Langzeitergebnisse der Kontinenzfunktion nach ileoanaler Pouch-Anlage

An important aim of proctocolectomy with ileal pouch-anal anastomosis (IPAA) is to maintain anal continence. Anal sphincter disruption during IPAA is felt to play an important role in loss of continence, which is described in up to 30% of the treated patients in the early postoperative period. Although sphincter function recovers gradually after surgery, some patients stay incontinent. In our investigation of possible parameters involved in preservation of continence after this operative procedure, we focused on changes in anal manometry. We compared these findings with the functional results obtained by questioning the patients and physical examination. Anal manometry was performed with a low-compliance hydraulic perfusion system. All patients underwent a J-pouch procedure with a short rectal cuff for ileoanal reconstruction. We examined 25 patients, 13 underwent operation for the treatment of ulcerative colitis, 12 because of adenomatous polyposis. In the colitis and polyposis group, 28% of the patients reported events of soiling. Three patients (12%) were incontinent. The remaining 15 patients were completely continent. The median time after operation was 58 months, ranging from 12 to 96 months. Comparing the results of anal manometry with standard values of ten age- and gender-matched healthy volunteers, it was found that there was a significant increase in the threshold of balloon awareness and urge to defecate. These sensations were sometimes elicited by pouch contractions. Median pouch- compliance was also clearly elevated in comparison to rectal compliance (P<0.005). Inhibitory reflexes during balloon inflation could not be evoked in any of the patients. Comparing continent with incontinent patients there were significant differences in balloon awareness, urge to defecate, and stool frequency (P<0.01,P<0.01 andP<0.001, respectively). But in contrast to other publications, we could not find significant differences in anal sphincter length, resting and squeezing, anal canal pressure. Pouch compliance was lowered in incontinent patients and negatively correlated with stool frequency (P<0.001,r=?0.82). In conclusion, our study indicates that anal sphincter resting pressure alone is not a crucial factor in continence preservation in the long-term after total proctocolectomy and IPAA. Poor pouch- compliance and concomitant higher stool frequencies seem to be related to incontinence in this patient group.     

Anorectal function following low anterior resection

Introduction Rectal function following rectal resection for carcinoma was studied in 43 patients. Methods Sixteen women and 27 men with a median age of 66 years (range 41–79 years) were included. Twenty‐three patients had a diverting ileostomy at the time of resection. Eight patients had a 6‐cm colonic J‐pouch. Ten patients had anastomotic leakage including two patients without diverting ileostomy. One patient had pre‐operative radiation with 25 Gy. The patients were studied at a median 12 months (range 3–30) after rectal resection. Distance from anal verge to the anastomosis was a median 7 cm (range 3–12 cm). Clinical data, anal manometry and rectal compliance were analysed. Results Stool frequency was 3 per day (range 1–10). Twenty‐two (51%) patients were continent, 11 (26%) were incontinent for flatus, and 10 (23%) were incontinent for faeces (three for liquid and seven for solid stool). Fourteen (33%) patients had constipation, two of whom also had incontinence for solid or liquid stool. The level of the anastomosis for patients with postoperative constipation was 5 cm (range 3–12 cm), while it was 7 cm (range 3–10 cm) for nonconstipated patients (NS). Anal manometry was normal. Rectal compliance was lower in patients with incontinence for liquid or solid faeces than in patients with flatus incontinence only (P < 0.01), and rectal volume tolerability was lower in incontinent patients compared with continent patients (P < 0.05). The rectoanal reflex was present in 31 (72%) patients. There was a negative correlation between maximal rectal volume and stool frequency and between level of the anastomosis and degree of incontinence. Age did not affect functional outcome. Conclusion Many patients had a poor functional result following low anterior resection. One in four suffered from incontinence to liquid or solid faeces and one third of the patients experienced constipation. A low level of anastomosis tended to increase stool frequency and carried a higher risk of incontinence. Patients with faecal incontinence tended to have lower rectal compliance and volume tolerability than patients who were continent, while there was no difference in anal pressures.     

