Patient position during cinedefecography

PURPOSE: This study was undertaken to assess the reproducibility of cinedefecography measurements and abnormal findings between the left lateral decubitus and seated positions. METHODS: Prospective patient evaluation included all patients who had lateral radiographs of the pelvis taken at rest, during squeezing, and pushing in both positions. Anorectal angle, perineal descent, and puborectalis length measurements were calculated for each set of radiographs. Pelvic floor dynamics during evacuation were measured as the changes between rest and pushing. Abnormal findings included both increased dynamic and fixed perineal descent, nonrelaxing puborectalis, and premature evacuation. RESULTS: One hundred five consecutive patients underwent cinedefecography. There were statistically significant differences between the positions with regard to anorectal angle (P <0.0001), perineal descent (P =0.0001), and puborectalis length (P =0.0001). Dynamic changes of the anorectal angle, perineal descent, and puborectalis length were not significantly different (P >0.05). However, 6 of 22 (27 percent) patients with fecal incontinence had premature evacuation severe enough to impede measurement only when seated (P =0.05). CONCLUSION: Because of the statistically significant differences between the two positions, centers should always employ the same position for a given diagnostic group.Dr. Ger was a visiting clinician from the Section of Colon and Rectal Surgery, Department of Surgery, National Defense Medical Center and Tri-Service General Hospital, Taipei, Taiwan.     

The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula

Complex perineal fistula and persistent perineal sinus are difficult to treat. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal approach. Ten patients were reconstructed by a rectus abdominis myocutaneous flap (n=7), rectus abdominis muscle flap (n=2), and omental graft (n=1). Primary healing was achieved in all cases. A median follow-up of 18 months (range 6–54 months) has shown no recurrence of perineal disease or associated abdominal incisional hernia. There were no perioperative deaths. We propose that the rectus abdominis myocutaneous flap is indicated if large amounts of perineal skin has to be sacrificed. When less skin is removed a repair with greater omentum or rectus muscle alone is adequate. The abdominoperineal approach together with filling the residual pelvic cavity with well-vascularized tissue allows definitive treatment to be carried out in one stage.Based on an oral presentation at the Tripartite Meeting, Birmingham, United Kingdom, June 19–22, 1989.     

Results of Delorme's procedure for rectal prolapse

PURPOSE: A retrospective study was undertaken to assess the results of Delorme's procedure for rectal prolapse and to determine the advantages of an innovative extended transrectal repair, which aims at performing a total pelvic floor repair. METHODS: A total of 85 patients, ranging in age from 21 to 97 years, were operated on. Sixty-five (82 percent) patients had varying degrees of fecal incontinence. Similar groups of patients were compared with regard to control of the prolapse and restoration of continence according to 1) age and medical condition and 2) operative technique: original vs.extended operation. RESULTS: Twelve patients (14 percent) developed postoperative complications. There was one perioperative death (1.2 percent). Eighty patients were followed for 6 to 136 (median, 33) months. Eleven (13.5 percent) developed recurrent full-thickness prolapse. The recurrence rate was significantly different 1) between 44 elderly and poor operative risk patients not suitable for abdominal surgery (22.5 percent) and 41 younger patients without concurrent medical conditions, electively submitted to perineal repair (5 percent) (P <0.05), and 2) between the original procedure (21 percent of 44 patients) and the modified technique (5 percent of 41 patients) (P <0.05). Forty five patients (69 percent) improved or regained full continence. No patient worsened. No residual dysfunction was induced. Restoration of continence was not influenced by selection of patients or surgical technique. CONCLUSIONS: Despite increased morbidity (22 percent; P <0.05), advantages of the modified technique were 1) over the original procedure, a reduced recurrence rate, 2) over perineal proctectomy, the absence of coloanal anastomosis and better functional outcome, and 3) over abdominal rectopexy, a less aggressive approach without disturbing effects on bowel habits.     

