Anorectal manometry in the diagnosis of paradoxical puborectalis syndrome

This prospective study was undertaken to compare the utility of anorectal manometry (ARM) with that of anal electromyography (EMG) and cinedefecography (CD) in the diagnosis of paradoxical puborectalis syndrome (PPS). One hundred sixteen consecutive patients with a history of chronic constipation were prospectively assessed. These 35 males and 81 females were of a mean age of 60 years, ranging from 18 to 84 years. The incidences of PPS were 63 percent for ARM, 38 percent for EMG, and 36 percent for CD. The correlations of PPS were suboptimal: ARM and EMG, 70 percent; and ARM and CD, 61 percent. A two-tiered system for the manometric classification of PPS was developed. First, the evacuation pressure curve pattern was classified as a normal relaxed downward (Type A; n=43), a nonrelaxed flat or equivocal (Type B; n=36), and a paradoxical upward (Type C; n=37). PPS was noted with increasing incidence within curve types (21 percent in Type A, 64 percent in Type B, and 95 percent in Type C). Second, an evacuation index (EI = evacuation pressure/squeeze pressure) was defined: Group I (El<0; n=43), Group II (0EI<0.25; n=24), Group III (0.25EI<0.5; n=27), and Group IV (EI0.5; n=18). The finding of PPS also correlated with the EI group: 21 percent in Group I, 67 percent in Group II, 74 percent in Group III, and 100 percent in Group IV. This subdivision of curve types and EI groups may provide a role in the diagnosis of PPS.Dr. Ger was a visiting colorectal surgeon from the Section of Colon and Rectal Surgery, Department of Surgery, National Defense Medical Centre and Tri-Service General Hospital, Taipei, Taiwan, R.O.C.     

Paradoxical puborectalis contraction in patients after pelvic pouch construction

Normal defecation is associated with relaxation of sphincters during the evacuation process. However, obstructive defecation is sometimes seen clinically manifested by abnormal contraction of the puborectalis during defecation rather than relaxing. This condition has not previously been described after pelvic pouch construction. PURPOSE: This study was done to evaluate patients for defecation difficulties caused by paradoxical puborectalis contraction after pelvic pouch procedures. METHODS: Prospectively, patients with defecation difficulties were questioned. They then underwent electromyography if they met particular criteria. Biofeedback was offered to all patients demonstrating paradox on electromyography. Follow-up was by clinic visits and interviews. RESULTS: After pelvic pouch construction, 13 patients were found to have paradoxical puborectalis contraction. Twelve of 13 patients elected to have biofeedback therapy. Eleven of these 12 were available for follow-up an average of eight (1–15) months after biofeedback. Nine improved, and two had no change in their defecation difficulty. Of the initial 13, 10 had an event, either pouchitis or abdominal trauma, directly before their defecation problems. CONCLUSION: Paradoxical puborectalis contraction can occur in patients after pelvic pouch surgery. It should be suspected in patients with defecation difficulties in the absence of an anatomic abnormality. Biofeedback is effective treatment.Read at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

Pudendal neuropathy is not related to physiologic pelvic outlet obstruction

Chronic straining because of pelvic outlet obstruction is hypothesized to cause pudendal neuropathy (PN) by stretch injury. PURPOSE: The aim of this study was to determine any association between PN and pelvic outlet obstruction. METHODS: One hundred forty-seven constipated patients were evaluated by cinedefecography and pudendal nerve terminal motor latency assessment. PN was defined as a latency longer than 2.2 ms. Pelvic outlet obstructive patterns of evacuation included paradoxic contraction, nonrelaxation of the puborectalis muscle, or failure of opening of the anal canal. RESULTS: Median length of constipation including straining during evacuation was eight (range, 1–47) years. Ninety-one (62 percent) subjects had a normal pattern of evacuation, and 56 (38 percent) had an obstructed pattern. Both groups had a similar median age (68 tvs.69 years, respectively;P>0.05) and same median length of symptoms. Overall incidence of PN was 23.8 percent (10.9 percent unilateral and 12.9 percent bilateral). There was no difference in the incidence of PN between patients with normal evacuation and patients with obstructed evacuation (24.2 percent vs.23.2 percent, respectively;P>0.05). Patients with PN had a similar incidence of physiologic pelvic outlet obstruction as did patients without PN. However, median age of patients with PN was higher than those without PN (73 tvs.66 years, respectively;P>0.05). CONCLUSION: There was a difference in the incidence of PN between normal and obstructed patterns of evacuation. Therefore, the espoused theory that obstructed defecation causes PN appears flawed.Dr. Carlos Vaccaro was a research fellow from the Section of Colon and Rectal Surgery, Department of Surgery, Italian Hospital, Buenos Aires, Argentina.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Orlando, Florida, May 8 to 13, 1994.     

