Disordered colorectal motility in intractable constipation following hysterectomy

Bowel dysfunction after total abdominal hysterectomy for benign conditions: a prospective longitudinal study

BACKGROUND AND AIM

On the basis of retrospective studies, hysterectomy has been considered a risk factor for functional bowel disorders. The aim of this study was to prospectively evaluate the patients' bowel function and general health-related quality of life (QoL) before and after hysterectomy. Our hypothesis was that hysterectomy in properly selected patients can impact positively on the patients' self-reporting of their general health and bowel function.

MATERIALS AND METHODS

A prospective longitudinal observational study was conducted in a university-based teaching hospital. Eighty-five patients who were scheduled for total abdominal hysterectomy for a nonmalignant cause completed the study. The main outcome measure was the patient's perception of her bowel function, which was assessed preoperatively and at 6, 12, 26 and 52 weeks postoperatively using the gastrointestinal quality of life questionnaire. The patient's general health was also assessed using a generic general health questionnaire (EQ5D and EQVAS). The effect of time on change in questionnaire score was assessed using mixed model repeated measures at a significance level of 0.05.

RESULTS

The scores in the three questionnaires declined significantly at 6 weeks postoperatively as compared with those obtained preoperatively. However, there was a subsequent increase in the scores up to 12 months postoperatively. Smoking and use of laxative were identified as potential confounding variables.

CONCLUSION

Apart from a transient negative effect, total abdominal hysterectomy improves the patient's gastrointestinal-related QoL, probably as part of general improvement in their QoL.

Biofeedback therapy for female patients with constipation caused by radical hysterectomy or vaginal delivery

BACKGROUND AND AIM

Chronic constipation is frequently seen in women who have undergone hysterectomy or delivery. However, reports regarding anorectal physiologic features in those patients are rare. Patients with constipation associated with either radical hysterectomy or vaginal delivery were analyzed in order to clarify the anorectal physiologic features and the effectiveness of biofeedback therapy.

METHODS

Of the constipated patients, a hysterectomy group (n = 40), delivery group (n = 41), and a control group (n = 89), who had no history of either surgery or delivery before developing functional constipation were included. Their anorectal physiological tests and the effectiveness of biofeedback therapy were investigated.

RESULTS

The volume of desire to defecate was greater in the hysterectomy group than in the control group (86.5 ± 55.0 mL vs 62.9 ± 33.7 mL; P = 0.03), and more than 240 mL of maximal volume of toleration was more frequently noted in the hysterectomy group (32.5%) than in the delivery group (14.6%) and control group (13.5%) (P = 0.02).The failure of balloon expulsion was more frequently noted in the delivery group (44.0%) than in the hysterectomy group (15.0%) and control group (25.0%) (P = 0.01). The defecation satisfaction score was significantly increased after biofeedback therapy in the hysterectomy group (2.0 ± 2.7 vs 7.8 ± 1.5, P < 0.001), the delivery group (1.6 ± 2.1 vs 6.7 ± 2.0, P < 0.001), and the control group (2.5 ± 2.7 vs 6.9 ± 2.1, P < 0.001).

CONCLUSIONS

Rectal hyposensitivity could have been the characteristic mechanism in the hysterectomy group, whereas dyssynergic defecation could have been the cause in the delivery group. Biofeedback therapy was effective for both groups.

Effects of vaginal hysterectomy on anorectal sensorimotor functions--a prospective study

BACKGROUND

While bowel and bladder dysfunction are recognized consequences of a radical hysterectomy, the effects of a simple hysterectomy on anorectal sensorimotor functions, particularly rectal sensation, vary among studies and the effects on rectal compliance remain unknown. Our aims were to prospectively evaluate anorectal sensorimotor functions before and after a hysterectomy.

METHODS

Anal pressures, rectal compliance, capacity, sensation, and bowel symptoms were assessed before, at 2 months, and at 1 year after a simple vaginal hysterectomy for benign indications in 19 patients. Rectal staircase (0-44 mmHg, 4-mmHg steps), ramp (0-200 mL at 50, 200 and 600 mL min(-1)) and phasic distentions (8, 16, and 24 mmHg above operating pressure) were performed.

KEY RESULTS

Anal resting (63 ± 4 before, 56 ± 4 mmHg after) and squeeze pressures (124 ± 12 before, 124 ± 12 mmHg after), rectal compliance and capacity (285 ± 12 before, 290 ± 11 mL 1 year after), and perception of phasic distentions were not different before vs after a hysterectomy. Sensory thresholds for first sensation and the desire to defecate were also not different, but pressure and volume thresholds for urgency were somewhat greater (Hazard ratio = 0.7, 95% CI [0.5, 1.0]) 1 year after (vs before) a hysterectomy. Rectal pressures were higher (P < 0.0001) during fast compared with slow ramp distention; this rate effect was greater at 1 year after a hysterectomy, particularly at 100 mL (P = 0.04).

CONCLUSIONS & INFERENCES

A simple vaginal hysterectomy has relatively modest effects (i.e., somewhat reduced rectal urgency and increased stiffness during rapid distention) on rectal sensorimotor functions.

Rectal sensorimotor dysfunction in constipation

The pathophysiological mechanisms underlying chronic constipation in both adults and children remain to be unravelled. This is a not inconsiderable challenge, but is fundamental to improving management of such patients. Rectal sensorimotor function, which encompasses both sensation and motility, as well as biomechanical components (compliance, capacity), is now strongly implicated in the pathogenesis of constipation. Rectal hyposensitivity, rectal hypercompliance, increased rectal capacity, rectal motor dysfunction (phasic contractility and tone), and altered rectoanal reflex activity are all found in constipated patients, particularly in association with 'functional' disorders of defaecation (i.e. pelvic floor dyssynergia). This review covers contemporary understanding of how components of rectal sensorimotor function may contribute to symptom development in both adult and paediatric populations. The complex interaction between sensory/motor/biomechanical domains, and how best to measure these functions are addressed, and where data exist, the impact of sensorimotor dysfunction on therapeutic outcomes is highlighted.

Clinical presentation and patterns of slow transit constipation do not predict coexistent upper gut dysmotility

BACKGROUND

Slow transit constipation (STC) is associated with upper gastrointestinal tract motor abnormalities in a subset of patients. This could influence the clinical approach, particularly in those rare cases where surgical management is considered.

AIMS

To identify factors that predict proximal gut dysmotility in patients with STC.

METHODS

Esophageal and small bowel motor function were evaluated in 77 patients with STC. Severity and pattern of colonic transit delay, prevalence of a co-existent rectal evacuatory disorder, and type (if present), and duration, and onset of constipation symptoms were compared.

RESULTS

Of the 77 patients studied, 43% exhibited altered motor function in the esophagus and/or small bowel. Frequency of defecation was lower in these patients than in those without upper gastrointestinal dysmotility (0.5 +/- 0.1 vs. 1.3 +/- 0.3 bowel movements/per week, respectively; P = 0.04). Severity and patterns of colonic transit delay and the mechanism associated with the onset of constipation symptoms or with their duration were similar in subjects with or without upper gastrointestinal tract dysmotility. Small bowel but not esophageal motor dysfunction was more frequently associated with a co-existent rectal evacuatory disorder (P = 0.01).

