Anorectal function in the solitary rectal ulcer syndrome

The anorectal function of nine patients with solitary rectal ulcer syndrome (SRUS) (5 F: 4 M, median age, 27 (range, 19–41 years) and nine control subjects (5 F: 4 M, median age, 47 (35–66)P<0.01) has been investigated by a new technique that radiologically visualizes the anorectum during voiding of a semisolid contrast medium, while simultaneously measuring intrarectal pressure and anal sphincter EMG activity. A degree of rectal prolapse was demonstrated in eight of the SRUS patients; six of these lesions were clinically occult. Abnormal failure of the anal sphincter to relax on voiding was present in seven of the SRUS patients. These abnormalities resulted in the SRUS patients requiring a greater increase in intrarectal pressure (median, 100 cm water) to void than the control subjects (median, 65 cm water,P<0.01). This combination of high intrarectal pressure and rectal prolapse during straining seems to be the cause of SRUS This work was supported by a grant from the Medical Research Council.     

Anorectal ergotism: another cause of solitary rectal ulcers

Anorectal ulceration was observed in 6 patients who excessively used suppositories containing ergotamine tartrate. The mucosal lesions of the rectum resembled those observed in the "solitary rectal ulcer syndrome." However, characteristic features of ergotamine-induced ulcers are absence of a mucosal prolapse, lack of a history of constipation, and rapid healing after discontinuation of the drug. Furthermore, the rectal lesion may be associated with anal ulceration, which occasionally presents as the only clinical manifestation of "anorectal ergotism."     

Solitary rectal ulcer syndrome in 102 patients: Do different phenotypes make sense?

BackgroundLittle is known about the pathophysiological mechanisms of solitary rectal ulcer syndrome (SRUS).AimsWe aim to identify the different phenotypes, taking into account complaints, anatomy and anorectal physiology.MethodsComplaints, endoscopy results, and physiology data of patients with histologically proven SRUS were collected and analysed. The associated anorectal diseases were faecal incontinence and obstructed defecation. The clinical aspects of SRUS were compared, and factors associated with anorectal diseases were identified.ResultsOverall, 102 consecutive patients were included. The predominant lesion was a rectal ulcer (66%), and inflammation of the rectal wall was present in 42% of patients. Abnormal rectal capacities and/or rectal perception was observed in more than half. Nearly half (52%) of the patients met the criteria for obstructed defecation and they tended to more frequently have psychiatric disease (66.7% vs 33.3%; p=0.07). Patients with faecal incontinence (17%) reported more self-perception of anal procidentia (p=0.01) and were more likely to have inflammation of the rectal wall (p=0.02), high-grade internal rectal procidentia (p=0.06) and anal hypotonia (p=0.004); their maximum tolerable volume was lower (p=0.004).ConclusionThe characteristics of patients with SRUS suggest different phenotypes. This may be a way to develop a comprehensive treatment strategy.     

Constipation after rectopexy for rectal prolapse

The pathophysiology of constipation after rectopexy remains unclear: acquired anorectal dysfunction or preoperative colonic state are, by turns, the supposed culprit. The aim of this prospective study was to characterize the colorectal motility abnormalities encountered after such a surgical procedure. Twelve patients (10 females, 2 males, aged 50.5±5.2 years) complaining of severe constipation or its worsening after orr rectopexy (OR) for rectal prolapse were studied. Each underwent detailed interrogation as to their symptoms, left colonic manometry (basal and postprandial motor indexes and their caudad gradients in the sigmoid), anorectal manometry, evacuation proctography, and colonic transit time with radiopaque markers. Results were compared to those obtained in two control groups: 10 healthy volunteers (HV) and 12 patients complaining of a rectal prolapse (RP) observed consecutively during the same period of evaluation (June 90 to December 91). Before surgery, the OR and RP groups were similar with respect to mean age, sex ratio, weekly stool frequency, subjective dyschezia and manual anal supplies, constipation symptoms, and anal incontinence. OR patients differed significantly from the RP group in having a lower weekly stool frequency (2.5±2.2 vs 5.2±3.7,P<0.01) and a higher prevalence of abdominal pain (7 vs 1 patients,P<0.05). Above the rectopexy, global (135.9±38 vs 51±30.5 hr,P<0.01) and left (61.6±10 vs 18.2 hr,P<0.01) colonic transit times were significantly higher in OR patients; moreover, the basal motor index gradient was negative in all but one case (–94.1±101 vs 177.3±131,P<0.01). The OR patients differed from HV by their prolonged segmental transit time in the right colon (24.2±14 vs 9.9±8.2 hr,P<0.01) and the negative values of the postprandial colonic motor index (–191±281 mm Hg/min vs 39.8±72 mm Hg/min,P<0.05). No postprandial peristaltic rush was observed in the OR group. Below the rectopexy, the segmental transit time in the rectosigmoid, the qualitative and quantitative rectal emptying during evacuation proctography, and the anal and rectal manometric values were not, for the most part, different between the groups. In conclusion constipation following surgical procedure of rectal prolapse seems to be related in this study to acquired sigmoid motility disturbances above the rectopexy rather than to anorectal emptying.This work has been presented at the Digestive Disease Week (American Gastroenterological Association), San Francisco, California, May 13, 1992.     

