Laparoscopic or transanal repair of rectocele? Comparison of a reduction in rectocele size.

PURPOSE: This study aimed to compare the reduction in rectocele size after laparoscopic ventral rectopexy (LVR) with that after transanal repair (TAR). METHODS: Forty-six patients with rectocele who underwent LVR and 45 patients with rectocele who received TAR between February 2012 and December 2022 were included. This was a retrospective analysis of prospectively collected data. All patients had clinical evidence of a symptomatic rectocele. Bowel function was evaluated using the constipation scoring system (CSS) and fecal incontinence severity index (FISI). Substantial symptom improvement was defined as at least a 50% reduction in the CSS or FISI scores. Evacuation proctography was performed before surgery and 6 months postoperatively. RESULTS: Constipation was substantially improved in 40-70% of the LVR patients and 70-90% of the TAR patients over 5 years. Fecal incontinence was markedly improved in 60-90% of the LVR patients across 5 years and in 75% of the TAR patients at 1 year. Postoperative proctography showed a reduction in rectocele size in the LVR patients (30 [20-59] mm preoperatively vs. 11 [0-44] mm postoperatively, P < 0.0001) and TAR patients (33 [20-55] mm preoperatively vs. 8 [0-27] mm postoperatively, P < 0.0001). The reduction rate of rectocele size in the LVR patients was significantly lower than that in the TAR patients (63 [3-100] % vs. 79 [45-100] %, P = 0.047). CONCLUSION: The reduction in rectocele size was lower in the patients who underwent LVR than in those who received TAR.

The incidences of metachronous multiple gastric cancer after various types of gastrectomy: analysis of data from a nationwide Japanese survey.

BACKGROUND: The incidence of metachronous multiple gastric cancer (MMGC) after gastrectomy remains unclear. This study evaluated the incidences of MMGC according to specific gastrectomy types, including pylorus-preserving gastrectomy (PPG), proximal gastrectomy (PG), and function-preserving gastrectomy (FPG), which was categorized as segmental gastrectomy and local resection. METHODS: We conducted a questionnaire survey of the Japanese Society for Gastro-Surgical Pathophysiology members, who were asked to report their institutional numbers of radical gastrectomy cases for cancer between 2003 and 2012. The cases were categorized according to whether the remnant stomach's status was followed for > 5 years, confirmation of MMGC, time to diagnosis, and treatment for MMGC. We calculated the "precise incidence" of MMGC by dividing the number of MMGC cases by the number of cases in which the status of remnant stomach was followed up for > 5 years. RESULTS: The responses identified 33,731 cases of gastrectomy. The precise incidences of MMGC were 2.35% after distal gastrectomy (DG), 3.01% after PPG, 6.28% after PG (p < 0.001), and 8.21% after FPG (p < 0.001). A substantial proportion of MMGCs (36.4%) was found at 5 years after the initial surgery. The rates of MMGC treatment using endoscopic submucosal dissection were 31% after DG, 28.6% after PPG, 50.8% after PG (p < 0.001), and 67.9% after FPG (p < 0.001). CONCLUSIONS: The incidence of MMGC was 2.4% after DG, and higher incidences were observed for larger stomach remnants. However, the proportion of cases in which MMGC could be treated using endoscopic submucosal dissection was significantly higher after PG and FPG than after DG.

Early prediction model of organ/space surgical site infection after elective gastrointestinal or hepatopancreatobiliary cancer surgery.