Simultaneous dynamic proctography and peritoneography for pelvic floor disorders

PURPOSE: We sought to evaluate a new diagnostic technique for the identification of rectal and pelvic floor pathology in patients with obstructed defecation, pelvic fullness/ prolapse, and/or chronic intermittent pelvic floor pain. METHODS: Thirteen symptomatic women with either a nondiagnostic physical examination or nondiagnostic dynamic proctography (DPG) were studied. After placement of intraperitoneal and intrarectal contrast material, resting and straining pelvic x-rays were obtained in all patients, and defecation was videotaped using fluoroscopy. RESULTS: Simultaneous DPG and peritoneography identified clinically suspected and unsuspected enteroceles in 10 of the 13 patients studied. An enterocele or other pelvic floor hernia was ruled out by the technique in three of the women studied. Rectoceles and rectal prolapse that were identified during physical examination were confirmed by DPG with peritoneography. Simultaneous DPG and peritoneography also gave a qualitative assessment of the severity and clinical significance of the identified pelvic floor disorders. Results of simultaneous DPG and peritoneography affected operative treatment planning in 85 percent of patients studied. CONCLUSION: Simultaneous DPG and peritoneography identifies both rectal and pelvic floor pathology and provides a qualitative assessment of pelvic floor pathology severity, which allows for better treatment planning in selected patients with obstructed defecation and pelvic prolapse.Video presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Indeterminate colitis predisposes to perineal complications after ileal pouch-anal anastomosis

This study retrospectively evaluated 288 patients who had undergone ileal pouch-anal anastomosis to determine the incidence of perineal complications and to relate these findings to the pathologic diagnosis, with the goal of specifically clarifying the appropriate surgical management of patients with indeterminate colitis. Of these 288 patients, 235 patients (82 percent) had a diagnosis of chronic ulcerative colitis, 18 patients (6 percent) had indeterminate colitis, 6 patients (2 percent) had Crohn's disease, and 29 patients (10 percent) had familial polyposis. All complications occurred at least 6 months after closure of the stoma and required operative therapy. Of 18 patients with indeterminate colitis, 9 patients experienced complications (50 percent) vs. 8 of 235 patients with chronic ulcerative colitis (3 percent), a highly significant difference (P <0.001). Furthermore, the risk of eventual ileostomy because of perineal complications was 0.4 percent in patients with chronic ulcerative colitis vs. 28 percent in patients with indeterminate colitis (P< 0.001). We conclude that a diagnosis of indeterminate colitis predisposes the patient undergoing ileal pouchanal anastomosis to perineal complications, with a resultant high chance of reservoir loss. Ileal pouch-anal anastomosis should be considered with caution in the patient with a diagnosis of indeterminate colitis.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Surgical treatment of traumatic cloaca

PURPOSE: This study was designed to evaluate the repair of traumatic cloaca and determine the satisfactory outcome as determined by improvement in the continence mechanism of patients. METHODS: Forty-four patients were entered in this study during a 14-year period. The majority of traumatic cloaca occurred secondary to obstetric injury, most frequently during the first childbirth. No definite medical illnesses precipitated the occurrence of traumatic cloaca. Only two patients had diabetes mellitus, and one patient had prior radiation. All patients underwent surgical repair using puborectalis interposition and sphincteroplasty and perineal body repair, approximating the internal and external sphincter fused bundles and transversus perinei muscles in a vest-over-pants manner. Average stay in the hospital was less than three days, and postoperative morbidity was minimal. One patient had minor postoperative bleeding, which was corrected with cauterization. One patient had a superficial subcutaneous infection, which was drained on the 15th postoperative day. RESULTS: Majority of patients regained excellent control of continence to both flatus and feces. Four patients had unsatisfactory control to passage of flatus. One patient had unsatisfactory control to passage of liquid stool in addition to flatus. All five patients improved, with very satisfactory results, following an exercise program and biofeedback therapy. Six of 12 patients who had perineal discomfort before the surgical procedure, with associated dyspareunia, were the most dissatisfied subgroup in the series. Exact mechanism for perineal discomfort is unclear at this point.Read at the XVth Bienniel Congress of the International Society of University Colon and Rectal Surgeons, Singapore, Singapore, July 2 to 6, 1994.     

