Preoperative Anal Manometry Predicts Continence After Perineal Proctectomy for Rectal Prolapse

Purpose This study examines whether preoperative anal manometry and pudendal nerve terminal motor latency predict functional outcome after perineal proctectomy for rectal prolapse. Methods All adult patients treated by perineal proctectomy for rectal prolapse from 1995 to 2004 were identified (N = 106). Forty-five patients underwent anal manometry and pudendal nerve terminal motor latency testing before proctectomy and they form the basis for this study. Results Perineal proctectomy with levatoroplasty (anterior 88.9 percent; posterior 75.6 percent) was performed in all patients, with a mean resection length of 10.4 cm. Four patients (8.9 percent) developed recurrent prolapse during a 44-month mean follow-up. Preoperative resting and maximal squeeze pressures were 34.2 ± 18.3 and 60.4 ± 30.5 mmHg, respectively. Pudendal nerve terminal motor latency testing was prolonged or undetectable in 55.6 percent of patients. Grade 2 or 3 fecal incontinence was reported by 77.8 percent of patients before surgery, and one-third had obstructed defecation. The overall prevalence of incontinence (77.8 vs. 35.6 percent, P < 0.0001) and constipation (33.3 vs. 6.7 percent, P = 0.003) decreased significantly after proctectomy. Patients with preoperative squeeze pressures >60 mmHg (n = 19) had improved postoperative fecal continence relative to those with lower pressures (incontinence rate, 10 vs. 54 percent; P = 0.004), despite having similar degrees of preoperative incontinence. Abnormalities of pudendal nerve function and mean resting pressures were not predictive of postoperative incontinence. Conclusions Perineal proctectomy provides relief from rectal prolapse, with good intermediate term results. Preoperative anal manometry can predict fecal continence rates after proctectomy, because patients with maximal squeeze pressures >60 mmHg have significantly improved outcomes. Supported exclusively using institutional funding. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Rectal Hypersensitivity Worsens Stool Frequency, Urgency, and Lifestyle in Patients With Urge Fecal Incontinence

PURPOSE Rectal sensory mechanisms are important in the maintenance of fecal continence. Approximately 50 percent of patients with urge incontinence have lowered rectal sensory threshold volumes (rectal hypersensitivity) on balloon distention. Rectal hypersensitivity may underlie the heightened perception of rectal filling; however, its impact on fecal urgency and incontinence is unknown. This study was designed to investigate the impact of rectal hypersensitivity in patients with urge fecal incontinence.METHODS Prospective and retrospective audit review of all patients (n = 258) with an intact native rectum referred to a tertiary colorectal surgical center for physiologic investigation of urge fecal incontinence during a 7.5-year period. Patients with urge fecal incontinence who had undergone pelvic radiotherapy (n = 9) or rectal prolapse (n = 6) were excluded.RESULTS A total of 108 of 243 patients (44 percent) were found to have rectal hypersensitivity. The incidence of anal sphincter dysfunction was equal (90 percent) among those with or without rectal hypersensitivity. Patients with urge fecal incontinence and rectal hypersensitivity had increased stool frequency (P < 0.0001), reported greater use of pads (P = 0.003), and lifestyle restrictions (P = 0.0007) compared with those with normal rectal sensation, but had similar frequencies of incontinent episodes.CONCLUSIONS Urge fecal incontinence relates primarily to external anal sphincter dysfunction, but in patients with urge fecal incontinence, rectal hypersensitivity exacerbates fecal urgency, and this should be considered in the management and surgical decision in patients who present with fecal incontinence.Christopher L. H. Chan, F.R.C.S., is supported by a MRC Clinical Training Fellowship.     