Changes in fatigability of the striated anal canal after childbirth

Aim Anal manometry is an established assessment tool for patients with faecal incontinence. Fatigue rate index (FRI) has been shown to discriminate between symptomatic patients and controls. The aim of this study was to compare manometry and fatigability of the anal canal in nulliparous women before and after childbirth. Method An air‐filled manometry device was used to record maximum resting and squeeze pressures, fatigue rate (recorded over 20 s) and FRI. Recordings were made before and after vaginal delivery. Results Nineteen women were studied. Resting anal canal pressure was not significantly different before and after delivery (57.1 ± 13.6 vs 51.1 ± 11.9 cmH₂O, P = 0.1). Squeeze pressure was significantly lower postpartum (106.5 ± 43.6 vs 75.5 ± 45.6 cmH₂O, P < 0.001). Fatigue rate was significantly reduced postpartum (?129.5 ± 74.7 vs?76.1 ± 54.8 cmH₂O/min, P = 0.001), but FRI was not significantly altered (1.23 ± 1.49 vs 1.41 ± 1.27 min, P = 0.09). Conclusion Maximal squeeze pressure and fatigue rate of the anal canal are significantly reduced after childbirth. Resting anal canal pressure and FRI are not significantly different.     

The impact of delivery on anorectal function in women with and women without anal incontinence – a prospective study

 A prospective study was carried out to evaluate the effect of delivery on anal physiological parameters in anally incontinent women (n=18) compared with continent women (n=42). Perineal plane, anal manometry, anal mucosa electrosensitivity and pudendal nerve terminal motor latency (PNTML) were all assessed at 26 weeks' gestation and at 3 and 6 months after delivery. No major effect on the incremental changes in anal physiological parameters was seen from 26 weeks of gestation to 3 months after delivery. At 26 weeks of gestation perineal plane and maximal squeeze pressure were impaired in incontinent women (P=0.02 and P=0.06); PNTML was impaired in incontinent women 6 months after delivery (P=0.05). Irrespective of continence status, delivery had an adverse effect on maximal squeeze pressure and PNTML. No major incremental changes were found between incontinent and continent women after delivery. However, there was a tendency to a higher degree of impairment of maximal squeeze pressure among incontinent women. Delivery per se had an adverse effect on maximal squeeze pressure and PNTML irrespective of continence status. Received: 21 December 2002 / Accepted: 24 June 2002     

Anal acoustic reflectometry: a new technique for assessing anal sphincter function

Objective Anal acoustic reflectometry (AAR) is a new technique that offers an assessment of anal sphincter function by the measurement of additional parameters not available with conventional manometry. The aim of this study is to describe the technique, methodology and initial pilot study results. Method Wideband sounds (100 Hz to 16 kHz) are transmitted into a thin polyurethane bag placed within the anal canal. Calculation of cross‐sectional area from reflected sound waves, over a range of pressures (0–200 cm H₂O) during inflation/deflation of the bag, results in five physiological parameters of anal canal function. Five patients [three continent (two female) and two incontinent (both female)] were assessed with AAR and anal manometry. Results Anal acoustic reflectometry parameters were reduced in incontinent when compared with continent patients. Resting Opening Pressures (cmH₂O) were 27 and 16 in patients with faecal incontinence (FI) vs 44 and 72 in continent patients; Resting Opening Elastance (cmH₂O/mm²) was 0.88 and 1.08 in FI patients vs 1.65 and 1.34 in continent patients. The Resting Opening Pressure of a similarly aged continent male (55 cmH₂O) was greater than three of the females. During assessment of voluntary contraction (one FI female vs one continent female), Squeeze Opening Pressure (cmH₂O) was 31 vs 100 and Elastance (cmH₂O/mm²) 0.61 vs 2.07. Conclusion Anal acoustic reflectometry appears to be promising technique. Further work is in place to clarify whether it will be useful in clinical assessment of incontinent patients.     