Postoperative perineal hernia

PURPOSE: Perineal hernia is an uncommon complication following abdominoperineal resection. The aim of the study was to evaluate the predisposing factors and the optimum method of repair. METHODS: A retrospective review of patients with postoperative perineal hernia at the Massachusetts General Hospital between 1963 and 1995 was performed. RESULTS: Twenty-one patients with perineal hernias were found. The original perineal operations were as follows: abdominoperineal resection in 13 patients, pelvic exenteration in 5 patients, cystourethrectomy in 2 patients, and perineal resection of the rectal stump in 1 patient. The incidence of symptomatic perineal hernia following abdominoperineal resection was estimated to be 0.62 percent. A total of 69 percent of patients had the original perineal wound left partially open, and in 10 percent it was left completely open. The peritoneal defect was not closed in 53 percent of patients, and only 21 percent had closure of the levator defect. Of the 19 patients who had hernia repair, 13 were repaired transperineally and 3 transabdominally and 3 required a combined abdominoperineal approach. The repair methods were as follows: simple closure of the pelvic defect (10 patients), mesh closure (5 patients), gluteus flap (1 patient), and retroflexion of the uterus (2 patients) or bladder (1 patient). Four patients had postoperative complications (mostly wound infections), and the recurrence rate was 16 percent. There was no difference in length of hospitalization among transperineal, transabdominal, and combined approaches. CONCLUSIONS: Primary closure of the perineal wound, with careful avoidance of wound infection is the most important consideration for avoiding a perineal hernia. Repairvia the perineum with simple closure of the defect or a mesh is successful in most cases.     

Abdominoperineal resection and perineal colostomy for low rectal cancer

PURPOSE: We sought to evaluate a new technique for creation of a continent perineal colostomy following abdominoperineal resection (APR) of the rectum for low rectal cancer. METHODS: Nine selected patients with low rectal cancer (two males; median age, 55.6 years; classified as Dukes A, 6 patients and as Dukes B, 3 patients) underwent APR. Following this, the original Lazaro da Silva technique was used as follows: 1) for performance of three circular myotomies in the distal sigmoid with a distance between each couple of no more than 8 cm; 2) repair of the myotomies, thus creating three circular colonic valves, the most distal of which remained extraperitoneally; 3) for construction of a perineal colostomy lying flush with the perineal skin; 4) after the patient starts consuming a regular diet, enemas through the perineal stoma are done, usually twice per week, to achieve defecation. Functional outcome was assessed by evaluation of bowel movements and neoanal continence. RESULTS: There were no deaths. From January 1994 until October 1995, no tumor recurrence has occurred, and fecal continence has been good. Four of the patients were able to defecate without enemas (2–4 times per week), and in five patients the self-administration of enemas (2–4 times a week) were necessary to accomplish defecation. CONCLUSION: Initial results with the Lazaro da Silva technique have been encouraging.     

Parameters of anorectal and colonic motility in health and in severe constipation

Anorectal function and colonic transit was assessed in 17 severely constipated patients and 15 age-matched controls. The constipated patients were divided into those who had immobile perineum (perineal descent 1.0 cm during attempted defecation) and those who had a normal descent (>1.0 cm) of the perineum. When constipation was accompanied by an immobile perineum, patients had impaired balloon expulsion, impaired and delayed artificial stool expulsion, decreased straightening of the anorectal angle, decreased descent of the pelvic floor with defecation, and prolonged rectosigmoid colon transit compared with the patients with constipation who had a mobile perineum and with normal controls. The mobile-perineum group differed from controls only in colon transit times, having prolonged total colon transit. Anal sphincter resting pressures, immediate artificial stool expulsion, resting anorectal angles, and electromyography of the external anal sphincter and puborectalis did not differentiate the constipated patients from the controls. We concluded that descent of the perineum of <1 cm was associated with impaired expulsion, an adynamic anorectal angle, and slowed distal colon transit. This simple sign of pelvic floor function distinguished constipated patients with disordered expulsion from constipated patients with normal pelvic floor function. These patients may respond poorly to surgery and conventional management and would therefore be candidates instead for pelvic floor retraining. Accurate characterization and appreciation of pelvic floor dysfunction in patients with severe chronic constipation may improve the selection for and results of surgical and nonsurgical intervention.Supported in part by Research Grants DK37990, RR585, and DK34988 from the National Institutes of Health and by the Mayo Foundation, Rochester, Minnesota.     