Slow transit of the colon associated with severe constipation after the ripstein operation

Eighteen patients with severe constipation after undergoing the Ripstein operation for rectal prolapse (n = 11) or internal rectal procidentia (n = 7) were studied with defecography, anorectal manometry, electromyography of the external anal sphincter and the puborectalis muscle, colonic transit time, and blood tests. Thirteen patients had slow-transit constipation. None showed a completely normal pattern in the parameters studied. The authors emphasize the importance of careful preoperative investigation to identify the patients who have associated colorectal disturbances together with their rectal prolapse or internal rectal procidentia.Read in part at Collegium Internationale Chirurgiae Digestivae Tenth Congress, Copenhagen 1988.     

Pressure and prolapse--the cause of solitary rectal ulceration

The cause of solitary rectal ulceration has been investigated using a method that radiologically visualises rectal voiding whilst simultaneously measuring intrarectal pressure and external anal sphincter electromyographic activity. Control subjects and patients with the solitary rectal ulcer syndrome, both with and without mucosal ulceration, have been studied. A high incidence of rectal prolapse (94%) was present in the patients who voided. Overactivity of the anal sphincter during evacuation contributed to the fact that patients with mucosal ulceration required higher intrarectal pressures to void than the controls and the patients without mucosal ulceration. The results indicate that a combination of rectal prolapse and a high voiding pressure may act to cause the mucosal ulceration in this syndrome by exposing the rectal wall to a high transmural pressure gradient.     

Ultrasonographic patterns in patients with obstructed defaecation

Background Anal ultrasound is helpful in assessing organic anorectal lesions, but its role in functional disease is still questionable. The purpose of the present study is to assess anal–vaginal–dynamic perineal ultrasonographic findings in patients with obstructed defecation (OD) and healthy controls. Materials and methods Ninety-two consecutive patients (77 women; mean age 51 years; range 21–71) with symptoms of OD were retrospectively evaluated. All patients underwent digital exploration, endoanal and endovaginal ultrasound (US) with rotating probe. Forty-one patients underwent dynamic perineal US with linear probe. Anal manometry and defaecography were performed in 73 and 43 patients, respectively. Ultrasonographic findings of 92 patients with symptoms of OD were compared to 22 healthy controls. Anismus was defined on US when the difference in millimetres between the distance of the inner edge of the puborectalis muscle posteriorly and the probe at rest and on straining was less then 5 mm. Sensitivity and specificity were calculated by assuming defaecography as the gold standard for intussusception and rectocele and proctoscopy for rectal internal mucosal prolapse. Since no gold standard for the diagnosis of anismus was available in the literature, the agreement between anal US and all other diagnostic procedures was evaluated. Results The incidence of anismus resulted significantly higher (P < 0.05) in OD patients than healthy controls on anal (48 vs 22%), vaginal (44 vs 21%), and dynamic perineal US (53 vs 22%). A significantly higher incidence of rectal internal mucosal prolapse was observed in OD patients when compared to healthy controls on both anal (61.9 vs 13.6%, P < 0.0001) and dynamic perineal US (51.2 vs.9% P = 0.001). For the diagnosis of rectal internal mucosal prolapse, anal US had a 100% sensitivity and specificity. For diagnosis of rectal intussusception, anal US had an 83.3% sensitivity and 100% specificity and perineal US had a 66.6% sensitivity and 100% specificity. In the diagnosis of anismus, anal ultrasonography resulted in agreement with perineal and vaginal US, manometry, defaecography, and digital exam (P < 0.05). Other lesions detected by US in patients with OD include solitary rectal ulcer, rectocele and enterocele. Damage of internal and/or external sphincter was diagnosed at anal US in 19/92 (20%) patients, all continent and with normal manometric values. Conclusion Anal, vaginal and dynamic perineal ultrasonography can diagnose or confirm many of the abnormalities seen in patients with OD. The value of the information obtained by this non-invasive test and its role in the diagnostic algorithm of OD is yet to be defined.     

