Rectal akinesia as a new cause of impaired defecation

Flow simulations of rectal evacuation: towards a quantitative evaluation from video defaecography

Mechanistic understanding of anorectal (patho)physiology is missing to improve the medical care of patients suffering from defaecation disorders. Our objective is to show that complex fluid dynamics modelling of video defaecography may open new perspectives in the diagnosis of defaecation disorders. Based on standard X-ray video defaecographies, we developed a bi-dimensional patient-specific simulation of the expulsion of soft materials, the faeces, by the rectum. The model quantified velocity, pressure and stress fields during the defaecation of a neostool with soft stool-like rheology for patients showing normal and pathological defaecatory function. In normal defaecation, the proximal-distal pressure gradient resulted from both the anorectal junction which formed a converging channel and the anal canal. The flow of the neostool through these anatomical parts was dominated by its shear-thinning viscous properties, rather than its yield stress. Consequently, the evacuation flow rate was significantly affected by variations in pressure applied by the rectum, and much less by the geometry of the anorectal junction. Lastly, we simulated impaired defaecations in the absence of obvious obstructive phenomena. Comparison with normal defaecation allowed us to discuss critical elements which should lead to effective medical management.

Towards an assessment of rectal function by coupling X-ray defecography and fluid mechanical modelling

Despite the numerous available clinical investi-gation tests, the associated alteration of quality of life and the socio-economic cost, it remains difficult for physicians to identify the pathophysiological origins of defecation disorders and therefore to provide the appropriate clinical care. Based on standardized dynamic X-ray defecography, we developed a 2D patient-specific computational fluid dynamic model of rectal evacuation. X-ray defecography was carried out in a sitting position with a standardized paste whose yield stress matched that of soft human feces. The flow was simulated with lattice-Boltzmann methods for yield stress fluids and moving boundary conditions. The model was applied for a patient with a normal recto-anal function. We deduced from the flow field that the main flow resistance during the defecation was due to the extrusion of the paste through the anal canal. We calculated also from pressure and stress fields the spatio-temporal evolution of the wall normal stress. This latter highlighted a gradient from the proximal to the distal part of the rectum. We discussed how this new set of hydrodynamical and biome-chanical parameters could be interpreted to gain new insights on the physiology of defecation and to diagnose underlying evacuation disorders. Clinical relevance - If confirmed, our approach should allow clinicians to obtain other parameters from a classic clinical examination and thus better adapt the response of clinicians to the defecation disorders observed in patients.

Rheology of human faeces and pathophysiology of defaecation

BACKGROUND

Rectal evacuation involves multiple mechanisms that are not completely understood. The aim of this study was to quantify the rheologic property, i.e., yield stress, which governs the ease of deformation of a range of faeces of differing consistency and understand its influence on the pathophysiology of defaecation.

METHODS

Yield stresses of faeces of differing consistencies and Bristol scores were determined by the Vane test. We then explored the effects of this property on ease of defecation using a simple static model of the recto-anal junction based on the laws of flow for yield stress pastes and checked the conclusions by X-ray defaecography experience.

RESULTS

The yield stress of faeces increased exponentially with their solid content, from 20 to 8000 Pa. The static model of the recto-anal junction showed that evacuation of faeces of normal consistency and yield stress is possible with moderate dilatation of the anal canal, whilst the evacuation of faeces with higher yield stress requires greater dilatation of the anal canal. X-ray defaecography showed that such increases occurred in vivo.

CONCLUSIONS

The diameter of the recto-anal junction is increased to enable the passage of feces with high yield stress. The finite limits to such dilation likely contribute to fecal impaction. Hence, difficulties in defaecation may result either from unduly high yield stress or pathologies of reflex recto-anal dilatation or a combination of the two.

European society of neurogastroenterology and motility guidelines on functional constipation in adults

INTRODUCTION

Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation.

DESIGN

After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation.

KEY RESULTS

Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation.

CONCLUSIONS AND INFERENCES

European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.