Long-term results of total pelvic floor repair for postobstetric fecal incontinence

PURPOSE: This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD: Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18–78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS: Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION: Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.Read at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Surgical treatment of low rectovaginal fistulas

Forty women with low rectovaginal fistulas were operated upon over a 9-year period. The etiology of the fistula in the majority was obstetric. Nine women had prior attempts to repair the fistula. All 40 women were managed with endorectal advancement flap with the addition of sphincteroplasty or perineal body reconstruction in 15 patients and rectocele repair in six patients. Postoperative complications included urinary difficulties (two patients) and wound complications (three patients). There were two recurrences. All women treated with sphincteroplasty or perineal body reconstruction were continent. Seven women complained of varying degrees of incontinence postoperatively; none had undergone sphincter or perineal body reconstruction. Endorectal advancement flap is a safe and effective operation for women with rectovaginal fistulas. Concomitant sphincteroplasty or perineal body reconstruction should be performed in women with historical, physical, or manometric evidence of incontinence.     

What is the relationship between perineal descent and anal mucosal electrosensitivity?

PURPOSE: Perineal descent is found in many patients with anorectal disorders. There is now substantial evidence against perineal descent causing damage to the motor axons in the pudendal nerves, but the sensory sequelae of perineal descent have been neglected. The purpose of this study was to establish the relationship between perineal descent and anal sensation. METHODS: Perineal position was determined in relation to the bony pelvis by means of defecating proctography. Anal mucosal electrosensitivity was determined by using a constant current generator. RESULTS: This study demonstrated significant correlations between perineal position at rest and sensitivity in each third of the anal canal in the study group overall. In women studied alone, there were significant correlations between perineal position at rest and at squeeze and anal mucosal electrosensitivity in each third of the anal canal. CONCLUSIONS: We propose that perineal descent traumatizes the pudendal nerves, damaging the large diameter sensory axons. This may be a precursor of motor axon damage or may correlate with the global pelvic sensory loss found in patients with perineal descent and fecal incontinence.Read at the meeting of the International Society of University Colon and Rectal Surgeons XVth Biennial Congress, Singapore, July 2 to 6, 1994.Mr. A. S. Gee is supported by the Wellcome Trust, London, United Kingdom.     

Long-term effect of vaginal deliveries on anorectal function in normal perimenopausal women

PURPOSE: This study was undertaken to determine the long-term effects of vaginal deliveries on anorectal function in healthy perimenopausal women. METHODS: An observational study of 144 perimenopausal women living in the county of Aarhus, Denmark, aged 45 to 57 (mean, 50) years were randomly selected from the National Register. All women had delivered 0 to 6 (mean, 2) times 10 to 34 years before the investigation. Examinations describing pelvic floor function were measurements of perineal position at rest and descent during straining, anal mucosa electrosensitivity, maximum resting pressure and maximum squeeze pressure of the anal sphincters, and pudendal nerve terminal motor latency. All tests were performed by one of the authors (AMR) and without knowledge of parity. Data were analyzed using the multiple regression technique, and all associations between anorectal function and parity were corrected for age and hysterectomy status. RESULTS: Increasing parity correlated with a lowered perineal position at rest (correlation coefficient (r)=0.26;P=0.003), an increased descent during straining (r=0.24;P=0.006), an increased threshold of anal mucosa electrosensitivity (r=0.22,P=0.008), and an increased pudendal nerve terminal motor latency on both sides (r=0.27;P=0.002). No effect of parity on the maximum resting pressure (r=0.06;P=0.70) and maximum squeeze pressure (r=0.06;P=0.36) was found. The number of vaginal deliveries account for only a minor fraction of the total variability seen in the tests of pelvic floor function (between 1.6 and 5.7 percent). CONCLUSION: Repeated vaginal deliveries have a long-term adverse effect on anorectal physiology in a population of randomly selected healthy perimenopausal women.Supported by a grant from the Danish Medical Research Council and Institute of Experimental Clinical Research, University of Aarhus and by K. E. Jensen Foundation.Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993, and at the Tripartite Meeting, Sydney, Australia, October 17 to 20, 1993.     