Laparoscopic rectopexy for complete rectal prolapse

Background: The purpose of this study was to evaluate the clinical outcome of laparoscopic rectopexy and its effect on anorectal function investigations. Methods: Twelve patients with complete rectal prolapse without constipation underwent laparoscopic rectopexy. Pre- and postoperative evaluation included scoring of incontinence, anorectal manometry, and anal endosonography. Results: No recurrences of rectal prolapse were seen (median follow-up 19 months). Continence improved in eight of nine preoperatively incontinent patients. Two patients had mild constipation after surgery. Median maximum basal pressure measured by anorectal manometry increased from 20 to 25 mmHg (p=0.005) and the rectoanal inhibitory reflex improved in seven patients (p=0.03). Rectal sensitivity did not change significantly. Endosonography showed asymmetry and thickening of the internal anal sphincter and submucosa preoperatively. After surgery the maximum internal anal sphincter thickness decreased from 3.0 mm to 2.6 mm (p=0.02). Conclusions: Laparoscopic rectopexy improved continence in our patients. Anorectal function tests show a partial recovery of the internal anal sphincter. Laparoscopic rectopexy combines the low morbidity of minimal invasive surgery with the good outcome of abdominal rectopexy.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Orlando, Florida, USA, 11–14 March 1995     

Anorectal function evaluation and predictive factors for faecal incontinence in 600 patients

Aim Anorectal function was assessed in patients with and without faecal incontinence (FI) . Risk factors predictive for FI were determined. Method Between 2003 and 2009, all consecutive patients referred were assessed by questionnaire, anorectal manometry and anal endosonography. Predictive factors were identified and used to develop a statistical model to predict FI. Results Of 600 patients (519 women), 285 (48%) were faecally incontinent. In comparison with continent women, incontinent women (mean Vaizey score 15.4), were older, had more liquid stools, more deliveries, more urinary incontinence, lower anal pressures, shorter sphincter length, smaller rectal capacity and more sphincter defects. Incontinent men (mean Vaizey score 15.3) were older and had lower anal pressures. Incontinent and continent patients showed an overlap in test results. Predictors in women were age, stool consistency, anal pressures, rectal capacity, and internal and external sphincter defects. The area under the ROC‐curve was 0.84 (P < 0.001; 95% confidence interval, 0.80–0.87). Using a cut off point of 0.4, FI was predicted with sensitivity, specificity, positive and negative predictive values of 86%, 68%, 74% and 82%, respectively. The model was studied in five women with a temporary stoma and was accurate in predicting FI after stoma closure. Conclusion Incontinent patients have lower pressures, smaller rectal capacity and more sphincter defects than controls, but show a large overlap. Our model shows a relatively high sensitivity and negative predictive value for predicting FI in women. The model seems promising in the patients studied with a temporary stoma.     

Post-surgical fecal incontinence

The primary endpoint of this work was to understand the pathophysiology of fecal incontinence manifested after rectal and anal surgery. A retrospective cohort study with negative colonoscopy patients was created and 169 postoperative incontinent patients were analyzed (114 women and 55 men: mean age 58.9 ± 6.3): clinical evaluation, endoanal ultrasound and anorectal manometry reports were scanned. The duration of incontinence was very long, with a mean of 21.7 months. The mean number of bowel movements/week was 18.2 ± 7.2. Urge incontinence was present in 82.2% of patients, mixed with passive incontinence in 44 patients. Patients’ Fecal Incontinence Severity Index (FISI) score was 27.0 ± 6.6. Operated patients had significantly lower anal resting pressure (P < 0.01) than controls while patients with colo-anal anastomosis and those who underwent Delorme operation had lowest values (P < 0.01). Maximal tolerated volume and rectal compliance were significantly impaired in operated patients with rectum involvement (colo-anal anastomosis, Delorme, restorative procto-colectomy and STARR). External anal sphincter (EAS) defects were present in 33.1% of all patients and internal anal sphincter (IAS) was damaged in 44.3%: a combined lesion of anal sphincters was detected in 39 patients (23.0%). A positive correlation was found between patients’ FISI score and thickness of both sphincters (EAS: ρ_{s =} 73; IAS: ρ_s = 81). Malfunctioning continence factors may induce fecal incontinence involving each time, in a different way, the volumetric capacity and/or the motility of the rectum, the perception of the fecal bolus and anal sphincter contraction.     

