Fecal seepage and soiling: A problem of rectal sensation

PURPOSE: To determine the physiologic alteration resulting in fecal seepage and soiling, results of anorectal manometric testing were evaluated in patients with varying degrees of fecal incontinence. METHODS: Anal manometric studies performed on 170 patients with fecal incontinence were reviewed. Results of their studies, including mean resting pressure, maximum resting pressure, maximum squeezing pressure, minimum rectal sensory volume, and minimum volume at which reflex relaxation first occurs, were compared with those of 35 control group subjects with normal fecal continence. Manometric studies were performed using a four-channel, water-perfused catheter. Incontinent patients were divided into three groups based on presenting complaints: complete incontinence (incontinence of gas and liquid and solid stool), partial incontinence (incontinence of gas and liquid), and seepage and soiling (incontinence of small amounts of liquid and solid stool without immediate awareness). RESULTS: Resting pressures were significantly lower in complete incontinence, partial incontinence, and seepage and soiling groups than in the controls (P<0.001). Resting pressures of the complete incontinence group were also significantly lower than those of the partial incontinence and seepage and soiling groups (P=0.03). Squeezing pressures were lower for both the complete incontinence and partial incontinence groups than for those in the control group (P<0.001) and in the seepage and soiling group, which did not differ significantly from controls. The minimum rectal sensory volume was greater in all incontinent groups than in controls (P<0.001). Sensory volume of the seepage and soiling group was significantly greater than that of the complete incontinence and partial incontinence groups (P<0.01). The difference between sensory volume and the volume producing reflex relaxation was greatest in the seepage and soiling group and differed from that of the partial incontinence and control groups. CONCLUSIONS: These findings suggest that the mechanism of incontinence is different in seepage and soiling patients and involves a dyssynergy of rectal sensation and anal relaxation. Patients with the pattern of seepage and soiling may be successfully treated with stool bulking agents (e.g.,psyllium or bran).     

Vectormanometry for differential diagnosis of fecal incontinence

PURPOSE: This study was designed to investigate the reliability of three-dimensional vectormanometry for differential diagnosis of fecal incontinence. METHODS: Eight-channel, continuous pull-out perfusion manometry was performed on 23 female patients with traumatic (n=11) or idiopathic (n=12) incontinence, respectively. RESULTS: At rest, the minimum sector pressure of patients with traumatic incontinence (32±14 mmHg) was significantly lower than it was in the controls (76±16 mmHg) and in those with idiopathic incontinence (64±28 mmHg) (P<0.001). At maximum squeezing, the minimum sector pressure was 57±22 mmHg in patients with traumatic incontinence and 79±33 mmHg in those with idiopathic incontinence, both being significantly lower than in the control group with 152±27 mmHg (P<0.001). The asymmetry index of the patients with a sphincter defect was significantly higher, both at rest (23±13 percent) and squeeze (26±12 percent), in comparison with the control group (7 ±2 percent at rest and 6.2±1.6 percent at squeeze) and the patients with idiopathic incontinence (10±5 percent at rest and 8.4±4 percent at squeeze). CONCLUSION: Three-dimensional vectormanometry identifies localized pressure deficits in the anal canal, thereby differentiating between sectorial and global sphincter insufficiency.     

Biofeedback treatment is ineffective in neurogenic fecal incontinence

PURPOSE: This study was undertaken to assess biofeedback treatment (active sphincter exercises under direct electromyography vision) in neurogenic fecal incontinence. METHODS: Twelve patients with neurogenic fecal incontinence have been studied prospectively. External sphincter contractions were exercised under direct electromyographic vision twice per day for 30 minutes during 12 weeks. Manometry was done at the beginning and after 12 weeks of training to evaluate objectively changes in sphincter functions. RESULTS: No patient experienced any improvement in fecal control. Mean resting pressure increased from 7 to 9 kPa and mean squeeze pressure from 3.9 to 4.9 kPA, which was of no statistical significance (P =0.20 and P =0.46, respectively). CONCLUSIONS: External sphincter contraction exercises under direct electromyographic vision are not effective in neurogenic fecal incontinence. Degree of continence does not improve, and external sphincter function is not increased significantly.     