BACKGROUND: Organ/space SSI is a significant clinical problem. However, early detection of organ/space SSI is difficult, and previous predictive models are limited in their prognostic ability. We aimed to develop and validate a prediction model of organ/space surgical site infection (SSI) using postoperative day 3 laboratory data in patients who underwent gastrointestinal or hepatopancreatobiliary cancer resection. METHODS: This retrospective cohort study using a single-center hospital data from April 2013 to September 2017 included all adult patients who underwent elective gastrointestinal or hepatopancreatobiliary cancer resection. The primary outcome was a presence of organ/space SSI including anastomotic leakage, pancreatic fistula, biliary fistula, or intra-abdominal abscess. We developed and validated a logistic regression model to predict organ/space SSI using laboratory data on postoperative day (POD) 3. Similar models using laboratory data on POD 1 or 5 were developed to compare the predictive ability of each model. RESULTS: A total of 1578 patients were included. Organ/space SSI was diagnosed in 107 patients, with median diagnosis days of 6 (interquartile range, 4-9 days) after surgery. A prediction model using five commonly measured variables on POD 3 was created with the area under the curve (AUC) of 0.883 (95%CI 0.819-0.946). The AUC of a model with POD 1 laboratory data was 0.751 (95%CI 0.655-0.848), while that of POD 5 laboratory data was 0.818 (95%CI 0.730-0.906). CONCLUSIONS: Laboratory data on POD 3 could forecast organ/space SSI precisely. Further prospective studies are warranted to investigate the clinical impact of this model.

Absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with rectal intussusception and fecal incontinence.

PURPOSE: Fecal incontinence (FI) is common in patients with rectal intussusception (RI), although the mechanism behind its formation is unclear. Recent data indicate that a reduction in internal sphincter tone may cause FI, which becomes notable with increasing RI levels. However, the roles of other anatomical abnormalities in anal function remain unclear. This study assessed the relationships between various pelvic floor abnormalities and anal sphincter function in patients with RI and FI. METHODS: Data for patients with RI, collected in a prospective pelvic floor database, were assessed retrospectively. All women with FI, without anal sphincter defect, were included. Data on anorectal physiology and evacuation proctography were analyzed. RESULTS: Of 397 patients with RI, 85, who had predominantly passive FI, met the inclusion criteria. Maximum resting pressure (MRP) was significantly lower in patients with rectoanal intussusception (RAI) than in those with rectorectal intussusception (RRI) [51.1 (17.9-145.8) vs. 70.7 (34.7-240.6) cmH2O, P = 0.007]. Moreover, MRP was significantly lower in RI patients without rectocele than in RI patients with rectocele [50.1 (17.9-111.0) vs. 69.9 (34.7-240.6) cmH2O, P < 0.0001]. Regression analysis showed that RAI rather than RRI and RI without rectocele rather than RI with rectocele were predictive of decreased MRP. However, no variable was significantly associated with decreased maximum squeeze pressure on multivariate analysis. CONCLUSION: In addition to an advanced level of intussusception, the absence of a rectocele may be correlated with reduced internal anal sphincter function in patients with RI and FI.

Recovery of gastric ileus following laparoscopic ventral rectopexy within an enhanced recovery protocol.

PURPOSE: The enhanced recovery after surgery (ERAS) protocol has had limited adoption in laparoscopic ventral rectopexy (LVR), and the extent of gastric ileus shortly after LVR remains unknown. This study was designed to assess the degree of gastric emptying shortly after LVR within an ERAS protocol. METHODS: From August 2012 to June 2014, 40 patients diagnosed with external or internal rectal prolapse were recruited. All patients underwent LVR within an ERAS protocol. Carbohydrate solution (CS) was administered before and 5 h after surgery on the same day. The pyloric area (PA) was measured using ultrasonography before and after each CS intake. RESULTS: The PA was measured in 34 patients. The PA measured prior to CS intake, before surgery, was not significantly different from that after surgery. The rate of increase in the PA, which was calculated by the PA measured 1 h after CS intake divided by the PA measured prior to CS intake before surgery, was not significantly different from that after surgery. The postoperative hospital stay was 1 (1-2) day, and 36 patients (90 %) were discharged on the first postoperative afternoon. CONCLUSION: Postoperative gastric ileus was resolved in most cases within 5 h after LVR under an ERAS protocol.

The translation and validation of the Japanese version of the patient assessment of constipation quality of life scale.

