Pudendal neuropathy in evacuatory disorders

PURPOSE: Aims of the present study were to assess frequency of pudendal neuropathy in patients with constipation and fecal incontinence, to determine its correlation with clinical variables, anal electromyographic assessment, and anal manometric pressures, and to determine usefulness of the pudendal nerve terminal motor latency assessment in evaluation of these evacuatory disorders. METHODS: From 1988 to 1993, 395 patients (constipated, 172; incontinent, 223) underwent pudendal nerve terminal motor latency, electromyography, and anal manometry. Pudendal neuropathy was defined as a pudendal nerve terminal motor latency greater than 2.2 ms. RESULTS: Patients were a mean age of 60.7 (range, 17–88) years. Overall incidence of pudendal neuropathy was 31.4 percent (constipated, 23.8 percent; incontinent, 37.2 percent; P<0.05). Incidence of pudendal neuropathy dramatically increased after 70 years of age in both groups (22 percent vs. 44 percent; P<0.05). Moreover, subjects with pudendal neuropathy were older than those without pudendal neuropathy (mean age, 67 vs. 57 years; P<0.05). The presence of pudendal neuropathy was associated with decreased motor unit potentials recruitment in patients with incontinence (P<0.01). Patients with and without pudendal neuropathy had a similar mean squeezing pressure in both groups. CONCLUSION: Pudendal neuropathy is an age-related phenomenon. Although pudendal neuropathy is associated with abnormal anal electromyographic findings in patients with incontinence, no association with anal manometric pressures was found. Pudendal nerve terminal motor latency assessment is a useful tool in the evaluation of patients with fecal incontinence, but its role in the assessment of constipated patients remains unknown.     

Transanal ultrasound and manometry in the evaluation of fecal incontinence

PURPOSE: This preliminary study was undertaken to clarify the role of ultrasonography of anal sphincters in the colorectal laboratory. METHODS: Twenty-eight parous female patients with fecal incontinence were evaluated with transanal ultrasonography (TAUS), anal manometry, and pudendal nerve terminal motor latency (PNTML). Ultrasound images were recorded and labeled in centimeters from the anal verge. The continuity of the internal anal sphincter (IAS) was identified as either intact or disrupted. The separation of the external anal sphincter (EAS) was measured at the 1.5-cm level and below. TAUS findings were then compared with anal manometric pressures. Clinical data were obtained by patient interview and examination during TAUS. RESULTS: Evidence of IAS disruption was associated with significantly decreased mean maximum resting pressures (P=0.023). EAS separation was inversely proportional to mean maximum squeezing pressures (r=?0.61). In the group of patients offered sphincteroplasty, the IAS was disrupted more often (P=0.016), mean maximum resting pressures were significantly lower (P=0.023), mean EAS separation was significantly greater (P=0.022), and mean PNTML was significantly faster (P=0.004). Twenty-five percent of patients with normal clinical examinations had significant muscular injury by TAUS requiring sphincteroplasty. CONCLUSIONS: Manometric findings correlate significantly with anal sphincter defects visualized by TAUS. TAUS is useful in the evaluation and management of patients with fecal incontinence.     

Subtotal colectomy for ulcerative colitis: Complications related to the rectal remnant

Complications related to the retained rectal remnant were reviewed in 136 patients undergoing subtotal colectomy for acute ulcerative colitis. Fifty-five patients (Group 1) had a closed rectal stump brought up into the subcutaneous tissue, and 30 (Group 2) had an open mucous fistula. These were compared with an intrapelvic Hartmann's pouch performed in 51 patients (Group 3). All patients eventually had a pelvic pouch procedure. Age, duration and activity of disease, and preoperative steroid use were similar in all groups. There was no mortality. The rectal stump in 19 Group 1 patients (35 percent) spontaneously opened, and seven (13 percent) developed local left lower quadrant wound infections. Two Group 1 patients (4 percent) developed pelvic septic complications, as compared with two Group 2 patients (7 percent) and six Group 3 patients (12 percent). Subsequent pelvic dissection was difficult in 20 percent of Group 3 patients,vs. 4 percent and 0 percent of Group 1 and Group 2 patients, respectively (P <0.05). Persistent rectal disease activity was present in 41 percent of Group 3,vs. 27 percent of Groups 1 and 2. Our study suggests that exteriorization of the closed rectal stump following subtotal colectomy is associated with fewer pelvic septic complications and minimal local morbidity, facilitates subsequent pelvic dissection, and is not associated with increased disease activity in the retained rectum.     