Pudendal neuropathy in evacuatory disorders

PURPOSE: Aims of the present study were to assess frequency of pudendal neuropathy in patients with constipation and fecal incontinence, to determine its correlation with clinical variables, anal electromyographic assessment, and anal manometric pressures, and to determine usefulness of the pudendal nerve terminal motor latency assessment in evaluation of these evacuatory disorders. METHODS: From 1988 to 1993, 395 patients (constipated, 172; incontinent, 223) underwent pudendal nerve terminal motor latency, electromyography, and anal manometry. Pudendal neuropathy was defined as a pudendal nerve terminal motor latency greater than 2.2 ms. RESULTS: Patients were a mean age of 60.7 (range, 17–88) years. Overall incidence of pudendal neuropathy was 31.4 percent (constipated, 23.8 percent; incontinent, 37.2 percent; P<0.05). Incidence of pudendal neuropathy dramatically increased after 70 years of age in both groups (22 percent vs. 44 percent; P<0.05). Moreover, subjects with pudendal neuropathy were older than those without pudendal neuropathy (mean age, 67 vs. 57 years; P<0.05). The presence of pudendal neuropathy was associated with decreased motor unit potentials recruitment in patients with incontinence (P<0.01). Patients with and without pudendal neuropathy had a similar mean squeezing pressure in both groups. CONCLUSION: Pudendal neuropathy is an age-related phenomenon. Although pudendal neuropathy is associated with abnormal anal electromyographic findings in patients with incontinence, no association with anal manometric pressures was found. Pudendal nerve terminal motor latency assessment is a useful tool in the evaluation of patients with fecal incontinence, but its role in the assessment of constipated patients remains unknown.     

Randomized trial of internal anal sphincter plication with pelvic floor repair for neuropathic fecal incontinence

PURPOSE: This study was designed to examine the role of adjuvant internal anal sphincter plication in women with neuropathic fecal incontinence undergoing pelvic floor repair. METHODS: We completed a randomized trial with symptomatic and physiologic assessment before and after surgery. RESULTS: There was no symptomatic advantage of adding internal sphincter plication; the mean improvement of functional score was 3.61±1.82 (standard deviation;P <0.01) following pelvic floor repair alone compared with 2.80±1.66 (standard deviation;P <0.01) when adjuvant internal anal sphincter plication was added. The addition of internal sphincter plication was associated with a significant fall in maximum anal resting and squeezing pressures (P <0.01). CONCLUSIONS: Addition of internal sphincter plication is not advised in women with neuropathic fecal incontinence treated by pelvic floor repair.     

Transanal ultrasound and manometry in the evaluation of fecal incontinence

PURPOSE: This preliminary study was undertaken to clarify the role of ultrasonography of anal sphincters in the colorectal laboratory. METHODS: Twenty-eight parous female patients with fecal incontinence were evaluated with transanal ultrasonography (TAUS), anal manometry, and pudendal nerve terminal motor latency (PNTML). Ultrasound images were recorded and labeled in centimeters from the anal verge. The continuity of the internal anal sphincter (IAS) was identified as either intact or disrupted. The separation of the external anal sphincter (EAS) was measured at the 1.5-cm level and below. TAUS findings were then compared with anal manometric pressures. Clinical data were obtained by patient interview and examination during TAUS. RESULTS: Evidence of IAS disruption was associated with significantly decreased mean maximum resting pressures (P=0.023). EAS separation was inversely proportional to mean maximum squeezing pressures (r=?0.61). In the group of patients offered sphincteroplasty, the IAS was disrupted more often (P=0.016), mean maximum resting pressures were significantly lower (P=0.023), mean EAS separation was significantly greater (P=0.022), and mean PNTML was significantly faster (P=0.004). Twenty-five percent of patients with normal clinical examinations had significant muscular injury by TAUS requiring sphincteroplasty. CONCLUSIONS: Manometric findings correlate significantly with anal sphincter defects visualized by TAUS. TAUS is useful in the evaluation and management of patients with fecal incontinence.     