PURPOSE: The aim of the present study was to conduct a psychometric evaluation of the patient assessment of constipation quality of life scale (PAC-QOL) in the Japanese language. METHODS: The PAC-QOL was translated into Japanese. After being linguistically validated, the Japanese version of the PAC-QOL was administered to a sample of 121 patients. Validation studies were conducted to evaluate the internal consistency reliability (Cronbach's alpha), reproducibility [intraclass correlation coefficients (ICCs)], the convergent validity (correlated with the Short-Forum 36 Health Survey), the discriminant validity [correlated with the constipation scoring system (CSS)], the cross-sectional validity (analysis of variance models), and responsiveness (effect size) of the PAC-QOL scales. RESULTS: The internal consistency was good for all of the scales (Cronbach's alpha coefficient >0.7) and reproducible (ICCs >0.7). The four scales of the PAC-QOL were significantly correlated with the Short-Forum 36 Health Survey (P < 0.01 except for the satisfaction subscale) and the CSS scores (P < 0.01 except for the satisfaction subscale). The PAC-QOL scale scores were significantly associated with constipation severity (P < 0.05). The effect size in patients reporting improvements in constipation over the treatment period was moderate to large, with a subscale effect size ranging from 0.69 to 1.18 and an overall scale effect size of 1.12. Similar findings were observed in the original validation study. CONCLUSIONS: The linguistic and psychometric evaluation demonstrated the validity of the Japanese version of the PAC-QOL.

Development and Validation of a Disease-Specific Instrument to Measure Diet-Targeted Quality of Life for Postoperative Patients with Esophagogastric Cancer.

BACKGROUND: Patients who have undergone esophagectomy or gastrectomy have certain dietary limitations because of changes to the alimentary tract. This study attempted to develop a psychometric scale, named "Esophago-Gastric surgery and Quality of Dietary life (EGQ-D)," for assessment of impact of upper gastrointestinal surgery on diet-targeted quality of life. METHODS: Using qualitative methods, the study team interviewed both patients and surgeons involved in esophagogastric cancer surgery, and we prepared an item pool and a draft scale. To evaluate the scale's psychometric reliability and validity, a survey involving a large number of patients was conducted. Items for the final scale were selected by factor analysis and item response theory. Cronbach's alpha was used for assessment of reliability, and correlations with the short form (SF)-12, esophagus and stomach surgery symptom scale (ES(4)), and nutritional indicators were analyzed to assess the criterion-related validity. RESULTS: Through multifaceted discussion and the pilot study, a draft questionnaire comprising 14 items was prepared, and a total of 316 patients were enrolled. On the basis of factor analysis and item response theory, six items were excluded, and the remaining eight items demonstrated strong unidimensionality for the final scale. Cronbach's alpha was 0.895. There were significant associations with all the subscale scores for SF-12, ES(4), and nutritional indicators. CONCLUSIONS: The EGQ-D scale has good contents and psychometric validity and can be used to evaluate disease-specific instrument to measure diet-targeted quality of life for postoperative patients with esophagogastric cancer.

Laparoscopic ventral rectopexy for rectoanal intussusception: postoperative evaluation with proctography.

