Overt Rectal Prolapse and Fecal Incontinence

PURPOSE  Rectal prolapse is frequently associated with fecal incontinence; however, the relationship is questionable. The study was designed to evaluate fecal incontinence in a large consecutive series of patients who suffered from rectal prolapse, focusing on both past history, anal physiology, and imaging. METHODS  Eighty-eight consecutive patients who suffered from an overt rectal prolapse (72 women, 16 men; mean age, 51.1 ± 19.5 years) as a main symptom were analyzed; 48 patients also experienced fecal incontinence compared with 40 without incontinence. Logistic regression analyses were performed. RESULTS  The two groups of patients did not differ with respect to parity, weekly stool frequency, main duration of symptoms before referral, occurrence of dyschezia, and digital help to defecate. Patients with prolapse who were older than 45 years (odds ratio (OR), 4.51 (1.49–13.62); P = 0.007) and those with a past history of hemorrhoidectomy (OR, 9.05 (1.68–48.8); P = 0.01) were significantly more incontinent. Incontinent group showed frequent internal anal sphincter defect compared with the continent group (60 vs. 6.2 percent; P = 0.0018). CONCLUSIONS  In patients with overt rectal prolapse, the occurrence of fecal incontinence needs special consideration for age and previous hemorrhoid surgery as causative factors. Anal weakness and sphincter defects are frequently observed.     

Prolapse of the rectum, long-term results of surgical treatment

Aims  This study evaluates patency and functional results of abdominal and perineal treatment approaches to prolapse of the rectum. Methods  A database search identified patients operated upon for prolapse of the rectum. The operations were abdominal or perineal approaches. The patient’s records were reviewed, patients alive were contacted, and a self-report form evaluated functional results. Patients were followed until the prolapse recurred. Results  A primary operation for prolapse of the rectum was performed in 56 patients. Median age was 59 years (range 20–87) and 78 (40–91) for abdominal and perineal approaches, respectively (p < 0.001). The average length of the prolapses was 8.7 cm (2–25) and 8.6 cm (2–15) for abdominal or perineal approaches. All prolapses treated with a Thiersch’s operation recurred within a few months and all prolapses treated with the Delorme’s operation recurred within 5 years, whereas the 5-year patency of the abdominal approach was 93% (p < 0.001). No prolapses recurred after mesh rectopexy and the 5-year patency of resection rectopexy was 86%. The abdominal approaches improved stool evacuation and constipation significantly, and anal leakage improved somewhat (p = 0.065). The median hospital stay was 11 (4–20) and 7 (2–155) days after abdominal and perineal approaches (p = 0.003). Complications occurred in 20% of patients. Conclusions  The patency of abdominal approach to prolapse of the rectum is better than that of perineal repairs. The abdominal approaches also have a favorable effect on constipation and anal insufficiency. Perineal approaches should be reserved for patients with a very short life expectancy.     

Stapled transanal rectal resection versus stapled anopexy in the cure of hemorrhoids associated with rectal prolapse. A randomized controlled trial