Anorectal manometric examination in encopretic-constipated children

PURPOSE: We have investigated the use of anorectal manometry to distinguish encopretic-constipated children (n=88) from sibling controls (n=16) and nonsibling controls (n=11). METHODS: Study variables included manometrically determined resting and maximum voluntary anal sphincter pressure, depth and speed of rectoanal inhibitory reflex, minimum rectal volume sensation, critical distending volume for fecal urgency, rectal and anal pressure responses during attempted defecation, and ability to defecate a water-filled balloon. RESULTS: Change in anal sphincter pressure during attempted defecation (P=0.03), gradient between rectal and sphincter pressure during attempted defecation (P=0.02), critical distending volume for fecal urgency (P=0.02), and ability to defecate a water-filled balloon (P=0.05) distinguished encopretic-constipated from control children. The change in rectal pressure associated with the rectoanal inhibitory reflex just escaped significance at P=0.07. CONCLUSIONS: Anal sphincter spasm and megacolon are pathophysiologic abnormalities associated with pediatric constipation-encopresis.     

Simplified solid sphere test to investigate anal sphincter strength in patients with anorectal diseases

PURPOSE: The solid sphere test has not gained general acceptance to investigate anal sphincters, despite its simplicity and low cost. We studied continent and incontinent patients to evaluate whether the solid sphere test is suitable in assessment of anal sphincter function. METHODS: Seventy colorectal patients with anal incontinence of varying severity were studied by means of incontinence grading, solid sphere test, and anal manometry. RESULTS: Anal sphincter strength, studied using the solid sphere test, declined gradually with increasing severity of anal incontinence from 1,186 (±334, SD) g in 28 continent patients to 619 (±256, SD) g in 13 patients with daily soiling (P<0.001). The test also correlated with anal manometry; there was positive correlation with maximum basal pressure (tr=0.643,P<0.001) and maximum voluntary contraction pressure (r=0.393,P<0.01). CONCLUSION: The solid sphere test is useful in the primary assessment of patients with anal incontinence as a screening test, but alone it is too inaccurate for clinical decision making.     

Variation in pudendal nerve terminal motor latency according to disease

PURPOSE: The aims of this study were first to establish whether any difference among pudendal nerve terminal motor latency (PNTML) values exists relative to diagnosis, second to determine whether left and right latencies are similar, and third to assess any correlation between age and neuropathy. Latency was elicited three times on each side, and an average latency was recorded as a result. MATERIALS AND METHODS: Between June 1989 and April 1995, 1,026 patients (775 females and 251 males) underwent PNTML study. These patients were divided into four groups according to diagnosis: Group I, fecal incontinence; Group II, chronic constipation; Group III, idiopathic rectal pain; Group IV, rectal prolapse. Overall mean age was 61.5 (range, 6–95) years. Student's t-test was used to calculate statistical differences. Patients were then analyzed according to age and gender. Correlation was calculated with the nonparametric Mann-Whitney U test. RESULTS: Unilateral or bilateral prolongation of PNTML was noted in 90 patients (21.2 percent) in Group I, 80 (20.4 percent) in Group II, 22 (18.1 percent) in Group III, and 38 (42.6 percent) in Group IV. Average PNTML on the left side was 1.88 ms in Group I, 1.94 ms in Group II, 1.98 ms in Group III, and 2.12 ms in Group IV. Average PNTML on the right side was 1.85 ms in Group I, 1.94 ms in Group II, 1.99 ms in Group III, and 2.07 ms in Group IV. The only statistically significant differences in PNTML were between Groups I and IV (left,P <0.005; right, <0.05) and between females and males ( P <0.0001). CONCLUSION: There is no statistically significant difference between latencies of left and right pudendal nerves. Similarly, there are no statistically significant differences among patients with fecal incontinence, chronic constipation, or chronic idiopathic rectal pain. Normal latency can be expected in patients with constipation or fecal incontinence. However, patients with rectal prolapse have a more prolonged PNTML. Age is correlated with a higher incidence of pudendal neuropathy. This study reveals significant overlap among PNTML values and diagnosis.     