CONCLUSION

Upper gastrointestinal tract dysmotility in patients with STC is frequent, but prediction on the basis of clinical history and characteristics of colonic transit is problematic.

Anorectal manovolumetry in the decision making before surgery for slow transit constipation

BACKGROUND

Colectomy with ileorectal anastomosis for slow transit constipation (STC) is being challenged by other operations, such as segmental resections. The importance of preoperative anorectal physiology testing may therefore be increased. The aim of this study was to identify anorectal abnormalities in patients with STC, which may influence the surgical approach.

METHODS

Fifty consecutive patients with STC (43 women; median age, 49 years) and 28 controls (23 women; median age, 50 years) were examined with anorectal manovolumetry. Anal pressures and rectal volumes were recorded, at stepwise rectal distension.

RESULTS

Anal resting pressure was lower in patients (median, 54 cm H(2)O; range, 22-130) than in controls (median, 68 cm H(2)O; range, 35-100) (p<0.05). Squeeze pressure tended to be lower in patients (median, 147 cm H(2)O; range, 53-382) than in controls (median, 177 cm H(2)O; range, 65-423) (p=0.09). Rectal sensory thresholds did not differ significantly between patients and controls, although 10 patients had a threshold for filling above the 95(th) percentile of controls. Rectal compliance was increased in patients in the pressure interval 5-35 cm H(2)O (p<0.05-0.01). The threshold and amplitude of the recto-anal inhibitory reflex did not differ significantly, but the recovery of resting pressure after eliciting the reflex was lower in patients than in controls in the pressure interval 10-50 cm H(2)O (p<0.05-0.001).

CONCLUSIONS

More than half of the patients with STC deviated in some parameter. An impaired internal sphincter function and increased rectal compliance were seen. One fifth of the patients had impaired rectal sensation.

Bowel, bladder and sexual function in women undergoing laparoscopic posterior compartment repair in the presence of apical or anterior compartment dysfunction

OBJECTIVE

The aim of the study was to analyse the functional outcome of women undergoing a laparoscopic posterior compartment repair in the presence of anterior or apical compartment dysfunction.

DESIGN

Prospective cohort study.

METHODS

Forty women, median age 65 years (41-78), with symptoms of genital prolapse 31 (78%), urinary dysfunction 32 (80%) and bowel dysfunction 40 (100%), underwent laparoscopic posterior compartment repair in conjunction with an anterior compartment repair. Pre-operative and postoperative bowel and bladder function was prospectively assessed with a Wexner continence score, Vienna constipation score and a urinary dysfunction score. Twenty-eight (70%) and 24 patients (60%) had pre-operative urodynamics and anorectal manometry. Post-operatively all women were also assessed with a Watt's sexual dysfunction score and a linear analogue patient satisfaction score. Twelve women (30%) had postoperative anal manometry.

RESULTS

At 20 months median follow-up, 30 (97%), 20 (62%) and 12 (31%) women reported improvement in their prolapse, urinary and bowel symptoms, respectively. Post-operatively, one woman reported denovo faecal incontinence, four worsening obstructive defecation and three denovo urinary dysfunction. Nine women (35%) reported denovo dyspareunia. The mean time to clinical deterioration following surgery was 11 months. Bowel function improvement was the only factor to significantly correlate with postoperative patient satisfaction.

CONCLUSION

The functional outcome of laparoscopic posterior compartment repair in the presence of anterior compartment dysfunction is disappointing. Preoperative counselling is important to ensure that patients have reasonable and realistic expectations from repair surgery, and an understanding that anatomical improvement might not be followed by long-term functional improvement.

Rectal hyposensitivity

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only "apparent" identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although "sensory-retraining biofeedback" appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.

Rectal intussusception: a study of rectal biomechanics and visceroperception

OBJECTIVES

Rectal intussusception (RI) is a significant cause of morbidity amongst those with a rectal evacuatory disorder. The pathophysiology is unknown, but may involve abnormal biomechanics of the rectal wall similar to that previously demonstrated in patients with overt rectal prolapse (RP). Using an electromechanical barostat, this study aimed to investigate the biomechanics and visceroperception of the rectal wall in patients with RI.

METHODS

Twenty consecutive patients (12 females, median age 46 yr (range 24-66)) with symptomatic, full-thickness RI were studied. Patients underwent assessment of rectal compliance, visceroperception, adaptive response to isobaric distension at urge threshold, and assessment of the postprandial response. Results were compared with those obtained in 28 asymptomatic volunteers, 10 with RI (6 females, median age 29 yr (range 21-36)) and 18 (9 females, median age 33 yr (range 21-62)) without.

RESULTS

In the absence of the clinical finding of solitary rectal ulcer syndrome (SRUS), patients with symptomatic RI have normal rectal wall biomechanics, as do asymptomatic volunteers with RI (p < 0.05). Patients with the clinical finding of SRUS had reduced compliance and adaptation. In all three groups, there was a linear relationship between rectal pressure and visceroperception. The postprandial contractile response was similar between groups.

CONCLUSIONS

Patients with RI have normal rectal wall biomechanics. This is in contrast to patients with RP, and suggests that while they may represent different stages of the same disease process, they are physiologically distinct. In patients with RI and SRUS, rectal wall inflammation and fibrosis, perhaps arising secondary to the intussusception, may explain the physiological changes observed.

Magnetic resonance imaging of the rectum during distension

PURPOSE

A knowledge of the relationships between the rectum and its surrounding structures during distention may improve our understanding of the results of studies assessing rectal sensory-motor responses to distention. This magnetic resonance imaging study was designed to assess the shape of the rectum and the degree of distention at which the surrounding structures are compressed.

METHODS

Nine healthy patients underwent magnetic resonance imaging of the rectum under resting conditions and after the inflation of a plastic bag to volumes of 50, 100, 150, 200, and 250 ml. The thickness of the rectovesical space was assessed as a measure of the compression of the perirectal structures, and the perception of sensations were recorded.

RESULTS

The shape of the rectum changed from being quasicylindrical at distention volumes of <100 ml to bean-shaped at larger volumes. The thickness of the rectovesical space at a distention volume of 50 ml was the same as when the bag was not inflated, but it progressively decreased until the difference became statistically significant at distention volumes of > or = 200 ml, corresponding to a mean +/- standard deviation rectal radius of 2.66 +/- 0.37 cm. Statistically significant compression of the rectovesical space was recorded when the sensations of gas, desire to defecate, and urgency were perceived.

CONCLUSIONS

The shape of the rectum changes during distention; it significantly compresses the extrarectal structures in the tested range of distention that induces non-painful sensations. Magnetic resonance imaging is a useful means of assessing the morphologic changes in the rectum during distention.