BACKGROUND: Laparoscopic ventral rectopexy can relieve symptoms of obstructed defecation and fecal incontinence in patients with rectoanal intussusception. However, pelvic floor imaging after surgery has not been reported. OBJECTIVE: This study was designed to assess the outcome of patients who underwent laparoscopic ventral rectopexy for rectoanal intussusception, with special reference to the postoperative findings on evacuation proctography. DESIGN: This study was a retrospective analysis of prospectively collected data. SETTING: The study was conducted from 2012 to 2013 at the Department of Surgery, Kameda Medical Center, Japan. PATIENTS: We included 26 patients with symptomatic rectoanal intussusception. INTERVENTION: Laparoscopic ventral rectopexy was performed. MAIN OUTCOME MEASURE: Evacuation proctography was performed before and 6 months after the procedure. Defecatory function was evaluated using the Constipation Scoring System and Fecal Incontinence Severity Index. RESULTS: Of 26 patients with rectoanal intussusception preoperatively, 22 had symptoms of obstructed defecation and 21 complained of fecal incontinence. Postoperatively, rectoanal intussusception was eliminated in all patients, though 8 developed recto rectal intussusception. There was an overall reduction in both grade 2 rectocele size (median preop 26 mm vs. postop 11 mm; p < 0.0001) and pelvic floor descent (median preop 26 mm vs. postop 20 mm; p < 0.0001). 6 months after surgery, a reduction of at least 50% was observed in the Constipation Scoring System score for 9 patients (41%) with obstructive defecation and in the Fecal Incontinence Severity Index score for 14 incontinent patients (67%). LIMITATIONS: This was a preliminary study with a small sample size, no control group, and short follow-up time. CONCLUSION: Evacuation proctography showed anatomical correction in patients with rectoanal intussusception who underwent laparoscopic ventral rectopexy. However, the data also indicate that such correction does not necessarily result in meaningful symptomatic relief.

Re-appraisal of risk classifications for primary gastrointestinal stromal tumors (GISTs) after complete resection: indications for adjuvant therapy.

BACKGROUND: A substantial number of localized gastrointestinal stromal tumor (GIST) patients have recurrences even after complete resection. The risk of recurrence after complete resection should be estimated when considering adjuvant therapy. In this study, we evaluated prognostic factors of GIST recurrence and compared several reported risk-stratification schemes for defining risk of recurrence to guide the use of adjuvant therapy using data from a large Japanese GIST population. METHODS: We analyzed clinicopathological data collected retrospectively and prospectively from 712 GISTs with complete resection from 1980-2010. We evaluated possible prognostic factors and compared the National Institutes of Health consensus criteria, the Armed Forces Institute of Pathology criteria, Joensuu's modified NIH classification (J-NIHC), the American Joint Committee on Cancer staging system (AJCCS), and the Japanese modified NIH criteria for prediction of tumor recurrence in adjuvant settings. RESULTS: Univariate analysis suggested that the following factors were prognostic: tumor size, mitotic count, site, clinically malignant features of rupture and/or invasion, and gender. In multivariate analysis, size >5 cm, mitotic count >5/50 HPF, non-gastric location, and the presence of rupture and/or macroscopic invasion were independent adverse prognostic factors. When adjuvant therapy is considered for patients with high-risk GIST, the J-NIHC was the most sensitive classification system, while the AJCCS appeared to be the most accurate for predicting recurrence. CONCLUSION: Tumor size, mitotic count, tumor site, and clinical features of rupture and/or invasion were important prognostic factors for GIST recurrence. Joensuu's classification appeared to best identify candidates for adjuvant therapy.

Hydration structure and mobility of the water contained in poly(ethylene terephthalate).

We have studied the state of the water contained in poly(ethylene terephthalate) (PET), which consists of repeat units of OCC6H4COOCH2CH2O, in variously hydrated states. We first determined the hydration structure of the water therein not only from its OH stretching spectrum in a thinner sample but also from the hydration energy, the effect of the hydrogen bonding on the lengths of the donor and acceptor bonds, and the OH stretching frequencies of the water for the optimized 1:1 hydrate structures (quantum-chemically calculated). It has been found that the water bridges two ester C═O's in the manner of C═O···H-O-H···O═C therein and that about a 0.05 mole fraction of the C═O groups is bridged by the water in a PET sample hydrated in open air. We then carefully analyzed the state of the hydrating water in a thicker sample from its combination band around 5240 cm(-1), which significantly changes in frequency and bandwidth depending on the quantity of the contained water. It has been shown that the hydrating water molecules are so mobile as to begin to intermolecularly interact among themselves at a low hydration density of 10-15 water molecules per 1000 repeat units of OCC6H4COOCH2CH2O in the solid matrix.