Anal sensitivity test: What does it measure and do we need it?

PURPOSE: This study was undertaken to determine the anal sensitivity in controls and in different patient groups and to establish factors that determine anal sensitivity. METHODS: Anorectal function tests were performed in 387 patients with different anorectal diseases. Anal sensitivity was measured in 36 controls. Anal sensitivity was measured by means of mucosal electrosensitivity (MES) using a catheter with two electrodes placed in the anal canal. A constant current (square wave stimuli 100 μsec, pulses per second) was increased stepwise from 1 to 20 mAmp until the threshold sensation was reached. Other tests used were anal manometry (maximum basal pressure, maximum squeeze pressure, rectal compliance (maximum rectal volume and pressure), endosonography (submucosal thickness), defects and thickness of internal and external sphincter), electromyography (maximum contraction pattern, Grade 1 (solitary contractions) to Grade 4 (interference pattern)), and pudendal nerve terminal motor latency. Multiple regression analysis was performed. It was postulated that age, local conditions (anal scars, anal fissures, hemorrhoids, mucosal prolapse, proctitis, sphincter thickness and defects, and submucosal thickness), and neurologic factors could influence anal sensitivity. RESULTS: Controls had an MES of 3.4±1.7. MES was significantly increased compared with controls in patients with fecal incontinence, soiling, hemorrhoids, mucosal prolapse, constipation, anal scars, anal surgery, and sphincter defects; patients with fecal incontinence had the highest MES (6.7±4.3;P <0.0001). Patients with anal fissures and proctitis showed no differences compared with controls. MES correlated significantly with age (R =0.29), maximum basal pressure (R =?0.29), maximum squeeze pressure (R =?0.32), submucosal thickness (R =0.19), maximum contraction pattern (R =?0.39), single-fiber electromyography (R =0.39), and maximum rectal volume and pressure (0.14). Multiple regression analysis showed that age, internal sphincter defects, and submucosal thickness significantly influenced anal sensitivity, but explained only 10 percent of the variance. CONCLUSION: Anal sensitivity is diminished in all patients with anorectal diseases except for anal fissures and proctitis. There are correlations with other anorectal function tests. Anal sensitivity is determined for 10 percent by age, internal sphincter defects, and thickness of the submucosa. Anal sensitivity measurement, therefore, has limited clinical value and should be used in conjunction with other tests in a research setting.     

Inhibitory effect of calcium on carcinogenesis at the site of colonic anastomosis

PURPOSE: A study was made to assess the effect of oral calcium supplementation on colorectal carcinogenesis at the colocolic suture line and in the rest of the colon following administration of a carcinogen. METHODS: Fifty-nine rats were randomly divided into two groups: control (given a standard diet for rats and mice containing 0.8 percent calcium) and treatment (given the same diet as before but with 2 percent calcium). Carcinogenesis was induced by 26 weekly injections of 1,2-dimethylhydrazine. All animals were subjected to an end-to-end colonic anastomosis at the beginning of the experiment using five stitches of steel wire. RESULTS: The control group developed significantly more tumors per animal at both the anastomosis ( P < 0.001) and in the rest of the colon ( P <0.001). In addition, the percentage of rats with tumors was significantly higher in the control group at both the anastomosis (chi-squared=12; df=1,P <0.001) and in the rest of the colon (chisquared=7.12; df=1,P <0.01). The mean surface of tumors was likewise greater in the control group at the anastomosis ( P <0.001) and throughout the rest of the colon ( P <0.001). Finally, there were significantly more small-bowel tumors (excluding the duodenum) in the control group ( P <0.05). CONCLUSIONS: It is concluded that calcium supplementation decreases the tumor yield at the site of end-to-end colonic anastomosis and in the rest of the colon and small bowel (excluding the duodenum).     