Dynamic Graciloplasty in Patients Born With an Anorectal Malformation

PURPOSE The aim of this study was to compare long-term results for patients born with an anorectal malformation and fecal incontinence treated with a dynamic graciloplasty with those for the total group of patients undergoing dynamic graciloplasty.METHODS Consecutive patients with fecal incontinence after surgical treatment of anorectal malformation and treated with dynamic graciloplasty were included in this study. Preoperative assessment was performed. Postoperative follow-up consisted of anorectal manometry and registration of defecation frequency, continence scores, and postponement time of defecation.RESULTS Twenty-eight patients with a median age of 25.5 years were included in the study. The median follow-up was 4 years. A high anorectal malformation was present in 89.3 percent of patients. Conventional graciloplasty had been previously performed in 36 percent. All patients were incontinent for stools. Median frequency of defecation was four times/day. Median postponement time of defecation was 0 minutes. Rectoanal inhibition reflex was present in 17 percent of patients. Median preoperative sensory threshold during balloon distention was 30 ml and median maximum urge threshold was 165 ml. Satisfactory continence was reached in 35 percent of patients, however, 7.1 percent of patients gained this continence score by additional bowel irrigation. Twenty-nine percent of patients were incontinent for loose stool, 36 percent were incontinent for formed stool. Satisfactory continence was achieved in only 18 percent of patients with a high anorectal malformation, compared with 100 percent in patients with a low anorectal malformation. In the total group of patients with dynamic graciloplasty, satisfactory continence was obtained in 76 percent. The sensitivity threshold in patients with a successful dynamic graciloplasty was lower than that in patients with a failing dynamic graciloplasty (45 vs. 24 ml, P = 0,06). When we compare median preoperative rectal sensitivity threshold in our study group with that in the total patient group with dynamic graciloplasty, statistical difference was established (P = 0.008). Postponement time (0 to 20 minutes) and anal squeeze pressure (81 to 120 mmHg) increased significantly after surgery. Patients with an anorectal malformation had significantly lower resting and stimulation pressure than that of the total group of patients, but the difference between resting and stimulation pressure in both groups was not significantly different (P = 0.33). The difference between resting and stimulation pressure was not significantly different between anorectal malformation patients with a failing dynamic graciloplasty and patients with a successful dynamic graciloplasty. Complications were noted in 57 percent of patients. Explantation of the dynamic graciloplasty was necessary in 32 percent of patients, mainly because of infection of the implant.CONCLUSIONS Results of dynamic graciloplasty for fecal incontinence are reasonable for this specific group of patients with limited treatment options. Despite functional dynamic graciloplasty, the results are worse than those for the total group of patients with dynamic graciloplasty. Rectal sensitivity and type of malformation are prognostic factors for outcome and can be used to select patients for treatment with dynamic graciloplasty, thereby improving treatment outcome.Presented at the meeting of the Nederlandse Vereniging Voor Gastro-Enterologie, Veldhoven, The Netherlands, October 2 to 3, 2003.     

Long-Term Effect of Preoperative Radiation Therapy on Anorectal Function

Purpose Preoperative radiotherapy improves local control in rectal cancer treatment, but there are few reports on the influence of radiotherapy on anorectal function. The aim of the present study was to assess late effects of short-course, high-dose radiotherapy on anorectal function after low anterior resection for rectal cancer. Methods Sixty-four patients, randomized within the Stockholm Radiotherapy Trials and operated on with low anterior resection with or without preoperative radiotherapy (mean, 14 years), previously were followed up with quality-of-life questionnaires, clinical examination, anorectal manometry, and endoanal ultrasound. Twenty-one patients had received preoperative radiotherapy of the rectum and 43 patients had been treated with surgery alone. Results Impaired anorectal function was common after low anterior resection for rectal cancer and the risk was increased after radiotherapy. Irradiated patients had significantly more symptoms of fecal incontinence (57 vs. 26 percent, P = 0.01), soiling (38 vs. 16 percent, P = 0.04), and significantly more bowel movements per week (20 vs. 10, P = 0.02). At anorectal manometry, irradiated patients had significantly lower resting (35 mmHg vs. 62 mmHg, P < 0,001) and squeeze pressures (104 mmHg vs. 143 mmHg, P = 0.05). At endoanal ultrasound, irradiated patients had significantly more scarring of the anal sphincters (33 vs. 13 percent, P = 0.03). There were no significant differences in quality-of-life scores between irradiated and nonirradiated patients; however, patients with anal incontinence had significantly lower quality-of-life scores compared to continent patients. Conclusions Short-course radiotherapy, including the anal sphincters, impairs anorectal function and increases gastrointestinal symptoms permanently when the anal sphincters are irradiated. Supported by the The Swedish Cancer Society and the Stockholm Cancer Society. Study was conducted at the Karolinska and Danderyd Hospitals, Stockholm, Sweden. Presented at the Tripartite Colorectal Meeting, Dublin, Ireland, July 3 to 7, 2005. Reprints are not available.     

Complications and Survival After Surgery for Rectal Cancer in Patients Younger Than and Aged 75 Years or Older

PURPOSE: An increasing number of rectal cancer patients are elderly and have comorbid medical diseases. This study was designed to compare perioperative morbidity, mortality, and survival after surgery for rectal cancer in patients younger than and aged 75 years or older.METHODS: Between 1980 and 1997, 294 patients with rectal cancer were admitted to the Fourth Department of Surgery, Helsinki University Central Hospital. Of these, 95 (32 percent) were aged 75 or older and comprise the elderly group.RESULTS: Major curative operation was possible in 59 of 95 patients in the elderly group and in 147 of 199 patients in the younger age group. Among those operated on with curative intent, 20 of 59 patients (34 percent) in the older age group and 39 of 147 patients (27 percent) in the younger age group had complications (P = 0.31). Thirty-day mortality was 2 percent (n = 1) and 0, respectively. Although five-year crude survival was significantly lower in the older age group (43 vs. 65 percent, P = 0.01), five-year cancer-specific survival (60 vs.70 percent, P = 0.6) and disease-free, five-year survival (60 vs. 69 percent, P = 0.4) were similar in both groups. Patients (n = 17) treated with local excision had a cancer-specific survival of 81 and 83 percent in younger and older age groups, respectively. After palliative resection, the two-year survival was similar (20 vs. 24 percent) in both age groups. Ten elderly patients (11 percent) were not operated on at all in contrast to two patients (1 percent) younger than aged 75 years (P = 0.003).CONCLUSIONS: Major, curative, rectal cancer surgery in selected elderly patients can be performed with similar indications, perioperative morbidity, and mortality, as well as five-year, cancer-specific and disease-free survival as in younger patients.Presented at the meeting of the Finnish Surgical Society, Helsinki, Finland, December 20 to 22, 2002.Reprints are not available.     