Anal sensitivity test: What does it measure and do we need it?

PURPOSE: This study was undertaken to determine the anal sensitivity in controls and in different patient groups and to establish factors that determine anal sensitivity. METHODS: Anorectal function tests were performed in 387 patients with different anorectal diseases. Anal sensitivity was measured in 36 controls. Anal sensitivity was measured by means of mucosal electrosensitivity (MES) using a catheter with two electrodes placed in the anal canal. A constant current (square wave stimuli 100 μsec, pulses per second) was increased stepwise from 1 to 20 mAmp until the threshold sensation was reached. Other tests used were anal manometry (maximum basal pressure, maximum squeeze pressure, rectal compliance (maximum rectal volume and pressure), endosonography (submucosal thickness), defects and thickness of internal and external sphincter), electromyography (maximum contraction pattern, Grade 1 (solitary contractions) to Grade 4 (interference pattern)), and pudendal nerve terminal motor latency. Multiple regression analysis was performed. It was postulated that age, local conditions (anal scars, anal fissures, hemorrhoids, mucosal prolapse, proctitis, sphincter thickness and defects, and submucosal thickness), and neurologic factors could influence anal sensitivity. RESULTS: Controls had an MES of 3.4±1.7. MES was significantly increased compared with controls in patients with fecal incontinence, soiling, hemorrhoids, mucosal prolapse, constipation, anal scars, anal surgery, and sphincter defects; patients with fecal incontinence had the highest MES (6.7±4.3;P <0.0001). Patients with anal fissures and proctitis showed no differences compared with controls. MES correlated significantly with age (R =0.29), maximum basal pressure (R =?0.29), maximum squeeze pressure (R =?0.32), submucosal thickness (R =0.19), maximum contraction pattern (R =?0.39), single-fiber electromyography (R =0.39), and maximum rectal volume and pressure (0.14). Multiple regression analysis showed that age, internal sphincter defects, and submucosal thickness significantly influenced anal sensitivity, but explained only 10 percent of the variance. CONCLUSION: Anal sensitivity is diminished in all patients with anorectal diseases except for anal fissures and proctitis. There are correlations with other anorectal function tests. Anal sensitivity is determined for 10 percent by age, internal sphincter defects, and thickness of the submucosa. Anal sensitivity measurement, therefore, has limited clinical value and should be used in conjunction with other tests in a research setting.     

Fecal seepage and soiling: A problem of rectal sensation

PURPOSE: To determine the physiologic alteration resulting in fecal seepage and soiling, results of anorectal manometric testing were evaluated in patients with varying degrees of fecal incontinence. METHODS: Anal manometric studies performed on 170 patients with fecal incontinence were reviewed. Results of their studies, including mean resting pressure, maximum resting pressure, maximum squeezing pressure, minimum rectal sensory volume, and minimum volume at which reflex relaxation first occurs, were compared with those of 35 control group subjects with normal fecal continence. Manometric studies were performed using a four-channel, water-perfused catheter. Incontinent patients were divided into three groups based on presenting complaints: complete incontinence (incontinence of gas and liquid and solid stool), partial incontinence (incontinence of gas and liquid), and seepage and soiling (incontinence of small amounts of liquid and solid stool without immediate awareness). RESULTS: Resting pressures were significantly lower in complete incontinence, partial incontinence, and seepage and soiling groups than in the controls (P<0.001). Resting pressures of the complete incontinence group were also significantly lower than those of the partial incontinence and seepage and soiling groups (P=0.03). Squeezing pressures were lower for both the complete incontinence and partial incontinence groups than for those in the control group (P<0.001) and in the seepage and soiling group, which did not differ significantly from controls. The minimum rectal sensory volume was greater in all incontinent groups than in controls (P<0.001). Sensory volume of the seepage and soiling group was significantly greater than that of the complete incontinence and partial incontinence groups (P<0.01). The difference between sensory volume and the volume producing reflex relaxation was greatest in the seepage and soiling group and differed from that of the partial incontinence and control groups. CONCLUSIONS: These findings suggest that the mechanism of incontinence is different in seepage and soiling patients and involves a dyssynergy of rectal sensation and anal relaxation. Patients with the pattern of seepage and soiling may be successfully treated with stool bulking agents (e.g.,psyllium or bran).     