Effect of Total Abdominal Hysterectomy on Pelvic Floor Function

Historically, hysterectomy is one of the oldest gynecologic operations, dating back to the 1840s. Currently, it is the most common gynecologic operation performed and is associated with marked improvement in the patients' quality of life. It is widely considered a safe procedure with an extremely low mortality rate (<0.1%). The majority of hysterectomies are done abdominally, with the vast majority being total abdominal hysterectomies. The effect of hysterectomy on pelvic floor function has been a subject of long debate. Various studies have reached different and rather contradictory results. Most of these studies lack stringent methodologic standards, being retrospective, observational, or uncontrolled. A recent excellent study assessed the effect of abdominal hysterectomy on pelvic floor function as 1 functional unit and concluded that both total and subtotal abdominal hysterectomies have no detrimental effect on the pelvic floor function up to 1 year postoperatively.

Nerve sparing radical hysterectomy: latest developments and historical perspective

Autonomic nerve damage during surgery is thought to play a crucial role in the aetiology of bladder dysfunction, sexual dysfunction and colorectal motility disorders which are seen in patients after radical hysterectomy. In order to prevent these complications, Japanese gynaecologists introduced a surgical technique with preservation of the pelvic autonomic nerves in the 1960s. In the 1980s the first English paper was published. Since then several surgical approaches have been described, i.e. liposuction, electrical stimulation to locate nerves intra-operatively and laparoscopically assisted techniques. Recently, more attention is being paid to the importance of sparing the sympathetic hypogastric nerve. All authors report results on small cohorts of patients. The incidence of urinary dysfunction seems very low after nerve sparing. Sparing the autonomic nerves during radical hysterectomy seems feasible and safe in both Japanese and Western patients. Literature review does not provide strong clues for a compromised radicality and cure due to nerve sparing. Future larger clinical trials will have to decide whether the technique of nerve sparing radical hysterectomy could be implemented as a standard treatment for cervical cancer patients.

Rectocele repair improves evacuation and prolapse complaints independent of anorectal function and colonic transit time

BACKGROUND AND AIMS

Evacuation disorders associated with a rectocele can be improved by rectocele repair. This study investigated whether anorectal function tests results change after rectocele repair.

PATIENTS AND METHODS

Fourteen patients with 2nd or 3rd degree rectocele and evacuation disorder were treated by posterior colporrhaphy and evaluated pre- and postoperatively (after 8 months, range 3-14) using questionnaires, anal manometry and endosonography, rectal barostat testing, and colonic transit time measurement with radio-opaque markers. Results from female controls were used for comparison.

RESULTS

Preoperatively, rectocele patients had high maximal basal sphincter pressures, large sphincter lengths, and low maximal squeeze pressures, with an anal sphincter defect in seven and lower visceral sensitivity scores than in controls. Postprandial rectal responses (more than 10% decrease in postprandial volume after 1 h) were found in 3 of 14 patients compared to 2 of 11 parous and 9 of 11 nulliparous controls. After repair, a rectocele of 2nd degree was found in four patients. Questionnaire scores were significantly decreased for straining, evacuation disorder, manual support, and protrusion. Overall patient satisfaction with the operation scored 8.25 (range 3-10). Defecation frequencies and stool consistencies were unaltered. Anal pressures, rectal compliance-curves, visceral sensitivity, and colonic transit times were unaltered after the rectocele repair.

CONCLUSION

Rectocele repair improved complaints of evacuation disorder and protrusion, but defecation frequency and stool consistency were not affected. Anorectal function was unaltered after rectocele repair. Selection of patients for rectocele repair should be performed based on evacuation and protrusion complaints, anorectal function, or colonic transit time measurements have a limited role.

Automated quantitative analysis of nocturnal jejunal motor activity identifies abnormalities in individuals and subgroups of patients with slow transit constipation

OBJECTIVE

Small bowel dysmotility has previously been demonstrated in some patients with slow transit constipation (STC), suggesting a generalized intestinal disorder. However, no study has addressed whether the incidence of small intestinal dysfunction differs between subgroups of patients in this heterogeneous population. Using appropriate methodology, we aimed to determine prospectively the proportion of individuals with abnormal small bowel motility, and to assess whether heterogeneity in terms of pattern of colonic transit delay (based on (111)In diethylene-triamine-pentaacetic acid (DTPA) isotope scintigraphy), or mode of onset (based on clinical history) is of importance.

METHODS

Thirty-seven patients with STC underwent 24-h ambulatory jejunal manometry; data were compared with those obtained in 38 healthy controls. Automated quantitative analysis of seven variables of the nocturnal migrating motor complex was performed, to assess whether differences existed between groups, and whether individual patients had evidence of small intestinal dysmotility, defined as two or more measures of migrating motor complex variables outside the normal range. Four variables differed significantly between STC patients and controls: in phase III, propagation was slower, duration was longer, and contraction amplitude was higher; in phase II, contraction frequency was increased. Seven of 24 patients with a generalized pattern of colonic transit delay had abnormal small bowel motility compared with none of 13 with a left-sided delay (p < 0.04). These included four patients with chronic idiopathic symptoms and three with acquired symptoms. Approximately one third of patients with a generalized delay in colonic transit had evidence of jejunal enteric neuromuscular dysfunction. Individual patients with a left-sided colonic delay did not satisfy the criteria for nocturnal small bowel dysmotility, but as a group, some differences were noted from controls. In contrast to previous reports, evidence of generalized enteric dysmotility may be present irrespective of the mode of onset.

Rectal sensory perception in females with obstructed defecation

PURPOSE

Parasympathetic afferent nerves are thought to mediate rectal filling sensations. The role of sympathetic afferent nerves in the mediation of these sensations is unclear. Sympathetic nerves have been reported to mediate nonspecific sensations in the pelvis or lower abdomen in patients with blocked parasympathetic afferent supply. It has been reported that the parasympathetic afferent nerves are stimulated by both slow ramp (cumulative) and fast phasic (intermittent) distention of the rectum, whereas the sympathetic afferent nerves are only stimulated by fast phasic distention. Therefore, it might be useful to use the two distention protocols to differentiate between a parasympathetic and sympathetic afferent deficit.

METHODS

Sixty control subjects (9 males; median age, 48 (range, 20-70) years) and 100 female patients (median age, 50 (range, 18-75) years) with obstructed defecation entered the study. Rectal sensory perception was assessed with an "infinitely" compliant polyethylene bag and a computer-controlled air-injection system. This bag was inserted into the rectum and inflated with air to selected pressure levels according to two different distention protocols (fast phasic and slow ramp). The distending pressures needed to evoke rectal filling sensations, first sensation of content in the rectum, and earliest urge to defecate were noted, as was the maximum tolerable volume.

RESULTS

In all control subjects, rectal filling sensations could be evoked. Twenty-one patients (21 percent) experienced no sensation at all in the pressure range between 0 and 65 mmHg during either slow ramp or fast phasic distention. The pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were significantly higher in patients with obstructed defecation (P < 0.001). In each subject, the pressure thresholds for first sensation, earliest urge to defecate, and maximum tolerable volume were always the same, regardless of the type of distention.