Patterns of anismus and the relation to biofeedback therapy

PURPOSE: A study was undertaken to assess physiologic characteristics and clinical significance of anismus. Specifically, we sought to assess patterns of anismus and the relation of these findings to the success of therapy. METHODS: Sixty-eight patients were found to have anismus based on history and diagnostic criteria including anismus by defecography and at least one of three additional tests: anorectal manometry, electromyography, or colonic transit time study. Interpretation of defecography was based on the consensus of at least three of four observers. Anal canal hypertonia (n=32) was defined when mean and maximum resting pressures were at least 1 standard deviation higher than those in 63 controls. There were two distinct defecographic patterns of anismus: Type A (n=26), a flattened anorectal angle without definitive puborectalis indentation but a closed anal canal; Type B (n=42), a clear puborectalis indentation, narrow anorectal angle, and closed anal canal. Outcomes of 57 patients who had electromyographybased biofeedback therapy were reported as either improved or unimproved at a mean follow-up of 23.7 (range, 6–62) months. These two types of anismus were compared with biofeedback outcome to assess clinical relevance. RESULTS: Patients with Type A anismus showed greater perineal descent at rest (mean, 5.1 vs. 3.5 cm;P < 0.01), greater dynamic descent between rest and evacuation (mean, 2.7 vs. 1.4 cm;P <0.01), greater difference of anorectal angle between rest and evacuation (mean, 14.6 vs. ?3.1°;P <0.001), higher mean resting pressure (mean, 77.1 vs. 62.8 mmHg;P <0.05), lower mean squeeze pressure (58.8 vs. 80.7 mmHg;P <0.05), and a higher incidence of anal canal hypertonia (69.2 vs. 33.3 percent;P <0.01) than did patients with Type B anismus. Only 25 percent of patients who had Type A anismus with anal canal hypertonia were improved by biofeedback therapy. Conversely, 86 percent of patients with Type B anismus without anal canal hypertonia were successfully treated with biofeedback (P <0.001; Fisher's exact test). CONCLUSIONS: These two distinct physiologic patterns of anismus correlate with the success of biofeedback treatment. Therefore, knowledge of these patterns may help direct therapy.     

Treatment of puborectalis syndrome with progressive anal dilation

PURPOSE: The aim of this study is to assess the ability of progressive anal dilations to improve frequency of spontaneous bowel movements in patients with puborectalis syndrome (PRS). METHOD: Thirteen patients (9 females and 4 males; mean age, 37 years) with severe, chronic constipation caused by PRS were treated with daily, progressive anal dilation for a three-month period. Three dilators of 20, 23, and 27 mm in diameter were used. Dilators were inserted every day for 30 minutes (10 minutes each dilator). Patients were evaluated with anorectal manometry and defecography halfway through treatment, at the end of treatment, and six months after the end of treatment. At six months, patients also underwent physical examination. RESULTS: There was a significant improvement of weekly mean spontaneous bowel movements from zero to six (P <0.0001), and the need for laxatives decreased from 12 patients with a weekly mean of 4.6 to 2 patients once per week (P < 0.001). Enemas used before treatment by eight patients who had a weekly mean of 2.3 were, after treatment, needed only by three patients once per week (P <0.01). During straining, tone measured with anorectal manometry decreased from 93 to 62 mmHg after six months of the end of therapy (F =6.97; P<0.01), and anorectal angle measured with defecography during the strain increased from 95° to 110° (P =not significant). CONCLUSIONS: Daily progressive anal dilation should be considered as the first and most simple therapeutic approach in patients with PRS.     

