Long-Term Anorectal Dysfunction After Postoperative Radiotherapy for Rectal Cancer

PURPOSE Adjuvant radiotherapy in the treatment of rectal cancer has been shown to increase long-term morbidity causing severe anorectal dysfunction with physiologic changes whose interaction remains poorly understood. This study examines long-term anorectal morbidity from adjuvant postoperative radiotherapy.METHODS In a prospective study, patients with Dukes B or C rectal carcinoma were randomized to postoperative radiotherapy or no adjuvant treatment after anterior resection. The long-term effect of radiotherapy on anorectal function in a subset of surviving patients was assessed from a questionnaire on subjective symptoms and from physiology laboratory evaluation and flexible sigmoidoscopy.RESULTS Twelve of 15 patients (80 percent) treated with radiotherapy had increased bowel frequency compared with 3 of the 13 patients (23 percent) who did not have radiation therapy (P = 0.003). The former group had loose or liquid stool more often (60 vs. 23 percent, P = 0.05), had fecal incontinence more often (60 vs. 8 percent, P = 0.004), and wore pad more often (47 vs. 0 percent, P = 0.004). They also experienced fecal urgency and were unable to differentiate stool from gas more often. Endoscopy revealed a pale and atrophied mucosa and telangiectasias in the irradiated patients. Anorectal physiology showed a reduced rectal capacity (146 vs. 215 ml, P = 0.03) and maximum squeeze pressure (59 vs. 93 cm H₂O, P = 0.003) in the radiotherapy group. Impedance planimetry demonstrated a reduced rectal distensibility in these patients (P < 0.0001).CONCLUSIONS Adjuvant postoperative radiotherapy after anterior resection causes severe long-term anorectal dysfunction, which is mainly the result of a weakened, less sensitive anal sphincter and an undistensible rectum with reduced capacity.     

Impairment of anorectal function in diabetes mellitus parallels duration of disease

PURPOSE: The aim of this study was to investigate any possible relation between the severity of anorectal dysfunction in diabetes mellitus and duration of disease and presence of microangiopathy or neuropathy or both. METHODS: Standard multiport anorectal manometry was performed in 25 healthy control subjects (10 males; age (mean±1 standard deviation), 62±14 years) and 38 patients with diabetes mellitus. Patients were divided into two groups according to the duration of the disease: Group A (19 patients) with a duration less than 10 years (7.2±2.5; 8 males; age, 57±18) and Group B (19 patients) with a duration longer than 10 years (19.8±5.6; 6 males; age, 62±15). RESULTS: Results are reported as mean ± one standard deviation. Patients showed lower resting and squeeze anal pressures (P<0.01), impaired rectoanal inhibitory and anocutaneous reflexes, and reduced sensitivity in rectal distention (P=0.004) as compared with controls. In addition, Group B showed a significantly increased incidence of microangiopathy (P=0.04) and autonomic and peripheral neuropathy (P=0.002), significantly reduced basal and squeeze anal pressures (52±16vs. 64±24 mmHg;P=0.03 and 98±39vs. 124±54 mmHg;P=0.04, respectively), reduced amplitude of slow waves (7.3±3vs. 9.5±3.7 mmHg;P=0.03), anal leak in smaller rectal volumes (P=0.003), and reduced response of the anal sphincter at the anocutaneous reflexes (29±14vs. 39±14 mmHg;P=0.05) compared with Group A. The former group of patients exhibited a significantly higher incidence of fecal incontinence (P=0.008). CONCLUSION: Patients with long-standing diabetes mellitus have increased incidence of fecal incontinence and severely impaired function of both the anal sphincters and the rectum. These findings could be attributed to the increased incidence of microangiopathy and autonomic and peripheral neuropathy observed in this subset of diabetic patients.Presented at the United European Gastroenterology Week, Birmingham, United Kingdom, October 18 to 23, 1997.     