CONCLUSION

Rectal sensory perception is blunted or absent in the majority of patients with obstructed defecation. The observation that this abnormality can be detected by both distention protocols suggests that the parasympathetic afferent nerves are deficient. Because none of the patients experienced a nonspecific sensation in the pelvis or lower abdomen during fast phasic distention, it might be suggested that the sympathetic afferents are also deficient. This finding implies that it is not worthwhile to use different distention protocols in patients with obstructed defecation.

Scintigraphic assessment of colonic transit in women with slow-transit constipation arising de novo and following pelvic surgery or childbirth

BACKGROUND

Colonic transit has not been compared between patients with slow-transit constipation (STC) arising de novo (idiopathic) and those whose symptoms followed pelvic surgery or childbirth (acquired).

METHODS

In 48 women, with either idiopathic (n = 36) or acquired (n = 12) STC, 111In-radiolabelled diethylene-triamine penta-acetic acid colonic scintigraphy was performed to determine patterns of delay (generalized or left sided), the 'severity' of transit disturbance between subgroups, and the association with age or duration of symptoms. Results were compared with those in healthy women. Patterns of colonic transit disturbance were assessed using previously defined criteria. In those with a generalized delay, variables reflecting the overall rate of isotope progression throughout the colon were calculated: gradient of geometric centre of isotope progression and estimated evacuation time of the isotope.

RESULTS

The pattern of transit delay was similar between the subgroups, but the 'severity' of the transit abnormality was significantly worse in those with chronic idiopathic symptoms. In the chronic idiopathic STC subgroup only, there was a significant correlation between both age and duration of symptoms and severity of transit disturbance.

CONCLUSION

This study demonstrates that differences in colonic transit exist between subgroups of patients with STC. These might be explained by differences in duration of symptoms or differences in aetiology.

Comparison of methods used for measurement of rectal compliance

INTRODUCTION

Compliance is defined as the change in volume or cross-sectional area divided by the change in pressure. Pressure-volume measurement during distention with a compliant balloon is the most commonly used method for computation of rectal compliance. However, intraindividual and interindividual variations are large, restricting the usefulness of the method. Other methods such as rectal distention by a large, noncompliant bag and rectal impedance planimetry for assessment of pressure-cross-sectional-area relations have been proposed as alternatives owing to the reduction of errors from elongation of the balloon within the rectal lumen. However, in vivo reproducibility of pressure-volume measurement during distention with a compliant balloon, pressure-volume measurement during rectal distention by a large, noncompliant bag, and rectal impedance planimetry have never been compared.

PURPOSE

The aim of this study was to compare in vivo reproducibility of the above-mentioned methods and to study their in vitro reproducibility and validity.

METHODS

Ten healthy volunteers (six men) aged 21-59 years were randomized to either rectal pressure-volume measurement with a compliant balloon or rectal impedance planimetry. After a one-hour rest, the other procedure was performed. After two weeks, both procedures were again performed in the same order. During rectal impedance planimetry the volume of the bag used (maximum volume 450 ml; secured at both ends to the probe) was continuously registered, measuring pressure-volume relations during rectal distention by a large, noncompliant bag. Reproducibility was tested by comparing the difference divided by the mean for each method at eight pressure steps in the range from 5 to 40 cm H2O. Furthermore, the in vitro reproducibility and validity of the three methods were studied using polyvinyl chloride tubes with known cross-sectional areas.

RESULTS

In vivo reproducibility for pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was significantly better than for pressure-volume measurement with a compliant balloon (P = 0.005 and P = 0.019, respectively). No statistically significant difference was found between pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry (P = 0.20). In vitro reproducibility of pressure-volume measurement with a large, noncompliant bag and rectal impedance planimetry was good, but some elongation occurred, reducing the validity of pressure-volume measurement with a large, noncompliant bag. Coiling and elongation of the balloon within the lumen were major sources of error for pressure-volume measurement with a compliant balloon.

CONCLUSION

In vivo and in vitro reproducibility of methods used for measurement of rectal compliance can be improved by restricting the effects of elongation within the lumen either by using a large-volume, noncompliant bag or by rectal impedance planimetry. However, pressure-volume measurement will to some degree depend on the properties of the balloons or bags.

Effect of colectomy on gastric emptying in idiopathic slow-transit constipation

INTRODUCTION

Gastric emptying is delayed in patients with idiopathic slow-transit constipation (ISTC). Gastric emptying was measured before and after colectomy and ileorectal anastomosis in patients with ISTC to determine whether the abnormality persists after operation.

METHODS

Twelve patients undergoing colectomy for severe ISTC had solid-phase gastric emptying measured after an overnight fast. All 12 had an uncomplicated subtotal colectomy and ileorectal anastomosis; 11 had an excellent functional outcome. In ten of these patients gastric emptying was repeated within 3 months of operation. Seven patients (including the remaining two) had the study performed at 1 year.

RESULTS

All 12 patients had severely delayed gastric emptying before operation. Gastric emptying remained delayed in the ten patients who underwent an early postoperative gastric emptying study. Six of seven patients assessed at 1 year had improved gastric emptying, of whom four had returned to normal. Functional outcome did not relate to gastric emptying.

CONCLUSION

Patients with ISTC have delayed gastric emptying. In some patients this returns to normal after colectomy, but is persistent in others. This may have implications for our understanding of ISTC.

Clinical and physiological heterogeneity in slow transit constipation: a review of 122 patients

OBJECTIVE

The outcome of surgery in patients with slow transit constipation (STC) is unpredictable. This may reflect clinical and physiological heterogeneity within this group of patients. This study attempts to identify subgroups of patients with STC according to clinical history, and compares the pathophysiological findings between the two largest: including patients with chronic idiopathic STC, and those with symptoms acquired after pelvic surgery or childbirth (post-pelvic intervention STC).

PATIENTS AND METHODS

Review of clinical and gastrointestinal pathophysiological findings of 122 consecutive patients with slow colonic transit.

RESULTS

Six subgroups of patients were defined according to the time and nature of onset of symptoms. Pathophysiological comparison of the two main groups: chronic idiopathic STC (n=65 (53%)) and post-pelvic intervention STC (n=22 (18%)), yielded three main conclusions: (i) the pattern of colonic transit is similar in both groups, i.e. predominantly (approximately 70%) generalized; (ii) the prevalence of a rectal evacuatory disorder is significantly higher in patients with post-pelvic intervention STC (77% vs 32%, P=0.004); and (iii) small bowel motility disturbances occur in both groups (overall 48%), and are therefore not limited to patients with chronic idiopathic STC.

CONCLUSION

There are pathophysiological similarities and differences between the main two subgroups of STC. Such findings may help our understanding of the pathogenesis and have implications in the future management of these patients.

Slow transit constipation: a model of human gut dysmotility. Review of possible aetiologies

Slow transit constipation is a severe condition of gut dysmotility that predominantly affects young women and may result in surgical intervention. Current medical treatments for STC are often ineffective, and the outcome of surgery is unpredictable. STC was first described almost a century ago. Since this time, progress in improving therapy for this condition has been complicated by a lack of understanding of the aetiology, and great variation in the methods and criteria used for the study of patients with this debilitating disorder. It is difficult to find unequivocal data, and harder still to give a definitive picture of the cause or causes of STC. Here we consider the evidence for various aetiologies of STC, in the light of the physiological and pathological findings.