Effect of radiotherapy on anorectal function in patients with cervical cancer

PURPOSE: The acute and long-term effects of pelvic radiation on defecation were studied. METHOD: Anorectal function was assessed based on manometry and subjective symptoms in 31 patients with cervical cancer treated by radiotherapy alone. Sixteen of 31 patients were examined periodically before, during, and after radiotherapy (early group). Fifteen others were examined more than six months after completion of radiotherapy (late group). RESULTS: One-third of patients in both groups had symptoms, mainly diarrhea and increased stool frequency. Patients in the late group also suffered from disturbed gas-stool discrimination, urgency, a sense of residual stool, and soiling. Anal canal resting pressure was significantly higher after radiotherapy (47±15.5 mmHg) than before radiotherapy (36.3±12.5 mmHg;P<0.05). The maximum tolerable volume decreased with radiation, from 163.3±45 before to 119.2±41.4 ml during, 112.7±36.6 ml immediately after, and 94.6±34.4 ml in the late group (P<0.01). Rectal compliance also decreased over time and was lower in the early group (before, 5.7±1.3 ml/mmHg;P<0.01; during, 4.6±2.2 ml/mmHg,P<0.01; after, 3.7±1.4 ml/mmHg;P<0.05) than the late group (2.1±1.5 ml/mmHg) and lower before than after in the early group (P<0.01). Although rectal pressure initiating continuous desire to defecate did not change, the maximum tolerable pressure was significantly higher in the late group (81±19.5 mmHg) than during (59±16.8 mmHg) or after (59.9±16.9 mmHg) radiotherapy in the early group (P<0.05). CONCLUSION: Radiation reduces the capacity of the rectal reservoir, even in asymptomatic patients. These changes develop during radiotherapy and progress over time.     

Kombinierte Stuhl- und Harninkontinenz

Background: Double (urinary and fecal) incontinence is relatively common in the elderly. 6% of men and 9.5% of women over 50 years suffer from combined urinary and fecal incontinence. 50% of males and 60% of females with fecal incontinence have concurrent urinary incontinence. The high rate of concurrence of urinary and fecal incontinence is due to an almost identical innervation of the urinary bladder and the rectum and the close vicinity and partial identity of the muscular sphincter mechanisms. Classification: There are two causal entities of double incontinence: 1. neurogenic disorders, 2. pelvic floor dysfunction. Neurogenic disorders can be classified in central and peripheral nervous lesions. Pelvic floor dysfunction can be due to nerve injury or direct muscular lesions. According to the International Continence Society, urinary incontinence is classified into five categories: 1. stress incontinence, 2. urge incontinence, 3. reflex incontinence, 4. overflow incontinence, 5. extraurethral incontinence. With respect to anal incontinence, the first four groups are important. Diagnosis: The diagnostic evaluation comprises meticulous history, physical examination including neuro-urological status, rectal and in females standardized pelvic examination, urinalysis, sonography of the kidneys and bladder after voiding (postvoid residual urine). In women, a transrectal ultrasound of the bladder, urethra and the pelvic floor is important and can replace lateral cystourethrography. In complex cases, dynamic NMR imaging is helpful. Functional investigations include urodynamic studies with uroflowmetry, filling and voiding cystometry and urethral pressure profiles and rectomanometry. Conclusion: For optimal therapy of double incontinence, an interdisciplinary approach is necessary.     

Anismus: Fact or fiction?