Purpose A remarkable incidence of failures after stapled axopexy (SA) for hemorrhoids has been recently reported by several papers, with an incomplete resection of the prolapsed tissue, due to the limited volume of the stapler casing as possible cause. The stapled transanal rectal resection (STARR) was demonstrated to successfully cure the association of rectal prolapse and rectocele by using two staplers. The aim of this randomized study was to evaluate the incidence of residual disease after SA and STARR in patients affected by prolapsed hemorrhoids associated with rectal prolapse. Methods Sixty-eight patients were selected on the basis of validated constipation and continence scorings, clinical examination, colonoscopy, anorectal manometry, and defecography and randomized: 34 underwent a SA and 34 a STARR operation. The operated patients were followed-up with clinical examination, visual analog scale for postoperative pain, a satisfaction index, and defecography. Results At a mean follow-up of 8.1 +/− 2.0 and 7.9 +/− 1.8 months for the SA and STARR groups, respectively, the incidence of residual disease was significantly higher in the first group (29.4 vs 5.9 in the STARR group, p = 0.007), while a significantly lower incidence of residual skin-tags was found after STARR (23.5% vs 58.8 after SA, p = 0.03). All patients with residual disease showed prolapsed tissue over half the length of the anal dilator at the time of the operation. Operative time and incidence of transient fecal urgency were significantly higher in the STARR group (with p = 0.001 and 0.08, respectively), while SA was followed by a significantly higher incidence of poor results at the overall patient satisfaction index (p = 0.04). No significant differences were found in hospital stay, operative complications, postoperative pain, time to return to normal activity, continence, and constipation scores. All the defecographic parameters significantly improved after STARR, while SA was followed only by a trend to a reduction of rectal prolapse. Conclusions STARR provides a more complete resection of the prolapsed tissue than SA in patients with association of prolapsed hemorrhoids and rectal prolapse with equal morbidity and significantly lower incidence of residual disease and skin-tags. The anal dilator can be used for selecting the surgical technique.     

Recurrent rectal prolapse

PURPOSE: The aim of this study was to assess the clinical and functional outcome of surgery for recurrent rectal prolapse and compare it with the outcome of patients who underwent primary operation for rectal prolapse. METHODS: All patients who underwent surgery for rectal prolapse were evaluated for age, gender, procedure, anorectal manometry and electromyography findings, and morbidity. The results for patients who underwent surgery for recurrent rectal prolapse were compared with a group of patients matched for age, gender, surgeon, and procedure who underwent primary operations for rectal prolapse. RESULTS: A total of 115 patients underwent surgery for rectal prolapse. Twenty-seven patients, 10 initially operated on at this institution and 17 operated on elsewhere, underwent surgery for recurrent rectal prolapse. These 27 patients were compared with 27 patients with primary rectal prolapse operated on in our department. In the recurrent rectal prolapse group, prior surgery included rectopexy in 7 patients, Delorme's procedure in 7 patients, perineal rectosigmoidectomy in 7 patients, anal encirclement procedure in 4 patients, and resection rectopexy in 2 patients. Operations performed for recurrence were perineal rectosigmoidectomy in 14 patients, resection rectopexy in 8 patients, rectopexy in 2 patients, pelvic floor repair in 2 patients, and Delorme's procedure in 1 patient. There were no statistically significant differences between the groups in preoperative incontinence score (recurrent rectal prolapse, 13.6±7.8vs. rectal prolapse, 12.7±7.2; range, 0–20) or manometric or electromyography findings, and there were no significant differences in mortality (0vs. 3.7 percent), mean hospital stay (5.4±2.5vs. 6.9±2.8 days), anastomotic complications (anastomotic stricture (0vs. 7.4 percent), anastomotic leak (3.7vs. 3.7 percent) and wound infection (3.7vs. 0 percent)), postoperative incontinence score (2.8±4.8vs. 1.5±2.7), or recurrence rate (14.8vs. 11.1 percent) between the two groups at a mean follow-up of 23.9 (range, 6–68) and 22 (range, 5–55) months, respectively. The overall success rate for recurrent rectal prolapse was 85.2 percent. CONCLUSION: The outcome of surgery for rectal prolapse is similar in cases of primary or recurrent prolapse. The same surgical options are valid in both scenarios.Funded in part by a generous grant from the Eleanor Naylor Dana Charitable Trust Fund and the Caporella Family.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, June 22 to 26, 1997.     