Hartmann's procedurevs. abdominoperineal resection for palliation of advanced low rectal cancer

In managing advanced low rectal adenocarcinomas in medically fit patients, surgical resection offers the best palliation. Tenesmus, bleeding per rectum, sacral pain, and sciatic pain are common complaints, which are not relieved by radiotherapy or fulguration. The most appropriate resection, however, remains controversial. Abdominoperineal resection is faster and simpler to perform but leaves behind a perineal wound with associated complications. Hartmann's procedure requires adequate mobilization below the tumor and may be technically more demanding but avoids a perineal wound. Therefore, an analysis of outcome in patients treated by Hartmann's procedure vs. abdominoperineal resection was made. METHOD: Fifty-four symptomatic patients with advanced rectal adenocarcinoma arising within a median of 5 (range, 4–8) cm from the anal verge treated between June 1989 and October 1995 were studied. Twenty-eight patients (17 males; mean age, 67.6±10.3 years) had Hartmann's procedure, and 26 patients (12 females; mean age, 68.8±8.3 years) were treated by abdominoperineal resection. Mean follow-up was 23.5 months (±17.5) and 18.6 months (±12.9) in Hartmann's procedure and abdominoperineal groups, respectively. RESULTS: Mean operative time was 138.4±26.7 minutes for Hartmann's procedure group and 124.6±27.1 minutes for the abdominoperineal resection group ( P >0.05; not significant). Postoperatively, Hartmann's procedure group started oral intake at a mean of 2.3 days, and stomas were functioning at a mean of 3.1 days compared with 2.6 days for oral intake and 3 days for stoma functioning in the abdominoperineal resection group. Hartmann's procedure group was ambulant after a mean of 2.4 days vs. a mean of 3.2 days in the abdominoperineal resection group. Postoperative abdominal wound infection occurred in 18 and 19 percent, respectively, in Hartmann's procedure and abdominoperineal resection groups. Forty-six percent of patients had perineal wound sepsis, and 38 percent had perineal wound pain in the abdominoperineal resection group. These complications were absent in Hartmann's procedure group. Postoperative stay was similar in both groups. CONCLUSION: We conclude that Hartmann's procedure offers superior palliation compared with abdominoperineal resection because it provides good symptomatic control without any perineal wound complications and pain.     

Surgical treatment of recurrent complete rectal prolapse

PURPOSE: Complete recurrent rectal prolapse (RRP) after initial prolapse surgery is well described. Our aim was to examine the possible causes for RRP, to learn of the operations performed most frequently, and to examine the outcome following recurrence surgery. METHODS: Patients with RRP were reviewed retrospectively from 1963 to 1993. RESULTS: A total of 24 patients (19 females) had RRP. Of these, 29 operations were performed; three patients had 2 RRP operations, and one patient had 3 RRP operations. Median age was 56 (range, 18–88) years. Median follow-up and median duration to recurrence were 6.75 (range, 0.08–17) years and 2 (range, 0.1–29) years. One patient had RRP at the end of the follow-up period. RRP occurred after 15 abdominal and 9 perineal operations. Treatment for RRP included 25 abdominal and 4 perineal operations. Causes for RRP were identified in 41 percent of cases and was most often attributable to problems with the mesh following the Ripstein procedure. Preoperative incontinence and constipation were largely unchanged by RRP operation. CONCLUSION: RRP occurred most commonly because of problems with the mesh, but no etiologic factor was found in the majority of patients. Abdominal operations were performed more frequently than perineal approaches for RRP. Elimination of prolapse can be obtained, but bowel dysfunction still remains in 60 percent of patients.     