Systematic review with meta-analysis: defecography should be a first-line diagnostic modality in patients with refractory constipation

BACKGROUND

Defecography is considered the reference standard for the assessment of pelvic floor anatomy and function in patients with a refractory evacuation disorder. However, the overlap of radiologically significant findings seen in patients with chronic constipation (CC) and healthy volunteers is poorly defined.

AIM

To systematically review rates of structural and functional abnormalities diagnosed by barium defecography and/or magnetic resonance imaging defecography (MRID) in patients with symptoms of CC and in healthy volunteers.

METHODS

Electronic searches of major databases were performed without date restrictions.

RESULTS

From a total of 1760 records identified, 175 full-text articles were assessed for eligibility. 63 studies were included providing data on outcomes of 7519 barium defecographies and 668 MRIDs in patients with CC, and 225 barium defecographies and 50 MRIDs in healthy volunteers. Pathological high-grade (Oxford III and IV) intussuscepta and large (>4 cm) rectoceles were diagnosed in 23.7% (95% CI: 16.8-31.4) and 15.9% (10.4-22.2) of patients, respectively. Enterocele and perineal descent were observed in 16.8% (12.7-21.4) and 44.4% (36.2-52.7) of patients, respectively. Barium defecography detected more intussuscepta than MRID (OR: 1.52 [1.12-2.14]; P = 0.009]). Normative data for both barium defecography and MRID structural and functional parameters were limited, particularly for MRID (only one eligible study).

CONCLUSIONS

Pathological structural abnormalities, as well as functional abnormalities, are common in patients with chronic constipation. Since structural abnormalities cannot be evaluated using nonimaging test modalities (balloon expulsion and anorectal manometry), defecography should be considered the first-line diagnostic test if resources allow.

Early experience with ambulatory robotic ventral rectopexy

OBJECTIVE OF THE STUDY

Ventral rectopexy can be performed robotically with only limited trauma for the patient, making its performance in an ambulatory setting potentially interesting. The aim of this study is to report our preliminary experience with ambulatory robotic ventral rectopexy in consecutive patients.

PATIENTS AND METHODS

Ten consecutive patients underwent robotic ventral rectopexy for total rectal prolapse (n=8) or symptomatic enterocele (n=2) between February 2014 and April 2015. Patients were selected for outpatient treatment based on criteria of patient motivation, favorable social conditions, and satisfactory general condition. Patient characteristics, technical results and cost were reported.

RESULTS

The mean operating time was 94minutes (range: 78-150). The average operating room occupancy time was 254minutes (222-339). There were no operative complications, conversion to laparotomy, or postoperative complication. The average duration of hospital stay was 11 (8-32) hours. Two patients required hospitalization: one for persistent pain and the other for urinary retention. The average maximum pain score recorded on postoperative day 1 was 2/10 on a visual analog scale (range: 0-5/10). Estimated average cost (excluding amortization of the purchase of the robot) was €9088 per procedure.

CONCLUSIONS

Ambulatory management of robotic ventral rectopexy is feasible and safe.

Difficult defecation in constipated patients and its relationship to colonic disorders

BACKGROUND

The importance in constipated subjects of having difficult defecation is poorly known. According to the Rome III criteria, constipated patients are classified as having either irritable bowel syndrome with constipation or functional constipation, depending on the presence and characteristics of abdominal pain. But, the Rome III criteria also identify another group of patients, labeled as suffering from functional anorectal disorders. Within this group, two complaints are akin to being constipated, but not labeled so: having dyssynergic defecation or inadequate defecation.

OBJECTIVE

The aim of this study was to search for an association between difficult defecation and colonic transit abnormalities in constipated patients and, thus, shed some light on the definition of constipation according to the Rome III criteria.

PATIENTS

Four hundred four consecutive patients (81% female), aged 44.9 ± 16.6 years, with a BMI of 25.5 ± 6.4 kg/m(2) (mean ± SD), suffering from chronic constipation were included in the present study. After filling out a standard Rome III questionnaire, patients were classified as suffering from an irritable bowel syndrome with constipation or functional constipation. In addition, they were classified as complaining of difficult defecation or not. Patients completed the Bristol Stool Form Scale as well as visual analogue scales for constipation, bloating, and abdominal pain. The colonic transit time was measured using radiopaque markers and analyzed according to three sites: the right colon, the left colon, and the rectosigmoid area.