Anal Resting Pressures at Manometry Correlate with the Fecal Incontinence Severity Index and with Presence of Sphincter Defects on Ultrasound

Introduction  We describe the relationship between anorectal manometry, fecal incontinence severity, and findings at endoanal ultrasound. Methods  A total of 351 women completed the Fecal Incontinence Severity Index, underwent anorectal manometry, and endoanal ultrasound. Severity index and manometry pressures in 203 women with intact sphincters on ultrasound were compared with pressures in 148 women with sphincter defects. Relationships between resting and squeeze pressures, severity index, and size of sphincter defects were evaluated. Results  Mean severity index in patients with and without sphincter defect was 35.7 vs. 36.7 (not significant). Worsening index correlated with worsening mean and maximum resting pressure (P < 0.0001). Differences were observed in mean and maximum resting pressure between the patients with and without sphincter defects (26.6 vs. 37.2, P < 0.0001; 39.4 vs. 51.7, P < 0.001). Resting pressures correlated with the sizes of defect (P < 0.0001). Conclusions  Patients with and without sphincter defects had similar severity scores, but patients with defects had a significant decrease in resting pressures. Patients with larger sphincter defects had lower severity scores and resting pressures. Until a manometry cutoff can be set to discriminate between absence and presence of defects, both manometry and ultrasound should be offered to patients with history of anal trauma. Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, June 2 to 6, 2007. 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.     

Anorectal pressure gradient and rectal compliance in fecal incontinence

To study whether anorectal pressure gradients discriminated better than standard anal manometry between patients with fecal incontinence and subjects with normal anal function, anorectal pressure gradients were measured during rectal compliance measurements in 36 patients with fecal incontinence and in 22 control subjects. Anal and rectal pressures were measured simultaneously during the rectal compliance measurements. With standard anal manometry, 75% of patients with fecal incontinence had maximal resting pressure within the normal range, and 39% had maximum squeeze pressure within the normal range. Anorectal pressure gradients did not discriminate better between fecal incontinence and normal anal function, since, depending on the parameters used, 61%–100% of the incontinent patients had anorectal pressure gradients within the normal range. Patients with fecal incontinence had lower rectal volumes than controls at constant defecation urge (median 138 ml and 181 ml, P<0.05) and at maximal tolerable volume (median 185 ml and 217 ml, P<0.05). We conclude that measurements of anorectal pressure gradients offer no advantage over standard anal manometry when comparing patients with fecal incontinence to controls. Patients with fecal incontinence have a lower rectal volume tolerability than control subjects with normal anal function. Accepted: 5 June 1998     

Preoperative Chemoradiation for Rectal Cancer Causes Prolonged Pudendal Nerve Terminal Motor Latency

Purpose A worsened anorectal function after chemoradiation for high-risk rectal cancer is often attributed to radiation damage of the anorectum and pelvic floor. Its impact on pudendal nerve function is unclear. This prospective study evaluated the short-term effect of preoperative combined chemoradiation on anorectal physiologic and pudendal nerve function. Methods Sixty-six patients (39 men, 27 women) with localized resectable (T3, T4, or N1) rectal cancer were included in the study. All patients received 45 Gy (1.8 Gy/day in 25 fractions) over five weeks, plus 5-fluorouracil (350 mg/m²/day) and leucovorin (20 mg/m²/day) concurrently on days 1 to 5 and 29 to 33. Patients who had rectal cancer with a distal margin within 6 cm of the anal verge had the anus included in the field of radiotherapy (Group A, n = 26). Patients who had rectal cancer with a distal margin 6 to 12 cm from the anal verge had shielding of the anus during radiotherapy (Group B, n = 40). The Wexner continence score, anorectal manometry and pudendal nerve terminal motor latency were assessed at baseline and four weeks after completion of chemoradiation. Results The median Wexner score deteriorated significantly (P < 0.0001) from 0 to 2.5 for both Groups A (range, 0–8) and B (range, 0–14). The maximum resting anal pressures were unchanged after chemoradiation. The maximum squeeze anal pressures were reduced (mean = 166.5–157.5 mmHg) after chemoradiation. This change was similar in both Groups A and B. Eighteen patients (Group A = 7, Group B = 11) developed prolonged pudendal nerve terminal motor latency after chemoradiation. These 18 patients similarly had a worsened median Wexner continence score (range, 0–3) and maximum squeeze anal pressures (mean = 165.5–144 mmHg). The results obtained were independent of tumor response to chemoradiation. Conclusions Preoperative chemoradiation for rectal cancer carries a significant risk of pudendal neuropathy, which might contribute to the incidence of fecal incontinence after restorative proctectomy for rectal cancer. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, April 30 to May 5, 2005.     