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.

Behavioural treatment (biofeedback) for constipation following hysterectomy

BACKGROUND

Constipation after hysterectomy has been postulated to be due to pelvic nerve damage, but there may be emotional or reversible physical factors of pathophysiological relevance. The aim of this study was to determine whether such constipation is responsive to behavioural treatment.

METHODS

Three groups of patients who had completed a course of biofeedback treatment were compared: women with no history of abdominal or pelvic surgery (n = 25), women for whom a hysterectomy had led to no change in bowel function (n = 27) and women who stated that their constipation was precipitated (n = 18) or severely worsened (n = 8) by hysterectomy. Pretreatment and post-treatment details about bowel function and symptoms were assessed using structured interview, and pretreatment whole-gut transit time and anorectal physiology testing were assessed for prognostic relevance.

RESULTS

Follow-up after completing treatment was a median of 28 (range 12-44) months. Forty-eight of 78 patients considered that their constipation had improved with treatment; the proportion in each group was similar (P = 0.73). Biofeedback reduced the need to strain, reduced abdominal pain, improved bowel frequency, and reduced laxative use to a similar degree in all three groups. Thirty-three of 53 patients with slow transit considered there was an improvement, compared with 15 of 22 with measured normal transit. Physiological testing did not predict outcome and did not differ between the three groups.

CONCLUSION

The majority of patients complaining of constipation induced or worsened by hysterectomy respond subjectively to behavioural treatment, in a similar proportion to those with idiopathic constipation. In contrast to the widely held view that nerve damage is responsible for symptoms, reversible factors are likely to be important in many patients.

Proceedings of the American Urogynecologic Society Multidisciplinary Symposium on Defecatory Disorders

The Multidisciplinary Symposium on Defecatory Disorders was created to delineate the breadth of defecatory disorders and propose investigations to address identified knowledge deficits. Seven experts in defecatory disorders and 24 members of the American Urogynecologic Society were invited. The experts provided brief summaries of the scope of defecatory disorders from the perspectives of their specialties. The group then divided into 3 subgroups that focused on pathophysiology, imaging, and evaluation and treatment. Defecatory disorders, including anal incontinence and constipation, are common among women of all ages. Determination of their prevalence is complicated by a lack of standardized definitions. Defecatory disorders carry lengthy differential diagnoses. Imaging studies and anorectal testing, although not standardized, can aid in distinguishing different causes of dysfunction. The lack of uniformity in diagnosis and evaluation compromises comparisons of different treatments. Standardization of diagnoses and diagnostic modalities is essential to the design of meaningful evaluations of treatments for defecatory disorders.

Transanal repair of rectocele corrects obstructed defecation if it is not associated with anismus

PURPOSE

Rectocele is often associated with anorectal symptoms. Various surgical techniques have been described to repair the rectocele. The surgical results are variable. This study evaluated the results of transanal repair of rectocele, with particular emphasis on the impact of concomitant anismus on postoperative functional outcome.

METHODS

Fifty-nine consecutive females who underwent transanal repair of rectocele for obstructed defecation were prospectively reviewed. All 59 patients were parous with a median parity of 2 (range, 1-6) and a median age of 58 (range, 46-68) years. The median length of follow-up was 19 (range, 6-40) months. Anismus was detected by anorectal physiology and defecography. The functional outcome was assessed by a standard questionnaire, physical examination, anorectal manometry, neurophysiology, and defecography. The quality-of-life index was obtained using a visual analog scale (from 1-10, with 10 being the best).

RESULTS

The functional outcome of transanal repair of rectocele was superior in patients without anismus. Forty (93 percent) of the 43 patients without anismus showed improved evacuation after repair compared with 6 (38 percent) of the 16 patients with anismus (P<0.05). The quality-of-life index improved (9 vs. 4) if anismus was not present (P<0.05). There were minimal complications. Hemorrhage requiring blood transfusion (2 units) occurred in one patient and urinary retention in another.

CONCLUSION

Transanal repair of rectocele is safe and, in the absence of anismus, effectively corrects obstructed defecation.

Outcome of colectomy for slow transit constipation

OBJECTIVE

To review the outcome data for colectomy performed for patients with slow transit constipation (STC).

BACKGROUND

The outcome of surgical intervention in patients with STC is unpredictable. This may be a consequence of the lack of effectiveness of such interventions or may reflect heterogeneity within this group of patients.

METHODS

The authors reviewed the data of all series in the English language that document the outcome of colectomy in > or = 10 patients in the treatment of STC.

RESULTS

Thirty-two series fulfilled the entry criteria. There was widespread variability in patient satisfaction rates after colectomy (39% to 100%), reflecting large differences in the incidence of postoperative complications and in long-term functional results. Outcome was dependent on several clinical and pathophysiologic findings and on the type of study, the population studied, and the surgical procedure used.

CONCLUSIONS

It may be possible to predict outcome on the basis of preoperative clinical and pathophysiologic findings. This review suggests a rationale for the selection of patients for colectomy.

Modern treatments of menorrhagia attributable to dysfunctional uterine bleeding

Menorrhagia (excessive uterine bleeding) affects some 20 percent of the women of reproductive age worldwide. The following review describes known and theorized etiologies of the disorder, followed by a discussion of treatment options that are currently in use as well as those on the horizon. There is much interest internationally in decreasing hysterectomy rates, particularly for those women with abnormal bleeding and anatomically normal uteri. It is these women who are the focus of this paper. Pharmacotherapy and surgery are the mainstay treatments for such patients with menorrhagia secondary to dysfunctional uterine bleeding. Most commonly, hormonal and nonhormonal medications are followed by dilatation and curettage, and ultimately, in many cases, hysterectomy. Endometrial ablation techniques have been evolving since the 1980s in response to the need for an efficacious, safer, and more cost-effective alternatives to hysterectomy. Hysteroscopic ablation achieves these goals but is difficult technically and requires significant additional training even for otherwise skilled and experienced gynecologists. The current decade has seen the development of many innovative approaches to performing endometrial ablation. These methods are intended to be much simpler to perform with less risk than electrosurgical or laser endometrial ablation. The final section of this article presents the published data to date on these new technologies, which should (in their refined state) revolutionize the treatment of menorrhagia secondary to dysfunctional uterine bleeding.

Complications of hysterectomy

Hysterectomy is a popular operation that has a number of complications associated with it. The most common are hemorrhage, infection, and injuries to adjacent organs. Unintended major surgical procedures and second operations occur in approximately 4% of patients undergoing hysterectomy. Laparoscopic hysterectomy is a controversial new procedure that has both advocates and detractors. In skilled hands, the complication rate of laparoscopic hysterectomy does not exceed that of traditional hysterectomy methods. At the present time, there is a growing consensus that removal of the uterus only does not lead to an increase in psychosexual morbidity. It also appears that hysterectomy procedures have little, if any, effect on lower urinary tract function.