Value of Intraoperative Radiotherapy in Locally Advanced Rectal Cancer

Purpose This study was designed to analyze the results of a multimodality treatment using preoperative radiotherapy, followed by surgery and intraoperative radiotherapy in patients with primary locally advanced rectal cancer. Methods Between 1987 and 2002, 123 patients with initial unresectable and locally advanced rectal cancer were identified in our prospective database, containing patient characteristics, radiotherapy plans, operation notes, histopathologic reports, and follow-up details. An evaluation of prognostic factors for local recurrence, distant metastases, and overall survival was performed. Results All patients were treated preoperatively with a median dose of 50 Gy radiotherapy. Surgery was performed six to ten weeks after radiotherapy. Twenty-seven patients were treated with intraoperative radiotherapy because margins were incomplete or ≤2 mm. Postoperative mortality was 2 percent. The median follow-up of all patients was 25.1 months. The overall five-year local control was 65 percent and the overall five-year survival was 50 percent. Positive lymph nodes and incomplete resections negatively influenced local control and overall survival. Intraoperative radiotherapy improved five-year local control (58 vs. 0 percent, P = 0.016) and overall survival (38 vs. 0 percent, P = 0.026) for patients with R1/2 resections. Conclusions The presented multimodality treatment is feasible with an acceptable mortality and a five-year overall survival of 50 percent. Addition of intraoperative radiotherapy for patients with a narrow or microscopic incomplete resection seems to overrule the unfavorable prognostic histologic finding.     

The effect of stool consistency on rectal and neorectal emptying

Although stool consistency is considered to be an important component of anorectal continence, its effect on rectal emptying has never been quantitated. In 12 healthy volunteers and 12 patients after ileal pouch-anal anastomosis (IPAA) (46±5 months after the operation; mean ± SEM), perfused anal manometry was performed; movements of the anorectal angle were quantitated scintigraphically; and rectal capacity and compliance were measured by air insufflation of an intrarectal balloon at three infusion rates. The efficiency of rectal evacuation of three consistencies (5 percent, liquid; 7.5 percent semisolid gel; 11.25 percent solid gel; w/w) of Tc99m labeled artificial stool (aluminum magnesium silicate gel) was quantitated by gamma camera imaging. No abnormalities of pelvic floor function were demonstrated in either controls or patients. The mean neorectal capacity and compliance of patients with IPAA did not differ from control, (capacity; IPAA: 215±22 mlvs. control; 245±29 ml; compliance; IPAA: 5.5±0.7 ml/cm H₂Ovs. control; 6.6±0.7 ml/cm H₂O;P>0.05). In controls, the percentage of the 7.5 percent consistency evacuated (81±5 percent, mean ± SEM) was significantly more than the percentage evacuation of either the 5 percent consistency (67±7 percent) or the 11.25 percent consistency (77±2 percent) (P<0.05). After IPAA, the mean overall percent evacuation of the three stool consistencies was significantly less than control (52±6 percent after IPAA; 75±5 percent control,P<0.05). However, there was no significant difference in neorectal emptying between the liquid, the semisolid gel and the solid gel (56±6, 55±6, 51±9 percent, respectively,P>0.1). We concluded that in healthy subjects but not in patients after IPAA, stool consistency affected the efficiency of evacuation of enteric content.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.Supported in part by USPHS Grants DK 37990, RR 585, and DK 34988 from the National Institutes of Health and the Mayo Foundation, Rochester, Minnesota.     

What affects continence after anterior resection of the rectum?