Anorectal function in Crohn's disease.

Anorectal function was assessed in 63 patients with Crohn's disease and in 10 controls. Eleven patients with Crohn's disease (17%) were partially and three (5%) totally incontinent. The results of anal sphincter function studies of continent patients with Crohn's disease were similar to those of partially incontinent patients and controls. Incontinent patients had significantly lower maximal basal pressure (P less than 0.01) and significantly lower maximal squeeze pressure (P less than 0.05) as compared to controls. There was no significant difference in rectal capacity between continent, partially incontinent and totally incontinent patients and controls. There were significantly more patients with symptoms of anal incontinence in the group of patients with anal Crohn's disease as compared to the Crohn's group with normal anorectum (P less than 0.001). Risk factors for total anal incontinence in Crohn's disease were severe anorectal stenosis and previous surgery for anal abscesses. The most important reason for partial incontinence was diarrhoea. In conclusion, Crohn's disease without macroscopic lesions in the anorectum and without diarrhoea does not affect anorectal function.     

Descripción de los hallazgos de la ecografía endoanal en pacientes con incontinencia fecal mediante un sistema de puntuación

Introduction

The main aim of the study was to apply a severity classification of sphincter lesions detected by endoanal ultrasound using Starck score in patients who suffered faecal incontinence.

Material and method

Data were analysed on 133 patients with faecal incontinence. Those in whom anal sphincter lesions were detected by endoanal ultrasound are described and their corresponding scores according to Starck classification calculated. This system scores severity of detected sphincter lesions from 0 to 16, involving the three axes of the anal canal. Patient demographic characteristics and anorectal manometry results were also analysed. The relationship between this score, patient gender and age, and anorectal manometric results were also analysed.

Results

A total of 83 (62.4%) patients had some type of anal sphincter lesion. The presence of sphincter defects was not related to gender (P=0.172), although it did correlate with younger ages (P=0.028). The severity of anal sphincter damage by Starck score did not show significant correlation to gender (P=0.327) or to the age (P=0.350) of patients. However, a significant correlation was detected between Starck score and anal resting pressure (P=0.008) or anorectal squeeze pressure (P=0.011).

Conclusions

The presence of anal sphincter injuries could be well defined by Starck score in patients with faecal incontinence. Severity of damage scored by Starck correlated with anorectal manometric results.     

Colorectal 25

Aims: To assess anal sphincter structure and functional outcomes following third-degree perineal tears and the effect of its disruption on the development of anal incontinence. Methods: Fifty-one consecutive patients, 41 primigravidae and 10 multigravidae, with third-degree intrapartum perineal tears, primarily repaired, were recruited 4 months postpartum. Patients completed questionnaires assessing faecal incontinence. Anal manometry and endosonography were then performed. Results: No patient reported incontinence prior to pregnancy. The incidence of faecal incontinence was 12 per cent. Six patients were incontinent of faeces and 10 incontinent of either flatus and/or fluid. Eighty-one per cent of anal incontinent patients were primigravidae (OR 0.96). Three women had previous third-degree tears, with one anal incontinence on subsequent delivery. Disruption of the external anal sphincter (EAS) was identified endosonographically in 26 patients. In 13 patients, there was an associated internal anal sphincter (IAS) defect. Clinically unsuspected tears of the Anal sphincter mechanism were diagnosed by anal endosonography in 46 per cent of asymptomatic patients. The EAS alone was involved in 14, IAS in three, and both in five patients. Clinical examination of women with anal incontinence identified an anal sphincter defect in 46 per cent. Ultrasound in anal incontinent patients showed an IAS defect in 42 per cent and an EAS defect in 52 per cent. All patients with faecal incontinence had a disruption of the EAS identified by endosonography (P < 0.05). No significant relationship was demonstrated between symptoms and anal manometry (P = 1.0, n.s.). Conclusions: Third-degree tears cause significant, although clinically unsuspected anal sphincter defects. It may be that anal manometry alone is not sufficient to exclude sphincter injury.     