Recovery of the internal anal sphincter following rectopexy: A possible explanation for continence improvement

Twenty-one patients suffering from rectal prolapse (n=15) or internal rectal procidentia (n=6) were investigated clinically and by anorectal manometry prior to and six months following rectopexy. Rectal prolapse was associated with incontinence in 67% (10/15) of the patients preoperatively. The moderately or severely incontinent patients had lower than normal maximum anal resting pressures (MAP) and those with severe incontinence also had lower than normal maximum squeeze pressure (MSP). Postoperatively only 20% (3/15) of the patients remained incontinent and none of them suffered severe incontinence. MAP values increased significantly indicating that improvement of the function of the internal anal sphincter may be one of the factors contributing to better continence. Rectal sensibility was impaired in patients with rectal prolapse as compared to 15 controls. There was no postoperative change. Patients with internal rectal procidentia had normal MAP and MSP and no postoperative change could be demonstrated.     

Proktitis aus Sicht der Proktologie*

Proctitis may cause anal bleeding, anal mucus secretion, diarrhea, urge incontinence, pain at defecation, etc. At digital rectal examination a thickened mucosal lining may be palpated and blood is found on the examination glove. At endoscopy erosive or ulcerative lesions are found that bleed easily on contact. Also polyp-like or even tumor-like lesions, telangiectasias and atypical fistulas can be seen. The symptoms and the findings on examination are quite often unspecific; a detailed history of the patient is most important in the work-up for the differential diagnosis. Serological and microbiological examinations should be done as well as biopsies (except for radiation proctitis). Proctitis may occur after applying external agents that cause chemical, thermal as well as pharmaceutical reactions in the rectum. Proctitis may occur after fecal diversion. Ischemic proctitis causes severe pain and fecal incontinence and may occur postoperatively, after shock/anaphylaxis, etc. The solitary rectal ulcer (syndrome) has a more or less mechanical etiology and shows clearly defined pathohistological lesions. It often occurs in women with outlet obstruction and/or rectal, mucosal or hemorrhoidal prolapse. Except for rectal prolapse, treatment of the solitary rectal ulcer is not always simple or successful. The same applies to radiation proctitis that may occur after radiotherapy. Radiated anorectal tissue regenerates slowly or not at all. Therefore invasive procedures should not be performed because of the high risk for the development of ulceration or fistula. Treatment of radiation proctitis is not always simple and it does not have a high level of evidence. In most cases therapy should be performed individually, according to the severity of complaints.     

Contributions of evacuation proctography and anorectal manometry to evaluation of adults with constipation and defecatory difficulty

We prospectively evaluated 36 patients who complained of chronic constipation and/or defecatory difficulties to determine the role of anorectal manometry and evacuation proctography in delineating the pathogenesis of these complaints. Twenty patients with constipation also underwent a colonic transit study with radioopaque markers, which identificd one group with normal transit (N=10) and another with slow transit (N=10). Nine of 36 patients (25%) had inappropriate puborectalis muscle contraction or exhibited weak expulsion efforts during evacuation proctography, and these correlated highly with poor rectal emptying of barium paste (20±6% vs 61±5% in patients with normal relaxation; P<0.01). However, poor rectal emptying did not correlate with the presence of high-grade intussusceptions, large rectoceles, anorectal angles at rest or with straining, rectal diameter, clinical features, or colonic transit. Moreover, abnormal expulsion patterns as seen with anorectal manometry correlated poorly with the presence of inappropriate puborectalis contraction and decreased rectal emptying by proctography. Although anatomic abnormalities occurred frequently in patients with constipation and/or defecatory difficulties, they were also prevalent in asymptomatic controls. In view of these findings, surgical intervention to correct anatomic abnormalities in patients with constipation and/or defecatory difficulties should be considered only with great caution.     