Are pelvic floor movements abnormal in disordered defecation?

Pelvic floor movements were assessed by videoproctography in 126 subjects: neuropathic fecal incontinence patients (n=44), chronic constipation patients (n =52), and controls (n=30). A significantly lower pelvic floor position at rest and a more obtuse anorectal angle were found in incontinent patients than in controls (P <0.01). constipated patients showed no significant difference from controls at rest. There was less pelvic floor movement during contraction in incontinent patients than in controls, indicating a flaccid, noncontractile pelvic floor in neuropathic incontinence. Movement during contraction in constipated subjects was also less than in controls. Changes in the pelvic floor position during straining were the same as in controls. These data indicate that the pelvic floor is flaccid and noncontractile in neuropathic fecal incontinence, which supports the concept of a progressive neuropathy involving the sacral outflow. Similar changes are not seen at rest in patients with constipation even though they have a long history of straining.     

Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps

PURPOSES: In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS: Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS: Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION: The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.Read at the meeting of the Midwestern Association of Plastic Surgeons, Bismarck, North Dakota, June 15 to 18, 1992.     

Treatment of rectal prolapse in the elderly by perineal rectosigmoidectomy

The results and complications of perineal rectosigmoidectomy for complete rectal prolapse in 114 patients have been reviewed. Most patients were elderly and high risk by virtue of other concurrent medical conditions. Fourteen patients (12 percent) developed significant postoperative complications. Hospital stay was short (median, four days). Ten patients were lost to follow-up. The remaining 104 patients were followed for 3 to 90 months. Eleven patients (10 percent) developed recurrent fullthickness rectal prolapse; six of them underwent repeat perineal rectosigmoidectomy. Sixty-seven patients had fecal incontinence prior to surgery. Eleven patients underwent concomitant levatoroplasty; 10 of them either improved or regained full continence of feces postoperatively. Twenty-six of the 56 patients who underwent perineal rectosigmoidectomy alone improved or regained full continence. Rectal prolapse can be successfully treated by perineal rectosigmoidectomy in elderly, highrisk patients with minimal morbidity. Levatoroplasty dramatically improves fecal incontinence occurring in association with rectal prolapse.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Videoproctographic assessment after restorative proctocolectomy

Videoproctography was performed in 40 patients after restorative proctocolectomy to evaluate pouch emptying, anopouch angle, and pelvic floor movement in relationship to functional outcome. Results were compared between the two different pouch designs tested and a control group of 26 patients who had an intact rectum. There was no difference in emptying between the two pouch designs or compared with the control subjects. Emptying did not influence either the frequency of defecation or patient soiling rate. The presence of an anal stricture was associated with poor emptying in each case in the pouch group. Anorectal angle was no different between the different pouch designs or compared with the control group at rest, during pelvic floor contraction, or attempted defecation. A similar finding was obtained with anorectal angle position and movement during pelvic floor contraction and attempted defecation in both pouch design groups and when compared with normal rectum. This study shows that the only factor that is consistently associated with poor pouch emptying is the presence of an anal stricture.Read at the meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Restoration of gastrointestinal continuity and continence after abdominoperineal excision of the rectum using an electrically stimulated neoanal sphincter

A new operation is described in which a neorectum and neoanal sphincter mechanism have been constructed to restore gastrointestinal continuity and continence in a patient who required abdominoperineal excision of the rectum for a low rectal cancer. The neorectum was constructed by bringing colon down into the pelvis and anastomosing it to the perineal skin. The neoanal sphincter was fashioned from a transposed gracilis muscle and was activated electrically by a totally implanted stimulator. A period of chronic low-frequency stimulation altered the muscle characteristics and enabled the neosphincter to contract continually without fatigue. The patient was continent when the stimulator was turned on and was able to void when the stimulator was turned off.