Faecal incontinence after lateral internal sphincterotomy is often associated with coexisting occult sphincter defects: a study using endoanal ultrasonography

Background : Troublesome faecal incontinence following a lateral internal sphincterotomy (LIS) is often attributed to faulty surgical techniques: division of excessive amount of internal sphincter or inadvertent injury to the external sphincter. The aim of the present paper was to assess the anatomic and physiological factors that may contribute to faecal incontinence following a technically satisfactory lateral internal sphincterotomy by a group of colorectal specialists. Methods : Fourteen patients (nine women, five men; median age: 38 years; range: 23–52 years) who developed troublesome postoperative faecal incontinence were evaluated by clinical assessment, endoanal ultrasonography and anorectal physiological studies (manometry, pudendal nerve terminal motor latency) by two independent observers. The Cleveland Clinic continence score (0–20; 0, perfect continence; 20, complete incontinence) was used to quantify the severity of faecal incontinence. Fourteen continent subjects after a LIS (nine female patients, five male patients; median age: 36 years; range: 20–44 years) were also evaluated as ‘continent’ controls (continence score ≤ 4). Results : In the incontinent group, the median postoperative Cleveland Clinic continence score was 9 (range: 6–13) compared with a preoperative score of 1 (range: 0–3). On assessment by endoanal ultrasonography the site of the internal sphincterotomy was clearly identified. There were additional coexisting defects, on endoanal ultrasonography, of the external anal sphincter in seven female patients, of the internal sphincter in two female and two male patients; and a defect of both the external and internal sphincters in a male patient who had had a prior fistulotomy. The pudendal nerve terminal motor latency (PNTML) was prolonged in two female patients on the side contralateral to the lateral internal sphincterotomy. In two of five male patients there was no evidence of any occult sphincter injuries. In the continent controls a defect of the distal portion of the external sphincter was noted in one female patient. None of the patients had a prolonged PNTML. The maximum voluntary contraction was significantly lower in the female subjects than in the female continent controls (92 mmHg vs 140 mmHg; P < 0.05), while the resting anal canal pressures and length of the high pressure zone were similar between the study subjects and the continent controls. Conclusion : Troublesome faecal incontinence after a satisfactorily performed lateral internal sphincterotomy is often associated with coexisting occult sphincter defects.     

Investigation of anal sphincter function following Mainz pouch type II urinary diversion after radical cystectomy

Purposes

Our aim was to evaluate the anal sphincter function following cystectomy with urinary diversion of Mainz pouch II.

Methods

Seventy-six patients were involved in our survey, and the cohort was for two groups divided. The first group was a retrospective review of 40 patients with examination of the state of continence. Comparative examinations on anal sphincter function and the quality of life survey were carried out. The second group consisting of 15 patients underwent a prospective investigation including rectal manometry in both the pre- and postoperative periods. Measurements of resting anal sphincter pressure (RASP), maximal anal closing pressure (MACP) and the function of the recto anal inhibitions reflex were taken.

Results

In the first part of our investigation, 80% of the patients were considered as continent. There were no significant differences observed between RASP values in the cases of continent as well as of incontinent patients (79.2?±?2 vs. 73.6?±?68.4?mmHg, p?=?0?C53); however, the MACP values of the continent patients were significantly higher (204.3?±?22.8 vs. 117.3?±?14?mmHg, p?=?0.001). In the course of the second experiment, both the RASP (86.3?±?18.7 vs. 76.1?±?13.9?mmHg p?=?0.0049) and the MACP (232.2?±?53.8 vs. 194.1?±?74.5?mmHg, p?=?0.0054) were detected as decreasing in the case of the incontinent group.