Solitary rectal ulcer and complete rectal prolapse: one condition or two?

We studied the physiological features of patients with complete rectal prolapse and different degrees of solitary rectal ulcer syndrome to determine whether these conditions are likely to form part of the same disorder. 52 solitary rectal ulcer patients (median age 31, 40 females), and 15 complete rectal prolapse patients (median age 31, 12 females) were studied. Solitary rectal ulcer patients were divided into 3 groups, based on the extent of accompanying rectal prolapse (no prolapse, internal prolapse, or external prolapse). Both solitary rectal ulcer patients without prolapse and with internal prolapse had significantly higher maximum anal resting (p<0.01 for both groups) and squeeze pressure (p<0.05 for both groups) than complete rectal prolapse patients. In contrast, solitary rectal ulcer patients having external prolapse were similar to those with complete rectal prolapse. Solitary rectal ulcer patients without rectal prolapse had significantly decreased anal and rectal electrosensitivity (p<0.01 for both) when compared to healthy control subjects. Solitary rectal ulcer patients therefore have a spectrum of clinical and physiological features — this condition may comprise a range of different disease entities. The findings also suggest a different underlying aetiopathophysiology of solitary rectal ulcer from that of complete rectal prolapse.

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Résumé Nous avons étudié les données physiologiques de patients présentant un prolapsus rectal complet et différents degrés du syndrome d'un ulcère solitaire du rectum afin de déterminer si ces conditions constituent des composantes d'un même trouble. Cinquante-deux patients porteurs d'un ulcère solitaire du rectum (médiane 31 ans, 40 femmes) et 15 prolapsus complets du rectum (âge médian 31; 12 femmes) ont été étudiés. Les ulcères solitaires du rectum ont été répartis en 3 groupes selon l'extension du prolapsus rectal (pas de prolapsus, prolapsus interne, prolapsus extériorié). Les patients porteurs d'un ulcère solitaire du rectum sans prolapsus et ceux porteurs d'un prolapsus interne ont une pression anale de repos maximale élevée de manière significative (P<0.001 dans les deux groupes) et une pression de rétention (P<0.005) dans les deux groupes ainsi qu'un canal anal plus long (P<0.005 dans les deux groupes comparativement aux patients porteurs d'un prolapsus rectal complet). A l'inverse, les patients porteurs d'un ulcère solitaire du rectum accompagné d'un prolapsus externe présentaient des valeurs similaires à celles observées en cas de prolapsus rectal complet. Les patients porteurs d'un ulcère solitaire du rectum sans prolapsus ont une diminution significative de l'électrosensitivité anale et rectale (P<0.001 dans les deux groupes) en comparaison à des sujets sains. Les patients porteurs d'un ulcère solitaire du rectum ont donc un large spectre d'anomalies cliniques et physiologiques pouvant comprendre un nombre très varié d'entités pathologiques différentes. Ces constatations suggèrent une étiopathophysiologie différente en cas d'ulcère solitaire du rectum qu'en cas de prolapsus rectal complet.

     