Functional results after anterior rectal resections are commonly considered satisfactory but variable percentages of postoperative incontinence are often reported. Continence was evaluated after 20 low anterior resections (LAR) and 13 high anterior resections (HAR) by means of clinical assessment, anorectal manometry, and evacuation proctography. Whereas all HAR patients had perfect continence, 10 patients (50 percent of the LAR group had occasional episodes of soiling from liquid feces, 5 patients (25 percent had frequent soiling or occasional incontinence for solid feces, and 1 patient (5 percent had frequent solid stool loss requiring surgical treatment. Anal canal resting pressure at 3 and 4 cm from the anal verge was significantly lower in the LAR group (P<0.02 and P<0.05, respectively) than in the HAR group. However, the maximum voluntary contraction did not differ between the two groups. Rectoanal inhibitory reflex was found to be present in 17 of the 20 patients with LAR and in all patients with HAR. The volume at which the anal sphincter is continuously inhibited was significantly reduced in the LAR group (P<0.001). Also, the conscious rectal sensibility volumes were found to be significantly reduced for threshold, constant, and maximum tolerated volume. Threshold volume for internal sphincter relaxation was lower than the threshold volume for rectal sensation in some patients with LAR. This could allow postoperative fecal soiling. Rectal compliance was decreased (P<0.001) in the LAR group. Evacuation proctography, performed in six LAR patients affected by major soiling or solid stool loss, revealed an abnormal obtuse anorectal angle and pathologic lowering of the perineum at rest and during defecation. The concomitance of internal anal sphincter impairment, reduction in rectal compliance, and previous pelvic floor muscle damage are postulated as cause affecting continence in patients who underwent LAR.Read at the Congress on Colo-Rectal Disease Milan, Italy, June 29–30, 1989.     

Abdominal rectovaginopexy

PURPOSE: We noted the combination of obstructed defecation or constipation and fecal incontinence, the poor results of abdominal rectopexy for constipation, and the well-known risk of postoperative induction of constipation after rectopexy. We developed a new operation to treat patients with constipation or fecal incontinence (with a concomitant rectocele, internal rectal intussusception, enterocele at dynamic defecography, or all three) or both. This new rectopexy technique avoided dorsolateral mobilization of the rectum and did not endanger the hypogastric nerves and pelvic autonomic nerves. A better effect on constipation compared with rectopexies with dorsolateral mobilization was expected. METHODS: The results of this new operation, which was called rectovaginopexy, were studied prospectively in a series of 27 patients. Four-year results were obtained. Preoperative and postoperative questionnaires, dynamic defecograms, and anorectal physiology studies were analyzed. RESULTS: Before the operation 17 patients were constipated, compared with 4 patients one year after rectovaginopexy (76 percent improvement;P=0.0015) and 5 patients four years after rectovaginopexy (71 percent improvement;P=0.005), respectively. At one year, fecal incontinence decreased significantly: 15 of 17 patients improved and 9 patients became fully continent (P=0.0007). Four years after rectovaginopexy the effect on fecal incontinence was no longer significant (P=0.09). Rectovaginopexy restored anatomy: all (9) enteroceles, all but 1 (17) internal rectal intussusception, and 12 of 20 rectoceles dissolved, and the majority were reduced in size. Rectal sensation for distention was unchanged, and rectal electrosensitivity improved (P=0.04). CONCLUSIONS: Rectovaginopexy provides significant one-year improvement of both constipation and fecal incontinence. The positive effect on constipation did not deteriorate with time, in contrast to the effect on fecal incontinence.     

Audit of postanal repair in the treatment of fecal incontinence

PURPOSE: The short-term results of postanal repair for idiopathic fecal incontinence are satisfactory but data on long-term outcome are lacking. This study was carried out to document the short-term and long-term results of this operation and to determine whether preoperative tests predict long-term outcome. METHODS: Thirty-six patients (33 females; mean age, 57 years) with major idiopathic fecal incontinence operated on by one surgeon were studied. Patients had resting and voluntary contraction anal pressures and pudendal nerve terminal motor latencies (PNTML) measured preoperatively. Symptoms were evaluated at 6 months after operation and again at a median of 25 (range, 6–72) months in all 36 patients. Symptoms were classified as: Group C, no improvement or worse; Group B, minor improvement; and Group A, marked improvement in comparison to the patient's preoperative symptoms. Seventeen patients had postoperative physiology performed. RESULTS: At 6 months there were 6 (17 percent) patients in Group C, 12 (33 percent) in Group B, and 18 (50 percent) in Group A. At final follow-up there were 17 (47 percent) in Group C, 9 (25 percent) in Group B, and 10 (28 percent) in Group A. Comparison of the preoperative data in the final outcome groups showed (mean±SE): Groups A and B vs.Group C-resting pressure, 24.6±6 cm H ₂ O vs.40.5±12.2 (P=0.2), voluntary contraction pressure, 23.7±5.7 vs.11.8±3.6 (P=0.09), and PNTML, 3.2±0.75 mS vs.3.3±0.99 (P=0.8). Mean differences between postoperative and preoperative results were: resting pressure, 28±8.2 cm H ₂ O (P=0.003); voluntary contraction pressure, 19.5±6.7 (P=0.01); and PNTML, –0.3±0.29 mS (P=0.3). CONCLUSIONS: At 6 months 83 percent of patients had obtained some benefit from postanal repair but only 53 percent maintained this improvement with only 28 percent being markedly better. There was a trend toward a more favorable outcome in patients with greater squeezing pressures preoperatively but other tests were not of long-term predictive value.Presented in part in abstract form at the meeting of the British Society of Gastroenterology, Spring 1992.     