A constipation scoring system to simplify evaluation and management of constipated patients

PURPOSE: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14–92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P<0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9). CONCLUSION: The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.     

Paradoxical puborectalis contraction is associated with impaired rectal evacuation

The role of paradoxical puborectalis contraction in the aetiology of constipation and how to best diagnose this condition is controversial. The aims of this study were to investigate whether absolute or relative paradoxical electrical activity during electromyography (EMG) are related to rectal emptying and to compare EMG, defecography and digital examination in the diagnosis of paradoxical puborectalis contraction. Included in the study were 171 consecutive patients with idiopathic constipation; 136 of these cases were also classified as paradoxical or unclear or not paradoxical at digital examination. Absolute amplitudes and a strain/squeeze index were used to grade the EMG activity in the puborectalis and external sphincter muscle. Rectal evacuation was analysed by defecography with image analysis of rectal area. The results showed that 142 patients had paradoxical EMG activity during straining. There was a correlation between rectal evacuation and amplitudes (r=–0.20 to –0.03, P<0.01) and between evacuation and index (r=–0.34 to –0.39, P<0.0001). Forty-two patients with an index of >50 had impaired rectal evacuation compared with those with an index ≤50 (P<0.0001). Thirty-three of 34 cases (n=136) with an index of >50 also were paradoxical at defecography whereas 19 were diagnosed digitally. In conclusion, paradoxical puborectalis contraction is associated with impaired rectal evacuation. The activity seems to be best reflected by a strain/squeeze index. The best correlation in diagnostic methods was between EMG and defecography. Accepted: 10 February 1998     

Patient position during cinedefecography

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

Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction

Eighteen patients with chronic constipation were diagnosed as having paradoxical puborectalis contraction (PPC) as the cause for their constipation. The diagnosis of PPC was made after office evaluation, colonic transit study, manometry, cinedefecography, and electromyography (EMG). These 18 patients had a mean duration of symptoms of 26.9 years; none of these patients had unassisted bowel movements. Fourteen patients had a mean of 4.6 laxative-induced bowel evacuations per week, and 11 patients had a mean of 4.4 enema-induced bowel evacuations per week. Patients underwent a mean of 8.9 one-hour EMG-based biofeedback sessions. At a mean follow-up of 9.1 (range, 0.5–12) months, these 18 patients had a mean of 7.3 unassisted bowel actions per week ( P <0.0001). In addition, persistent laxative use was reported by only two patients, and, in both cases, this was once a week or less ( P <0.001). Similarly, enema use was reported by only three patients, one once weekly and the other two thrice weekly ( P <0.002). No biofeedback-related complications were identified. EMG-based biofeedback is a valuable technique associated with an 89 percent success rate in the treatment of PPC.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Electromyographic findings of paradoxical puborectalis contraction correlate poorly with cinedefecography

Abstract. Background: Both intra-anal sponge electromyography (SEMG) and needle electromyography (NEMG) are used to diagnose paradoxical puborectalis contraction (PPC). The aim of this retrospective study was to assess the correlation among SEMG and NEMG and cinedefecography (CD) in the diagnosis of PPC. Methods: Between 1992 and 1999, a total of 261 constipated patients underwent both CD and EMG: 64 had NEMG while 197 had SEMG. PPC was diagnosed by EMG when there was failure to achieve a significant decrease in electrical activity of the puborectalis muscle during attempted evacuation. CD criteria for PPC included lack of straightening of the anorectal angle or persistence of the puborectalis impression during evacuation. CD was considered diagnostic and EMG results were thus compared with those of CD. Agreement was calculated using the kappa statistics () for concordance. Results: Both NEMG and SEMG had low positive predictive rates (33% in NEMG, 28% in SEMG) and high negative predictive rates (91% in NEMG, and 78% in SEMG) when correlated with CD findings. Agreement between NEMG and CD was noted in 46 of 64 patients (72%, =0.274) while there was agreement between SEMG and CD in 120 of 197 patients (61%; =0.067); p>0.05 needle vs. sponge. Conclusion: Although both NEMG and SEMG have a low positive predictive values, they have high negative predictive value for PPC. Therefore, neither NEMG nor SEMG alone are optimal tests for diagnosing the presence of PPC.This work was presented in poster format at the Annual Meeting of the Association of Coloproctology of Great Britain and Ireland, 19–12 July 2000, Brighton, UK.     