A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment

The management of rectal internal mucosal prolapse (RIMP) is not based on an accepted classification of the lesion which helps to choose the appropriate treatment. The aim of this prospective study was to report a new endoscopic grading of RIMP and to evaluate its clinical value. Thirty-two patients (7 men, 25 women; mean age 56 years, range 28–72) affected by symptomatic RIMP were prospectively classified as follows: RIMP was defined as first degree when detectable below the anorectal ring on straining, as second degree when it reached the dentate line, and as third degree when it reached the anal verge. Anal manometry was carried out in 26 patients, and anal ultrasound and defecography in 6 prior to surgery. A correlation was found between the occurrence and severity of symptoms and the degree of the prolapse as obstructed defecation, bleeding and fecal soiling affected mainly patients with third-degree RIMP. At manometry the maximal resting tone was 60±23 mmHg and voluntary contraction 96±41 mmHg (mean±SEM). At anal ultrasound the mean internal sphincter thickness was 2.1±0.2 mm, and external sphincter thickness was 7.0±0.8 mm. A significant rectocele and rectal intussusception (n=2) and a nonrelaxing puborectalis muscle on straining (n=2) were observed at defecography in cases with third-degree RIMP. The anorectal angle was 100±75° at rest, 63±20° on squeezing, and 115±9° on straining. A conservative treatment with high-fiber diet and/or rubber band ligation was carried out in all cases of first and in most patients with second-degree RIMP (n=26). Those who required surgery, i.e., stapled transanal excision of the prolapse (n=6), had either severely symptomatic third-degree RIMP with solitary ulcer syndrome (n=4) or second-degree RIMP (n=2). A positive outcome was achieved in 71% of cases. The proposed classification evaluated by the present study may be of clinical value in managing rectal internal mucosal prolapse. Accepted: 18 June 1999     

Continence is improved after the ripstein rectopexy

PURPOSE: This study was undertaken to evaluate anal manometric changes after Ripstein's operation for rectal prolapse and rectal intussusception and to study the clinical outcome following the operation, with special reference to anal incontinence. METHODS: Forty-two patients with rectal prolapse or rectal intussusception were subjected to anorectal manometry preoperatively and seven days and six months postoperatively. A detailed history was obtained from each patient preoperatively and six months postoperatively. RESULTS: Preoperatively, patients with rectal intussusception had higher maximum resting pressure (MRP) (52±23 mmHg) than patients with rectal prolapse (34±20 mmHg;P <0.01). In the group of patients with rectal prolapse, there was a postoperative increase in MRP after six months (P <0.001) but not after seven days. Maximum squeeze pressure (MSP) did not increase. Neither MRP nor MSP increased postoperatively in patients with internal rectal procidentia. Continence was improved postoperatively both in patients with rectal prolapse (P <0.01) and rectal intussusception (P <0.01). There was no postoperative increase in rectal emptying difficulties. CONCLUSION: Ripstein's operation often improved anal continence in patients with rectal prolapse and rectal intussusception. This improvement was accompanied by increased MRP in patients with rectal prolapse, indicating recovery of internal anal sphincter function. No postoperative increase in MRP was found in patients with rectal intussusception. This suggests an alternate mechanism of improvement in patients with rectal intussusception.Supported by grants from Kjell and Märta Beijers Stiftelse and Marianne and Marcus Wallenbergs Stiftelse.     

Rectal compliance as a routine measurement

PURPOSE: The clinical impact of rectal compliance and sensitivity measurement is not clear. The aim of this study was to measure the rectal compliance in different patient groups compared with controls and to establish the clinical effect of rectal compliance. METHODS: Anorectal function tests were performed in 974 consecutive patients (284 men). Normal values were obtained from 24 controls. Rectal compliance measurement was performed by filling a latex rectal balloon with water at a rate of 60 ml per minute. Volume and intraballoon pressure were measured. Volume and pressure at three sensitivity thresholds were recorded for analysis: first sensation, urge, and maximal toleration. At maximal toleration, the rectal compliance (volume/pressure) was calculated. Proctoscopy, anal manometry, anal mucosal sensitivity, and anal endosonography were also performed as part of our anorectal function tests. RESULTS: No effect of age or gender was observed in either controls or patients. Patients with fecal incontinence had a higher volume at first sensation and a higher pressure at maximal toleration (P=0.03), the presence of a sphincter defect or low or normal anal pressures made no difference. Patients with constipation had a larger volume at first sensation and urge (P<0.0001 andP<0.01). Patients with a rectocele had a larger volume at first sensation (P=0.004). Patients with rectal prolapse did not differ from controls; after rectopexy, rectal compliance decreased (P<0.0003). Patients with inflammatory bowel disease had a lower rectal compliance, most pronounced in active proctitis (P=0.003). Patients with ileoanal pouches also had a lower compliance (P<0.0001). In the 17 patients where a maximal toleration volume<60 ml was found, 11 had complaints of fecal incontinence, and 6 had a stoma. In 31 patients a maximal toleration volume between 60 and 100 ml was found; 12 patients had complaints of fecal incontinence, and 6 had a stoma. Proctitis or pouchitis was the main cause for a small compliance. All 29 patients who had a maximal toleration volume>500 ml had complaints of constipation. No correlation between rectal and anal mucosal sensitivity was found. CONCLUSION: Rectal compliance measurement with a latex balloon is easily feasible. In this series of 974 patients, some patient groups showed an abnormal rectal visceral sensitivity and compliance, but there was an overlap with controls. Rectal compliance measurement gave a good clinical impression about the contribution of the rectum to the anorectal problem. Patients with proctitis and pouchitis had the smallest rectal compliance. A maximal toleration volume<60 ml always led to fecal incontinence, and stomas should be considered for such patients. A maximal toleration volume>500 ml was only seen in constipated patients, and therapy should be given to prevent further damage to the pelvic floor. Values close to or within the normal range rule out the rectum as an important factor in the anorectal problem of the patient.Drs. Sloots and Poen were supported by a grant from Janssen-Cilag. Presented at the meeting of the Dutch Society of Gastroenterology, Veldhoven, the Netherlands, October 7 to 8, 1999.     