Transanal approach to rectocele repair may compromise anal sphincter pressures

PURPOSE: This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation. METHOD: Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later. RESULTS: All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n=19; after, n=3;P=0.001), need to digitate per vagina (before, n=16; after, n=0;P=0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2);P=0.004), and laxative requirements (before, n=7; after, n=0;P=0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P<0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P<0.05) after operations. There was no other morbidity. CONCLUSION: Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.     

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

Background Anal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography. Methods A cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography. Results Absent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (±SD) manometric findings: mean resting pressure 41.3 (±20), 43.8 (±20) and 61.6 (±23) Hg (p<0.001); incremental squeeze pressure 20.6 (±20), 38.4 (±31) and 62.4 (±34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography. Conclusions Anal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.     

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.     

Histologic Analysis of the Irradiated Anal Sphincter

PURPOSE: There is accumulating evidence, both quantitative and qualitative, that pelvic irradiation adversely affects anorectal function. However, histologic evidence of sphincter injury has not been demonstrated. This study was designed to perform histologic assessment of collagen deposition and nerve alteration in the internal anal sphincters of rectal cancer patients who underwent abdominoperineal resection after adjuvant chemoradiation therapy and to correlate the degree of histologic changes with the time interval between chemoradiotherapy and abdominoperineal resection. METHODS: Anal canal specimens were prospectively collected in patients undergoing abdominoperineal resection. Representative slides were cut transversely at the level of the dentate line. Using trichrome and S-100 protein staining, a single pathologist blinded to the patients treatment assessed collagen deposition and nerve fiber densities in the internal anal sphincter, respectively. RESULTS: Twelve patients received radiation for rectal cancer (chemoradiotherapy group) and six were treated by surgery alone, including four patients with rectal cancer (1 leiomyosarcoma) and two with Crohns disease (control group). There was a trend toward increased fibrosis (replacement of >10 percent of normal structures by collagen) and nerve density in the chemoradiotherapy group compared with the control group (P = 0.08 and P = 0.05, respectively). Nerve density significantly increased as chemoradiotherapy to abdominoperineal resection interval increased (P = 0.04). CONCLUSIONS: Pelvic irradiation results in damage to the myenteric plexus of the internal anal sphincter of patients with rectal cancer; these alterations seem to be time-dependent. A trend toward increased collagen deposition also was observed. Together, these results provide a morphologic basis, which concurs to previously described physiologic and clinical alterations in the anal sphincter of patients irradiated for rectal cancer.     

Anal endosonography and manometry

PURPOSE: Correlations between anal sphincter function as assessed by anorectal manometry and anal sphincter anatomy measured by endoluminal ultrasound have been reported in the literature both for patients and for healthy individuals but have not been confirmed by other authors. METHODS: For a larger series of patients (152 consecutive patients, mean age 54.1±15.5 years; female:male ratio, 11141) with anorectal dysfunctions such as incontinence (n=92), constipation (n=37), and other symptoms (n=23), diagnostic work-up included conventional multilumen anorectal manometry to evaluate internal sphincter pressure at rest, maximum external sphincter squeeze pressure during contraction, and endoanal sonography to determine anal sphincter integrity and to measure dorsal, left lateral, and right lateral diameter of the internal anal sphincter (IAS) and external anal sphincter (EAS) muscles. RESULTS: Maximum squeeze pressure was significantly correlated to muscle thickness of the EAS(P =0.001). No association was found between resting pressure and IAS diameter. Women had significantly lower resting and squeeze pressures than men(P =0.008 and P =0.003, respectively), but age-related changes of function were only found for resting pressure. Endosonographic values of IAS and EAS did not differ between genders but were significantly correlated with age(P =0.008 and P =0.02, respectively). Because all correlations were rather weak, they only can explain a small portion of data variance. CONCLUSION: Anal manometry and anal ultrasound, therefore, are of complementary value and are both indicated in adequate clinical problems.Supported by a grant from Deutsche Forschungsgemeinschaft, En 50/10, Bonn, Germany.     