Outcome of the pelvic pouch procedure in patients with prior perianal disease

PURPOSE: There is concern that patients with presumed ulcerative colitis and significant perianal disease may in fact have Crohn's disease. Moreover, prior perianal disease may be an independent factor for poor outcome of the pelvic pouch. The aim of this study was to evaluate the effect of prior perianal disease on pelvic pouch outcome. METHODS: Between 1982 and 1994, 52 of 753 patients (6.9 percent) who had a pelvic pouch procedure were prospectively identified as having perianal disease. Outcome of the pelvic pouch of these 52 patients (Group I) were compared with the outcome of 701 pelvic pouch patients with no prior perianal disease (Group II). The perianal diseases identified in Group I were fissure-in-ano (17), perianal abscesses (13), fistula-in-ano (7), rectovaginal fistula (3), and significant hemorrhoids/skin tags (25). Eleven patients (21 percent) had more than one type of perianal disease. Twenty-seven patients (52 percent) required a total of 33 perianal operations for the different anal pathologies. RESULTS: Both groups were comparable for the following characteristics: age at time of pelvic pouch procedure, pathology (ulcerative colitis or indeterminate colitis), design of pouch, and type of ileoanal anastomosis (handsewn or stapled). An ileoanal anastomosis leak developed in 21 percent of patients (n=11) in Group I vs.11.4 percent (n=80) in Group II (P<0.05). Perianal postoperative complications occurred in 11.5 percent of patients (n=6) in Group I vs.1.7 percent (n=12) in Group II (P<0.05). Total pouch failure rate was not significantly different between the two groups (11.5 vs.7.6 percent;P>0.05). Crohn's disease was subsequently diagnosed in 1.9 vs.2.7 percent (P>0.05). Subgroup analysis of Group I patients showed no significant difference in outcome according to type of perianal lesion or a history of perianal surgery. CONCLUSION: Prior perianal disease significantly increases the risk of developing an ileoanal anastomotic leak and postoperative perianal complications. However, a pelvic pouch procedure may be an acceptable surgical alternative for selected ulcerative colitis patients with prior perianal disease because the overall pouch failure rate is not significantly increased.     

Defecography and proctography

PURPOSE: Radiographic imaging of dynamic changes within the pelvic cavity and rectum during evacuation has been recognized as a valuable method of assessment. This study was designed to assess the incidence and clinical significance of defecographic findings in patients with possible evacuation disorders. MATERIALS AND METHODS: All defecographic studies were reviewed by a single colorectal surgeon familiar with patients' histories and physical findings. RESULTS: Between July 1988 and July 1995, 744 patients (566 females and 178 males) with a mean age of 63.5 (range, 12–95) years had defecographic and proctographic examination. Four hundred forty-six (60 percent) patients were diagnosed who complained of constipation, 123 (16.5 percent) of fecal incontinence, 42 (5.6 percent) of rectal prolapse, 82 (11 percent) of rectal pain, and 51 (6.9 percent) had a combination of more than one of these diagnoses. Although 93 (12.5 percent) of these evaluations were considered normal, 61 (8 percent) revealed rectal prolapse, 191 (25.7 percent) rectocele, 82 (11 percent) sigmoidocele, and 94 (12.6 percent) intussusception; in 223 (30 percent) patients, a combination of these findings was noted. Patients with paradoxical puborectalis contraction had an extremely high frequency of constipation compared with other symptoms ( P <0.0001). CONCLUSION: Defecography can reveal abnormalities in the majority of patients with evacuatory disorders. There was a high incidence of rectocele, sigmoidocele, and intussusception. Care must be taken not to treat patients strictly based on radiographic findings.     

