respectively, in the incontinent group. An incontinent external sphincter function could be defined as a function of the external sphincter causing a pressure increase of 5 kPa or less during straining. The ability to retain feces, therefore, is based on external sphincter function. Anal manometry is, indeed, a suitable technique to determine anal sphincter functions, but the presence of a retention disorder cannot definitely be determined. Its clinical application remains under discussion.

Application of the colorectal laboratory in diagnosis and treatment of functional constipation.

Defecography, pelvic floor electromyography, and segmental colonic transit times were performed in 74 patients with functional constipation. Signs of functional outlet obstruction occurred in 74 percent. Transit times were normal in 33 percent. Measurement of colonic transit time in patients with disordered evacuation studies is useless from a clinical point of view, because abnormal segmental transit time is the result of outlet obstruction in most cases and will return to normal after adequate treatment. Only when evacuation studies are normal, or have become normal after treatment and constipation persists, are segmental transit studies indicated because they may demonstrate primary slow transit constipation. Primary slow transit constipation probably is caused by impaired motility of the whole gastrointestinal tract. As small-bowel transit time increases, defecation frequency decreases, laxatives are taken again, and abdominal pain persists. Surgery should be performed with restraint.

Postanal repair restores anatomy rather than function.

The effects of postnatal repair on internal and external sphincter function has been assessed by comparing preoperative and postoperative manometric results in 39 patients with neurogenic fecal incontinence. Postanal repair was effective in 70 percent. The urge to defecate was restored in 70 percent, the ability to retain feces in 45 percent. The procedure caused an increase in squeeze pressure (P = .001), but clinical results were not related absolutely to improvement of external sphincter function, which remained within limits of fecal incontinence in most cases. The procedure restores anatomy rather than function. The influence of the procedure on resting pressure was not statistically significant (P = .4).

Treatment of the spastic pelvic floor syndrome with biofeedback.

The spastic pelvic floor syndrome is a functional disorder based on contraction instead of relaxation of the pelvic floor muscle during straining, which inhibits defecation and gives rise to constipation. Until now no adequate treatment has been found for this condition. The treatment described here is aimed at teaching patients to relax their pelvic floor muscle during straining. Treatment consists of a training program with EMG feedback, followed by simulation of the defecation process, using oatmeal porridge. Patients are then given instructions to generalize the relaxation response in their daily lives. Treatment was completely successful in seven of ten patients. The three remaining patients learned to strain in the correct manner, but could not achieve generalization. Two of them underwent subtotal colectomy because of delayed colonic transit times, which subsequently resulted in normal evacuation. In the third patient, the generalization was most likely hampered by psychologic problems, for which she now receives psychotherapy.

Diagnosis of functional disorders of defecation causing the solitary rectal ulcer syndrome.

The solitary rectal ulcer and colitis cystica profunda are different manifestations of the solitary rectal ulcer syndrome. The cause of solitary rectal ulcer syndrome remains unknown. Since defecation disorders are common among patients with solitary rectal ulcer syndrome, defecography is indicated. Defecography was performed on 19 patients with solitary rectal ulcer syndrome. In five patients, the spastic pelvic floor syndrome had occurred. Twelve patients had internal intussusception of the rectum, and one patient had an anterior rectal wall prolapse. In one patient, no abnormalities could be detected. These abnormalities led to severe straining, which can damage the anterior rectal wall. Findings strongly support the hypothesis that solitary rectal ulcers are traumatic lesions caused by straining. Defecography is a suitable procedure for detecting the causative disorder of defecation and for selecting patients for treatment.

The spastic pelvic floor syndrome. Large bowel outlet obstruction caused by pelvic floor dysfunction: a radiological study.

To determine whether a persistent contraction of the pelvic floor muscle during straining, as observed in constipated patients during defaecography, was due to a conscious action of the patients or really represented a functional disorder, segmental colonic transit studies were performed in 24 patients in whom the diagnosis spastic pelvic floor syndrome was made. Abnormal segmental transit indicating outlet obstruction occurred in 92% of the patients. Four different types of segmental transit abnormalities were observed which suggested that the spastic pelvic floor syndrome involved a functional outlet obstruction leading to retrograde filling of the colon and severe straining. A causative relation with other anorectal abnormalities is suggested.

The spastic pelvic floor syndrome. A cause of constipation.

In 12 patients with constipation, it was detected by defecography that, during straining, the anorectal angle did not increase, but remained at 90 degrees. These patients were unable to excrete barium. Since the anorectal angle is a measure of activity of the pelvic floor musculature, a dysfunction of this muscle was suspected. In order to determine whether this abnormality represented a true functional disorder or just a voluntary contraction of the pelvic floor muscles due to embarrassment, we performed electromyographic, manometric, and transit time studies in these patients. The electromyographic studies confirmed the persistent contraction during defecation straining. Both manometry and electromyography revealed normal muscle function at rest and during squeezing. Colonic transit time studies demonstrated rectal retention in nine of 12 patients, indicating outlet obstruction. Persistent contraction of the pelvic floor muscles, for which we propose the name "spastic pelvic floor syndrome," represents a functional disorder of normal pelvic floor muscles, causing a functional outlet obstruction.

Is prophylactic abdominal irrigation with polyvinylpyrrolidone iodine (PVPI) safe?

In order to investigate the safety of abdominal irrigation with polyvinylpyrrolidone iodine (PVPI), the abdominal cavities of normal rats were irrigated with the highest nonlethal dose. Samples of the peritoneal fluid were taken before and 1, 2, and 4 hours after irrigations. Control studies were done with saline. After irrigation with PVPI, the protein concentration in the peritoneal fluid showed a 40-fold increase, compared with only a doubling after saline irrigations. Irrigation with PVPI causes serious peritoneal damage, and should therefore not be performed as a prophylactic procedure.

Fistulography for fistula-in-ano. Is it useful?

In order to assess fistulography for anal fistula, 25 fistulograms were reviewed. The results as for extensions and internal openings were compared with the surgical findings. Fistulograms were correct in only 16 percent. False-positive results occurred in 10 percent. Fistulography is inaccurate and unreliable.