The effect of posterior rectopexy on fecal continence

Twenty-three patients with rectal prolapse or intussusception were studied to specifically focus on the effect of posterior rectopexy on fecal continence, anal pressure, and rectal capacity. Before operation, five patients were fully continent (A), 10 were continent for solid stools (B) and eight patients were fully incontinent (C). Group A remained fully continent; continence was regained nine times in group B and in group C, three patients regained full continence, two became continent for solid stools, three patients remained incontinent. Other symptoms such as constipation, false urgency, and a feeling of incomplete evacuation were not beneficially influenced by rectopexy. The patients' continence status was correlated to anorectal manometry and rectal capacity measurement. In group B, incremental pressure (P=squeeze — basal P) increased significantly (P<0.02) as well as incremental volume (V=maximum tolerated volume-volume of first sensation) (P<0.05). We conclude that, by an increase of incremental anal pressure and incremental rectal volume, posterior rectopexy offers an 83 percent chance of regaining full continence, or a major improvement, and a 17 percent chance of stabilization of fecal incontinence.Read at the spring meeting of the British Society of Gastroenterology, Bradford, April 1989.     

Results of treatment for rectal prolapse and fecal incontinence

Fifty-six patients were treated for rectal prolapse or incontinence. Rectal prolapse was present in 32 patients and was associated with fecal incontinence in 24 (75 per cent). Incontinence without prolapse was present in 24 patients, 12 of whom were less than 40 years old. Rectopexy was used for treatment of rectal prolapse. Surgical treatment of fecal incontinence was by post-anal repair; external sphincter reconstruction and surgery was advised only if control of diarrhea and electrical therapy had been of no benefit. Rectopexy was completely successful at controlling rectal prolapse in all cases, and only four of the 20 (20 per cent) patients with incontinence and prolapse remained incontinent after rectopexy alone. Incontinence was completely controlled by postanal repair in 58 per cent of patients and by external sphincter repair alone or in combination with postanal repair in 67 per cent. Using a combination of therapies 45 of 48 patients who were initially incontinent were improved (94 per cent), and 42 of the patients have complete control of defecation (87 per cent).     

Ripstein procedure is an effective treatment for rectal prolapse without constipation

The operation of choice for complete rectal prolapse is controversial. We reviewed 169 patients undergoing 185 surgical procedures for rectal prolapse over a 27-year period. The most common surgical procedure employed was the Ripstein procedure (n=142) and is the focus of this report. Other surgical procedures used included resection rectopexy (n=18), anterior resection (n=7), Altemeier's (n=9), Delorme's (n=2), and anal encirclement (n=7). The median age was 59 years (range, 12–94 years), and the female-to-male ratio was 51. The incidence of fecal incontinence, solitary rectal ulcer syndrome, and prior surgery elsewhere for rectal prolapse was 40 percent, 12 percent, and 19 percent, respectively. Operative mortality was 0.6 percent; morbidity was 16 percent. Median follow-up was 4.2 years (range, 1–15 years). Complete recurrence of prolapse after the Ripstein procedure was 8 percent; one-third of these patients recurred 3 to 14 years after surgery. Fecal incontinence improved after the Ripstein procedure or resection rectopexy in about half the patients. Persistence of prior constipation was more common after the Ripstein procedure than after resection rectopexy (57 percent vs. 17 percent;P=0.03, chi-squared). Fifteen patients developed constipation for the first time after the Ripstein procedure. About one in three patients, irrespective of surgical procedures, remained dissatisfied with the final outcome despite anatomic correction of the prolapse. The Ripstein procedure has proven to be a safe procedure with good anatomic repair of the prolapse and may improve continence. In the presence of constipation, procedures other than the Ripstein procedure may be preferable.Read in part at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 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.     