Effect of fibrin sealant on perianastomotic tumor growth in an experimental model of colorectal cancer surgery

Viable intraluminal tumor cells can penetrate a clinically intact rodent colonic anastomosis and give rise to perianastomotic tumor growth. The aim of this study was to determine whether transanastomotic cell migration can be prevented by fibrin-based tissue sealant. Following distal colonic transection and reanastomosis with 5/0 silk sutures, Fischer F344 rats were randomly allocated to three experimental groups. In Group A, a circumferential ring of tissue sealant was placed around the serosal surface of the anastomosis; in Group B, sealant was limited to 50 percent of the anastomotic circumference; and, in Group C, no sealant was applied. All rats then had 10 ⁵ Mtln ₃ carcinoma cells injected into the proximal colonic lumen via a rectal catheter. The incidence of perianastomotic tumor at 21 days was significantly lower in Group A (3 of 14 animals) than in Group B (11 of 16 rats) (P =0.012; Fisher's exact test) or Group C (10 of 14 rats;P=0.011). A further experiment demonstrated that sealant did not protect the anastomosis when tumor cells were instilled directly into the peritoneal cavity. A topical carcinocidal action therefore appears unlikely, but our results suggest that a circumferential anastomotic ring of fibrin sealant forms an effective mechanical barrier preventing intraluminal tumor cells from reaching the peritoneal cavity.     

Action ofin situ nitroglycerin on upper anal canal pressure of patients with terminal constipation

Nitroglycerin (NTG) in situ reduces the pressure of the upper anal sphincter (UAS). We have tested the effects of NTG on the UAS of patients with terminal constipation. We studied two groups of constipated patients. Group 1 consisted of 11 patients (nine females and two males) with hypertonicity of the UAS (>70 mm Hg); age was 49.5±15.6 years. Group 2 consisted of 10 patients (nine females and one male) without hypertonicity; age was 40.1±14.1 years. Group 3 consisted of eight asymptomatic controls (four females and four males); age was 51.7±6.9 years. After a 10-minute resting pressure recording of the UAS with a water-filled balloon, the probe was pulled through the outside and the UAS was assessed after spreading 5 mg of placebo and then 5 mg of NTG on the balloon. Resting pressure (RP), delay of the pressure decrease (DP), pressure after five minutes either during the NTG (PN5) or placebo (PP5) period, and mean duration of the pressure decrease (MD) were measured. None of the subjects experienced a decrease of PP5 vs.RP. All patients in Group 1 (106.2 vs.38.4 mm Hg), Group 2 (57.9 vs.31.4 mm Hg), and controls (62.2 vs.33.7 mm Hg) experienced a significant decrease of pressure of the UAS (P <0.005). Delay of the pressure decrease was less than two minutes, with wide interindividual variability of duration of the pressure decrease. Mild side effects—anal pain and transient headache—were reported in five patients.In situ NTG significantly reduced UAS Pressure in all groups. NTG has to be evaluated in anal pathology, especially in patients with hypertonic sphincter terminal constipation or acute hypertonicity of the sphincter due to a fissure.     

Vectormanometry for differential diagnosis of fecal incontinence

PURPOSE: This study was designed to investigate the reliability of three-dimensional vectormanometry for differential diagnosis of fecal incontinence. METHODS: Eight-channel, continuous pull-out perfusion manometry was performed on 23 female patients with traumatic (n=11) or idiopathic (n=12) incontinence, respectively. RESULTS: At rest, the minimum sector pressure of patients with traumatic incontinence (32±14 mmHg) was significantly lower than it was in the controls (76±16 mmHg) and in those with idiopathic incontinence (64±28 mmHg) (P<0.001). At maximum squeezing, the minimum sector pressure was 57±22 mmHg in patients with traumatic incontinence and 79±33 mmHg in those with idiopathic incontinence, both being significantly lower than in the control group with 152±27 mmHg (P<0.001). The asymmetry index of the patients with a sphincter defect was significantly higher, both at rest (23±13 percent) and squeeze (26±12 percent), in comparison with the control group (7 ±2 percent at rest and 6.2±1.6 percent at squeeze) and the patients with idiopathic incontinence (10±5 percent at rest and 8.4±4 percent at squeeze). CONCLUSION: Three-dimensional vectormanometry identifies localized pressure deficits in the anal canal, thereby differentiating between sectorial and global sphincter insufficiency.     