Initial North American experience with botulinum toxin type a for treatment of anismus

PURPOSE: Botulinum toxin type A (BTX-A), produced by Clostridium botulinum,is a potent neurotoxin. The purpose of this study was to evaluate the efficacy of BTX-A for treatment of anismus. MATERIALS AND METHODS: All patients treated with BTX-A for anismus were evaluated. Eligibility criteria included a history of chronic assisted evacuation (laxatives, enemas, or suppositories), demonstration of anismus by cinedefecogram and electromyography, and failure of a minimum of three sessions of supervised biofeedback therapy (BF). Contingent on body mass, 6 to 15 units of BTX-A was injected bilaterally under electromyography guidance into the external sphincter or the puborectalis muscle. Treatment was repeated as necessary for a maximum of three sessions during a three-month period. Success was considered as discontinuation of evacuatory assistance and was evaluated between one and three months and again at up to one year. RESULTS: Between July 1994 and May 1995, four patients ranging from 29 to 82 years in age (2 females, 2 males) had anismus that failed to respond to between 3 and 15 biofeedback sessions. All patients improved between one and three months after BTX-A injection, and two had sustained improvement for a range of three months to one year. There was no morbidity or mortality associated with BTX-A injection. CONCLUSIONS: BTX-A is extremely successful for temporary treatment of anismus that is refractory to BF management. However, because the mechanism of action is short, longer term results are only 50 percent successful. Hopefully, modifications in the strain of BTX-A and dose administered will allow longer periods of success or a repeat trial of BF. Nonetheless, this preliminary report is very encouraging in offering a method of managing this recalcitrant condition.Supported in part by a grant from the Cleveland Clinic Florida Institutional Review Board and the David G. Jagelman MD Memorial Research and Education Fund.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1996.     

Preoperative biopsy of pararectal lymph nodes in rectal cancer using endoluminal ultrasonography

PURPOSE: Because definitive information regarding lymph node status in rectal cancer would be valuable preoperatively, we evaluated the safety, feasibility, and accuracy of performing endoluminal ultrasound-guided biopsies of pararectal lymph nodes in 26 rectal cancer patients. Biopsies were compared with the pararectal tissues removed at surgery. METHODS: Using a longitudinally oriented 7.0-MHz ultrasound probe and an 18-gauge spring-loaded core biopsy needle, patients underwent biopsies of lymph nodes detected ultrasonographically without complications. RESULTS: A biopsy of adenocarcinoma was obtained in 13 patients, lymphoid material in 5 patients, and irrelevant material in 8 patients. Accuracy rate (true positives divided by number of procedures) was 77 percent, with a sensitivity of 71 percent, a specificity of 89 percent, a positive predictive value of 92 percent, and a negative predictive value of 62 percent. When adenocarcinoma or lymphoid material was obtained, there was only one false positive and one false negative. CONCLUSION: Endoluminal ultrasonographyguided lymph node biopsy is simple and safe, and when adenocarcinoma or lymphoid material is obtained on biopsy, clinical decision making can be based on this information.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.Winner of the Pennsylvania Society of Colon and Rectal Surgeons Award.     

Role of pudendal nerve terminal motor latency assessment in constipated patients

The importance of pudendal nerve terminal motor latency assessment for the evaluation of incontinence is well established. However, its role in constipated patients remains unclear. PURPOSE: The purpose of the present study was to assess the incidence of pudendal neuropathy in constipated patients and its correlation with others variables including age, sex, anal pressures, and anal electromyography. RESULTS: From 1988 to 1993, 161 patients with chronic constipation underwent pudendal nerve terminal motor latency assessment, anal electromyography, and anal manometry. The overall incidence of pudendal neuropathy was 23.6 percent; females and males had a similar incidence (24 percentvs. 23 percent, respectively;P >0.05). Patients over 70 years old had a significantly higher incidence of pudendal neuropathy than did patients under 70 years (37 percentvs. 12 percent, respectively;P<0.01). Patients with paradoxical puborectalis contraction on anal electromyographic assessment had a higher incidence of bilateral neuropathy, paradoxical puborectalis contraction (+)23 percentvs. paradoxical puborectalis contraction (–)8 percent,P<0.05. Patients with pudendal neuropathy also had a higher incidence of decreased motor units potential recruitment than did patients without pudendal neuropathy (31.5 percentvs. 17 percent, respectively;P>0.05). CONCLUSIONS: Pudendal nerve terminal motor latency assessment was able to detect unsuspected pudendal neuropathy in 24 percent of patients. This finding correlated with age and with the presence of paradoxical puborectalis contraction but not with manometric anal pressures, motor unit potentials recruitment, or the presence of polyphasia. However, the often espoused relationship between pudendal latency and external sphincter function could not be demonstrated.Dr. Vaccaro is a visiting surgeon from the Section of Colon and Rectal Surgery, Department of Surgery, Italian Hospital, Buenos Aires, Argentina.Dr. Cheong is a visiting surgeon from the Department of Surgery, Tan Tock Seng Hospital, Singapore.     