An increased rectal maximum tolerable volume and long anal canal are associated with poor short-term response to biofeedback therapy for patients with anismus with decreased bowel frequency and normal colonic transit time

PURPOSE: Biofeedback is an effective therapy for a majority of patients with anismus. However, a significant proportion of patients still failed to respond to biofeedback, and little has been known about the factors that predict response to biofeedback. We evaluated the factors associated with poor response to biofeedback. METHODS: Biofeedback therapy was offered to 45 patients with anismus with decreased bowel frequency (less than three times per week) and normal colonic transit time. Any differences in demographics, symptoms, and parameters of anorectal physiologic tests were sought between responders (in whom bowel frequency increased up to three times or more per week after biofeedback) and nonresponders (in whom bowel frequency remained less than three times per week). RESULTS: Thirty-one patients (68.9 percent) responded to biofeedback and 14 patients (31.1 percent) did not. Anal canal length was longer in nonresponders than in responders (4.53±0.5vs. 4.08±0.56 cm;P=0.02), and rectal maximum tolerable volume was larger in nonresponders than in responders. (361±87vs. 302±69 ml;P=0.02). Anal canal length and rectal maximum tolerable volume showed significant differences between responders and nonresponders on multivariate analysis (P=0.027 andP=0.034, respectively). CONCLUSIONS: This study showed that a long anal canal and increased rectal maximum tolerable volume are associated with poor short-term response to biofeedback for patients with anismus with decreased bowel frequency and normal colonic transit time.Presented in part at Digestive Disease Week, Orlando, Florida, May 16 to 19, 1999.     

Anorectal Physiology in Solitary Ulcer Syndrome: A Case-Matched Series

PURPOSE Solitary ulcer syndrome is a rare condition characterized by inflammation and chronic ulcer of the rectal wall in patients suffering from outlet constipation. Despite similar surgical options (rectopexy, anterior resection), solitary ulcer syndrome may differ from overt rectal prolapse with regard to symptoms and pathogenesis. The present work analyzed differences between these conditions in a case-control physiology study. METHODS From 1997 to 2002, 931 consecutive subjects were investigated in a single physiology unit for anorectal functional disorders. Standardized questionnaires, anorectal physiology, and evacuation proctography were included in a prospective database. Diagnosis of solitary ulcer syndrome was based on both symptoms and anatomic features in 25 subjects with no overt rectal prolapse (21 females and 4 males; mean age, 37.2 ± 15.7 years) and no past history of anorectal surgery. They were compared with age-matched and gender-matched subjects: 25 with outlet constipation (also matched on degree of internal procidentia), 25 with overt rectal prolapse without any mucosal change, and 14 with overt rectal prolapse and mucosal changes. RESULTS Subjects with solitary ulcer syndrome reported symptomatic levels (digitations, pain, incontinence) similar to those of patients with outlet constipation, but they had significantly more constipation and less incontinence than patients with overt rectal prolapse. Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3, and 1, respectively ; P < 0.01) and a paradoxical puborectalis contraction (15 vs. 9, 1, and 1, respectively; P < 0.05). With respect to evacuating proctography, complete rectal emptying was achieved less frequently in this group (5 vs. 12, 23, and 10, respectively; P < 0.05). Compared with patients with overt rectal prolapse, mean resting and squeezing anal pressures were significantly higher in both groups of subjects with solitary ulcer syndrome and with outlet constipation. Prevalence and levels of anatomic disorders (perineal descent, rectocele) did not differ among the four groups except for rectal prolapse grade and prevalence of enterocele (higher in overt rectal prolapse group). Interestingly, and despite matched controls for degree of intussusception, individuals with solitary ulcer syndrome had circular internal procidentia more often compared with those suffering from outlet constipation without mucosal lesions (15 vs. 8, P < 0.05). CONCLUSION This case-controlled study quantifies functional anal disorders in patients suffering from solitary ulcer syndrome. Despite no proven etiologic factor, sphincter-obstructed defecation and circular internal procidentia both may play an important part in the pathogenesis and an exclusive surgical approach may not be appropriate in this context. Presented at the meeting of the American Gastroenterology Association, New Orleans, Louisiana, May 18, 2004.     