Gastric emptying in patients with constipation following childbirth and due to idiopathic slow transit

BACKGROUND

Idiopathic slow transit constipation (ISTC) is considered to be a heterogeneous condition in which patients have varying sites and degrees of delayed gastrointestinal transit. The majority of patients have pancolonic disease, and colectomy with ileocolorectal anastomosis has been the mainstay of surgical treatment. Severe constipation following traumatic childbirth is now being recognized and this subgroup of patients may have delayed transit confined to the rectosigmoid colon. In theory, proximal transit in these patients should be normal.

METHODS

Gastric emptying was studied in patients with constipation following childbirth or ISTC and in controls. After an overnight fast, both patients and controls received breakfast, which consisted of cornflakes, sugar and milk. The liquid marker 111In-labelled di-ethylene tri-amine penta-acetic acid (DTPA) was added to the milk. A solid marker, 99mTc-labelled colloid, was impregnated on to paper and sealed with cellulose. The t1/2 for gastric emptying was calculated.

RESULTS

Liquid phase emptying was normal in both constipation following childbirth and ISTC. Solid phase emptying was delayed significantly in ISTC compared with that in patients with constipation following childbirth and controls. In addition, half the patients with ISTC had delayed transit through the small bowel and proximal colon. Small bowel and colonic transit were normal in patients with constipation following childbirth.

CONCLUSION

Patients with constipation following childbirth represent a distinct subgroup with normal proximal gastrointestinal function. Gastric emptying studies may be helpful in selecting patients for surgical management of severe constipation.

Selective autonomic and sensory deficits in slow transit constipation

Chronic idiopathic constipation is likely to be a heterogeneous condition. Our previous studies on the stimulated sweating response suggested that autonomic dysfunction may be a cause in a subset of patients. Our aims were to test selectively the neural and sweat gland components of the sweat response and to test unmyelinated sensory fibres so as to determine whether a small fibre neuropathy is present. Twelve female patients with proven slow transit constipation and nineteen age-matched healthy volunteers took part in the study. The sensory tests included thermal thresholds and axon reflex vasodilatation in response to intradermal capsaicin, measured with a laser Doppler. Direct and axon reflex sweating was induced with intradermal methacholine and nicotine, respectively, and measured with an evaporimeter. Non-parametric tests were used for statistical comparison with a group of seven control subjects. Results are expressed as medians and range. All four patients who reported constipation from childhood had a selective deficit of unmyelinated afferent fibre function in the feet, with markedly elevated thresholds to warm sensation (controls 5.2; 4.3-10.6, patients 13.8; 11.8-16.1 delta T (degree C), P < 0.02) and heat pain (controls 10.6; 8.2-14.7, patients 18.1; 13.9-22.6 delta T (degree C), P < 0.05) and a reduced response to capsaicin (controls 47.0; 24-117, patients 13.5; 12-30 delta Flux (V), P < 0.005). In contrast, patients with adult onset constipation (n = 7) had a selective neural sweating deficit (controls 49.8; 32.0-61.8; patients 27.7; 7.3-44.3 g/m2 h, P < 0.05), indicating dysfunction of post-ganglionic sympathetic cholinergic fibres. Patients from both groups were shown to have normally functioning sweat glands in direct response to methacholine. Our findings suggest that patients with severe chronic idiopathic constipation may have selective small fibre neuropathies, of which constipation is a manifestation.

Age and anorectal sensibility in normal women

BACKGROUND

Our aim was to study associations between age and anorectal sensibility in healthy women.

METHODS

Seventy-five women, with a mean age of 50 (range, 20-83) years, and mean parity of 2 (range, 0-4), were studied. Anal mucosa electrosensitivity (AME) was measured 1 and 2 cm from the anal verge. Rectal sensibility was also measured (minimum perceived volume (MPV), desire to defaecate (DD), and urgency (U)). Associations between anorectal sensibility and age were corrected for parity by using multiple regression analysis.

RESULTS

Threshold values of AME increased with age (P = 0.03) (1 cm) and P = 0.01 (2 cm)). Rectal sensibility threshold values were also positively associated with age (MPV, P = 0.003; DD, P = 0.04; and U, P = 0.06). Changes in AME were greater after menopause, whereas associations between rectal sensibility and age seemed linear.

CONCLUSION

Impairment of the anorectal sensibility appears to be part of the normal ageing process, thus increasing the risk of faecal incontinence in old women.

Biliary dyskinesia in idiopathic slow-transit constipation

BACKGROUND

Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder. We have screened patients referred to surgery for constipation for the presence of biliary dyskinesia.

METHOD

Patients had cholecystokinin-augmented trimethyl-3-bromo iminodiacetic acid scans to measure gallbladder ejection fraction.

RESULTS

There is a significant difference in gallbladder ejection fraction between patients with idiopathic slow-transit constipation (median value, 28.5) compared with patients with other causes of constipation (median value, 71; Mann-Whitney, P = 0.0025).

CONCLUSION

Idiopathic slow-transit constipation may be a pangastrointestinal motility disorder.

Does surgical repair of a rectocele improve rectal emptying?

PURPOSE

This study was undertaken to assess results of surgical repair of rectocele and to identify possible determinants of outcome from patient's history and preoperative defecography. Another aim was to evaluate how surgery affects rectal evacuation.

METHOD

Thirty-four women with constipation and rectal emptying difficulties underwent surgery with a transanal technique. A preoperative defecography was performed in each patient. They were followed up after a median of 10 (range, 2-60) months with a questionnaire (n = 34) and a defecography (n = 31). Computer-based image analysis of defecographies was used to evaluate rectal evacuation.

RESULTS

In 27 patients (79 percent), the result of surgery was good with subjectively improved emptying. The need for vaginal or perineal digitation preoperatively was related to a good result (P < 0.05), whereas a previous hysterectomy (P < 0.01) and a large rectal area on defecography (P < 0.01) related to a poor result. Preoperative use of enemas, motor stimulants, or several types of laxatives also related to a poor outcome (P < 0.05). Surgical treatment resulted in reduction of the rectocele (P < 0.001), an elevated position of the anorectal junction (P < 0.05), and improved rectal evacuation on defecographies (P < 0.001).

CONCLUSIONS

Surgical repair reduces the size of the rectocele and improves rectal emptying. These changes are accompanied by a symptomatic improvement in the majority of patients. Preoperative patient data and defecography may help in selecting patients for surgery.

A retrospective study of the effects of pelvic irradiation for gynecological cancer on anorectal function

PURPOSE

To evaluate the prevalence of anorectal dysfunction following therapeutic pelvic irradiation.

METHODS AND MATERIALS

Anorectal function was evaluated in 15 randomly selected patients (aged 47-84 years) who had received pelvic irradiation for treatment of carcinoma of the uterine body and cervix 5 and 10 years earlier. The following parameters were assessed in each patient: (a) anorectal symptoms (questionnaire), (b) anorectal pressures at rest and in response to rectal distension, voluntary squeeze, and increases in intraabdominal pressure (multiport anorectal manometry with concurrent electromyography of the anal sphincters), (c) rectal sensation (rectal balloon distension) and, (d) anal sphincteric morphology (ultrasound). Results were compared with those obtained in nine female control subjects.