Positron emission tomography for preoperative staging of colorectal carcinoma

PURPOSE: Positron emission tomography (PET) is an imaging technique based onin vivo cellular metabolism. Increased glucose metabolism in neoplastic cells is detected by using fluorine-18 deoxyglucose. In an ongoing pilot study to determine the usefulness of this technique, PET is compared with computerized tomography (CT) for the preoperative staging of colorectal carcinoma. METHODS: Sixteen patients were evaluated with both PET and CT of the abdomen and pelvis. Results were compared with operative and histopathologic findings. Fifteen malignant lesions were found in 16 patients by histology. PET had a positive predictive value of 93 percent and a negative predictive value of 50 percent. By comparison CT had a positive predictive value of 100 percent and a negative predictive value of 27 percent. CONCLUSIONS: These preliminary results indicate that PET has increased sensitivity for staging colorectal carcinoma, whereas CT has higher specificity. The predictive value of a positive PET compares favorably with CT. Furthermore, the predictive accuracy for detection of colorectal carcinoma is 83 percent for PET and 56 percent for CT.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.Presented in part in the Nebraska Medical Journal, February 1993.     

The effect of stool consistency on rectal and neorectal emptying

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

Progress in the assessment of lymphatic spread in rectal cancer Rectal endoscopic lymphoscintigraphy

Rectal endoscopic lymphoscintigraphy was performed in 10 control subjects and in a series of 85 patients with adenocarcinoma of the rectum as a prospective study to evaluate lymphatic drainage of the rectum and lymphatic spread in rectal cancer. Complete cranial drainage was demonstrated in all control subjects, and internal iliac nodes were also visible in 50 percent of cases. Results were correlated with histologic node examination in all patients operated upon for rectal cancer. Rectal endoscopic lymphoscintigraphy was assessed for sensitivity (85 percent), specificity (68 percent), overall accuracy (76 percent), positive predictive value (71 percent), and negative predictive value (83 percent). False-negative and false-positive results are discussed. Rectal endoscopic lymphoscintigraphy represents the only method currently available for evaluation of lymphatic spread in rectal cancer.     

Colectomy for constipation: Physiologic investigation is the key to success

The results of total abdominal colectomy (TAC) with ileorectal anastomosis as a treatment for colonic inertia (CI) were prospectively assessed. One hundred sixtythree patients were evaluated for chronic constipation between July 1988 and November 1990. Patients underwent pancolonic transit times, anorectal manometry, cinedefecography (CD), and electromyography (EMG). CI was defined as diffuse marker delay on transit study without evidence of puborectalis contraction on CD or EMG. Sixteen patients (10 percent; 15 females and 1 male) with a mean age of 45 years (range, 24–75 years) with CI underwent TAC. Preoperative bowel frequency ranged from three per week to one per month; all 16 patients evacuated only with high doses of laxatives, enemas, or both. TAC was performed with no postoperative mortality or major morbidity; three patients were readmitted four times for successful conservative treatment of partial small bowel obstruction. At a mean followup of 15 months (range, 2–35 months), these 16 patients reported a mean frequency of spontaneous bowel evacuations of 3.5 per day (range, one to six per day). Patient satisfaction with the operation was excellent or good in 15 cases (94 percent). Thorough preoperative physiologic evaluation permits the selection of a small group of patients with CI who may benefit tremendously from TAC.Read at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Balloon expulsion test facilitates diagnosis of pelvic floor outlet obstruction due to nonrelaxing puborectalis muscle