RESULTS

Difficult defecation is more frequent in patients with irritable bowel syndrome with constipation (84%) than in patients with functional constipation (68%). It is associated with an increase in constipation and abdominal pain scores on Likert scales, and a longer oroanal transit time, due to a delay in the left part of the colon.

CONCLUSIONS

This study demonstrates that difficult defecation is part of a more generalized colorectal dysfunction in both irritable bowel syndrome and in functional constipation patients with an overlap of symptomatology. It also demonstrates the relative inadequacy of the Rome III criteria to describe the relationship between constipation and difficult defecation.

Rectal prolapse traumatizes rectal neuromuscular microstructure explaining persistent rectal dysfunction

PURPOSE

Internal rectal prolapse is common and correlates with age. It causes a plug-like physical obstruction and is a major cause of defecation disorder. The progressive distortion of the prolapsing rectum likely causes secondary defects in the rectal wall, which may exacerbate rectal dysfunction. We undertook a prospective observational study to detect and quantify the neurologic and histopathologic changes in the rectal wall.

METHODS

We examined dorsal and ventral rectal wall specimens from consecutive patients with internal rectal prolapse undergoing stapled transanal rectal resection (STARR). We subjected specimens to histopathologic and neuropathologic assessment, including immunohistochemistry. We also recorded patients' clinical and demographic characteristics and sought correlations between these and the pathologic findings.

RESULTS

We examined 100 specimens. The severity of rectal prolapse and the extent of descent of the perineum correlated significantly with age. Concomitant hemorrhoidal prolapse was noted in all male patients and in 79 % of female patients. Muscular and neuronal defects were detected in 94 and 90 % of the specimens, respectively. Only four specimens (4 %) were free of significant structural defects.

CONCLUSION

Rectal prolapse traumatizes the rectum causing neuromuscular defects. The tissue trauma is due to shearing forces and ischemia caused by the intussusception. This initiates a self-reinforcing vicious circle of physical and functional obstruction, further impairing rectal evacuation and causing constipation and incontinence. The correlation between extent of prolapse and age suggests that internal rectal prolapse can be considered a degenerative disorder. Neural and motor defects in the wall of the rectum caused by rectal prolapse are likely irreversible.

Anterior rectopexy for full-thickness rectal prolapse: Technical and functional results

AIM: To assess effectiveness, complications, recurrence rate, and recent improvements of the anterior rectopexy procedure for treatment of total rectal prolapse.

METHODS: MEDLINE, PubMed, EMBASE, and other relevant database were searched to identify studies. Randomized controlled trials, non-randomized studies and original articles in English language, with more than 10 patients who underwent laparoscopic ventral rectopexy for full-thickness rectal prolapse, with a follow-up over 3 mo were considered for the review.

RESULTS: Twelve non-randomized case series studies with 574 patients were included in the review. No surgical mortality was described. Conversion was needed in 17 cases (2.9%), most often due to difficult adhesiolysis. Twenty eight patients (4.8%) presented with major complications. Seven (1.2%) mesh-related complications were reported. Most frequent complications were urinary tract infection and urinary retention. Mean recurrence rate was 4.7% with a median follow-up of 23 mo. Improvement of constipation ranged from 3%-72% of the patients and worsening or new onset occurred in 0%-20%. Incontinence improved in 31%-84% patients who presented fecal incontinence at various stages. Evaluation of functional score was disparate between studies.

CONCLUSION: Based on the low long-term recurrence rate and favorable outcome data in terms of low de novo constipation rate, improvement of anal incontinence, and low complications rate, laparoscopic anterior rectopexy seems to emerge as an efficient procedure for the treatment of patients with total rectal prolapse.