RESULTS

Ten of the 15 patients had urgency of defecation and 4 also suffered fecal incontinence. Basal anorectal pressures measured just proximal to the anal canal (p = 0.05) and anorectal pressures generated in response to voluntary squeeze measured at the anal canal were less (p < 0.01) in the patients. The fall in anal pressures in response to rectal distension was greater in the patients (p < 0.05) and the desire to defecate occurred at lower rectal volumes (p < 0.05). The slope of the pressure/volume relationship in response to rectal distension was greater (p < 0.05) in the patients, suggestive of a reduction in rectal compliance. In 14 of the 15 patients at least one parameter of anorectal motor function was outside the control range. There was no difference in the thickness of the anal sphincters between the two groups.

CONCLUSION

Abnormal anorectal function occurs frequently following pelvic irradiation for gynecological malignant diseases and is characterized by multiple dysfunctions including weakness of the external anal sphincter, stiffness of the rectal wall, and a consequent increase in rectal sensitivity.

A medical audit and patient survey of hysterectomies performed for menstrual disorders

The aim of the study was to carry out an audit of 283 hysterectomies performed for menstrual disorders over a one year period, and to determine the satisfaction of the women concerned towards their treatment. The medical records of these patients were examined, and they were each sent a questionnaire, 69% of which were completed and returned. The most common presenting symptoms were menorrhagia and dysmenorrhoea. In 53% of cases no clinical abnormality was postulated and in 31% of cases no pathological abnormality was found. The preoperative clinical and pathological diagnoses were in agreement for 59% of patients. Over 90% of women were satisfied with the management of their case by their GP and the gynaecology outpatient clinic. The use of patient-controlled analgesia systems was associated with better post-operative pain relief than intramuscular injections. Thirteen percent of patients required blood transfusion; 21% suffered some form of postoperative complication, most of which were minor. Ninety-four percent of the women were pleased that they had undergone hysterectomy, and 76% wished that they had had the operation sooner. It was concluded that hysterectomy is perceived positively by patients and should not necessarily be considered as a last resort treatment for menstrual disorders.

Anorectal sensitivity in patients with obstructed defaecation

Patients with obstructed defaecation (OD) perform major defaecatory efforts that lead progressively to pudendal motor neuropathy. Anorectal sensory function in these patients and its possible influence in the pathogenesis of the disease have been little studied. In the present paper we investigated anorectal sensitivity to electric and thermal stimuli in patients with OD, and studied the possible existence of pudendal sensory neuropathy associated to their known pudendal motor neuropathy. Forty subjects were divided into two groups: 21 healthy controls (11 females and 10 males; mean age 51.8 +/- 11 years, range 33-67) and 19 patients with OD (18 females and 1 male; mean age 48 +/- 15 years, range 20-71). The patients with OD suffered constipation and an obstruction sensation upon defaecating, even in the case of soft stools. Clinical perineometry, manometry, pudendal motor latency studies, external anal sphincter single fibre electromyography and the evaluation of sensitivity to electric and thermal stimuli were carried out in all cases. All pudendal motor function parameters showed statistically significant differences between the two groups. In the controls the electrical sensitivity threshold was minimal in the mid anal canal, where sensory receptor presence is greater. Sensitivity was significantly higher in the upper and lower anal canal regions (P < 0.05), and much higher in the rectum (P < 0.001). A similar sensory profile was recorded in the patients with OD, though with significantly higher thresholds at all points with respect to the controls. The thermal stimulus thresholds in the lower and middle anal canal were significantly smaller than in the upper canal region and rectum, and the thresholds were again higher among the patients with OD than among the controls. In all cases the thresholds for heat were lower than for cold stimuli. In both groups the motor function parameters were correlated with the sensory function variables, and the latter between themselves. Patients with OD presented sensory deterioration at all points studied in the anal canal and rectum. Sensory pudendal neuropathy was found to be associated with the pudental motor neuropathy.

Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study

OBJECTIVE

To describe the indications for total abdominal hysterectomy for women with nonmalignant disease and to determine the immediate (initial ten days) and medium term outcome.

DESIGN

A prospective cohort study.

SETTING

Three district general hospitals in shire counties, two in outer London and one London teaching hospital.

SUBJECTS

Three hundred and sixty-six women undergoing total abdominal hysterectomy (with or without other procedures) for nonmalignant disease.

INTERVENTIONS

Self-completed patient questionnaires before and ten days, six weeks and three months after surgery. Data extracted from patients' hospital case notes.

MAIN OUTCOME MEASURES

Complications plus change in symptoms, urinary and bowel function, general health status, sexual function, activities of daily living and quality of life.

RESULTS

The principal indications were bleeding, pain or both. Symptoms were severe enough to be socially debilitating and have a major impact on lifestyle. Otherwise, the women were in good health. During the first ten post-operative days the women suffered more pain, urinary discomfort, constipation and a reduction in their ability to perform activities of daily living. Urinary (25%) and wound (25%) infections were the commonest complications. At the same time, significant improvements in psychological health occurred. By six weeks, the principal symptoms had resolved for 95% of the women and early adverse effects on urinary and bowel function had settled. This was reflected in improvements in health status and quality of life including sexual activity. Despite this, these changes did not meet the pre-operative expectations of some women.

CONCLUSIONS

Most women reported substantial benefits from hysterectomy. However, women should be warned about early, transient adverse effects. These findings can serve as a benchmark for nonexperimental evaluations of the effectiveness of new treatment modalities.

Abdominal rectopexy for rectal prolapse. Influence of surgical technique on functional outcome

PURPOSE

The aim of this study was to investigate the influence of surgical technique on functional and manovolumetric results in patients treated with Marlex mesh abdominal rectopexy.

METHODS

The lateral ligaments were completely divided (the Wells procedure) in 16 patients and preserved (the Ripstein procedure) in 16 patients. Clinical and physiologic assessment were performed before and at 3, 6, and 12 months after operation.

RESULTS

Improvement of continence was similar. Bowel regulation problems which were unchanged after the Ripstein procedure increased significantly after the Wells procedure (P < 0.01). Rectal volume became reduced in the group who received the Wells procedure (225 ml vs. 115 ml, P < 0.05 at one year), but remained unchanged after receiving the Ripstein procedure. The pressure thresholds required to elicit sensation of rectal filling and defecation urge were increased after the Wells procedure (15 cm of H2O vs. 25 cm of H2O, P < 0.05 and 25 cm of H2O vs. 45 cm of H2O, P < 0.05, respectively). In the Ripstein group there was only a slight increase of the threshold for urge (P < 0.05).

CONCLUSION

The Wells procedure was followed by severe rectal dysfunction accompanied by increased constipation and evacuation problems. The Ripstein procedure, preserving the lateral ligaments, appears not to affect such symptoms adversely. On the other hand, improvement is not likely to occur.