Anal Sphincter Damage After Vaginal Delivery

PURPOSE: This study was designed to assess the relationship of anal endosonography and manometry to anorectal complaints in the evaluation of females a long time after vaginal delivery complicated by anal sphincter damage. METHODS: Thirty-four patients with anal sphincter damage after delivery, 22 with and 12 without anorectal complaints, and 12 controls without anorectal complaints underwent anal endosonography, manometry, and rectal sensitivity testing. Complaints were assessed by questionnaire, with a median follow-up of 19 years. RESULTS: Median maximum anal resting pressures were significantly lower in patients with anal sphincter damage with complaints (31 mmHg) than in controls (52 mmHg; P < 0.001). Median maximum anal squeeze pressures were significantly lower in patients with (55 mmHg) and without (69 mmHg) complaints than in controls (112 mmHg; P < 0.001 for both). Maximum anal resting pressures were significantly lower in patients with anorectal complaints after anal sphincter damage than in patients without complaints (P = 0.02). Results of anal manometry showed a large overlap between all groups. Rectal sensitivity showed no significant differences between the three groups. Persisting sphincter defects, shown by anal endosonography, were significantly more present in patients with anal sphincter damage after delivery with (86 percent) and without (67 percent) complaints than in controls (8 percent; P < 0.001 and P < 0.01, respectively). No differences in the number of echocardiographically proven sphincter defects were found between patients with or without anorectal complaints after anal sphincter damage CONCLUSIONS: Echographically proven sphincter defects are strongly associated with a history of anal sphincter damage during delivery. Sphincter defects are present in the majority of patients with anorectal complaints. Anal manometry provides little additional therapeutic information when performed after anal endosonography in patients with anorectal complaints after anal sphincter damage during delivery.     

Critical reappraisal of anorectal function tests in patients with faecal incontinence who have failed conservative treatment

Objective

Anorectal function tests are often performed in patients with faecal incontinence who have failed conservative treatment. This study was aimed to establish the additive value of performing anorectal function tests in these patients in selecting them for surgery.

Patients and methods

Between 2003 and 2009, all referred patients with faecal incontinence were assessed by a questionnaire, anorectal manometry and anal endosonography. Patients with diarrhea, inflammatory bowel disease, pouches or rectal carcinoma were excluded.

Results

In total, 218 patients were evaluated. Of these, 107 (49%) patients had no sphincter defects, 71 (33%) had small defects and 40 (18%) had large defects. Anorectal manometry could not differentiate between patients with and without sphincter defects. Patients with sphincter defects were only found to have a significantly shorter sphincter length and reduced rectal capacity compared to patients without sphincter defects. Forty-three patients (20%) had a normal anal pressures ≥40?mmHg. Seventeen patients (8%) had also a dyssynergic pelvic floor both on clinical examination and anorectal manometry. Fifteen patients (7%) had a reduced rectal capacity between 65 and 100?ml. There was no difference in anal pressures or the presence of sphincter defects in these patients compared to patients with a rectal capacity >150?ml. There was no correlation between anorectal manometry, endosonography and faecal incontinence severity scores.

Conclusion

In patients with faecal incontinence who have failed conservative treatment, only anal endosonography can reveal sphincter defects. Anorectal manometry should be reserved for patients eligible for surgery to exclude those with suspected dyssynergic floor or reduced rectal capacity.     