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.     

Cumulative incidence of metachronous colorectal cancer

The incidence of metachronous colorectal cancer has most often been reported as a crude rate: second cancers/index cancers. The reported incidence varies between 0.5 percent and 3.6 percent. However, these calculations do not take into account factors such as length of survival and length of follow-up. The cumulative incidence more accurately reflects the risk for developing a metachronous cancer and was determined in a retrospective analysis of 5,476 patients who were diagnosed with colon or rectal cancer between 1965 and 1985. The cumulative probability was calculated by determining the number of patients developing a metachronous colon cancer vs.the number remaining at risk at that point in time. The calculated annual incidence for metachronous tumors was 0.35 percent per year. The cumulative incidence at 18 years was 6.3 percent. Analysis also demonstrated that metachronous cancers were diagnosed at earlier stages than were index cancers (P=0.03). Subgroup analysis was performed on patients diagnosed with metachronous cancer before and after 1980. There was a difference in the incidence of metachronous cancers between these two groups (P=0.04).     

Anorectal manometric examination in encopretic-constipated children

PURPOSE: We have investigated the use of anorectal manometry to distinguish encopretic-constipated children (n=88) from sibling controls (n=16) and nonsibling controls (n=11). METHODS: Study variables included manometrically determined resting and maximum voluntary anal sphincter pressure, depth and speed of rectoanal inhibitory reflex, minimum rectal volume sensation, critical distending volume for fecal urgency, rectal and anal pressure responses during attempted defecation, and ability to defecate a water-filled balloon. RESULTS: Change in anal sphincter pressure during attempted defecation (P=0.03), gradient between rectal and sphincter pressure during attempted defecation (P=0.02), critical distending volume for fecal urgency (P=0.02), and ability to defecate a water-filled balloon (P=0.05) distinguished encopretic-constipated from control children. The change in rectal pressure associated with the rectoanal inhibitory reflex just escaped significance at P=0.07. CONCLUSIONS: Anal sphincter spasm and megacolon are pathophysiologic abnormalities associated with pediatric constipation-encopresis.     

Relationship between manometric anal waves and fecal incontinence

PURPOSE: The significance of manometric anal waves is uncertain, and their fate and diagnostic importance are unknown. It is conceivable that in neurogenic fecal incontinence (NFI) the frequency and amplitude of these waves may be altered into specific, recognizable patterns. Evaluation of this unexplored relationship between fecal incontinence and anal manometric waves has potential diagnostic use. METHODS: Anal motility was studied in 20 patients, each with NFI and traumatic fecal incontinence (TFI), and results were compared with findings in 20 control subjects to determine changes in frequency and amplitude of anal waves in fecal incontinence. RESULTS: Frequency of slow waves when present (NFI=9.5/minute; TFI=9.5/minute; control subjects=9.1/minute) was identical in the three groups (P>0.05). Amplitude of slow waves (NFI=mean, 4.3 mmHg; TFI=mean, 3.9 mmHg; control subjects =mean, 6.6 mmHg) was reduced in patients who were incontinent compared with control subjects but failed to reach statistical significance (P>0.05). Frequency of ultraslow waves when present (NFI=mean, 0.75/minute; TFI =mean, 0.6/minute; control subjects=mean, 1.2/minute) was not statistically different between the three groups (P>0.05). Amplitude of ultraslow waves (NFI=mean, 10.5 mmHg; TFI=mean, 23.4 mmHg; control subjects=mean, 29.6 mmHg) was significantly reduced in NFI vs.control subjects (P<0.01) and between TFI vs.control subjects (P<0.05). CONCLUSIONS: Manometric slow and ultraslow waves, when present, retain their frequency characteristics, irrespective of underlying disease. Amplitude of slow waves was not statistically different from control subjects, but the amplitude of ultraslow waves was significantly decreased in patients who were incontinent.     