PURPOSE: Although anismus has been considered to be the principal cause of anorectal outlet obstruction, it is doubtful whether contraction of the puborectalis muscle during straining is paradoxical. The present study was conducted to answer this question. METHODS: During the first part of the study, we retrospectively reviewed 121 patients with constipation and/or obstructed defecation (male:female, 10/111; median age, 51 years). All of these patients underwent electromyography (EMG) of the pelvic floor and the balloon expulsion test (BET) in the left lateral position. Evacuation proctography was performed in all of these patients in the sitting position. Both the posterior anorectal angle and the central anorectal angle were measured. EMG and BET were also performed in ten controls (male:female, 4/6; median age, 47). In 147 patients with fecal incontinence (male:female, 24/123; median age, 58) only EMG activity was recorded. Criteria for anismus during straining were increase or insufficient (<20 percent) decrease of EMG activity, failure to expel an air-filled balloon on BET, and decrease or insufficient (<5 percent) increase of anorectal angle on evacuation proctography. Between June 1994 and March 1995, we conducted a second prospective study in a consecutive series of 49 patients with constipation and/or obstructed defecation and 28 patients with fecal incontinence. Both groups were compared with 19 control subjects. In this study, all three tests were performed. EMG and BET were performed both in the left lateral position and in the sitting position. RESULTS: The retrospective study was undertaken by comparing the constipated patients with the incontinent patients and the controls, and the anismus detected by EMG was found in, respectively, 60, 46, and 60 percent. Failure to expel the air-filled balloon was observed in 80 constipated patients (66 percent) and in 9 control subjects (90 percent). Based on posterior anorectal angle and central anorectal angle measurements, anismus was diagnosed in, respectively, 21 and 35 percent of constipated patients. In the prospective study, none of the tests showed significant differences regarding the prevalence of anismus between the two subgroups of patients and the control subjects. The prevalence of anismus only differed between constipated and incontinent patients when the diagnosis was based on BET in the sitting position (67 vs.32 percent;P <0.005). Our study shows that contraction of the puborectalis muscle during straining is not exclusively found in patients with constipation and/or obstructed defecation. The three tests most commonly used for the diagnosis of anismus showed an extremely poor agreement. CONCLUSION: Based on these findings, we doubt the clinical significance of anismus.     

Prospective study of circulating T-lymphocyte subpopulations and disease progression in colorectal cancer

PURPOSE: It has recently been reported that CD4 ⁺ T-lymphocytes are reduced in advanced colorectal cancer patients. However, it is not clear whether such changes in T-lymphocyte subsets are an early or late event in such patients. The aim of this study was to examine the relationship between these subsets and disease progression in colorectal cancer. METHODS: Flow cytometric analysis of T-lymphocyte subsets was performed in 39 patients who, approximately 12 months previously, had undergone surgery for colorectal cancer. These patients were grouped according to whether they developed a recurrence in the following two years. A group of healthy subjects was studied as controls. RESULTS: There was a significant increase in the median neutrophil count (4.3 vs.3.7 10 ⁶ /ml) and the median numbers of platelets (282 vs.216 10 ⁶/ml)of the recurrence group compared with the control group, respectively (P <0.05). The median numbers (0.28 vs.0.73 10 ⁶/ml)and percentage (29 vs.38 percent) of CD4 ⁺ T-lymphocytes of the recurrence group were significantly reduced compared with that of the control group (P <0.05). There were also reductions in the median percentage of CD3 ⁺ cells (67 vs.74 percent) and the median numbers of CD4 ⁺ T-lymphocytes (0.28 vs.0.46 10 ⁶ /ml) of the recurrence group compared with the no recurrence group (P < 0.05). CONCLUSIONS: Reduction of CD4 ⁺ T-lymphocytes occurs before detectable recurrence of colorectal cancer. Results of the present study are consistent with impaired immunity, as measured by such lymphocyte subset populations, being important in tumor recurrence in colorectal cancer.     