Dynamic cystocolpoproctography is superior to functional pelvic MRI in the diagnosis of posterior pelvic floor disorders: results of a prospective study

AIM

The accuracy of dynamic cystocolpoproctography (DCP) and dynamic MRI were compared in diagnosing posterior pelvic floor disorders.

METHOD

Fifty consecutive female patients (mean age 51 years) complaining of posterior compartment pelvic floor disorder and referred to a tertiary centre entered the prospective study. The Institutional Review Board stated that informed consent from the patients was not necessary for this study. Patients underwent a DCP and a supine functional MRI by two different radiologists. Assessment of radiological examinations was prospective and blind. All patients underwent surgery that led to the final diagnosis. Agreement between the operative diagnosis and the diagnoses following DCP and MRI was assessed using the weighted kappa statistic. A matched-pairs McNemar's test was applied to demonstrate whether or not one radiological method was superior to the other.

RESULTS

Full-thickness rectal prolapse was best diagnosed by clinical examination. Internal rectal prolapse and peritoneocele were best diagnosed by DCP. A better agreement with the operative diagnosis, which is not true superiority, was observed for DCP compared with functional pelvic MRI for full-thickness rectal prolapse, internal rectal prolapse and peritoneocele. There was no significant difference between DCP and functional pelvic MRI in the diagnosis of internal rectal prolapse (P = 0.125) or peritoneocele (P = 0.10).

CONCLUSION

As full-thickness rectal prolapse, internal rectal prolapse and peritoneocele might be missed by functional pelvic MRI, there should still be a place for DCP in particular cases where the clinical diagnosis is not clear in women with symptomatic posterior pelvic floor disorders.

Understanding and treating refractory constipation

Chronic constipation is a frequently encountered disorder in clinical practice. Most constipated patients benefit from standard medical approaches. However, current therapies may fail in a proportion of patients. These patients deserve better evaluation and thorough investigations before their labeling as refractory to treatment. Indeed, several cases of apparent refractoriness are actually due to misconceptions about constipation, poor basal evaluation (inability to recognize secondary causes of constipation, use of constipating drugs) or inadequate therapeutic regimens. After a careful re-evaluation that takes into account the above factors, a certain percentage of patients can be defined as being actually resistant to first-line medical treatments. These subjects should firstly undergo specific diagnostic examination to ascertain the subtype of constipation. The subsequent therapeutic approach should be then tailored according to their underlying dysfunction. Slow transit patients could benefit from a more robust medical treatment, based on stimulant laxatives (or their combination with osmotic laxatives, particularly over the short-term), enterokinetics (such as prucalopride) or secretagogues (such as lubiprostone or linaclotide). Patients complaining of obstructed defecation are less likely to show a response to medical treatment and might benefit from biofeedback, when available. When all medical treatments prove to be unsatisfactory, other approaches may be attempted in selected patients (sacral neuromodulation, local injection of botulinum toxin, anterograde continence enemas), although with largely unpredictable outcomes. A further although irreversible step is surgery (subtotal colectomy with ileorectal anastomosis or stapled transanal rectal resection), which may confer some benefit to a few patients with refractoriness to medical treatments.

Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: short- and long-term follow-up

BACKGROUND

There are multiple procedures to treat full-thickness rectal prolapse. No consensus exists as to the best surgical option. All procedures have a significant recurrence rate.

OBJECTIVE

The aim of this study was to report short- and long-term technical results following laparoscopic removal of the Douglas pouch peritoneum and anterior rectopexy in patients with total rectal prolapse.

DESIGN

This study is a prospective evaluation of consecutive patients.

SETTINGS

This investigation was conducted at a single academic colorectal unit.

PATIENTS

Between May 1996 and June 2009, 175 consecutive patients (17 males) with a mean age of 58 years (range, 16-94) were operated on.

INTERVENTION

The Douglas pouch peritoneum was excised, 2 synthetic meshes were fixated to the anterior part of the lower rectum with five 4-mm staples and to the promontory with 3 spiked chromium staples, and the peritoneum was closed over the meshes to isolate them from the abdominal cavity.