Openvs. closed sphincterotomy for chronic anal fissure

PURPOSE: This study was undertaken to compare the healing rate and long-term effects on continence of open and closed lateral internal sphincterotomy. METHODS: Charts of 864 patients with chronic anal fissure who underwent internal sphincterotomy as a single procedure over five years by a group of 12 colorectal surgeons were reviewed. Open internal sphincterotomy (OIS) was performed in 521 patients, whereas 343 had closed internal sphincterotomy (CIS). There was no difference in sex or age between the groups. A questionnaire inquiring about clinical outcome, changes in continence, and degree of satisfaction with the procedure was mailed to all patients. A total of 549 (63.5 percent) patients, 324 (62.2 percent) with OIS and 225 (65.6 percent) with CIS, returned their questionnaires. Average follow-up was three (range, 1–6) years. RESULTS: Differences in persistence of symptoms (3.4 OIS vs. 5.3 percent CIS), recurrence of the fissure (10.9 vs. 11.7 percent CIS), and need for reoperation (3.4 percent OIS tvs. 4 percent CIS) were statistically not significant. However, statistically significant differences were seen in the percentage of patients with permanent postoperative difficulty controlling gas (30.3 vs. 236 percent;P 0.062), soiling underclothing (26.7 vs. 16.1 percent;P < 0.001), and accidental bowel movements (11.8 vs. 3.1 percent;P < 0.001) between those who underwent OIS and those who had CIS. Although 90 percent of patients reported general overall satisfaction, more patients undergoing CIS (64.4 percent) than OIS (49.7 percent) were very satisfied with the results of the procedure. CONCLUSIONS: Lateral internal sphincterotomy is highly effective in treatment of chronic anal fissure but is associated with significant permanent alterations in continence. CIS is preferable to OIS because it effects a similar rate of cure with less impairment of control.     

Simplified solid sphere test to investigate anal sphincter strength in patients with anorectal diseases

PURPOSE: The solid sphere test has not gained general acceptance to investigate anal sphincters, despite its simplicity and low cost. We studied continent and incontinent patients to evaluate whether the solid sphere test is suitable in assessment of anal sphincter function. METHODS: Seventy colorectal patients with anal incontinence of varying severity were studied by means of incontinence grading, solid sphere test, and anal manometry. RESULTS: Anal sphincter strength, studied using the solid sphere test, declined gradually with increasing severity of anal incontinence from 1,186 (±334, SD) g in 28 continent patients to 619 (±256, SD) g in 13 patients with daily soiling (P<0.001). The test also correlated with anal manometry; there was positive correlation with maximum basal pressure (tr=0.643,P<0.001) and maximum voluntary contraction pressure (r=0.393,P<0.01). CONCLUSION: The solid sphere test is useful in the primary assessment of patients with anal incontinence as a screening test, but alone it is too inaccurate for clinical decision making.     

Rate and treatment of pelvic recurrence after abdominoperineal resection and low anterior resection for rectal cancer

PURPOSE: This study was designed to analyze factors of importance for local recurrence after radical surgery for rectal cancer and to analyze course and outcome of treatment of pelvic recurrence. METHODS: One hundred seventy-five patients treated for rectal cancer with low anterior resection (LAR) or abdominoperineal resection (APR) were studied, retrospectively. Seventy-four patients had LAR and 101 had APR. RESULTS: The two groups were comparable with respect to Dukes classification, histologic differentiation, and male to female ratio. The rate of pelvic recurrence was 18 percent for LAR and 24 percent for APR (not significant). Recurrence rates were 27 percent after stapled anastomoses and 10 percent after handsewn anastomoses respectively (P=0.09). Twenty five had pelvic recurrence diagnosed without signs of distant metastatic disease. They were treated with radiotherapy, palliative operations, or analgesics. The group receiving radiotherapy had a significantly longer survival (15.9 months) compared with other groups (2.4 months;P <0.001). CONCLUSIONS: There is no difference in local recurrence rate after LAR and APR. Radiotherapy seems to increase survival in patients with an unresectable recurrence and should be offered irrespective of pain.     

Must early postoperative oral intake be limited to laparoscopy?