Adult intussusception: a retrospective review.

BACKGROUND: Intussusception is common in children but rare in adults. The goal of this study was to review retrospectively the symptoms, diagnosis, and treatment of intussusception in adults. METHODS: From 1997 to 2013, we experienced 44 patients of intussusception in patients older than 18 years. The patients were divided into enteric, ileocolic, ileocecal, and colocolonic (rectal) types. The diagnosis and treatment of these patients were reviewed. RESULTS: Of the 44 patients of adult intussusception, 42 were diagnosed with abdominal ultrasonography and abdominal computed tomography. There were 12 patients of enteric intussusception, six patients of ileocolic intussusception, 16 patients of ileocecal type intussusception, and 10 patients of colonic (rectal) intussusception. Among them, 77.3 % were associated with a tumor. Among 12 patients of enteric intussusception, three were associated with a metastatic intestinal tumor, and one was associated with a benign tumor. Among six patients of ileocolic intussusception, two patients were associated with malignant disease. Also, 93.8 % of ileocecal intussusceptions were associated with tumors, 80.0 % of which were malignant. Similarly, 90.0 % of colonic intussusceptions were associated with malignant tumors. Intussusception was reduced before or during surgery in 28 patients. Surgery was performed in 41 patients, and laparoscopy-assisted surgery was performed for ab underlying disease in 12 patients. CONCLUSIONS: Preoperative diagnoses were possible in almost all patients. Reduction greatly benefited any surgery required and the extent of the resection regardless of the underlying disease and surgical site.

Lymph node metastasis after endoscopic submucosal dissection of a differentiated gastric cancer confined to the mucosa with an ulcer smaller than 30 mm.

In the expanded indications for endoscopic resection, Japanese guidelines for gastric cancer include differentiated cancers confined to the mucosa with an ulcer <30 mm. We describe a patient with lymph node metastasis after curative endoscopic submucosal dissection (ESD) for a tumor of this indication. The patient was a 70-year-old man with chronic hepatitis C. He underwent ESD for early gastric cancer in May 2010. Pathology revealed a moderately differentiated adenocarcinoma, 22 × 17 mm in size, that was confined to the mucosa with an ulcer. The horizontal and vertical margins were negative for the tumor. We diagnosed thiscase as curative resection of expanded indication and followed this patient with endoscopy, abdominal ultrasonography (AUS) or enhanced computed tomography (CT) approximately every 6 months. After 17 months, lymph node metastasis was detected with AUS and CT and diagnosed by endoscopic ultrasound-guided fine-needle aspiration biopsy in August 2011. Distal gastrectomy with D2 dissection was carried out in December 2011. Although it is low, the possibility of recurrence should be borne in mind after endoscopic treatment of early gastric cancer, despite its inclusion in the expanded indications for endoscopic resection.

Subgroups of patients with very large gastrointestinal stromal tumors with distinct prognoses: a multicenter study.

BACKGROUND AND OBJECTIVES: Any gastrointestinal stromal tumors (GISTs) larger than 10 cm are classified as "high risk" according to the modified National Institutes of Health consensus criteria. We conducted a multicenter study to identify a subgroup with moderate prognosis even within the "high-risk" group. METHODS: We retrospectively collected data on 107 patients with tumors ≥10 cm from a multicenter database of GIST patients. Patients with macroscopic residual lesions or tumor rupture were excluded. The relationship between recurrence-free survival (RFS) and clinicopathological factors was analyzed. RESULTS: The median tumor size and mitotic count were 12.5 cm and 8/50 HPF. The RFS rate was 58.5% at 3 years, 52.1% at 5 years. Only mitotic count was an independent prognostic factor of RFS in the multivariate analysis (P = 0.001). The hazard ratio for recurrence in the subgroup with mitotic count >5/50 HPF was 2.91 (95% confidence interval, 1.53 to 5.56). The subgroup with mitotic count ≤5/50 HPF showed significantly better RFS than the mitotic count >5/50 HPF subgroup (P < 0.001). CONCLUSIONS: Mitotic count is closely associated with outcome in patients with large GISTs. This suggests that the subset of large GISTs with low mitotic counts may be considered as "intermediate-risk" lesions.