MAIN OUTCOME MEASURES

Patients were reviewed at months 1, 6, 12, and then annually. Mortality, morbidity, and recurrence were analyzed. Median follow-up was 74 months (range, 24-181). Recurrence rate was calculated according to the Kaplan-Meier method.

RESULTS

: There was no mortality. Morbidity (5.1%) consisted in temporary brachial plexus palsy in 2 cases, urinary infection in 3 cases, ureteral lesion in 1 patient having had a previous bone graft on the promontory for spondylolisthesis (JJ catheter), and perforation of the small bowel because of adhesions (laparoscopic suture) in 1 case. One patient presented with a rectal erosion at month 9 (transanal removal of the mesh). Two patients presented with a recurrence of the rectal prolapse at months 6 and 24 (recurrence rate of 3% at 5 years) that was treated with anal artificial sphincter in one and redo operation in the other.

CONCLUSION

Laparoscopic removal of the Douglas pouch peritoneum and rectopexy to the promontory is a safe and efficient procedure to treat full-thickness rectal prolapse.

An assessment of enteric nervous system and estroprogestinic receptors in obstructed defecation associated with rectal intussusception

BACKGROUND

The pathophysiological basis of obstructed defecation (OD) is still incompletely understood. In particular, few or no data are available concerning the enteric nervous system (ENS) in this condition. We investigated ENS abnormalities in patients with OD, undergoing surgery, together with the presence of estrogen (α and β) and progesterone receptors, and compare the results with those obtained in controls.

METHODS

Full-thickness rectal samples were obtained from 17 patients undergoing stapled transanal rectal resection for OD associated with rectal intussusception. Samples were analyzed by immunohistochemistry for enteric neurons, enteric glial cells, interstitial cells of Cajal (ICC), and for estrogen and progesterone receptors. Data were compared with those obtained in 10 controls.

KEY RESULTS

No differences between patients and controls were found for enteric neurons, whereas (compared with controls) OD patients displayed a significant decrease of enteric glial cells in both the submucous (P = 0.0006) and the myenteric (P < 0.0001) plexus. ICC were significantly increased in patients in the submucosal surface (P < 0.0001) and the myenteric area (P < 0.0001). Concerning estroprogestinic receptors, both were present on ICC in patients and controls. Estrogen receptors α and progesterone receptors were absent on enteric neurons and enteric glial cells in patients and controls, whereas estrogen receptors β were present in all controls and in 69% of patients' enteric neurons (P = 0.18) and in 12% of patients' glial cells (P = 0.0001).

CONCLUSIONS & INFERENCES

Patients with OD associated to rectal intussusception display abnormalities of the ENS and of estrogen receptors β.

Morphological alterations of the enteric nervous system in young male patients with rectal prolapse

OBJECTIVES

The pathogenesis of rectal prolapse (RP) defined by a circumferential, full-thickness invagination of the rectal wall into the anal canal is controversial. RP is normally encountered in elderly women and attributed to several etiological factors (e.g., advanced age, pudendal nerve injury, laxity of supporting ligaments). RP affecting young male patients is unlikely to be explained by these factors and may be due to a rectal motility disorder. Therefore, the enteric nervous system (ENS) as key regulator of intestinal motility was evaluated by a systematic morphometric analysis.

PATIENTS AND METHODS

Full-thickness rectosigmoid specimens obtained from young male patients with symptomatic RP (n = 5) and male controls (n = 15) were processed for conventional histology and immunohistochemistry using anti-HuC/D as pan-neuronal marker. Enteric ganglia, nerve and glial cells were quantified separately in the myenteric (MP) and submucosal plexus (SMP).

RESULTS

Compared to controls, patients with RP showed significantly (p < 0.05) increased mean ganglionic area both in MP and SMP, increased mean neuronal content of submucosal ganglia, and nearly threefold higher frequency of submucosal ganglia containing ≥7 neurons.