Conclusions

A decrease in rectal sphincter function is responsible for incontinence following Mainz pouch type II diversion, and this dysfunction can be correlated with the surgery. Ureterosigmoideostomy is therefore considered as a useful method of urinary diversion only in selected cases with proven good sphincter function.     

Idiopathic Hypertensive Anal Canal: A Place of Internal Sphincterotomy

Background  Hypertensive anal canal is frequently known to be associated with the presence of anal fissure. Based on clinical experience, we hypothesized that idiopathic anal sphincter hypertonia was a condition equivalent to anal fissure, and therefore, it could be treated the same way. Patient and methods  Sixty-three patients complaining of anal pain without any anal pathology and ten healthy volunteers were examined. All patients underwent clinical evaluation, neurological examination, anorectal manometry, and measurement of pudendal nerve terminal motor latency. All patients with hypertensive anal canal were randomized into three groups. Group I (surgical group) underwent closed lateral sphincterotomy (LS), group II using nitroglycerine ointment (GTN), and group III received injection of botulinum toxin in internal sphincter. Post-procedures data were recorded at follow-up period. Results  The mean resting anal pressure (MRAP) was significantly higher in the patient group (114.6 ± 7.4 mmHg) than control group (72.5 ± 6.6 mmHg, P < 0.001). Anal pain is the main presenting symptoms aggravated by defecation and not relived by analgesics or local anesthetics. After LS, pain visual analogue scale decreased significantly at follow-up period than after chemical sphincterotomy using GTN or BTX (P = 0.001). There was a significant decrease in MRAP postoperatively from 114.6 ± 7.4 to70.8 ± 5.5 mmHg than after using GTN or BTX (P = 0.03). Conclusion  Idiopathic hypertensive anal canal is a fact and already exists presented by anal pain aggravated by defecation. It can be managed safely by closed lateral sphincterotomy, but chemical sphincterotomy had a minor role in its management.     

Functional results after laparoscopic rectopexy for rectal prolapse

We investigated the functional results after laparoscopic rectopexy for rectal prolapse in 29 patients at least 12 months postoperatively. Twenty patients were evaluated completely pre- and postoperatively (median 22 months postoperatively, range 12 to 54 months). Six patients were interviewed by telephone, two patients were lost to follow-up, and one patient died of causes unrelated to rectal prolapse. Patients underwent a proctologic examination, anoscopy, rigid sigmoidoscopy, fluoroscopic defecography, and anorectal manometry pre- and postoperatively, and an additional standardized interview postoperatively. Anorectal manometry showed a significant increase in maximum anal resting and squeeze pressures postoperatively (resting pressure 72 ±8 vs. 95 ±13 mm Hg, pre- vs. postoperatively; P = 0.046; squeeze pressure 105 ±17 vs. 142 ±19 mm Hg, pre- vs. postoperatively; P = 0.035), and continence improved postoperatively (Wexner incontinence score 6.0 ±1.0 vs. 3.9 ± 0.8 pre- vs. postoperatively, P = 0.02). Twenty (77%) of 26 patients were satisfied with the operative result, but functional morbidity was observed in four patients, with two patients complaining of severe evacuation problems. Rectal prolapse recurred in one patient 42 months postoperatively (recurrence rate 1 [3.8%] of 26 patients). Functional results were very similar to those obtained after open rectopexy, with symptoms of prolapse and incontinence improved in the great majority of patients. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Effect of rectal distension on voluntary external anal sphincter function in healthy subjects