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.     

The pathogenesis and pathophysiology of rectal prolapse and solitary rectal ulcer syndrome

Rectal prolapse and solitary rectal ulcer syndrome are both benign conditions affecting the rectum, mainly in women; prolapse tends to occur late in life, while solitary rectal ulcer syndrome has a predilection for the younger adult. Complete rectal prolapse probably starts as a mid-rectal intussusception, although a combination of this theory and the 'sliding hernia' theory has been proposed by Altemeier et al (1971). The pelvic floor weakness associated with prolapse, which gives rise to incontinence, is most likely due to a traction injury to the pudendal nerve. Anorectal manometry will indicate those incontinent patients likely to benefit from rectopexy. Abnormal descent of the perineum may be found in rectal prolapse and solitary rectal ulcer syndrome as well as descending perineum syndrome per se. The clinical features of these three conditions can overlap. Solitary rectal ulcer syndrome is essentially due to prolapse and traumatization of the rectal mucosa. Inappropriate puborectalis contraction, abnormal perineal descent, and overt rectal prolapse have all been cited as possible mechanisms of development of the condition. Defecography is the radiologic investigation of choice. Electromyography, as in rectal prolapse, may show evidence of pudendal nerve damage although incontinence is rare.     

Laparoscopic surgery for rectal prolapse and outlet obstruction

PURPOSE: The aim of this study was to assess the outcome of both laparoscopic suture rectopexy and resection-rectopexy in the treatment of complete and incomplete rectal prolapse, outlet obstruction, or both. METHODS: Data from surgery were collected prospectively. Semiannual follow-up was performed by assessment of recurrence, continence, and constipation using patients' history, physical examination, continence score, and anorectal manometry. Statistical analysis was performed by chi-squared test and Student'st-test (P<0.05 was accepted as statistically significant). RESULTS: Between September 1992 and February 1997, 72 patients (68 females) with a mean age of 62 (range, 23–88) years were treated laparoscopically. Indications for surgery were rectal prolapse in 21 patients, rectal prolapse combined with outlet obstruction in 36 patients, and outlet obstruction alone in 15 patients. Standard procedure was a laparoscopic suture rectopexy. A sigmoid resection was added in 40 patients. Mean duration of surgery was 227 (range, 125–360) minutes for rectopexy and 258 (range, 150–380) minutes for resection-rectopexy. Conversion was necessary in 1.4 percent (n=1). Overall complication rate was 9.7 percent (n=7) and mortality rate was 0 percent. Mean postoperative hospitalization was 15 (range, 6–47) days. All patients with a minimal follow-up of two years (n=53) could be enrolled in a prospective follow-up study (mean follow-up, 30 months). No recurrence of rectal prolapse had to be recognized. Sixty-four percent of patients with incontinence before surgery were continent or had improved continence. In patients experiencing constipation preoperatively, constipation was improved or completely removed in 76 percent. No additional symptoms of constipation occurred after surgery. CONCLUSION: Laparoscopic procedures in the treatment of pelvic floor disorders,e.g., rectal prolapse or outlet obstruction, lead to acceptable functional results. However, follow-up has to be extended and long-term results of recurrence, continence, and constipation have to be evaluated.     