CONCLUSION

The morphometric analysis reveals distinct quantitative alterations of the ENS in young male patients with RP mainly characterized by submucosal hyperganglionosis similar to histopathological features described in intestinal neuronal dysplasia. The data give evidence that RP in this unusual subgroup is associated with morphological changes of enteric ganglia which may contribute to the development of RP and complement established etiological concepts.

Can "functional" constipation be considered as a form of enteric neuro-gliopathy?

Constipation has been traditionally viewed and classified as a functional or idiopathic disorder. However, evidence has been accumulating that suggests how constipation might be considered as due to abnormalities of the enteric nervous system, since alterations of this system, not evident in conventional histological examination, may be present in these patients. These abnormalities often consist in decrease or loss of the enteric glial cells, a pathological finding present in most types of constipation so far investigated. In this article we will discuss these evidences, and will try to consider constipation no more as a simple functional or idiopathic disorder but as a form of enteric neuro-gliopathy.

Sacral nerve stimulation for fecal incontinence: causes of surgical revision from a series of 87 consecutive patients operated on in a single institution

PURPOSE

Sacral nerve stimulation is offered to patients presenting with fecal incontinence of neurological or idiopathic etiology, when medical management has failed. The purpose of this study was to investigate the causes of surgical revision following sacral nerve stimulation in consecutive patients who had received implants.

PATIENTS AND METHODS

From September 2001 to August 2009, 123 patients (105 women) of mean age 56 years were operated on for neurological (n = 104) or idiopathic (n = 19) fecal incontinence. The mean preoperative Cleveland Clinic score was 13/20 (range 6/20 to 19/20). Eighty-seven patients of 123 had a positive test and underwent stimulator implantation. Any stimulator dysfunction was prospectively studied.

RESULTS

Among the 87 patients, 36 had surgical revision of the device for the following reasons: device-related failure due to infection in 4 (successful reimplant in 4), electrode displacement in 2, electrode breakage in 2 (reimplantation of electrode in 4), and dysfunction owing to impedance increase of the system in 4; adverse stimulation with pain in 7 (stimulator repositioning in 4 and explantation in 3); battery depletion either spontaneously (n = 6) or owing to a MRI examination (n = 2); total or partial loss of clinical efficacy in 9 (removal of the generator and electrode).

CONCLUSION

Sacral nerve stimulation is a recognized treatment for fecal incontinence. The stimulator reoperation rate is high and is caused by stimulator dysfunction in 24% of cases.

[Anal incontinence]

Anal incontinence today is more frequent than current estimates indicate. When a patient seeks care for this condition, its cause and severity are assessed by a careful history and clinical examination. Two essential atraumatic examinations are decision-support tools: transrectal ultrasound and anal manometry. Treatment should always be proposed. Surgery is necessary in some cases: obvious rupture of the external sphincter, if possible confirmed by transrectal ultrasound, should be directly repaired. Should this treatment fail, a repeated repair or a sphincter replacement (graciloplasty or artificial sphincter) is called for. Neuromodulation therapy is often indicated in the absence of obvious rupture, especially in cases of pudendal neuropathy.

Colonic neuropathological aspects in patients with intractable constipation due to obstructed defecation

One of the most frequent subtypes of constipation is represented by obstructed defecation, and it has recently been reported that these patients may have colonic motor abnormalities in addition to alterations of the anorectal area. However, it is unknown whether these patients display abnormalities of the enteric nervous system, as reported in other groups of constipated subjects. For this reason, we evaluated the neuropathologic aspects of the enteric nervous system in a homogeneous group of patients with obstructed defecation. Colonic specimens from 11 patients (nine women, age range 39-66 years) undergoing surgery for symptoms refractory to any therapeutic measure, including biofeedback training, were obtained and examined by means of conventional histological methods and immunohistochemistry (NSE, S100, c-Kit, formamide-mAb, Bcl-2, CD34, alfa-actin). Analysis of the specimens showed that the enteric neurons were significantly decreased only in the submucosal plexus of patients (P<0.0001 vs controls), whereas the enteric glial cells of constipated patients were reduced in both the myenteric (P=0.018 vs controls) and the submucosal plexus (P=0.004 vs controls). No difference between patients and controls were found concerning c-Kit and CD34 expression, and the number of apoptotic neurons. These findings support the concept that at least a subgroup of patients with obstructed defecation and severe, intractable symptoms display abnormalities of the enteric nervous system, mostly related to the enteric glial cells. These findings might explain some of the pathophysiological abnormalities, and help to better understand this condition.