Surgery for Rectal Prolapse: Orr-Loygue Ventral Rectopexy With Limited Dissection Prevents Postoperative-Induced Constipation Without Increasing Recurrence

Purpose Abdominal rectopexy is the preferred surgical technique for the treatment of total rectal prolapse. In many reported series, its results are impaired by induced constipation. Lateral rectal ligaments preservation could prevent constipation but increase recurrence rates. We report anatomic and functional results of abdominal Orr-Loygue ventral rectopexy with dissection limited to anterior and posterior rectal wall. Methods Consecutive patients with total rectal prolapse or intra-anal rectal prolapse associated to fecal incontinence or outlet obstruction were treated by abdominal rectopexy. Recurrences, correction of symptoms, and induced constipation were prospectively analyzed. Results Seventy-three patients were treated between 1993 and 2004. Recurrence was observed in 3 of 73 patients (4.1 percent) after a mean follow-up period of 28.6 (range, 6–84) months. Overall patient satisfaction (correction of prolapse, incontinence, and/or outlet obstruction) after the procedure was classified in three categories: Cured: n = 45 (61.6 percent); Improved: n = 24 (32.9 percent); Failure: n = 4 (5.5 percent). Postoperative constipation appeared in 2 of 36 (5.5 percent) preoperatively nonconstipated patients and worsened in 2 of 37 (5.4 percent) preoperatively constipated patients. Conclusions Orr-Loygue abdominal ventral rectopexy with limited dissection and preservation of rectal lateral ligaments is a safe and effective procedure for the treatment of complete rectal prolapse, or internal prolapse associated with fecal incontinence or outlet obstruction. Preservation of lateral ligaments seems to prevent postoperative constipation without increasing the risk of prolapse recurrence.     

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

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

Recovery of anal sphincter function following transabdominal repair of rectal prolapse: Cause of improved continence?

Twenty-eight patients with complete rectal prolapse underwent anorectal manometry before and 6 months and 1–2 years after abdominal rectopexy and sigmoid resection in a study of the mechanisms responsible for postoperatively improved anal continence. Preoperatively, 22 patients reported defective anal control. Seven patients (all with minor incontinence) regained normal control and eight other patients achieved improved continence after surgery. Anal resting, squeeze, and voluntary contraction pressures were significantly lower for defective than for normal control, with a significant rise in these pressures at 6 months after the operation, except for those incontinent patients in whom continence was not improved. No further pressure rise was seen later. Improvement of continence was not accompanied by changes in rectal sensation or reflexive functions of the internal anal sphincter. These results suggest that recovery of the resting and voluntary contraction functions of the sphincter muscles was the cause of continence improvement observed after surgery. Anal manometry was unable to predict outcome of function. Therefore, supplementary procedures for restoration of continence are not advisable, although patients with only minor incontinence are likely to regain full continence after rectopexy alone.     

Abdominal rectopexy for complete prolapse: Prospective study evaluating changes in symptoms and anorectal function

The effect of abdominal rectopexy on bowel function is difficult to assess in retrospective studies because preoperative bowel habit cannot be determined accurately. This study examined bowel symptoms and physiologic tests of anorectal function prospectively in 23 patients before and at three months after rectopexy. Rectopexy eliminated complete prolapse in all and stopped bleeding in 16 of 18 patients. Incontinence improved significantly. Constipation (<3 bowel actions per week or straining for more than 25 percent of defecation time) was relieved in 4 of 11 affected patients but developed in 5 of the 12 who were not constipated preoperatively. Since the median bowel frequency was 21 motions per week before surgery and 17 afterward, the main determinant of constipation was straining. Abdominal pain was relieved after rectopexy in 6 of 12 patients but developed in 3 of 13 who were pain-free before surgery. Three patients (13 percent) had a first-degree relative with rectal prolapse. Perineal descent decreased significantly. Maximal anal resting pressure increased significantly, but this did not correlate significantly with improved continence. Twenty-one patients (91 percent) could expel a 50-ml balloon preoperatively; 18 of those 21 could still do so postoperatively. The two patients who could not expel the balloon preoperatively were able to do so postoperatively. This study shows that rectal prolapse is associated with profoundly abnormal defecation and abdominal pain. While abdominal rectopexy improved continence, it may improve or worsen other bowel symptoms, including constipation.Support for this study was received from the Imperial Cancer Research Fund, ICI Pharmaceuticals (SA) Ltd., the St. Mark's Research Foundation, and the Medical Research Council of South Africa.     

Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse

PURPOSE: The study was undertaken to evaluate the role of laparoscopic suture rectopexy without resection as a safe and effective treatment for full-thickness rectal prolapse. METHOD: Data were prospectively collected and analyzed on 25 patients who underwent laparoscopic rectopexy without resection for full-thickness rectal prolapse between October 1994 and July 1998. Four patients had conversions from laparoscopic to open surgery. Two patients had recurrent prolapse previously managed by Delorme's procedure. Another two patients had solitary rectal ulcer syndrome associated with their full-thickness rectal prolapse. There were a total of three males. Mean age was 72 (range, 37–89) years. The preoperative and postoperative course of each patient was followed up, with attention paid to first bowel movement, hospital stay, duration of surgery, fecal incontinence, constipation, recurrent prolapse, morbidity, and mortality. Follow-up was made by clinic appointments and, if necessary, by telephone review. RESULTS: Median follow-up period was 26 (range, 1–41) months. Mean duration of surgery was 96 (range, 50–150) minutes. Postoperatively, the median time for first bowel movement was four (range, 2–10) days. Median hospital stay was seven (range, 3–23) days. Overall, 15 patients (60 percent) either improved or remained unchanged with respect to continence. There was an improvement in 10 of 20 patients (50 percent) among those with continence Grade 2 or more (P<0.05). Seven patients (28 percent) remained incontinent. No patient became more incontinent after surgery. Constipation, which was present in 9 patients (36 percent) preoperatively, affected 11 patients (44 percent) after rectopexy (P>0.05; not significant). Postoperative morbidity included a port site hernia and deep venous thrombosis in one patient, a repaired rectal perforation, a retroperitoneal hematoma with prolonged ileus (1 case), and a superficial wound infection (1 case). One patient with solitary rectal ulcer syndrome in the laparoscopic surgery group remained unhealed despite resolution of the rectal prolapse after rectopexy and required abdominoperineal resection. Two patients (laparoscopic surgery = 1 and open surgery = 1) had severe constipation after surgery and both required loop colostomies. There were no cases of operative mortality or recurrent prolapse. CONCLUSION: Laparoscopic suture rectopexy without resection is both safe and effective in this frequently frail population and offers a minimally invasive approach that may have potential advantages for selected groups of patients with full-thickness rectal prolapse.Mr. Hartley was supported by an education grant from Autosuture UK.Presented in part to the Association of Surgeons of Great Britain and Ireland, Brighton, United Kingdom, May 4 to 7 1999.     

Spectrum of abnormal rectoanal reflex patterns in patients with fecal incontinence

PURPOSE: Abnormalities of rectoanal inhibitory or excitatory reflex in patients with fecal incontinence are well described. A spectrum of abnormal responses, other than those already described in the literature, has been observed in some patients with fecal incontinence and forms the subject of this report. METHOD: Forty-three patients with idiopathic or traumatic fecal incontinence were studied to evaluate their reflex responses to balloon distention of the rectum, and results were compared with reflex responses of 29 control subjects with no anorectal complaints. RESULTS: Control subjects revealed normal reflex responses consisting of initial excitation followed by inhibition in the proximal anal canal and an excitatory response in the distal anal canal. Patients who were incontinent revealed five different types of reflex patterns. Eleven patients (25.5 percent) with segmental sphincter defects from obstetric injuries exhibited no distal excitation but had normal response in the proximal anal canal (Group 1). Eleven patients (25.5 percent) with idiopathic incontinence exhibited normal proximal response but an inhibitory as opposed to excitatory response in the distal anal canal (Group 2). Three patients (7 percent) with iatrogenic trauma failed to register an excitatory response in the proximal or distal anal canal but revealed a normal inhibitory reflex (Group 3). Nine patients (21 percent) with idiopathic incontinence revealed excitatory response in the entire anal canal but no inhibition (Group 4). Nine patients (21 percent) with idiopathic incontinence had a normal reflex pattern (Group 5). CONCLUSION: Excitatory and inhibitory components of rectoanal reflexes may selectively be abolished in neurogenic or traumatic insults to visceral and somatic anal sphincters, resulting in altered rectoanal reflex patterns.Read in part at the meeting of the New England Society of Colon and Rectal Surgeons, Stowe, Vermont, March 18 to 20, 1994.     

Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse

PURPOSE: The aim of this study was to determine the prevalence, severity, and associations between urinary incontinence and genital prolapse in females after surgery for fecal incontinence or rectal prolapse. METHODS: All patients who underwent surgery for fecal incontinence (Group I) or rectal prolapse (Group II) were compared with a control group of females (Group III) by 43 questions regarding demographic data, past medical and surgical history, and diagnosis and treatment of anal and urinary incontinence and genital and rectal prolapse. The type (stress, urge, and total) of urinary incontinence was determined and graded using an incontinence severity questionnaire (Individual Incontinence Impact Questionnaire). RESULTS: Overall response rate in the three groups of patients was 40.1 percent. The questionnaire was sent to 240 patients operated on for fecal incontinence or rectal prolapse, and 83 of them responded (34.5 percent). The patients were distributed into three groups: Group I consisted of 51 patients (mean age 56.7 +/- 14); Group II consisted of 32 patients (69.7 +/- 11); and Group III consisted of 40 patients (60.5 +/- 16). The prevalence of urinary incontinence in Group I was 27 (54 percent), in Group II was 21 (65.6 percent), and Group III was 12 patients (30 percent; P = 0.003). Genital prolapse was present in 9 (17.6 percent), 11 (34.3 percent), and 5 patients (12.5 percent), respectively (P = 0.03). The prevalence of coexistent urinary incontinence and genital prolapse in both study groups was 22.8 percent (19 patients). There were no statistically significant differences between Groups I and II relative to prevalence, type, and severity of urinary incontinence and genital prolapse, but there were significant differences between the two study groups and the control group. Of the patients in the study group, 67 percent had urinary incontinence before or at the time of surgery. CONCLUSION: There is a higher prevalence and severity of urinary incontinence and pelvic genital prolapse in females operated on for either fecal incontinence or rectal prolapse than in a control group. Therefore, female patients with fecal incontinence or rectal prolapse should be evaluated and treated by a multidisciplinary group of pelvic floor clinicians, including a gynecologist or urologist with special training in female pelvic floor dysfunction and a colorectal surgeon.     

Combined anorectal manometry and defecography in 50 consecutive adults with fecal incontinence

Fifty consecutive patients presenting with fecal incontinence were evaluated prospectively with anorectal manometry, defecography, and other tests of anorectal function to assess the clinical utility of defecography in fecal incontinence. Leakage of contrast at rest and failure to narrow the anorectal angle with pelvic squeezing were specific but not sensitive predictors of decreased sphincter pressures as determined by manometry. Thus, after manometry, defecography provided no additional information regarding sphincter strength. Retention of contrast in large rectoceles or incomplete rectal evacuation at defecography had excellent correlation with the presence of clinical symptoms of outlet obstruction constipation (present concurrently with incontinence) and indicated an etiology of outlet obstruction symptoms. Defecography may provide useful information in incontinent patients with outlet obstruction constipation symptoms but has little additive value to anorectal manometry in incontinent patients without such symptoms.     