The Development of a Validated Instrument to Evaluate Bowel Function After Sphincter-Preserving Surgery for Rectal Cancer

PURPOSE Sphincter-preserving surgery is technically feasible for many rectal cancers, but functional results are not well understood. Therefore, the purpose of this study was to develop an instrument to evaluate bowel function after sphincter-preserving surgery.METHODS A 41-item bowel function survey was developed from a literature review, expert opinions, and 59 patient interviews. An additional 184 patients who underwent sphincter-preserving surgery between 1997 and 2001 were asked to complete the survey and quality-of-life instruments (Fecal Incontinence Quality of Life, European Organization for Research and Treatment of Cancer QLQ 30/Colorectal Cancer 38). A factor analysis of variance was performed. Test–retest reliability was evaluated, with 20 patients completing two surveys within a mean of 11 days. Validity testing was done with clinical variables (gender, age, radiation, length of time from surgery), surgical variables (procedure: local excision, low anterior resection, coloanal anastomosis), reconstruction (J-pouch, straight), anastomosis (handsewn, stapled), and quality-of-life instruments.RESULTS The survey response rate was 70.1 percent (129/184). Among the 127 patients with usable data, 67 percent were male, the median age was 64 (range, 38–87) years, and the mean time for restoration of bowel continuity after sphincter-preserving surgery was 22.9 months. Patients had a median of 3.5 stools/day (range, 0–30), and 37 percent were dissatisfied with their bowel function. Patients experienced a median of 22 symptoms (range, 7–32), with 27 percent reported as severe, 37 percent as moderate, and 36 percent as mild. The five most common symptoms were incomplete evacuation (96.8 percent), clustering (94.4 percent), food affecting frequency (93.2 percent), unformed stool (92.8 percent), and gas incontinence (91.8 percent). The factor analysis identified 14 items that collapsed into three subscales: FREQUENCY (α = 0.75), DIETARY (α = 0.78), and SOILAGE (α = 0.79), with acceptable test–retest reliability for the three subscales and total score (0.62–0.87). The instrument detected differences between patients with preoperative radiation (n = 67) vs. postoperative radiation (n = 15) vs. no radiation (n = 45) (P = 0.02); local excision (n = 10) vs. low anterior resection (n = 55) vs. coloanal anastomosis (n = 62) (P = 0.002); and handsewn (n = 18) vs. stapled anastomosis (n = 99) (P = 0.006). The total score correlated with 4 of 4 Fecal Incontinence Quality of Life (P < 0.01) and 9 of 17 European Organization for Research and Treatment of Cancer subscales (all P < 0.01).CONCLUSIONS Patients undergoing sphincter-preserving surgery for rectal cancer have impaired bowel function, and those treated with radiation, coloanal anastomoses, or handsewn anastomoses have significantly worse function. This reliable and valid instrument should be used to prospectively evaluate bowel function after sphincter-preserving surgery in patients undergoing rectal cancer therapy.Supported in part by a Limited Project Grant from The American Society of Colon and Rectal Surgeons Research Foundation, 2002.Presented at the meeting of The American Society of Colon and Rectal Surgeons in Dallas, Texas, May 8 to 13, 2004.     

Rectal tone and compliance affected in patients with fecal incontinence after fistulotomy

AIM: To investigate the anal sphincter and rectal factors that may be involved in fecal incontinence that develops following fistulotomy(FIAF).METHODS: Eleven patients with FIAF were compared with 11 patients with idiopathic fecal incontinence and with 11 asymptomatic healthy subjects(HS). All of the study participants underwent anorectal manometry and a barostat study(rectal sensitivity, tone, compliance and capacity). The mean time since surgery was 28 ± 26 mo. The postoperative continence score was 14 ± 2.5(95%CI: 12.4-15.5, St Mark's fecal incontinence grading system).RESULTS: Compared with the HS, the FIAF patients showed increased rectal tone(42.63 ± 27.69 vs 103.5 ± 51.13, P = 0.002) and less rectal compliance(4.95 ± 3.43 vs 11.77 ± 6.9, P = 0.009). No significant differences were found between the FIAF patients and the HS with respect to the rectal capacity; thresholds for the non-noxious stimuli of first sensation, gas sensation and urge-to-defecate sensation or the noxious stimulus of pain; anal resting pressure or squeeze pressure; or the frequency or percentage of relaxation of the rectoanal inhibitory reflex. No significant differences were found between the FIAF patients and the patients with idiopathic fecal incontinence.CONCLUSION: In patients with FIAF, normal motor anal sphincter function and rectal sensitivity are preserved, but rectal tone and compliance are impaired. The results suggest that FIAF is not due to alterations in rectal sensitivity and that the rectum is more involved than the anal sphincters in the genesis of FIAF.     