Enhanced Approach to Treating Chronic Anal Fissures: Fissurectomy with Vertical Non-full-thickness Midline Sphincterotomy and Mucosal Advancement Flap.

Objectives: Lateral internal sphincterotomy is a conventional surgical intervention for chronic anal fissures, yet the potential for postoperative anal incontinence underscores the need for an alternative approach. This study aimed to evaluate the outcomes of patients with chronic fissures who underwent a combination of fissurectomy, vertical non-full thickness midline sphincterotomy (VNMS), and mucosal advancement flap (MAF), as a means of mitigating the risk of incontinence. Methods: This retrospective analysis included forty-six consecutive patients with chronic anal fissures, unresponsive to topical diltiazem, who underwent fissurectomy combined with VNMS and MAF between April 2018 and May 2023. Primary outcome measures encompassed fissure healing rates. Continence was assessed using the Fecal Incontinence Severity Index (FISI), and manometric assessments were conducted before the procedure and three months postoperatively. Results: With a median follow-up of 27 months, there were no postoperative complications, and the overall fissure healing rate reached 96% (44/46). At three months post-procedure, FISI scores were reduced to 0, with no instances of fecal soiling. Anal resting pressure exhibited a significant reduction at 3 months [pre-op: 133 (95% CI, 128-150) vs. 3 mo: 109 (95% CI, 100-117) cmH2O; p = 0.01]. Similarly, maximum anal squeeze pressure showed a significant decrease three months post-surgery [pre-op: 317 cmH2O (95% CI, 294-380) vs. 3 mo: 291 cmH2O (95% CI, 276-359), p = 0.03]. Conclusions: The combination of fissurectomy, VNMS, and MAF proved to be an effective approach for chronic anal fissures, yielding favorable medium-term outcomes without postoperative anal incontinence.

Comparison of Safety and Efficacy between Laparoscopic Ventral Rectopexy and Delorme's Procedure for External Rectal Prolapse in Nonagenarians.

Objectives: This study evaluates the safety and efficacy of laparoscopic ventral rectopexy (LVR) in nonagenarian patients with external rectal prolapse (ERP) compared to Delorme's procedure. Methods: We conducted a retrospective analysis of prospectively collected data, including nonagenarian patients who underwent either LVR or Delorme's procedure, comparing outcomes such as morbidity, length of hospital stay (LOS), and recurrence rates. Results: Between September 2009 and August 2023, 22 patients (median age 91, range 90-94 years) underwent LVR, while 12 patients (median age 91, range 90-96 years) received Delorme's procedure. Baseline characteristics, including sex ratio, parity, American Society of Anesthesiology grade, and Body Mass Index, did not significantly differ between the groups. LVR had a significantly longer operating time but lower blood loss than Delorme's procedure. Postoperative LOS was significantly shorter for LVR patients (median 1, range 1-3 days) compared to Delorme's procedure patients (median 2.5, range 1-13 days; P = 0.001). Notably, no significant morbidity occurred in the LVR group, while one case of delirium and another of solitary rectal ulcer syndrome were observed in the Delorme's procedure group. Recurrence rates were lower in the LVR group, with no recurrences during a median follow-up of 23 months (range 1-65 months), compared to one recurrence at 2 months during a median follow-up of 34 months (range 1-96 months) in the Delorme's procedure group. Conclusions: LVR is a safe and effective surgical option for nonagenarian ERP patients, showing favorable outcomes in terms of morbidity, LOS, and recurrence rates compared to Delorme's procedure.

Impact of gastrectomy for incurable advanced gastric cancer in urgent situations in the elderly.