Dyschezia and rectocele--a marriage of convenience? Physiologic evaluation of the rectocele in a group of 52 women complaining of difficulty in evacuation

Herniation of the anterior rectal wall into the lumen of the vagina (so called rectocele) may be encountered in patients who complain of constipation and emptying difficulties but it is difficult to ascertain whether this anatomic abnormality is an etiologic factor or a consequence of the dyschezia.

PURPOSE

The aim of our study was to assess symptomatic, anatomic, and physiologic features encountered in women with a clearly defined rectocele in order to determine the predisposing factors, symptoms, functional associations, and effects on quantified rectal emptying.

METHODS

Clinical, physiologic (manometry), and anatomic (evacuation proctography) assessments were carried out in 26 consecutive women (mean age, 47.6 +/- 12 years) with dyschezia and a large rectocele as evidenced by radiography and compared with a group of 26 consecutive women complaining of dyschezia without a significant rectocele (mean age, 42.6 +/- 14 years). Both groups were similar with respect to mean age, parity, laxative abuse, manual anal evacuation, fecal incontinence, urgency, and weekly stool frequency.

RESULTS

Patients having a rectocele differed significantly from those without a rectocele in having frequent endovaginal digitation during defecation (7 vs. 1, P < 0.05), more frequent symptoms of urinary incontinence (14 vs. 3, P < 0.001), and a surgical history of hysterectomy (9 vs. 2, P < 0.05). The rectocele group differed in having a delayed rectal emptying (55.5 +/- 38 vs. 30.3 +/- 23 seconds, P < 0.005), a more frequent incomplete rectal emptying (23 vs. 11, P < 0.0005), and was more often associated with a manometric anismus (16 vs. 6, P < 0.01). During the straining effort, there was a correlation between the depth of the rectocele and the duration of rectal emptying (rs = 0.3, P < 0.05). In the group without manometric anismus, women with a rectocele (n = 10) had a more incomplete rectal emptying than those without rectocele (8/10 vs. 8/19, P = 0.05).

CONCLUSION

Some of our results indicate that the rectocele itself could be a contributory factor in difficult evacuation. These results also exhibit the importance of other disorders, such as anismus, in the occurrence of dyschezia. Physiologic examination therefore should be made before considering surgical repair in any patient with rectocele and dyschezia.

Constipation after rectopexy for rectal prolapse. Where is the obstruction?

The pathophysiology of constipation after rectopexy remains unclear: acquired anorectal dysfunction or preoperative colonic state are, by turns, the supposed culprit. The aim of this prospective study was to characterize the colorectal motility abnormalities encountered after such a surgical procedure. Twelve patients (10 females, 2 males, aged 50.5 +/- 5.2 years) complaining of severe constipation or its worsening after Orr rectopexy (OR) for rectal prolapse were studied. Each underwent detailed interrogation as to their symptoms, left colonic manometry (basal and postprandial motor indexes and their caudad gradients in the sigmoid), anorectal manometry, evacuation proctography, and colonic transit time with radiopaque markers. Results were compared to those obtained in two control groups: 10 healthy volunteers (HV) and 12 patients complaining of a rectal prolapse (RP) observed consecutively during the same period of evaluation (June 90 to December 91). Before surgery, the OR and RP groups were similar with respect to mean age, sex ratio, weekly stool frequency, subjective dyschezia and manual anal supplies, constipation symptoms, and anal incontinence. OR patients differed significantly from the RP group in having a lower weekly stool frequency (2.5 +/- 2.2 vs 5.2 +/- 3.7, P < 0.01) and a higher prevalence of abdominal pain (7 vs 1 patients, P < 0.05). Above the rectopexy, global (135.9 +/- 38 vs 51 +/- 30.5 hr, P < 0.01) and left (61.6 +/- 10 vs 18.2 hr, P < 0.01) colonic transit times were significantly higher in OR patients; moreover, the basal motor index gradient was negative in all but one case (-94.1 +/- 101 vs 177.3 +/- 131, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Idiopathic slow-transit constipation

Until recently, the surgical management of idiopathic slow-transit constipation had remained unchanged since the condition was first described by Arbuthnot Lane in 1908. Although colectomy and ileorectal anastomosis is a successful treatment for the majority of patients, symptoms persist or are worse in some cases following such surgery. The previously inaccessible colon is now an area of interest in both health and disease; recent observations on aetiology, clinical investigation, neuropathology and surgical outcome lead us to question the rationale of colectomy for all patients with severe constipation.

Relationship between intra-abdominal and intrarectal pressure in the proctometrogram

During normal defaecation the intrarectal pressure increases but, in the absence of a reference catheter in the pelvis, the contribution of abdominal straining and rectal contraction to this rise is unclear. Anorectal manometry was performed in ten consecutive women with no gastrointestinal symptoms in an attempt to measure intrapelvic pressure using a catheter in the bladder. During filling the mean (s.e.m.) rectal pressure increased from 2(1) to 18(4) cmH2O. The mean(s.e.m.) intravesical pressure remained unchanged at 2(1) cmH2O. Evacuation of the rectal balloon produced an increase in mean (s.e.m.) intrarectal pressure from 18(4) (end-filling pressure) to 68(15) cmH2O. The mean (s.e.m.) intravesical pressure increased from 2(1) to 51(18) cmH2O. The true intrarectal pressure (intrarectal minus intravesical) did not rise during defaecation. The rise in intrarectal pressure during rectal evacuation occurs by increased intrapelvic pressure alone.

[Value of abdominal rectopexy in obstructive disorders of defecation. A prospective study using a defecation index, manometry and radiology]

A prospective clinical, manometric, electromyographic and radiological study was conducted to judge the degree of success achieved with anterior-posterior rectopexy in 18 female patients suffering from obstructed defecation and varying degrees of incontinence. Prior to being operated on, 6 of the patients showed symptoms of intussusception, 4 an internal prolapse of the anterior rectum wall, and 5 a rectocele at least 2 cm in size; all of them had significant perianal descent. The main aim of this study was more precise definition of the pre- and postoperative bowel evacuation using a defecation index. This study shows that obstructed defecation is significantly associated with a lasting feeling of needing to defecate after evacuation, a sensation of incomplete evacuation, perianal pain and necessity for manual support during defecation. The patients had a mean age of 62 (range, 38-78) years. All underwent anterior-posterior rectopexy (Ivalon or Vicryl) with posterior pelvic repair of the puborectalis muscle. In 2 patients rectopexy was combined with sigmoidectomy, in 11 cases, with left hemicolectomy, and in 2, with subtotal colectomy. The median follow-up was 40.8 months (range, 6-66 months). Postoperatively anorectal manometry showed a significant increase in the resting anal pressure and the maximum voluntary pressure (P = 0.05). Continence was improved in 10 patients (55%), 7 (39%) of whom regained normal continence. No significant change in pelvic descent or anorectal angle was observed. Only 8 patients reported a complete evacuation of the rectum postoperatively.