Aim Quantification of the anorectal reflex function is critical for explaining the physiological control of continence. Reflex external anal sphincter activity increases with rectal distension in a dynamic response. We hypothesized that rectal distension would similarly augment voluntary external anal sphincter function, quantified by measuring the anal maximum squeeze pressure. Method Fifty‐seven subjects (32 men, 25 women; median age 62 years), with normal anal canal manometry and endoanal ultrasound results, underwent a rectal barostat study with simultaneous anal manometry. Stepwise isovolumetric 50‐ml distensions (n = 35) or isobaric 4‐mmHg distensions (n = 22) above the minimum distending pressure were performed (up to 200 ml or 16 mmHg respectively), whilst anal resting pressure and maximum squeeze pressure were recorded and compared with the baseline pressure. Results The distension‐induced squeeze increment was calculated as the maximum percentage increase in maximum squeeze pressure with progressive rectal distension. This was observed in 53 of the 57 subjects as a mean ± standard deviation (range) increase of 32.8 ± 24.1 (?5.5 to 97.7)%. The mean ± standard deviation (range) distension‐induced squeeze increment in male subjects was 36.1 ± 25.7 (?5.5 to 97.7)% and in female subjects was 28.1 ± 20.1 (?3.8 to 70.2)%. There was no significant difference between the sexes (P = 0.194). Conclusion Rectal distension augments external anal sphincter function, confirming the existence of a dynamic rectoanal response. This may represent a quantifiable and important part of the continence mechanism.     

Maximum anal sphincter strength measured by the solid sphere test and anal pressure profiles.

OBJECTIVE--To evaluate two methods of quantifying external anal sphincter function. DESIGN--Open study. SETTING--Helsingborg Hospital, Sweden. SUBJECTS--73 patients (63 women and 10 men), of whom 25 were incontinent of gas and liquid or solid stool. INTERVENTIONS--Anal pressure profiles and the "solid sphere" test. OUTCOME MEASURE--Correlation between results of tests and presence of incontinence. RESULTS--Continent patients were younger than incontinent ones. The correlation between the maximum force the patient could retain and the maximum anal squeeze pressure was good (r = 0.67, p < 0.001). Younger continent patients (n = 48) and significantly higher pressures than incontinent patients (n = 25), but the range and overlap were wide. The reproducibility of both methods was good. CONCLUSIONS--Although the solid sphere test is easier and quicker to do, anal pressure profiles yield more information that is important in the evaluation of incontinence.     

Preservation of continence after ileoanal anastomosis by the coordination of ileal pouch and anal canal motor activity.

Nocturnal incontinence may occur after ileoanal anastomosis and may be related to loss of an effective anal canal pressure barrier during sleep; how pressure and contractions in the proximal bowel influence this barrier is unknown. Our aim was to evaluate the relationship between anal canal pressure and contractions and contractile activity of the pouch in continent subjects after ileal pouch-anal anastomosis (IPAA) and of the rectum in normal controls. A fully ambulatory system for 24-hour pressure recording was used. A flexible transducer catheter was introduced endoscopically so that sensors were at 2, 3, 8, 12, 16, and 24 cm from the anal orifice in 12 healthy controls (7 men, 5 women, mean age: 35 years) and 7 fully continent IPAA patients (4 men, 3 women, mean age: 34 years) more than 12 months postoperatively. Twenty-four hour spontaneous motor activity was stored in a 2.5 megabyte (MB) digital portable recorder. Mean anal canal pressure was calculated, and rectal motor complexes and ileal pouch large pressure waves were characterized. During sleep, resting anal canal pressures were similar in the two groups (72 +/- 12 mm Hg in controls versus 66 +/- 9 mm Hg in IPAA patients [mean +/- standard deviation (SD)], p = NS), but anal canal pressure showed cyclic relaxations (periodicity: 95 +/- 11 min in controls, 54 +/- 18 min in IPAA patients, p less than 0.05), during which the mean pressure trough was 15 +/- 4 mm Hg in controls and 14 +/- 5 mm Hg in IPAA patients (p = NS). In the control patients, during sleep, a mean of six rectal motor complexes were identified (range: 3 to 9). In patients with IPAA, during sleep, a mean of eight large pressure waves per hour were identified (range: 2 to 20). Importantly, in both controls and patients, rectal motor complexes or large pressure waves were always accompanied by rapid return of anal canal pressure from trough to basal values and increased contractile activity. We concluded that, in healthy patients and in continent patients after IPAA, motor activity of the rectum and of the ileal pouch was associated with changes in pressure and contractile activity of the anal canal so that rectal- and neorectal-anal canal pressure gradient, and, in turn, fecal continence were preserved.     