BACKGROUND: Chemotherapy is the standard treatment for incurable advanced gastric cancer; however, its indications are limited in elderly patients. Furthermore, the efficacy of chemotherapy and surgery as well as the treatment strategy for incurable gastric cancer in elderly patients with urgent conditions are unclear. In these situations, palliative gastrectomy or gastrojejunostomy is often performed. Less invasive surgical procedures should be performed on elderly patients in consideration of their condition; however, gastrectomy may be preferable if it can improve the prognosis. Therefore, we investigated the significance of palliative gastrectomy in elderly patients with incurable advanced gastric cancer who underwent surgery due to stenosis or bleeding. METHODS: Fifty-six patients aged >80 years with stage IV incurable advanced gastric cancer who underwent surgery at our department between February 1992 and July 2021 were included in the study. The patients underwent gastrectomy (distal and total gastrectomy) or gastrojejunostomy. We examined the association between the clinicopathological factors and overall survival after surgery. RESULTS: The subjects included 43 men and 13 women. Twenty-nine patients underwent distal gastrectomy or total gastrectomy, and 27 underwent gastrojejunostomy. The median follow-up duration for all patients was 297 days. The univariate analysis indicated significant differences in the surgical procedure and blood loss. Multivariate analysis showed a significant difference only in the surgical procedure (hazard ratio, 5.32; 95% confidence interval, 2.43-11.6; P < 0.001). CONCLUSIONS: Gastrectomy as a palliative surgery for incurable advanced gastric cancer in elderly patients may improve their prognosis.

Annual long-term functional outcomes after transanal repair for symptomatic rectocele.

Purpose: This study was performed to assess the long-term annual functional outcomes and quality of life (QOL) after transanal rectocele repair. Methods: We evaluated retrospectively collected data from patients who underwent transanal repair for symptomatic rectocele between February 2012 and December 2018. The Constipation Scoring System (CSS), the Fecal Incontinence Severity Index (FISI), and several QOL questionnaires (e.g., the Patient Assessment of Constipation-QOL [PAC-QOL], Fecal Incontinence QOL, and the 36-Item Short Form Survey [SF-36]) were administered before surgery and annually after surgery. Additionally, physiological assessments and defecography were performed before and after surgery. Substantial symptom improvement, indicated by at least a 50% reduction in the CSS or FISI score, was evaluated postoperatively. All postoperative follow-up results were compared with the preoperative data. Results: Thirty-two patients were included in the study. The median follow-up period was 5 years (range, 0.5-7 years). Postoperative defecography showed that the rectocele size significantly decreased (P<0.0001). However, the physiological assessment did not reveal postoperative changes. The CSS score 1 year after surgery was significantly lower than the preoperative score (P<0.0001) and remained significantly low until the long-term follow-up. Constipation improved by more than 80% 2 to 5 years postoperatively, and fecal incontinence improved in 2/3 of the patients after 5 years. The PAC-QOL scores significantly improved (all P<0.05) over time until the 3-year and long-term follow-ups, and 6 of the 8 SF-36 scores significantly improved at specific points postoperatively. Conclusion: Transanal rectocele repair provides long-term improvement for constipation and constipation-specific QOL.

Reappraising the Role of Enterocele in the Obstructed Defecation Syndrome: Is Radiological Impaired Rectal Emptying Significant in Enterocele?