Anorectal dysfunction and rectal prolapse in progressive systemic sclerosis

Our aim was to characterize the clinical spectrum of anorectal dysfunction among eight patients with progressive systemic sclerosis (PSS) who presented with altered bowel movements with or without fecal incontinence. The anorectum was assessed by physical examination, proctosigmoidoscopy, and anorectal manometry. There was concomitant involvement of the other regions of the digestive tract in all patients as determined by barium studies, endoscopy, or manometry: eight esophageal, three gastric, four small bowel, and two colonic. Seven patients had fecal incontinence, and four also had second-degree complete rectal prolapse. Abnormal anorectal function, particularly abnormal anal sphincter resting pressures, were detected in all patients; anal sphincter pressures were lower in those with rectal prolapse. Rectal capacity and wall compliance were impaired in seven of seven patients. Successful surgical correction of prolapse in three patients resulted in restoration of incontinence for six months and seven years in two of the three patients. We conclude that rectal dysfunction and weakness of the anal sphincters are important factors contributing, respectively, to altered bowel movements and fecal incontinence in patients with gastrointestinal involvement by PSS. Rectal prolapse worsens anal sphincter dysfunction and should be sought routinely as it is a treatable factor aggravating fecal incontinence in patients with PSS.This work was presented in part at the Annual Meeting of the American Gastroenterological Association, May 1992, and appears in abstract form in Gastroenterology 1992;102:A473.Supported in part by the General Clinical Research Center Grant 00585 from the National Institutes of Health.     

Anal encirclement with polypropylene mesh for rectal prolapse and incontinence

Seventeen selected patients (mean age, 74 years)—14 with rectal prolapse and 3 with persisting anal incontinence after previous operations—underwent high anal encirclement with polypropylene mesh. There was no operative mortality. Prolapse recurred in 2 (15 percent) of the 13 patients followed up for 6 months or more (mean, 3.5 years). Three (27 percent) of the 11 patients with associated anal incontinence improved functionally, as did the three operated on for persisting incontinence, but only one patient regained normal continence. No breakage, cutting out, or infection related to the mesh was observed. Because of the risk of fecal impaction encountered in three of our patients, the procedure is not advocated for severely constipated patients. Despite the somewhat disappointing results regarding restoration of continence, we find this method useful in patients with rectal prolapse who are unfit for more extensive surgery, in controlling the prolapse to an acceptable degree.     

Enterocele is correctable using the Ripstein rectopexy

PURPOSE: About one-third of the patients with rectal prolapse or rectal intussusception have concurrent enterocele at defecography. The purpose of this study was to evaluate the effect of the Ripstein procedure on the concurrent enterocele and to study the outcome of the procedure with respect to the patients' symptoms. METHODS: Twenty-two patients with enterocele and either rectal prolapse or rectal intussusception at defecography were treated using the Ripstein procedure. Postoperatively, the patients were evaluated with clinical examination (22 patients) and defecography (16 patients). RESULTS: None of the patients had recurrence of enterocele, rectal prolapse, or intussusception at postoperative follow-up. Continence was improved in 15 of 16 incontinent patients. Emptying difficulties were unchanged in eight patients, improved in five patients, and had deteriorated in four patients. CONCLUSIONS: Enterocele is corrected by using the Ripstein rectopexy. Persisting defecation difficulties after the Ripstein procedure are unlikely to be secondary to enterocele. The Ripstein procedure can be an alternative in the treatment of enterocele, as a majority of these patients also have rectal prolapse or rectal intussusception.     

Prospective trial of pelvic floor retraining in patients with fecal incontinence

PURPOSE: Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence. METHODS: PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29–85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy. RESULTS: Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P <0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound. CONCLUSIONS: PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.Read at the Tripartite Colorectal Meeting, London, United Kingdom, July 8 to 10, 1996.     