Endoanal Ultrasound Compared to Anorectal Manometry for the Evaluation of Fecal Incontinence: A Study of the Effect These Tests Have on Clinical Outcome

Tests for evaluating incontinence include endoanal ultrasound (EUS) and anorectal manometry. We hypothesized that EUS would be superior to anorectal manometry in identifying the subset of patients with surgically correctable sphincter defects leading to an improvement in clinical outcome in these patients. The purpose of this study was to compare these 2 techniques to determine which is more predictive of outcome for fecal incontinence. Thirty-five unselected patients with fecal incontinence were prospectively studied with EUS and anorectal manometry to evaluate the internal anal sphincter (IAS) and external anal sphincter (EAS). EUS was performed with Olympus GFUM20 echoendoscope and a hypoechoic defect in the EAS or IAS was considered a positive test. Anorectal manometry was performed with a standard water-perfused catheter system. A peak voluntary squeeze pressure of < 60 mm Hg in women and 120 mm Hg in men was considered a positive test. All patients were administered the Cleveland Clinic Continence Grading Scale at baseline and at follow-up. Improvement in fecal control was defined as a 25% or greater decrease in continence score. EUS versus manometry were compared with subsequent surgical treatment and outcome. P-values were calculated using Fisher's exact test. Patients (n = 32; 31 females) were followed for a mean 25 months (range 13–46). Sixteen patients had improved symptoms (50%). There was no correlation between EUS or anorectal manometry sphincter findings and outcome. Seven of 14 (50%) patients who subsequently underwent surgery versus 9 of 18 (50%) without surgery improved (P = .578). In long-term follow-up, approximately half of patients improve regardless of the results of EUS or anorectal manometry, or whether surgery is performed. Supported in part by a Glaxo-Wellcome Institute for Digestive Health Award.     

Rectoanal motility in Crohn's disease patients

PURPOSE: It has been documented that Crohn's disease affects anorectal function when anorectal manifestations of the disease are present. The aim of this study was to investigate whether the presence of histologic lesions in rectal biopsy affected anorectal motility in patients with Crohn's disease but no evidence of macroscopic anorectal involvement. METHODS: Forty-one patients with documented Crohn's disease were included in the study. Twenty-one of them had no endoscopic or histologic lesions in the rectum, and 20 patients had a positive histology for Crohn's disease on rectal biopsy, with or without macroscopic or endoscopic involvement of the anorectum. All patients underwent a standard anorectal manometry, with an eight-channel, water-perfused catheter. RESULTS: Patients with positive rectal biopsy but no evidence of endoscopic rectal involvement had lower anal resting and squeeze pressures (76±16 standard deviationvs. 86±19 standard deviationP=0.002; 152±56 standard deviationvs. 192±52 standard deviationP<0.001, respectively), and a lower sphincter and high-pressure zone length (2.8±0.8 standard deviationvs. 3.2±0.8 standard deviationP=0.006; 1.7±0.6 standard deviationvs. 2±0.6 standard deviationP=0.005, respectively) compared with patients with negative rectal histology. Also, slow and ultra slow wave amplitude and ultra slow wave frequency were significantly lower (10±6 standard deviationvs. 13±7 standard deviationP=0.04; 17±16 standard deviationvs. 34±24 SDP=0.004; 0.9±0.8 standard deviationvs. 1.3±0.6 standard deviationP=0.05, respectively), rectal sensation more affected, and rectal compliance significantly reduced (7.4±1 standard deviationvs. 11.1±2.2 standard deviationP<0.001) in the former group of patients. Simultaneous presence of endoscopic and histologic lesions in the rectum was associated with further impairment of the anorectal function. CONCLUSION: Microscopic presence alone of Crohn's disease in the rectum appears to induce anorectal motility disorders. The synchronous presence of endoscopic rectal and macroscopic anal involvement is associated with further deterioration of anorectal function.     

Transanal endoscopic microsurgery excision: is anorectal function compromised?