Outcome of excision of megarectum in children with anorectal malformation

Background/Purpose

Megarectum in association with anorectal malformation contributes to chronic constipation and fecal incontinence. Resection of megarectum in anorectal malformation improves bowel function, but neuropathy and poor sphincter quality may affect the outcome of fecal continence adversely. The aim of this study was to evaluate the benefits of resection of megarectum in anorectal malformation and to ascertain the impact of anal sphincter quality and neuropathy on the outcome.

Methods

We studied 62 children with intractable fecal incontinence after repair of anorectal malformation between January 1991 and January 2005. All patients were investigated with anorectal manometry and anal endosonography under ketamine anesthesia. On endosonography, an intact or scarred internal anal sphincter (IAS) was classified as good and a fragmented or absent IAS as poor. On manometry, a resting anal sphincter pressure equal to or more than 30 mm Hg was classified as good and a lower pressure as poor. Functional assessment of fecal continence was done before and after excision of megarectum using a modified Wingfield scores.

Results

Sixteen children had excision of megarectum with median age of 9 years (range, 2-15 years) and postoperative follow-up of 5 years (range, 1-10 years). Seven had formation of antegrade continent enema stoma before excision of megarectum. Children were classified into three groups of anomalies: low (n = 6), intermediate (n = 4), and high (n = 6). All children were incontinent of feces. After excision of megarectum, of the 9 children with good IAS and no neuropathy, 7 became continent of feces. Of the remaining 7 children, 4 had poor IAS and 3 had neuropathy, 5 of whom required an antegrade continent enema stoma to be clean.

Conclusion

Excision of megarectum in children who had previous repair of anorectal malformation results in fecal continence in the presence of a good IAS and absence of neuropathy. Patients with a poor IAS or neuropathy will often require artificial means of fecal continence.     

Comparison of clinical outcomes and anorectal manometry in patients with congenital anorectal malformations treated with posterior sagittal anorectoplasty and laparoscopically assisted anorectal pull through

Purpose

The objective of this study is to analyze the clinical outcomes and anorectal manometry (AM) in infants with congenital high anorectal malformations treated with posterior sagittal anorectoplasty (PSARP) and laparoscopically assisted anorectal pull through (LAARP).

Materials and Methods

From August 2005 to December 2008, 23 patients with congenital high anorectal malformations were randomly distributed into PSARP and LAARP groups. All of them underwent LAARP (11 cases) or PSARP (12 cases) at 2 or 3 months old. Clinical outcomes and results of anorectal manometry were compared between patients at the age of 17.4 ± 4.9 and 19.3 ± 6.2 months (P = .4270), respectively.

Results

Kelly's clinical score for patients in LAARP and PSARP groups was 3.91 ± 1.14 and 3.83 ± 1.40 (P = .8827), respectively. Anal canal resting pressure and high-pressure zone length were 29.4 ± 7.2 vs 23.4 ± 6.5 mm Hg (P = .0479) and 14.9 ± 3.0 vs 13.9 ± 3.1 mm (P = .4414), respectively. Rectal anal inhibitory reflex was observed in 81.8% (9/11) and 83.3% (10/12) patients (P = 1.0000), respectively. The mean length of stay during the second hospitalization was 10.6 ± 0.9 and 14.3 ± 1.4 days (P < .0001), respectively.

Conclusions

Although no significant difference can be noted in clinical scoring between both groups, the results of anorectal manometry indicate that LAARP can significantly improve anal canal resting pressure and reduce the length of stay.