Selective treatment of rectal cancer with single-stage coloanal or ultralow colorectal anastomosis does not adversely affect morbidity and mortality

Background and aims The surgical treatment of low rectal cancer commonly includes low pelvic anastomoses with coloanal or ultralow colorectal anastomoses. Anastomotic leak rates in low pelvic anastomoses range from 4 to 26%. Many surgeons opt to routinely create a diverting ostomy to reduce the extent of morbidity should an anastomotic leak occur. The intent of our study was to determine if our policy of selected diversion is safe. Materials and methods A retrospective chart review of 66 rectal cancer patients who underwent proctectomy and low pelvic anastomoses—less than 6 cm from anal verge, with or without a diverting ostomy—was undertaken. Temporary diverting stomas were utilized at the discretion of the attending surgeon primarily based on subjective criteria. The main outcome was postoperative complications. Results/findings Forty-nine patients (78% preoperatively irradiated) were treated with a one-stage operation, whereas 17 (53% preoperatively irradiated) underwent reconstruction with proximal diversion. The mean anastomotic height for patients with a single stage procedure was 3.8 cm above the anal verge versus 2.6 for patients with a two-stage procedure (p = 0.076). Complication rates were lower in patients who did not undergo diversion (29% vs 47%, p = 16). With regard to anastomotic-associated complications for single stage versus two stage, complication rates were 8% versus 18%, respectively (p = 0.27). Interpretation/conclusion Low pelvic anastomoses in rectal cancer patients can be safely performed as a single-stage procedure, reserving the use of diversion for select cases.     

Colonic transit disorders in systemic sclerosis

Systemic sclerosis (SS) alters smooth muscle function throughout the gastrointestinal tract, the oesophagus being the segment most often involved. Involvement of the colon, though less common, may lead to life-threatening complications. We studied 23 unselected patients with SS and 20 age-matched healthy controls using radionuclide colon transit studies. The geometric centre (GC) at 4 and 24 hours was used to summarise overall transit in the colon. In patients with SS, colon transit was delayed (GC₄: 0.39 ± 0.36 vs 0.85 ± 0.45; P = 0.001) (GC₂₄: 1.68 ± 0.9 vs 2.58 ± 1.08; P = 0.006). These findings suggest that delayed colon transit is common in patients with SS. Received: 21 August 2000 / Accepted: 26 February 2001     

Physiologic and clinical assessment of patients with rectoanal intussusception

The aims of this study were (1) to establish an objective baseline to assess the severity of rectoanal intussusception by the depth of rectal infolding and (2) to compare manometric and defecographic parameters in patients to validate this new objective classification of intussusception. Between July 1988 and September 1997, 224 patients with rectoanal intussusception confirmed by cinedefecography who underwent anal manometry were evaluated. These patients were classified into two groups based on the depth infolding: group I (n = 163), intussusception < 10 mm infolding seen on the rectal wall; and group II (n = 61), intussusception ≥ 10 mm infolding extending into the anal canal. There were 32 males and 192 females, of a mean age of 61 years (range, 19–88). Patients were subdivided into 5 groups according to their dominant complaint. Complaints were constipation with incomplete evacuation (n = 113, 69.3%), fecal incontinence (n = 28, 17.2%), rectal pain (n = 19, 11.7%) and others (n = 3, 1.8%) in group I and constipation (n = 34, 55.7%), sensation of prolapse (n = 14, 23.0%) and others (n = 13, 21.3%) in group II. There was a significant difference in the degree of intussusception relative to sensation of prolapse (p < 0.05). Manometry showed that the rectoanal inhibitory reflex was absent more often in patients in group II (19.7% vs. 8.5%) than in group I (p < 0.05). Moreover, group I patients had higher mean and maximum squeeze pressures when compared to group II (78.1 vs. 62.5, 105.9 vs. 88.8 mm Hg, respectively, p < 0.05). the incidences of combined cinedefecographic anomalies, such as rectocele, sigmoidocele and perineal descent, were high: 85.2% in group II and 79.1% in group I (p > 0.05). In conclusion, this study showed manometric and symptomatic differences relative to the size of the intussusception. The decreased pressure seen in patients with larger intussusception may auger for the subsequent development of incontinence in these patients. Received: 28 February 2000 / Accepted in revised form: 15 March 2000     