Delorme's operation and sphincteroplasty for rectal prolapse and fecal incontinence

Clinical and manometric results of Delorme's operation and sphincteroplasty were assessed retrospectively in patients undergoing this procedure for fecal incontinence and rectal prolapse. A series of 33 patients (11 males, 22 females; aged 18–83 years, mean 59) with external rectal prolapse were treated by Delorme's operation between 1989 and 1996. Mean follow-up was 39 months (range 7–84). Sphincteroplasty was associated in 12 cases with severe fecal incontinence due to striated muscle defects. Good results were achieved in 27 patients (79%); prolapse recurrence was observed in 6 (21%), the mean recurrence time being 9 months (range 1–24 months). There were no postoperative deaths. Minor complications occurred in 15 patients. Changes in preoperative and postoperative manometric patterns were as follows (mean±SEM): voluntary contraction from 59±6.9 to 66±7.1 mmHg (P=0.05), resting tone from 33±5 to 32±4.3 mmHg, rectal sensation from 59±5 to 61±5.2 ml of air (n.s.). A solitary rectal ulcer syndrome was detected in five patients. The histological pattern demonstrated pathological changes in 40% of cases. Fecal incontinence was resolved in 6 of 20 cases (30%) and chronic constipation in 4 of 9 (44%). Failure (n=3) was related primarily to postoperative sepsis. The incontinence score showed a mean improvement of 35% decreasing, from 4.5±0.39 to 2.9±0.44 after surgery (P<0.01). In conclusion, Delorme's procedure did not lead to constipation and improved anal continence when associated with sphincteroplasty. Accepted: 20 January 1998     

Anorectal manometric abnormalities and colonic propulsive impairment in patients with severe chronic idiopathic constipation

Idiopathic chronic constipation is a frequent and disabling symptom, but its pathophysiological grounds are still poorly understood. In particular, there is little knowledge about the relationships between distal (anorectal area) and proximal (colonic area) motor abnormalities in this condition, especially concerning high-amplitude propagated colonic activity. For this purpose, we studied 25 patients complaining of severe idiopathic constipation and categorized them as normal- or slow-transit constipation according to colonic transit time. Twenty-five age-matched controls were also studied. Investigations included standard anorectal motility testing and prolonged (24-hr) colonic motility studies. Analysis of results showed that both groups of constipated patients displayed significantly different (P<0.05) minimum relaxation volumes of the internal anal sphincter, defecatory sensation thresholds, and maximum rectal tolerable volumes with respect to controls. Patients with normal-transit constipation also showed lower internal anal sphincter pressure with respect to slow-transit constipation and controls (P<0.001 andP<0.02, respectively). The daily number of high-amplitude propagated contractions (mass movements) as well as their amplitude and duration, was significantly reduced in both subgroups of constipated patients (P<0.02 vs controls). We conclude that (1) in normal-transit constipation, motor abnormalities are not limited to the anorectal area; (2) patients with slow-transit constipation probably have a severe neuropathic rectal defect; (3) prolonged colonic motility studies may highlight further the functional abnormalities in constipated subjects; and (4) an approach taking into account proximal and distal colon motor abnormalities might be useful to understand pathophysiological grounds of chronic constipation and lead to better therapeutic approaches.     

Solitary Rectal Ulcer Syndrome—Clinical, Endoscopic, and Histological Spectrum

Nineteen patients with solitary rectal ulcer syndrome are presented. The diagnosis was established on sigmoidoscopic and histopathological grounds; the clinical, endoscopic, and histological states were assessed at presentation and on last follow-up. Most of the patients suffered from rectal bleeding, abdominal and anorectal pains, constipation, and straining at defecation. Thirteen patients had macroscopic ulcerations on presentation and six patients did not. These six patients did not develop ulcer during the follow-up period. Four patients entered clinical and endoscopic remission with no histological improvement. Three of them managed conservatively and one underwent suturing of the ulcer and internal anal sphincter dilatation. They remained in remission for a mean follow-up of 1 yr.