PURPOSE: This prospective, randomized study was designed to evaluate whether or not early postoperative feeding (claimed as a unique benefit of laparoscopic surgery) is possible after laparotomy and colorectal resection. METHODS: The trial was performed between July 1, 1992 and October 31, 1992 and included all 64 consecutive patients who underwent laparotomy with either a colonic or an ileal resection. In all cases the nasogastric tube was removed immediately after the operation. Group 1 consisted of 32 patients (age range, 15–81 years; mean, 52 years) who received a regular diet on the first postoperative morning. Group 2 consisted of 32 patients (age range, 15–87 years; mean, 52 years) who were fed in a traditional manner. Regular food was permitted after resolution of ileus as defined by resumption of bowel movements in the absence of abdominal distention, nausea, or vomiting. RESULTS: The rate of nasogastric tube reinsertion for distention with persistent vomiting was 18.7 percent (six patients) in Group 1 and 12.5 percent (four patients) in Group 2. Although vomiting was experienced more frequently by patients in Group 1 (44 percent vs. 25 percent, respectively), there was no difference between the two groups with regard to the duration of postoperative ileus (3.6 vs. 3.4 days, respectively). In the 26 patients from Group 1 who did not require nasogastric tube reinsertion, there was a trend toward shorter hospitalization (6.7 vs.8.0 days, respectively). CONCLUSION: Early oral intake is possible after laparotomy and colorectal resection. Thus, the laparoscopic surgeon's claim of early tolerated oral intake may not be unique to laparoscopy.     

A twenty-year review of malignant colorectal neoplasms at University College Hospital,Ibadan, Nigeria

PURPOSE: Colorectal malignancies are less common in developing than developed nations because of lower per capita income and higher dietary fiber consumption. This clinicopathologic study attempts to determine changes in the pattern of these neoplasms in Ibadan, Nigeria, during the last two decades. METHODS: The present study is based on the clinical Cancer Registry records and gross and morphologic surgical pathology findings of 526 patients with histologically verified malignant colorectal neoplasms received in the Department of Pathology, University College Hospital, Ibadan, between 1971 and 1990. RESULTS: Colonic malignancies increased by 81 percent, whereas rectal malignancies decreased 16.1 percent in frequency (P <0.05). The modal ages were 55 to 60 years and 45 to 50 years for colonic and rectal neoplasms, respectively, in contrast to reported peak occurrence in the seventh decade among Caucasians. Colonic neoplasms were predominantly right-sided (34.3 percent cecal), abdominal mass and pain being major clinical manifestations. This differs from the pattern in American Negroes, among whom colonic carcinomas are predominantly left-sided, dyschezia being an important presentation. As in most other studies, adenocarcinomas were the predominant neoplasms. CONCLUSIONS: Further work is required to determine prognostically significant features of colorectal cancer in our environment.     

Indeterminate colitis

Uncertainty persists concerning the long-term results of ileal pouch-anal anastomosis performed for indeterminate colitis. PURPOSE: This study was designed to compare functional outcomes of ileal pouch-anal anastomosis in patients with typical chronic ulcerative colitis and indeterminate colitis. METHOD: Seventy-one ileoanal pouch patients were identified with a diagnosis of indeterminate colitis. Mean follow-up was 56 months. Outcomes were compared with 1,232 chronic ulcerative colitis patients after ileal pouchanal anastomosis. Mean follow-up was 60 months. RESULTS: (mean±SD) There was no difference in the frequency of daily bowel movements (indeterminate colitis, 7±3,vs.chronic ulcerative colitis, 7±2). Daytime and nighttime incontinence rates were likewise similar. Prevalence of pouchitis was identical (33 percent). However, failure rate was higher in the indeterminate colitis group (indeterminate colitis, 19 percent,vs. chronic ulcerative colitis, 8 percent; (P =0.03)). CONCLUSIONS: At a mean of nearly five years after surgery, failure appears to occur more frequently in patients with indeterminate colitis than in patients with chronic ulcerative colitis. However, the great majority of indeterminate colitis patients (>80 percent) have long-term functional results identical to those of patients with chronic ulcerative colitis.