Computers in the Exam Room: Differences in Physician–Patient Interaction May Be Due to Physician Experience

Background The use of electronic medical records can improve the technical quality of care, but requires a computer in the exam room. This could adversely affect interpersonal aspects of care, particularly when physicians are inexperienced users of exam room computers. Objective To determine whether physician experience modifies the impact of exam room computers on the physician–patient interaction. Design Cross-sectional surveys of patients and physicians. Setting and Participants One hundred fifty five adults seen for scheduled visits by 11 faculty internists and 12 internal medicine residents in a VA primary care clinic. Measurements Physician and patient assessment of the effect of the computer on the clinical encounter. Main Results Patients seeing residents, compared to those seeing faculty, were more likely to agree that the computer adversely affected the amount of time the physician spent talking to (34% vs 15%, P = 0.01), looking at (45% vs 24%, P = 0.02), and examining them (32% vs 13%, P = 0.009). Moreover, they were more likely to agree that the computer made the visit feel less personal (20% vs 5%, P = 0.017). Few patients thought the computer interfered with their relationship with their physicians (8% vs 8%). Residents were more likely than faculty to report these same adverse effects, but these differences were smaller and not statistically significant. Conclusion Patients seen by residents more often agreed that exam room computers decreased the amount of interpersonal contact. More research is needed to elucidate key tasks and behaviors that facilitate doctor–patient communication in such a setting.     

Paradoxical sphincter contraction is rarely indicative of anismus

Background—Anismus is thought to be a cause ofchronic constipation by producing outlet obstruction. The underlyingmechanism is paradoxical contraction of the anal sphincter orpuborectalis muscle. However, paradoxical sphincter contraction (PSC)also occurs in healthy controls, so anismus may be diagnosed too often because it may be based on a non-specific finding related to untoward conditions during the anorectal examination.
Aims—To investigate the pathophysiologicalimportance of PSC found at anorectal manometry in constipated patientsand in patients with stool incontinence.
Methods—Digital rectal examination and anorectalmanometry were performed in 102 chronically constipated patients, 102 patients with stool incontinence, and in 18 controls without anorectal disease. In 120 of the 222 subjects defaecography was also performed. Paradoxical sphincter contraction was defined as a sustained increase in sphincter pressure during straining. Anismus was assumed when PSCwas present on anorectal manometry and digital rectal examination andthe anorectal angle did not widen on defaecography.
Results—Manometric PSC occurred about twice asoften in constipated patients as in incontinent patients (41.2% versus25.5%, p<0.017) and its prevalence was similar in incontinentpatients and controls (25.5% versus 22.2%). Oroanal or rectosigmoidtransit times in constipated patients with and without PSC did notdiffer significantly (total 64.6 (8.9) hours versus 54.2 (8.1) hours; rectosigmoid 14.9 (2.4) hours versus 13.8 (2.5) hours).
Conclusions—Paradoxical sphincter contraction is acommon finding in healthy controls as well as in patients with chronic constipation and stool incontinence. Hence, PSC is primarily a laboratory artefact and true anismus is rare.

Keywords:anismus; paradoxical sphincter contraction; constipation; stool incontinence; anorectal manometry

     

Are Physician Estimates of Asthma Severity Less Accurate in Black than in White Patients?