Colonic response to food in constipation

OBJECTIVES

Colonic response to food is possibly abnormal in constipation.

METHODS

The colonic response to food was evaluated in 323 patients and 60 healthy subjects by following the movements of radiopaque markers after ingestion of a standard 1,000-cal test meal. Constipated patients were divided into four groups: one with a normal, and three with a delayed colorectal transit time. When the delay was found mainly in the ascending colon, the group was labeled as suffering from "colonic inertia". In "hindgut dysfunction", the delay was predominantly found in the descending colon, whereas the term "outlet obstruction" was reserved for constipated patients whose major site of delay was the rectosigmoid area. Colonic response to food was quantified by evaluating the variation of markers in a given abdominal region and the evolution of the geometric center on the entire plain film of the abdomen.

RESULTS

Emptying of the caecum-ascending colon and filling of the rectosigmoid area characterize the colonic response to food in healthy subjects. Constipated patients also filled the rectosigmoid, but different patterns were found in the colon. In constipated patients with transit in the normal range, there was a frequent (41%) absence of colonic response to food as compared to controls (13%) and constipated patients with delayed transit (p<0.0001). The response to food of patients with colonic inertia was similar to that of healthy subjects in terms of distal progression, but less marked. The hindgut dysfunction group emptied the entire left colon but failed to empty the caecum and ascending colon. In the outlet obstruction group, there was no distal progress of the geometric center after meal.

CONCLUSIONS

Abnormal colonic response to food is frequently found in constipated patients, with different patterns according to the type of constipation.

Technical and functional results after laparoscopic rectopexy to the promontory for complete rectal prolapse. Prospective study in 54 consecutive patients

INTRODUCTION

Laparoscopic rectopexy for complete rectal prolapse offers short-term advantages compared with operations performed by laparotomy. The aim of this prospective study was to report technical and functional outcome after laparoscopic rectopexy to the promontory in consecutive patients operated on by a single surgeon.

PATIENTS AND METHODS

From May 1996 to July 2004, 54 consecutive patients (47 women), median age 53 years (range: 16-84 years), underwent laparoscopic rectopexy to the promontory for complete rectal prolapse. Preoperative evaluation included physical examination, dynamic videoproctography and, in patients with constipation, colonic transit time (with radiopaque markers). Postoperative evaluation included the same examinations and a simple global quality-of-life questionnaire.

RESULTS

Conversion to laparotomy was required for three patients during the learning curve. Median duration of operation was 157 minutes (range: 50-370). There was no mortality and morbidity was 5.5% (brachial plexus palsy in two patients and urinary tract infection in one). Median hospital stay was 3.5 days (range: 1-11). There were 4 recurrences (7.4%). Functional outcome at 12 months showed the presence of constipation in 20.3% of patients (persistence in eight and de novo in three) and the presence of outlet obstruction in 25.9% of patients (persistence in six and de novo in eight). Anal continence improved in 72.4% of the 29 patients who complained of this symptom. The global quality-of-life questionnaire showed a satisfactory result in 96% of patients.

CONCLUSION

Laparoscopic rectopexy to the promontory is a safe and efficient procedure to treat complete rectal prolapse; morbidity is low. Functional outcome is at least equivalent to that obtained with open procedures in terms of continence, constipation and outlet obstruction.

Sacral neuromodulation in the treatment of severe anal incontinence

INTRODUCTION

Sacral neuromodulation is a recognized therapeutic option in severe anal incontinence from neurogenic origins, when medical treatment has failed.