Evaluation of preoperative and postoperative radiotherapy on long-term functional results of straight coloanal anastomosis

PURPOSE: Preoperative radiotherapy for rectal cancer avoids radiation to the reconstructed rectum and may circumvent the detrimental effects on bowel function associated with postoperative radiotherapy. We compared the long-term functional results of patients who received preoperative radiotherapy, postoperative radiotherapy, or no radiotherapy in conjunction with low anterior resection and coloanal anastomosis to assess the impact of pelvic radiation on anorectal function. METHODS: One hundred nine patients treated by low anterior resection and straight coloanal anastomosis for rectal cancer between 1986 and 1997 were assessed with a standardized questionnaire at two to eight years after resection. All radiotherapy was given to a total dose of 4,500 to 5,400 cGy with conventional doses and techniques. Most patients received concurrent 5-fluorouracil–based chemotherapy. RESULTS: There were 39 patients in the preoperative radiotherapy group, 11 patients in the postoperative radiotherapy group, and 59 patients in the no radiotherapy group. The postoperative radiotherapy group reported a significantly greater number of bowel movements per 24-hour period (P < 0.01) and significantly more episodes of clustered bowel movements (P < 0.02) than either the preoperative radiotherapy group or the no radiotherapy group. No significant difference in anal continence or satisfaction with bowel function was found among the three groups. CONCLUSION: In this study of straight (nonreservoir) coloanal anastomoses, postoperative pelvic radiotherapy had significant adverse effects on anorectal function, with higher rates of clustering and frequency of defecation than with preoperative radiotherapy. No differences in continence rates were demonstrated, perhaps because of the sample size of the compared groups. We attribute the adverse effects of postoperative radiotherapy to irradiation of the neorectum, which is spared when treatment is given preoperatively. The deleterious effects of adjuvant radiation on long-term anorectal function can be reduced by preoperative treatment.     

Are Survival Rates Different for Young and Older Patients With Rectal Cancer?

PURPOSE Although it is generally believed that young patients with rectal cancer have worse survival rates, no comprehensive analysis has been reported. This study uses a national-level, population-based cancer registry to compare rectal cancer outcomes between young vs. older populations.METHODS All patients with rectal carcinoma in the Surveillance, Epidemiology, and End Results cancer database from 1991 to 1999 were evaluated. Young (range, 20–40 years; n = 466) and older groups (range, 60–80 years; n = 11,312) were compared for patient and tumor characteristics, treatment patterns, and five-year overall and stage-specific survival. Cox multivariate regression analysis was performed to identify predictors of survival.RESULTS Mean ages for the groups were 34.1 and 70 years. The young group was comprised of more black and Hispanic patients compared with the older group (P < 0.001). Young patients were more likely to present with late-stage disease (young vs. older: Stage III, 27 vs. 20 percent respectively, P < 0.001; Stage IV, 17.4 vs. 13.6 percent respectively, P < 0.02). The younger group also had worse grade tumors (poorly differentiated 24.3 vs. 14 percent respectively, P < 0.001). Although the majority of both groups received surgery (85 percent for each), significantly more young patients received radiation (P < 0.001). Importantly, overall and stage-specific, five-year survival rates were similar for both groups (P = not significant).CONCLUSIONS Although previous studies have found young rectal cancer patients to have poorer survival compared with older patients, this population-based study shows that young rectal cancer patients seem to have equivalent overall and stage-specific survival.Supported in part by The American Society of Colon and Rectal Surgeons Limited Project Grant.Presented at the meeting of the Association for Academic Surgery, Sacramento, California, November 13 to 15, 2003.     

A prospective evaluation of the value of anorectal physiology in the management of fecal incontinence