Background  Racial differences in asthma care are not fully explained by socioeconomic status, care access, and insurance status. Appropriate care requires accurate physician estimates of severity. It is unknown if accuracy of physician estimates differs between black and white patients, and how this relates to asthma care disparities. Objective  We hypothesized that: 1) physician underestimation of asthma severity is more frequent among black patients; 2) among black patients, physician underestimation of severity is associated with poorer quality asthma care. Design, Setting and Patients  We conducted a cross-sectional survey among adult patients with asthma cared for in 15 managed care organizations in the United States. We collected physicians’ estimates of their patients’ asthma severity. Physicians’ estimates of patients’ asthma as being less severe than patient-reported symptoms were classified as underestimates of severity. Measurements  Frequency of underestimation, asthma care, and communication. Results  Three thousand four hundred and ninety-four patients participated (13% were black). Blacks were significantly more likely than white patients to have their asthma severity underestimated (OR = 1.39, 95% CI 1.08–1.79). Among black patients, underestimation was associated with less use of daily inhaled corticosteroids (13% vs 20%, p < .05), less physician instruction on management of asthma flare-ups (33% vs 41%, p < .0001), and lower ratings of asthma care (p = .01) and physician communication (p = .04). Conclusions  Biased estimates of asthma severity may contribute to racially disparate asthma care. Interventions to improve physicians’ assessments of asthma severity and patient–physician communication may minimize racial disparities in asthma care.     

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     

Undifferentiated Spondyloarthropathies: A 2-Year Follow-up Study

The aim of the study was to analyse the 2-year follow-up of a series of patients with the diagnosis of undifferentiated spondyloarthropathy (uSpA). A prospective study was carried out analysing 68 patients with symptomatic uSpA who fulfilled the European Spondylarthropathy Study Group (ESSG) criteria for seronegative spondyloarthropathies (SpA) and were aged between 18 and 50 years. Inclusion criteria included inflammatory low back pain (ILBP) (without radiographic sacroiliitis), asymmetric oligoarthritis (predominantly affecting large joints in the lower limbs) and heel enthesopathies (Achilles tendinitis and/or plantar fasciitis). Imaging methods included pelvic radiography (at study entry and after 2 years) and calcaneal radiography (at study entry). There was a predominance of male gender (78%), caucasoid race (72%) and positive HLA-B27 (54%), with a mean age of 31 years and mean disease duration of 5 years. The first disease manifestations were ILBP (49%), asymmetric oligoarthritis (35%) and heel enthesopathies (16%). A positive family history of a definite SpA was mentioned by 9% of the patients. Seventeen patients (25%) scored 5 points in the Amor set of SpA criteria; logistic regression analysis showed that HLA-B27, heel enthesopathy and asymmetric oligoarthritis were significantly associated with Amor criteria ≥6, whereas ILBP was associated with Amor criteria <6. Male sex was associated with heel enthesopathies (p = 0.041) and ankle involvement (p = 0.015). Caucasoid race was associated with ILBP (p = 0.015) and buttock pain (p = 0.047). Positive HLA-B27 was associated with wrist involvement (p = 0.019) and Amor criteria ≥6 (p = 0.001). After a 2-year follow-up the following outcomes were observed: uSpA 75%; disease remission 13%; ankylosing spondylitis 10%; psoriatic arthritis 2%. Logistic regression analysis showed that buttock pain and positive HLA-B27 (trend) were statistically associated with progression to a definite SpA. In conclusion, uSpA can represent a provisional diagnosis in the group of SpA and a systematic follow-up is necessary in order to better establish the different patterns of the disease. Received: 2 June 2000 / Accepted: 5 January 2001     

External Pelvic Rectal Suspension (the Express Procedure) for Internal Rectal Prolapse, with or without Concomitant Rectocele Repair: A Video Demonstration