METHODS

We report the results of this procedure applied in 40 consecutive patients operated on by a single surgeon from August 2001 to June 2004. Mean duration of incontinence was 5 years. There were 33 women and 7 men of mean age 59 (range 29-89). All patients had had medical treatment, 26 had had physiotherapy and 9 had been previously operated on for that problem. Neuromodulation consisted in a temporary electrical stimulation test followed by implantation of a stimulator in case of efficacy.

RESULTS

Twenty nine patients had a positive test and were implanted. Ten had a negative test and one is waiting for implantation. From the 29 patients, 23 had uneventful postoperative course. Incontinence score varied from 17 before neuromodulation to 6 after in the 24 patients who were improved. Mean resting pressure, mean maximum squeeze pressure and mean duration of squeeze pressure did not change from pre to postoperative period.

CONCLUSION

Sacral neuromodulation is a safe and efficacious procedure in properly selected anal incontinent patients. However, we observed no correlation between clinical and manometric data.

Long-term results of the anterior Délorme's operation in the management of symptomatic rectocele

PURPOSE

Although the results of surgery for symptomatic rectocele seem satisfactory initially, there is a trend toward deterioration with time. This study was designed to assess the long-term outcome of Anterior Délorme's operation for rectocele.

METHODS

Questionnaires were sent to all females who had Anterior Délorme's operation performed in Auckland between 1990 and 2000. The questionnaires included obstructed defecation symptoms and a validated fecal incontinence severity index questionnaire and fecal incontinence quality of life questionnaire. Preoperative and postoperative obstructed defecation symptoms and incontinence score were compared.

RESULTS

A total of 150 females (mean age, 56 (range, 30-83) years) who had an Anterior Délorme's operation for a rectocele were identified. One hundred seven patients (71.5 percent; mean age, 56 years) completed the questionnaire. Median follow-up was four (range, 2-11) years. The number of patients with obstructed defecation reduced from 87 preoperatively to 23 postoperatively using Rome II criteria (P < 0.0001). Postoperatively there was a reduction in the number of patients with each of the symptoms of obstructed defecation from 83 to 27 for straining, 87 to 33 for incomplete emptying, 64 to 14 for feeling of blockage, 41 to 10 for digitation (P < 0.0001 for all). The median incontinence score reduced from 20 of 61 preoperatively to 12 of 61 postoperatively (P = 0.0001).

CONCLUSIONS

In patients with symptomatic rectocele, Anterior Délorme's operation provides long-term benefit for patients with obstructed defecation and leads to a significant improvement of incontinence scores.

Abnormal predefecatory colonic motor patterns define constipation in obstructed defecation

BACKGROUND & AIMS

The pathophysiology of constipation in the syndrome of obstructed defecation is unknown. Using 24-hour pancolonic manometric recordings of the unprepared colon to record basal pressures and spontaneous defecation episodes, we tested the hypothesis that the frequency, timing, or spatial distribution of propagating colonic pressure waves is abnormal in patients with obstructed defecation.

METHODS

In 11 patients with obstructed defecation and 16 healthy controls, pressures were recorded using a nasocolonic catheter that was positioned such that 16 recording sites spanned the unprepared colon at 7.5-cm intervals.

RESULTS

The overall frequency of propagating sequences (PS) in the colon did not differ between patients and controls. When compared with controls, patients had a significant increase in the frequency of retrograde and antegrade PS (P < 0.05) in the left colon and a significant reduction in the amplitude of propagating pressure waves throughout the entire colon (P < 0.03). Defecation occurred in 6 of 11 patients and 9 of 16 controls. In the 15 minutes before defecation, controls showed a highly significant increase in frequency (P = 0.001) and amplitude (P = 0.01) of PS. In contrast, patients did not demonstrate this or the typical spatiotemporal organization of PS normally observed before expulsion of stool.

CONCLUSIONS

Patients with obstructed defecation lack the normal predefecatory augmentation in frequency and amplitude of propagating pressure waves and lack the normal stereotypic spatiotemporal patterning of colonic pressure waves that would normally culminate in effective expulsion of stool.