PURPOSE: This study was designed to determine whether anorectal physiology testing significantly altered patient management in the setting of fecal incontinence. METHODS: Patients referred to the anorectal physiology laboratory for evaluation of fecal incontinence were prospectively interviewed and examined by a colon and rectal surgeon. A decision to treat either medically or surgically was reached. The patients underwent physiologic testing with transanal ultrasound, pudendal nerve terminal motor latency, and anorectal manometry. A panel of board-certified colon and rectal surgeons then reviewed the history and physical examination, as well as the anorectal physiology tests, of each patient and reached a consensus on management. Management plans before and after physiologic evaluation were compared. RESULTS: Ninety patients (6 males) were entered into the study. The patients were divided in two groups: those with pretest medical management plans (n=45) and those with pretest surgical management plans (n=45). A change in management was noted in nine patients (10 percent). In the medical management group, the management changed from medical to surgical therapy in five patients. Transanal ultrasound detected anal sphincter defects in all patients who changed from medical to surgical management but in only 10 percent of those who remained under medical management (P=0.0001). In the surgical management group, three patients (7 percent) changed from surgical to medical therapy and one patient (2 percent) changed from sphincteroplasty to neosphincter. Transanal ultrasound detected a limited anal sphincter defect in one patient (33 percent) who changed from surgical to medical management and a significant defect in all 41 patients (100 percent) who remained under surgical management (P=0.003). CONCLUSIONS: Anorectal physiology testing is useful in the evaluation of patients with fecal incontinence. Without the information obtained from physiologic testing, 11 percent of patients who may have benefited from surgery would not have been given this option, and 7 percent of patients could have potentially undergone unnecessary surgery. Transanal ultrasound is the study most likely to change a patient's management plan.Presented at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, June 24 to 29, 2000.Winner of the Pittsburgh Society of Colon & Rectal Surgeons Karl A. Zimmerman, M.D., Award.     

Electrophysiologic Studies and Clinical Findings in Females With Combined Fecal and Urinary Incontinence: A Prospective Study

Purpose Several clinical, urodynamic, and manometric findings suggest neurologic damage as a contributing factor in the development of combined fecal and urinary incontinence. In this study, we wanted to test the hypothesis of pudendal nerve neuropathy being a more frequent lesion in patients with double incontinence compared with patients with isolated fecal incontinence. Patients Ninety-three females with combined fecal and urinary incontinence and 36 females with isolated fecal incontinence were investigated. All patients underwent anal manometry, endoanal ultrasound, electromyography, and pudendal nerve terminal motor latency. Results No statistically significant differences were found in the age, history of vaginal delivery, and chronic straining between both groups. However, the rate of postmenopausal females was higher in the combined fecal and urinary incontinence group (85 vs. 67 percent; P = 0.02). Menopause was an independent risk factor of having double incontinence (odds ratio, 1.4; P = 0.02). Concentric needle electromyography of the external anal sphincter revealed increased duration of the motor unit potentials in 43 and 53 percent of patients with combined fecal and urinary incontinence and isolated fecal incontinence, respectively (P = 0.28). An increased number of polyphasic motor unit potentials was detected in 52 and 58 percent (P = 0.6). There was no statistically significant difference in the prevalence of bilateral (20 vs. 27 percent) or unilateral (23 vs. 14 percent) prolonged mean pudendal nerve terminal motor latency between both groups (P = 0.3). Conclusions Pudendal neuropathy is not a distinct characteristic of patients with double incontinence. The prevalence of pudendal neuropathy in these patients is similar to that observed in patients with isolated fecal incontinence. Others factors should be investigated to explain the common association of both types of incontinence. Presented at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005, and the International Symposium Neurogastroenterology and Motility, Toulouse, France, July 3 to 6, 2005. Reprints are not available.     

Influence of Intraoperative and Postoperative Radiotherapy on Functional Outcome in Patients Undergoing Standard and Deep Anterior Resection for Rectal Cancer

Purpose This study was designed to investigate the influence of intraoperative and postoperative radiotherapy on functional outcome after rectal resection for rectal cancer. Methods One hundred patients who underwent deep or standard anterior resection for rectal cancer were included in this follow-up study. All patients filled out questionnaires regarding morbidity and functional outcome; a subgroup (n = 63) underwent further clinical evaluation. The results were stratified according to radiation: Group I, no radiation (n = 37); Group II, only intraoperative radiation (n = 12); Group III, intraoperative and postoperative radiation (n = 51). Results Anal continence measured by Kirwan-Parks classification and Wexner score was significantly different within the three groups (P < 0.005, P < 0.0001), whereas continence impairment was least in Group I and greatest in Group III. Patients in Group III demonstrated a significantly worsecategory in the Kirwan-Parks classification and worse Wexner scores compared with patients in Group I (P < 0.0001). Patients only having undergone intraoperative radiotherapy had a significantly worse continence (Kirwan-Parks classification) than patients without any radiotherapy (P < 0.05). More patients after intraoperative and postoperative radiation therapy complained of fragmented stools (P < 0.05) and urgency (P < 0.05) compared with patients only having undergone surgery; the need towear pads was higher (P = 0.001). Vector volume manometry revealed better resting sphincter function in Group I compared with Group III (P ≤ 0.005). Conclusions Patients with anterior resection for rectal cancer who undergo full-dose radiotherapy have significantly more impairment of anorectal function than patients without radiotherapy. Patients who were only exposed to intraoperative radiotherapy showed moderate impairment of continence function, suggesting that the influence of radiotherapy on anal function may be dose-dependent and application-dependent.     

Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse

Purpose: This study was undertaken to document the effect of pudendal nerve function on anal incontinence after repair of rectal prolapse. METHODS: Patients with full rectal prolapse (n=24) were prospectively evaluated by anal manometry and pudendal nerve terminal motor latency (PNTML) before and after surgical correction of rectal prolapse (low anterior resection (LAR; n=13) and retrorectal sacral fixation (RSF; n=11)). RESULTS: Prolapse was corrected in all patients; there were no recurrences during a mean 25-month follow-up. Postoperative PNTML was prolonged bilaterally (>2.2 ms) in six patients (3 LAR; 3 RSF); five patients were incontinent (83 percent). PNTML was prolonged unilaterally in eight patients (4 LAR; 4 RSF); three patients were incontinent (38 percent). PNTML was normal in five patients (3 LAR; 2 RSF); one was incontinent (20 percent). Postoperative squeeze pressures were significantly higher for patients with normal PNTML than for those with bilateral abnormal PNTML (145 vs.66.5 mmHg; P =0.0151). Patients with unilateral abnormal PNTML had higher postoperative squeeze pressures than those with bilateral abnormal PNTML, but the difference was not significant (94.8 vs.66.5 mmHg; P=0.3182). The surgical procedure did not affect postoperative sphincter function or PNTML. CONCLUSION: Injury to the pudendal nerve contributes to postoperative incontinence after repair of rectal prolapse. Status of anal continence after surgical correction of rectal prolapse can be predicted by postoperative measurement of PNTML.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Transanal or Vaginal Approach to Rectocele Repair: A Prospective,Randomized Pilot Study

PURPOSE This study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair.METHODS Thirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded.RESULTS The study groups were comparable in terms of demographic factors and rectocele-related symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 ± 1.6 cm vs. 5.6 ± 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement.CONCLUSION Patients symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.Supported by a grant from the Medical Research Fund of Tampere University Hospital and the Research Fund of the Finnish Gynecologic Association.Presented at the meeting of the International Continence Society, Florence, Italy, October 5 to 9, 2003.     

Is Laparoscopic Colectomy Applicable to Patients With Body Mass Index >30? A Case-Matched Comparative Study With Open Colectomy

PURPOSE The benefits of early postoperative recovery, reduced postoperative pain, pulmonary dysfunction, and hospitalization after laparoscopic colectomy may improve outcome over open colectomy in obese patients. This case-matched study compares outcomes after open and laparoscopic colectomy.METHODS A total of 94 laparoscopic colectomy patients with a body mass index >30 (Jan 1999–June 2003) were identified from a prospective database and matched to open colectomy cases for age, gender, body mass index, American Society of Anesthesiologists class, procedure, indication, and date of surgery. Operating time, length of stay, conversion, intraoperative and postoperative complications, reoperation, 30-day readmission rate, and costs were compared. Data are presented as means ± standard deviations, and appropriate statistical tests were used.RESULTS The two groups were matched for age (P = 0.06), gender (P = 1), American Society of Anesthesiologists class (P = 0.2), body mass index (P = 0.4), indication for surgery (P = 1), and procedure (P = 1). By using intention-to-treat–type analysis, there was no difference in median operating time (100 vs. 110 (mean, 123 vs. 112) minutes; P = 0.1), complications (21 vs. 24 percent; P = 0.74), readmission (17 vs. 10.6 percent; P = 0.3), reoperation rates (6.4 vs. 4.3 percent; P = 0.75), or direct costs (median, $3,368 vs. $3,552; mean, $4,003 vs. $4,037; P = 0.14) between laparoscopic colectomy or open colectomy; however, the median length of stay (3 vs. 5.5 (mean, 3.8 vs. 5.8) days; P = 0.0001) was significantly shorter after laparoscopic colectomy. Twenty-eight patients required conversion for adhesions (n = 11), bleeding (n = 3), obesity-hindering vision or dissection (n = 9), large phlegmon or tumor (n = 4), and ureteric injury (n = 1). The mean operating time for conversions was 142 minutes and length of stay was 6.4 days. Compared with laparoscopically completed cases, the median length of stay (5 vs. 2 (mean, 6.4 vs. 2.8) days; P = 0.0001) and median operating times (150 vs. 95 (mean, 142 vs. 115) minutes; P = 0.02) were significantly higher in the converted group, but there was no difference in the complication (P = 0.8), readmission (P = 1), or reoperation (P = 0.7) rates. Compared with open colectomy, the operating time (P = 0.02) was significantly higher in the converted group but there were no significant differences in the length of stay (P = 0.18), complication (P = 1), readmission (P = 0.35), or reoperative (P = 1) rates.CONCLUSIONS Laparoscopic colectomy can be performed safely in obese patients, with shorter postoperative recovery than that with open colectomy. Although obesity is associated with a high conversion rate, outcome in these converted cases is comparable to the matched open cases.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.