Purpose Internal rectal prolapse has been proposed as a cause of symptomatic rectal evacuatory dysfunction. Abdominal rectopexy, the standard surgical approach, has significant attendant risk and does not address any concomitant rectocele. This video was designed to demonstrate a novel surgical method that uses porcine collagen implants (Permacol™), designed to correct internal rectal prolapse, with or without rectocele. Methods Inclusion criteria: severe rectal evacuatory dysfunction refractory to maximal conservative therapy and full-thickness internal rectal prolapse impeding rectal emptying on defecography with or without associated functional rectocoele; normal colonic transit. Patients undergo comprehensive preoperative and postoperative symptomatic assessment and anorectal physiologic testing, including defecography. A crescenteric perineal skin incision allows development of the rectovaginal/rectoprostatic plane to Denonvilliers fascia, with rectal mobilization. A curved tunneller inserted via the perineal wound is guided retropubically to emerge through suprapubic wounds created on each side. Permacol™ T-strips are sutured to the anterolateral rectal wall bilaterally, upward traction exerted, and the stem of each T-strip is sutured to the suprapubic periosteum, suspending the rectum. Concomitant rectocele is repaired using a Permacol™ patch in the rectovaginal plane. Results Short-term results for the “Express” are encouraging with improvement in evacuatory and prolapse symptoms and concomitant anatomic improvement at defecography. Conclusions This procedure promises to be an effective technique for managing patients with refractory evacuatory dysfunction secondary to internal rectal prolapse, with or without rectocele. This multimedia article (video) has been published online and is available for viewing at . As a subscriber to Diseases of the Colon & Rectum, you have access to our SpringerLink electronic service, including Online First. Presented at the meeting of The Association of Coloproctology of Great Britain and Ireland, Gateshead, United Kingdom, July 3 to 6, 2006. Reprints are not available. Professor N. S. Williams is a consultant to Tissue Science Laboratories plc, the company that manufactures Permacol™.     

Effects and Mechanisms of Anal Electrical Stimulation on Anorectal Compliance and Tone in Dogs

Purpose This study was designed to investigate the changes in rectal compliance and tone during anal electric stimulation and the involvement of the α-adrenergic pathway in conscious dogs. Methods Eight healthy dogs were studied in five randomized sessions. Anal sphincter pressure was quantified by using the area under the contractile curve. Rectal compliance and tone were measured in a pressure-controlled phasic and isobaric distention by using an electronic barostat. Anal electric stimulation was performed via a pair of ring electrodes attached to the catheter. Results The electric stimulation-induced increase in sphincter pressure was lowered by the presence of an α₁-adrenergic receptor antagonist, prazosin (18.6 ± 7.4 vs. 45.4 ± 9.7, P < 0.05), or α₂-adrenergic receptor antagonist, yohimbine (10.2 ± 8.2 vs. 38.3 ± 7.6, P < 0.05), compared with the control. The threshold volume in rectoanal inhibitory reflex during electric stimulation was significantly higher than during baseline (27.5 ± 0.9 vs. 22.5 ± 1.9 ml, P < 0.05). There were no significant differences between the percentage drops in sphincter pressure with and without stimulation at a rectal distention level of 45 ml of air. Anal electric stimulation significantly increased rectal compliance reflected as reduced P_1/2 (11.1 ± 1.5 vs. 16.7 ± 1.1, P = 0.027) and reduced κ (11.6 ± 2.5 vs. 20.5 ± 2.6, P = 0.0095), compared with the control session, but did not significantly alter rectal tone. Conclusions Anal electric stimulation increases anal sphincter pressure, mediated at least partially by the α-adrenergic pathway. It also increases rectal compliance but does not alter rectal anal inhibitory reflexes.     

Non-sphincter splitting fistulectomy vs conventional fistulotomy for high trans-sphincteric fistula-in-ano: a prospective functional and manometric study

Purpose This study compared the clinical and physiological results of non-sphincter splitting fistulectomy (N-SSF) with those of sphincter splitting fistulotomy (SSF) for treatment of high trans-sphincteric fistula-in-ano. Materials and methods A prospective, observational study was undertaken in 70 consecutive patients with high trans-sphincteric fistula treated by SSF (n = 35) or N-SSF (n = 35). Anal manometry was performed before and 3 months after surgery. Anal continence was assessed using the Cleveland Clinic Florida Incontinence Score. Results There was no difference between the two groups in age, gender, presence of horseshoe extension, preoperative incontinence score and manometric values. The incidence of recurrence was similar between the two groups. The postoperative incontinence score of the SSF group was significantly higher than that of the N-SSF group (1.9 ± 2.9 vs 1.1 ± 2.9, P = 0.0347). Maximum resting pressure showed significant decrease after surgery in both groups (83.2 to 56.1 mmHg, P = 0.0001 and 85.1 to 58.4 mmHg, P = 0.0001). Voluntary contraction pressure and functional anal canal length did not change after N-SSF (137.6 to 138.2 mmHg, P = 0.9524 and 4.06 to 4.07 cm, P = 0.9524), but significantly decreased after SSF (120.2 to 96.7 mmHg, P = 0.0085 and 4.12 to 3.74 cm, P = 0.0183). Conclusion Non-sphincter splitting fistulectomy for high trans-sphincteric fistula provided better functional results than fistulotomy. Less impairment of anal continence was achieved possibly not only by maintenance of the external anal sphincter function but also by preservation of the length of the high-pressure zone.     