Cytokine production in pouchitis is similar to that in ulcerative colitis

PURPOSE: Controversy exists as to whether pouchitis represents a reactivation of the immunologic mechanisms that lead to ulcerative colitis (UC). The aims of this study were to determine local levels of the cytokines: interleukin-1 β (IL-1 β ), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor alpha (TNF α ) in the mucosa of patients with “asymptomatic” ileoanal pouch (n=25), pouchitis (n=9), active UC (n=20), normal ileum (n=15), proctitis (n=10), and normal colon (n=15). METHODS: Lamina propria mononuclear cells were isolated from mucosal biopsies by enzymatic dispersion and cultured for 48 hours. Proinflammatory cytokine levels were measured in the supernatants by enzyme-linked immunosorbent assay. RESULTS: IL-1 β,IL-6, IL-8, and TNF α secretions were significantly greater in pouchitis and active UC than in the noninflamed ileoanal pouch and normal controls ( P <0.001). There was significant correlation ( r =0.63,P < 0.05) between levels of cytokines expressed in pouchitis and active UC. CONCLUSIONS: Increased cytokine expression occurs in both active UC and pouchitis and to a lesser extent in the long-standing ileoanal pouch.     

Indeterminate colitis

Uncertainty persists concerning the long-term results of ileal pouch-anal anastomosis performed for indeterminate colitis. PURPOSE: This study was designed to compare functional outcomes of ileal pouch-anal anastomosis in patients with typical chronic ulcerative colitis and indeterminate colitis. METHOD: Seventy-one ileoanal pouch patients were identified with a diagnosis of indeterminate colitis. Mean follow-up was 56 months. Outcomes were compared with 1,232 chronic ulcerative colitis patients after ileal pouchanal anastomosis. Mean follow-up was 60 months. RESULTS: (mean±SD) There was no difference in the frequency of daily bowel movements (indeterminate colitis, 7±3,vs.chronic ulcerative colitis, 7±2). Daytime and nighttime incontinence rates were likewise similar. Prevalence of pouchitis was identical (33 percent). However, failure rate was higher in the indeterminate colitis group (indeterminate colitis, 19 percent,vs. chronic ulcerative colitis, 8 percent; (P =0.03)). CONCLUSIONS: At a mean of nearly five years after surgery, failure appears to occur more frequently in patients with indeterminate colitis than in patients with chronic ulcerative colitis. However, the great majority of indeterminate colitis patients (>80 percent) have long-term functional results identical to those of patients with chronic ulcerative colitis.     

Does the level of stapled ileoanal anastomosis influence physiologic and functional outcome?

PURPOSE: The aim of this investigation was to ascertain how the length of anal canal preserved above the dentate line in stapled end-to-end ileoanal anastomosis influenced late outcome. METHODS: Two groups, high cuff group and low cuff group of nine subjects with stapled anastomosis, matched for sex, age, pouch configuration, and mean follow-up, representing the highest (median, 2.5 cm) and lowest (median, 0.7 cm) anal cuff lengths in our series, were selected. Physiologic and functional parameters were appraised preoperatively, at the time of ileostomy closure, and at 1, 3, 6, and 12 months after reestablishment of intestinal continuity. RESULTS: At one year, the drop in mean anal canal resting pressure was 13 percent in the high cuff group (not signficant) and 31 percent in the low cuff group (P <0.05); mean maximum squeezing pressure did not differ significantly from preoperative values in both groups. The mean volume of the ileal pouch was higher in the low cuff group at all insufflation pressures. The rectoanal inhibition reflex reappeared in four high cuff group patients and in none of the low cuff group patients. Mean distention pressure (cm H ₂ O) and volume (ml) eliciting urge sensation were 80 and 360 in the low cuff group compared with 40 and 240 in the high cuff group (P ?0.05). Daytime bowel movements and night incontinence were significantly better in the low cuff group. No statistical differences were observed for night stool frequency, daytime incontinence, pad use (day and night), discrimination between gas and feces, ability to defer evacuation, and difficulty in emptying the pouch. CONCLUSION: Patients with stapled anastomoses and a low rectal cuff length, despite presenting lower anal resting pressure and absence of rectoanal inhibition reflex, had a better functional outcome in terms of continence than those with a high cuff length.