Objectives: The role of enterocele in the obstructed defecation syndrome (ODS) has remained to be controversial, as patients with enterocele frequently exhibit multiple risk factors, including aging, parity, concomitant different abnormalities, previous histories of pelvic surgery, and incomplete emptying of the rectum. Thus, in this study, we aimed to investigate the association between enterocele and ODS using multivariate analysis. Methods: Between June 2013 and June 2021, 336 women underwent defecography as they had symptoms of ODS. Of those, 293 women (87%) who had anatomical abnormalities were included in this study. Results: Enterocele was detected in 104 (36%) patients. More women with enterocele had histories of hysterectomy compared to those without enterocele (29% vs. 10%, P < 0.0001). The frequency of radiological incomplete emptying was found to be significantly lower in women with enterocele (36%) than in those without enterocele (50%), whereas the mean (95% confidence interval) ODS scores in women with enterocele were significantly higher than those without enterocele [12.1 (11.0-13.3) versus 10.8 (10.5-11.5), P = 0.023]. As per the results of our multivariate analysis, it was determined that the presence of enterocele was associated with higher ODS scores (P = 0.028). However, the small differences in the mean score (1.3) would be clinically negligible. The specific radiological type of enterocele which compressed the rectal ampulla at the beginning of defecation was not associated with the increased ODS scores. Conclusions: The presence of enterocele may not be a primary cause of ODS. Other anatomical abnormalities combined with enterocele, or the hernia itself, may have a role in causing ODS.

Early postoperative outcomes of a novel nonexcisional technique using aluminum potassium sulfate and tannic acid sclerotherapy with mucopexy on patients with grade III hemorrhoids.

PURPOSE: Aluminum potassium sulfate and tannic acid (ALTA; Zion, Mitsubishi Pharma Corp.) is an effective sclerosing agent for internal hemorrhoids. ALTA therapy with a rectal mucopexy (AM) is a new approach for treating hemorrhoidal prolapse. This study compared the early postoperative outcomes of AM surgery with Doppler-guided transanal hemorrhoidal dearterialization and mucopexy (DM) in patients with third-degree hemorrhoids. METHODS: AM surgery was performed on 32 patients with grade III hemorrhoids and was compared with a cohort of 22 patients who underwent DM surgery in a previous randomized controlled trial. RESULTS: The pain scores during defecation were significantly lower in the AM patients beginning 4 days after surgery. The total use of analgesics 2 weeks postoperatively was significantly lower in the AM patients than in the DM patients (3.5 tablets [range 1.6-5.5] vs. 7.6 tablets [range 3.3-11.9], P=0.04). The length of operation, blood loss, and incidence of postoperative complications were significantly lower in the AM patients than in the DM patients. During 12 months follow-up, recurrence of prolapse occurred in 1 patient who underwent AM surgery. CONCLUSION: AM surgery is effective, with lower complication rates and postoperative analgesic requirements, and is a less invasive treatment for patients with grade III hemorrhoids compared to DM surgery.

A Retrospective Investigation on Electric Bidet Use as a Possible Cause of Anal Incontinence.

OBJECTIVES: The present study aimed to explore whether symptoms of anal incontinence (AI) in patients who used electric bidet toilets to clean the anus may improve after discontinuing bidet use. METHODS: Fifty-three patients with AI who habitually used the bidets before or after defecation and were examined between June 2019 and September 2020 were included in this retrospective study. Questionnaires on Likert-scaled items that assessed bidet use were administered at baseline. The sum of all points was regarded as the "bidet use score". The patients were instructed to discontinue bidets until subsequent examination. Incontinence severity was documented using the fecal incontinence severity index (FISI) score. RESULTS: Follow-up data were available for 49 patients (92%). Of those, 43 had fecal incontinence and 6 had only mucus discharge at baseline. The median duration between the baseline and follow-up was 4 weeks. The median FISI score was significantly reduced at the follow-up [baseline vs. follow-up: 15 (range: 3-43) vs. 10 (range: 0-43); P < 0.0001]. The incidence of fecal incontinence was significantly lower at the follow-up than at the baseline (59% vs. 88%, P = 0.003). A higher maximum squeeze pressure and the absence of associated factors that may cause AI (such as rectoanal intussusception and/or rectocele, mucosal prolapse, and previous anorectal surgery) were significantly associated with a reduction of at least 50% in the FISI scores at follow-up; however, this was not observed for the bidet use score. CONCLUSIONS: Our findings suggest that electric bidet use is a possible cause of AI.