Functional Results After the Orr-Loygue Transabdominal Rectopexy for Complete Rectal Prolapse

PURPOSE: The aim of this study was to assess functional results after Orr-Loygue transabdominal rectopexy for complete rectal prolapse. METHODS: Thirty-one consecutive patients operated on for complete rectal prolapse between 1995 and 1998 were evaluated preoperatively and postoperatively with regard to anal incontinence, constipation, evacuation difficulties, and overall satisfaction with a standardized questionnaire. Anal continence assessment was based on a clinical scoring system. RESULTS: After a mean follow-up of 28 ± 13 (range, 12–57) months, no prolapse recurred. Preoperative and postoperative rates of incontinence were 81 percent (25/31) and 55 percent (17/31), respectively (P < 0.03). Continence improved in 24 (96 percent) of the 25 patients who were incontinent before surgery. The mean incontinence score decreased from 11.7 ± 7.8 preoperatively to 3.2 ± 4.2 postoperatively (P < 0.001). The self-reported constipation rate was 61 percent (19/31) before surgery and 71 percent (22/31) after surgery (P = nonsignificant). Constipation appeared or worsened in 16 patients (52 percent), whereas it disappeared or improved in 8 (26 percent; P = nonsignificant). Evacuation difficulties increased significantly after surgery from 23 percent (7/31) to 61 percent (19/31; P < 0.003). Ninety-seven percent of patients reported good or very good satisfaction. CONCLUSIONS: Transabdominal Orr-Loygue rectopexy resulted in improved continence and a high satisfaction level. Despite a significant postoperative increase in evacuation difficulties, only a 10 percent (nonsignificant) increase in the self-reported constipation rate was observed.     

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.     

Anorectal pressure gradient in patients with anal incontinence

Anorectal pressures in patients with fecal incontinence have been investigated. With anal manometry, 34 percent of patients with fecal incontinence had maximal resting pressure and 39 percent had maximal squeeze pressure within the normal range. When a pressure gradient was calculated as the pressure difference between maximal resting pressure and rectal pressuring during filling of a rectal balloon, patients with fecal incontinence could be better distinguished from controls: 20 percent of patients with fecal incontinence had values within the normal range when the rectal pressure at the earliest defecation urge was used (P <0.05), and 12 percent had values within the normal range when the rectal pressure at maximal tolerable volume was used (P <0.01). Anorectal pressure gradient measurements seem to distinguish patients with fecal incontinence from controls better than maximal resting pressure or maximal squeeze pressure alone.     

Disorders of impaired fecal control a clinical and manometric study

Two hundred eight patients with retention disorders have been studied. Most frequent causes were idiopathic (107), iatrogenic (57), and obstetric (33). Twenty-five patients experienced soiling, 31 had insufficient function, and 152 complained of incontinence. Seventy percent of patients with idiopathic incontinence did not experience urge, compared with 38 percent with iatrogenic and only 3 percent with obstetric incontinence. The incidence of prolapse was 58 percent in patients with idiopathic incontinence, 20 percent in patients with iatrogenic incontinence, and only 3 percent in patients with obstetric incontinence. The authors conclude that the function of the puborectalis sling is to create the anorectal angle to evoke the feeling of urge and to support intra-abdominal contents and, furthermore, that fecal incontinence after anorectal surgery was likely caused by denervation. Anal resting and squeeze pressures varied widely. There was a huge overlap in the different groups. Mean resting and squeeze pressures were 9.5 kPa and 9.4 kPa, respectively, in controls, 4.8 kPa and 10.3 kPa, respectively, in the soiling group, 7.1 and 6.1 kPa, respectively, in the insufficient group, and 5.1 and 2.7 kPa, respectively, in the incontinent group. An incontinent external sphincter function could be defined as a function of the external sphincter causing a pressure increase of 5 kPa or less during straining. The ability to retain feces, therefore, is based on external sphincter function. Anal manometry is, indeed, a suitable technique to determine anal sphincter functions, but the presence of a retention disorder cannot definitely be determined. Its clinical application remains under discussion.