We compared balloon expulsion, defecography, colonic transit times, anal manometry, and electromyography in 21 patients with severe constipation. Defecography demonstrated nonrelaxation of the sphincter during straining in all patients. Only 12 patients were unable to expel a balloon. Colonic transit was normal (five) or showed rectosigmoid delay (seven). All 12 patients were offered biofeedback. The nine patients able to expel a balloon had normal colonic transit (six) or colonic inertia (two). Rectosigmoid delay was due to severe intussusception in one patient. Anal manometry and pudendal nerve latencies revealed no difference between those who could and those who could not expel a balloon. Balloon expulsion seems to be a more reliable way to diagnose pelvic floor outlet obstruction due to nonrelaxation of the puborectalis muscle. Nonrelaxation of the sphincter on defecography should be correlated with balloon expulsion and colonic transit studies.Read at the meeting of The American Society of Colon and Rectal Surgeons, St. Louis, Missouri, April 29 to May 4, 1990.     

Current follow-up strategies after resection of colon cancer

The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown. PURPOSE: The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts. METHODS: The 1,663 members of The American Society of Colon and Rectal Surgeons were asked, via a detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five post-treatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy. RESULTS: Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (>75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1,2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III. CONCLUSION: The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993.     

Clinical course of Crohn's disease in older patients

The authors retrospectively reviewed the records of 50 patients whose initial diagnosis of Crohn's disease was made after the age of 50 years on the basis of strict histopathologic criteria. Progress of the 32 women and 18 men with a median age of 60 years (range, 50 to 78 years) was followed for a median of 95.5 months (range, 81.1 to 236.6 months). The most common presenting signs and symptoms were abdominal pain (82 percent), diarrhea (70 percent), weight loss (56 percent), bleeding from the gastrointestinal tract (26 percent), abdominal mass (16 percent), and fistula (14 percent). Initial operations performed were ileocolic resection (38 percent), proctocolectomy (16 percent), small bowel resection (10 percent), colostomy (2 percent), and a variety of segmental resections of the colon (34 percent). The overall recurrence rate of disease in patients in whom all obvious disease was resected, based on distribution of disease, was 80 percent (ileocolitis), 38 percent (ileitis), and 35 percent (colitis). Crohn's disease more often affects the distal gastrointestinal tract in older age groups. After resection, however, the clinical course is similar to that of the younger population. The high recurrence rate of Crohn's colitis is probably a result of the large number of initial segmental resections.Read at the Annual Meeting of The American Society of Colon and Rectal Surgeons, Toronto, Canada, June 11 to 16, 1989.     

Adenocarcinoma of the anal glands

Anal gland adenocarcinoma is rare, with information concerning this lesion communicated mostly as case reports. Cases seen by authors, combined with a survey of the membership of The American Society of Colon and Rectal Surgeons, allowed 52 cases with sufficient data for analysis. It became clear from the survey that most colorectal surgeons have not treated this malignancy. Predominant symptoms are anal pain (58 percent), rectal bleeding (40 percent), and the presence of perianal mass (37 percent). Fifty-four percent of patients present with a fistula, the incidence of fistula being significantly higher in males. Metastases, which may be inguinal, pelvic, or hepatic, are present at diagnosis in 13.5 percent of patients. Three-fourths of patients are eventually treated by abdominoperineal resection (APR). Twelve percent of the patients in this series had an APR after a failed local excision. The conclusions from this study are: 1) if local excision is attempted, it must be complete, and the patient must be followed closely for many years, and 2) APR is needed in most patients for local control, with the role of subsequent radiation therapy and/or chemotherapy not yet defined.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Boston, Massachusetts, May 12 to 17, 1991.     

Application of the colorectal laboratory in diagnosis and treatment of functional constipation

Defecography, pelvic floor electromyography, and segmentai colonic transit times were performed in 74 patients with functional constipation. Signs of functional outlet obstruction occurred in 74 percent. Transit times were normal in 33 percent. Measurement of colonic transit time in patients with disordered evacuation studies is useless from a clinical point of view, because abnormal segmental transit time is the result of outlet obstruction in most cases and will return to normal after adequate treatment. Only when evacuation studies are normal, or have become normal after treatment and constipation persists, are segmental transit studies indicated because they may demonstrate primary slow transit constipation. Primary slow transit constipation probably is caused by impaired motility of the whole gastrointestinal tract. As small-bowel transit time increases, defecation frequency decreases, laxatives are taken again, and abdominal pain persists. Surgery should be performed with restraint.Read at the meeting of The American Society of Colon and Rectal Surgeons, Anaheim, California, June 12 to 17, 1988.Reprints will not be available.