PURPOSE: Transanal endoscopic microsurgery is a new technique that has not yet found its place in routine practice. The procedure results in dilation of the anal sphincter with a large-diameter operating sigmoidoscope, sometimes for a prolonged period. The purpose of the present study was to assess the effect of transanal endoscopic microsurgery on anorectal function. METHODS: Eighteen consecutive patients undergoing transanal endoscopic microsurgery excision of rectal tumors, of whom 13 were available for evaluation, were included. Continence was scored by a numeric scale before surgery and at three and six weeks after surgery. Anorectal physiology studies were performed preoperatively and six weeks postoperatively with manometry, pudendal nerve motor terminal latency, anal mucosal electrosensitivity, rectal balloon volume studies, and endoanal ultrasound. RESULTS: There was a significant reduction in mean anal resting pressure (104 ± 32 cm H2O before surgery, 73 ± 30 cm H2O after surgery; P = 0.0009). There was no significant change in squeeze or cough pressure, pudendal nerve terminal motor latency, anal mucosal electrosensitivity, or rectal balloon study volumes. Fall in resting pressure was significantly correlated with length of operating time (r2 =0.39, P = 0.047). There was no significant change in mean continence score after surgery. CONCLUSION: Transanal endoscopic microsurgery results in a reduction in internal sphincter tone. This did not affect continence in a short-term study.     

Use of vector volume manometry and endoanal magnetic resonance imaging in the adult female for assessment of anal sphincter dysfunction

PURPOSE: This study compared conventional water-perfused and vector volume anal manometry in female patients with neurogenic fecal incontinence and chronic anal fissure and in healthy female volunteers. We used endoanal magnetic resonance (MR) imaging to measure internal and external sphincter lengths and thicknesses and contrasted these with the manometric findings in the different anorectal conditions. METHODS: One hundred thirty-three female subjects were studied over an eight-month period, including 33 control volunteers, 83 patients with neurogenic fecal incontinence, and 17 patients with chronic anal fissure. Conventional manometry was contrasted with automated vector volume-derived parameters. Endoanal magnetic resonance images were obtained using a previously described internal coil with a 0.5 T Asset scanner measuring quadrantal internal sphincter thickness and averaged coronal internal and external sphincter lengths. RESULTS: There was a statistically significant relationship between parameters measured by conventional manometry and those variables derived from vector volume manometry at rest and squeeze. There was no difference in sectorial vector-derived pressures within any anorectal condition and no correlation between quadrantal internal sphincter thickness measurements and sectorial pressures at rest. Patients with chronic anal fissure and neurogenic fecal incontinence had constitutionally shorter superficial and subcutaneous external sphincters than healthy control subjects (P<0.001). CONCLUSIONS: There is no association between manometric findings and morphologic sphincter measurement; however, the shorter distal external sphincter in patients with fissure might render the lower anal canal relatively unsupported after internal sphincterotomy in the female patient.Poster presentation at the meeting of the Association of Coloproctology of Great Britain and Ireland, Jersey, United Kingdom, June 29 to July 1, 1998.     

Defecography in patients with anorectal disorders

To evaluate the results and clinical impact of defecography in patients with anorectal disorders, 100 results of defecographic examinations from 92 patients were reviewed. The defecographic results were screened for the anorectal angle, defined both at rest and during straining, perineal descent, and abnormalities of the rectal configuration during straining. Anal manometry, saline infusion test, rectal capacity measurement, and anal electromyography (EMG) were also performed. There was a significant difference (P<0.001) both at rest (22°) and during straining (12°) between the two anorectal angle measurements. Incontinent patients had a larger anorectal angle, both at rest and during straining, than continent patients (P<0.04), but with a large overlap. The anorectal angle was not influenced by gender or age. An abnormal rectal configuration was found in 62 defecographic examinations. From the 8 patients with rectopexy performed for a large rectocele or intussusception, incontinent patients with an intussusception had the best results. In four patients, anal EMG showed an increased activity of the external sphincter during straining. Two of these four patients had abnormal defecograhic results. No correlations were found between anorectal angle and the other function tests. In conclusion, the anorectal angle lacks clinical relevance. In patients with defecation problems, defecography may be indicated whenever other investigations (physical examination, anal manometry, anal EMG) have excluded local pathology or a spastic pelvic floor syndrome. In these situations, defecography could detect an intussusception, which could easily be treated with rectopexy.Read in part at the meeting of the Dutch Society of Gastroenterology, Noordwijkerhout (The Netherlands), March 25 to 26, 1988.     

