Perineal rectosigmoidectomy in the elderly

Recent advances in the surgical treatment of faecal incontinence

BACKGROUND

Improved imaging and refined technology have led to a number of recent advances in the surgical treatment of faecal incontinence.

METHODS

Original articles, identified using a computer database (Medline), and recently published abstracts of meetings were selected on the basis of greatest clinical relevance; these were reviewed.

RESULTS

Ultrasonographic characterization has led to improved therapeutic strategies. Simple structural damage is readily identified and external sphincter repair results in a good outcome for a majority of patients. For more complex structural damage, or for the newly recognized primary internal sphincter degeneration, alternative treatment strategies are emerging. The electrically stimulated gracilis neosphincter and the artificial bowel sphincter offer good results. The latter may be a more simple operation. For structurally intact but weak sphincters, sacral nerve stimulation is a promising therapy. Other therapies, such as antegrade irrigation, may be helpful for patients with neurological disorders.

CONCLUSION

Better imaging, refined classification and new operations are leading to improved surgical techniques for faecal incontinence.

Parameters of the rectoanal inhibitory reflex in patients with idiopathic fecal incontinence and chronic constipation

PURPOSE

The rectoanal inhibitory reflex is a response of the internal anal sphincter to rectal distention, reflecting the functional nature of the anal sampling mechanism of rectal discrimination. The aim of this study was to assess the parameters of the rectoanal inhibitory reflex in healthy volunteers and incontinent and symptomatically constipated patients.

METHODS

The rectoanal inhibitory reflex was recorded in 42 patients using reproducible threshold volumes. Excitatory and inhibitory latencies, maximum excitatory and inhibitory pressures, amplitude, and slope of inhibition, slope and time of pressure recovery, and area under the inhibitory curve were estimated. Pudendal nerve terminal motor latency and endoanal magnetic resonance imaging were performed in all incontinent patients.

RESULTS

Significant linear trends were found for most parameters at each sphincter level when analyzed. Recovery time and area under the inhibitory curve differed between the sphincter levels and patient groups, with the most rapid recovery occurring in the distal sphincter of incontinent patients (P < 0.001). These pressure findings were not accounted for by differences in excitation between patient groups.

CONCLUSION

A coordinated response by the internal anal sphincter to rectal distention with recovery of anal pressure from the distal to the proximal sphincter is suggested. Continence may rely on the character of internal anal sphincter inhibition, and recovery and preoperative assessment of rectoanal inhibitory reflex parameters may be important for predicting functional result following low anastomosis.

Functional problems in adult rectal prolapse and controversies in surgical treatment

BACKGROUND

Rectal prolapse is a condition that has fascinated surgeons for a long time. To date, no single ideal surgical treatment has been identified. The aetiology of rectal prolapse remains highly controversial, but it is recognized that associated functional problems, such as incontinence and constipation, are common. The pathophysiology, and controversies surrounding continence and constipation, remain topics of debate.

METHOD

All relevant papers derived from Medline and manual searching on rectal prolapse and associated functional problems were reviewed.

RESULTS AND CONCLUSION

The surgical management of rectal prolapse has evolved from historical encirclement procedures to current minimally invasive ones. Successful management must include adequate attention to the associated functional problems in order to eradicate the basic abnormality.

The best operation for rectal prolapse

Rectal prolapse remains a disorder for which the cause is not clearly understood and the best method of management is debated. Because the natural history of prolapse frequently leads to complications of incontinence and constipation, we believe that all patients presenting with internal and external prolapse should be considered for repair. Although the type of operative repair recommended may vary, it is clear that all patients with external rectal prolapse should be offered some type of repair. What is not clear from the literature is the appropriate management of those patients with internal prolapse. As shown in the George Washington University experience, surgery is rarely performed for isolated internal prolapse. Most patients who present with internal prolapse also have an associated enterocele, rectocele, or cystocele. Repair of the internal prolapse and the associated disorder may benefit many of these patients. If internal prolapse is an isolated finding, it is not clear to what extent the prolapse is responsible for the patient's symptoms, and repair is generally not advised. These guidelines are easy to enumerate but may be difficult to practice in some patients. Therefore, ongoing evaluation of clinical results is critical to improve our understanding of these disorders. This discussion has outlined the current theories of the cause of rectal prolapse, the symptoms and findings patients present with, and the possible approaches to repair.

Defecography and proctography. Results of 744 patients

PURPOSE

Radiographic imaging of dynamic changes within the pelvic cavity and rectum during evacuation has been recognized as a valuable method of assessment. This study was designed to assess the incidence and clinical significance of defecographic findings in patients with possible evacuation disorders.

MATERIALS AND METHODS

All defecographic studies were reviewed by a single colorectal surgeon familiar with patients' histories and physical findings.

RESULTS

Between July 1988 and July 1995, 744 patients (566 females and 178 males) with a mean age of 63.5 (range, 12-95) years had defecographic and proctographic examination. Four hundred forty-six (60 percent) patients were diagnosed who complained of constipation, 123 (16.5 percent) of fecal incontinence, 42 (5.6 percent) of rectal prolapse, 82 (11 percent) of rectal pain, and 51 (6.9 percent) had a combination of more than one of these diagnoses. Although 93 (12.5 percent) of these evaluations were considered normal, 61 (8 percent) revealed rectal prolapse, 191 (25.7 percent) rectocele, 82 (11 percent) sigmoidocele, and 94 (12.6 percent) intussusception; in 223 (30 percent) patients, a combination of these findings was noted. Patients with paradoxical puborectalis contraction had an extremely high frequency of constipation compared with other symptoms (P < 0.0001).

CONCLUSIONS

Defecography can reveal abnormalities in the majority of patients with evacuatory disorders. There was a high incidence of rectocele, sigmoidocele, and intussusception. Care must be taken not to treat patients strictly based on radiographic findings.