Patient–Physician Communication in the Primary Care Visits of African Americans and Whites with Depression

Background Little research investigates the role of patient–physician communication in understanding racial disparities in depression treatment. Objective The objective of this study was to compare patient–physician communication patterns for African-American and white patients who have high levels of depressive symptoms. Design, Setting, and Participants This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study–Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices. Main Outcomes Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients’ physical and emotional health status and stress levels were measured by post-visit surveys. Results African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07). Conclusions This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care.     

Surgical Management of Pelvic Organ Prolapse in Females: Functional Outcome of Mesh Sacrocolpopexy and Rectopexy as a Combined Procedure

Purpose Urogenital prolapse is relatively common compared with rectal prolapse and the combination of urogenital prolapse and rectal prolapse is still more infrequent. This study was designed to evaluate the functional outcome of a series of patients who have undergone open mesh sacrocolporectopexy surgery for combined vaginal and rectal prolapse. Methods Consecutive patients from June 2000 to June 2004 with confirmed vaginal and rectal prolapse subsequently underwent open mesh sacrocolporectopexy. The Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory questionnaire with Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal-Anal Distress Inventory subscales was completed by all patients preoperatively and at six months postoperatively. Results There were 29 patients with a median age of 66 (interquartile range, 59–73) years. Median period of follow-up was 26 (interquartile range, 15–33) months. Median global pelvic floor distress inventory scores were lower postoperatively compared with preoperatively (96.4 (interquartile range, 50.8–149.7) vs. 182.3 (interquartile range, 140.6–208.6; P = 0.001). All three median subscales scores also were significantly lower postoperatively compared with preoperatively. Conclusions In patients with concurrent vaginal and rectal prolapse, open mesh sacrocolporectopexy confers good symptomatic improvement for urinary-, vaginal-, and rectal-related symptoms. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006.     

Juvenile Chronic Arthritis in Adult Life: A Study of Long-term Outcome in Patients with Juvenile Chronic Arthritis or Adult Rheumatoid Arthritis

We compared the prognostic factors and outcome of 30 patients with juvenile chronic arthritis (JCA) extending into adult life with those of 30 patients with adult rheumatoid arthritis (RA) at a university adult rheumatology clinic; pairs were matched for sex and duration of disease (mean 8 years). One-third of JCA patients had seronegative polyarticular disease and another third had oligoarticular disease. In a third of the JCA patients, the clinical presentation changed during the follow-up. Over half of the RA patients had seropositive polyarticular and a one-third had seronegative polyarticular disease. Fewer seropositive patients were recorded in the JCA group than in the RA group both at the beginning (16.7% versus 56.7%; p = 0.003) and at the end of the follow-up (14.3% versus 59.3%; p = 0.001). JCA patients developed less radiographic changes than RA patients (46.7% versus 76.7%; p = 0.034); oligoarthritis in the JCA group had the best prognosis whereas seropositive polyarthritis in the RA group had the worst prognosis. Significantly more patients with JCA than RA (60% versus 23%; p = 0.009) were in remission at the end of the follow-up. In conclusion, when studied in adult life, the long-term prognosis is better in patients with JCA than in those with RA. Received: 23 March 1998 / Accepted: 3 November 1998