Effects of adjuvant radiotherapy on bowel function and anorectal physiology after low anterior resection for rectal cancer

We compared bowel function and anorectal physiology testing in rectal cancer patients who had undergone surgery alone, i.e. low anterior resection with colonic pouch (SA), to those also having preoperative radiotherapy (PREOP) or postoperative radiotherapy (POSTOP). The PREOP group were recruited from those who received 50.4 Gy (28 daily fractions over 5 1/2 weeks), and had their ileostomies closed for at least 1 year. Equivalent gender- and age-matched SA and POSTOP (50.4–54 Gy) patients who were operated upon during the similar time period were recruited. Bowel function questionnaire, anorectal manometry, anal electrosensation, pudendal nerve motor terminal latencies, barostat rectal sensation measurements and endoanal ultrasound were performed. There were 6 patients in each group. Bowel function questioning revealed that PREOP had significantly more incontinent episodes than SA patients (SA 2.9 ± 1.3, PREOP 10.3 ± 3.4, POSTOP 3.8 ± 0.6 episodes per week: p < 0.05; values expressed as mean ± SEM). The rectal volume of initial distension sensation on barostat ramp program testing was more impaired in the POSTOP than in PREOP group (SA 27.4 ± 5.3, PREOP 17.8 ± 4.3, POSTOP 37.5 ± 6.8 ml; p < 0.05). The left pudendal nerve motor terminal latency was more prolonged in the POSTOP than in the SA patients (SA 1.9 ± 0.2, PREOP 2.3 ± 0.1, POSTOP 4.3 ± 0.7 ms; p < 0.05). Patients who had preoperative radiotherapy had more incontinent episodes, and the rectal sensation may be more impaired after postoperative radiotherapy. Received: 30 December 1999 / Accepted: 17 January 2000     

Diagnosing anal sphincter injury with transanal ultrasound and manometry

PURPOSE: This study was undertaken to evaluate how well anorectal manometry and transanal ultrasonography diagnose anal sphincter injury. METHODS: Anorectal manometry and transanal ultrasonography were performed in 20 asymptomatic nulliparous women and 20 asymptomatic parous women, and the results were compared with those obtained in 31 incontinent women who subsequently underwent sphincteroplasty and, thus, had operatively verified anal sphincter injury. By using computerized manometry analysis, mean maximum resting and squeeze pressures, sphincter length, and vector symmetry were determined in all women. All transanal ultrasounds were interpreted blinded as to the patient's history, physical examination, and manometry results. RESULTS: Manometric resting and squeeze pressures were significantly higher in the asymptomatic nulliparous women than in the asymptomatic parous women, and both groups had significantly higher pressures than the incontinent women ( P <0.001). Anal sphincter length and vector symmetry index were significantly decreased in incontinent women compared with asymptomatic women ( P <0.01). Decreased resting and squeeze pressures suggestive of possible sphincter injury were found in 90 percent of incontinent women with known anal sphincter injury. Decreased anal sphincter length and vector symmetry were found in only 42 percent of women with known anal sphincter injury. Transanal ultrasound was able to identify 100 percent of the known sphincter injuries but also falsely diagnosed injury in 10 percent of the asymptomatic nulliparous women with intact anal sphincters. False identification of sphincter injury increased when transanal ultrasound scanning was performed proximal to the distal 1.5 cm of the anal canal. CONCLUSION: Although nonspecific, decreased resting and squeeze pressures were found in 90 percent of patients with anal sphincter injury. Decreased anal sphincter length or vector symmetry index were present in only 42 percent of patients with known sphincter injury. When limited to the distal 1.5 cm of the anal canal, transanal ultrasound identified all known sphincter injuries but falsely identified injury in 10 percent of women with intact anal sphincters. Transanal ultrasound in combination with decreased anal pressures correctly identified all intact sphincters and 90 percent of known anal sphincter injuries.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994. Winner of the New England Society of Colon and Rectal Surgeons Award.