Descending Perineum Syndrome: Are Abdominal Hysterectomy and Bowel Habits Linked?

PURPOSE This retrospective study evaluates the effect of abdominal hysterectomy on patients affected by descending perineum syndrome. METHODS Eighty-nine female patients affected by descending perineum syndrome and one group of 10 healthy women with normal bowel habits were studied retrospectively. Thirty-two descending perineum syndrome patients (Group 1) had received an abdominal hysterectomy for benign diseases, while 57 descending perineum syndrome patients (Group 2) had not undergone this surgery. All 99 subjects underwent clinical evaluation, computerized anorectal manometry, and defecography. RESULTS Dyschezia was found predominantly in Group 2 subjects (P < 0.05). Fecal incontinence was significantly higher in Group 1 than in Group 2 (P < 0.05). The worst anal resting pressure was found in the incontinent Group 1 patients (P < 0.01). Rectoanal intussusception was a significant defecographic sign in Group 1 subjects (P < 0.05). CONCLUSIONS Clinical evaluation and instrumental data suggested a possible link between fecal incontinence and abdominal hysterectomy in patients affected by descending perineum syndrome.     

Rehabilitation of Fecal Incontinence After Sphincter-Saving Surgery for Rectal Cancer: Encouraging Results

Purpose  Some patients, having undergone sphincter-saving operations for rectal cancer, may suffer from fecal incontinence. This study was designed to evaluate the results of rehabilitative treatment in patients with fecal incontinence after sphincter-saving operations and to identify the negative factors that influence therapeutic success. Methods  Between January 2000 and June 2007, 88 incontinent patients (54 women; age range, 47–73 years; 69 had received a low anterior rectal resection; 19 a straight coloanal anastomosis) were included in the study. After a preliminary clinical evaluation, including the Wexner Incontinence Scale score, anorectal manometry was performed. All 88 patients underwent rehabilitative treatment according to the “multimodal rehabilitative program” for fecal incontinence. At the end of program, all 88 patients were reassessed by means of a clinical evaluation and anorectal manometry; their results were compared with the clinical and manometric data from ten healthy control subjects. Postrehabilitative Wexner Incontinence Scale scores were used for an arbitrary schedule of patients divided into three classes: Class I, good (score ≤3); Class II, fair (score >3 to ≤6); Class III, poor (score >6). Results  After rehabilitation, there was a significant improvement in the overall mean Wexner Incontinence Scale score (P < 0.03) for both surgical operation types (low anterior rectal resection: P < 0.05; coloanal anastomosis: P < 0.02). Only 21 patients (23.8 percent) were symptom-free, and 37 (42 percent) were considered Class III. A significant postrehabilitative direct correlation was found between: 1) Wexner Incontinence Scale score and degree of genital relaxation (rρ _s 0.78; P < 0.001); 2) Wexner Incontinence Scale score and irradiation (rρ _s 0.72; P < 0.01); and 3) Wexner Incontinence Scale score and pelvic (rρ _s 0.65; P < 0.01) or anal surgery (rρ _s 0.68; P < 0.01). No significant differences were found between prerehabilitative and postrehabilitative anal pressures in low anterior rectal resection and coloanal anastomosis patients. Conclusions  After rehabilitation, some patients become symptom-free, many patients show an improvement in the Wexner Incontinence Scale score, and others exhibit the highest grades of fecal incontinence. Genital relaxation, radiotherapy, and previous pelvic, and/or anal surgery are impeding factors to rehabilitative success.     

Preoperative Radiochemotherapy in T3 Operable Low Rectal Cancers: A Gold Standard?

Background  

Preoperative chemoradiation followed by total mesorectal excision (TME) has become a standard treatment of preoperatively staged T3 low rectal cancers in many institutions; however, a direct comparison of generalized preoperative versus selective adjuvant chemoradiation has never been assessed in a clinical practice setting.     

Tumor angiogenesis in lymph node-negative rectal cancer: Correlation with clinicopathological parameters and prognosis

BACKGROUND: Intratumoral microvessel density (MVD) could be used as a prognostic factor in colorectal cancer. We retrospectively analyzed the value of microvessel count in predicting the clinical outcome of stage I and II (Dukes A and B) rectal cancer patients. METHODS: Eighty-four patients who had undergone curative resection of lymph node-negative rectal cancer were included. Tumor type and differentiation, the depth of local invasion, venous invasion, the character of the invasive margin, and the degree of lymphocytic infiltration were evaluated for each tumor specimen. Immunohistochemical staining for the CD31 endothelial antigen was performed to highlight the microvessels. RESULTS: The median value of MVD was 45 microvessels. Low MVD (microvessels < or = 45) was observed in 41 patients (48.8%), and high MVD (>45) was found in 43 (51.2%). The presence of conspicuous lymphocytic infiltration was significantly associated with increased vessel density. With uni- and multivariate survival analysis MVD did not show any prognostic significance. The character of the invasive margin was the only parameter with independent prognostic value. CONCLUSIONS: MVD does not seem to provide any additional prognostic information when compared with standard histopathological parameters in lymph node-negative rectal cancer. It is likely that the strong association between MVD and the presence of conspicuous lymphocytic infiltration may interfere with its predictive value.     

Obstructed defaecation: what is the role of rehabilitation?

Aim The study was designed to evaluate the results of rehabilitative treatment in patients suffering from obstructed defaecation. Method Between January 2008 and July 2010, 39 patients (37 women, age range 25–73 years; and two men, aged 57 and 67 years) affected by obstructed defaecation were included in the study. After a preliminary clinical evaluation, including the Obstructed Defaecation Syndrome (ODS) score, defaecography and anorectal manometry were performed. All 39 patients underwent rehabilitative treatment according to the ‘multimodal rehabilitative programme’ for obstructive defaecation. At the end of the programme, all 39 patients were reassessed by clinical evaluation and anorectal manometry. Postrehabilition ODS scores were used to categorize patients arbitrarily into three classes, as follows: class I, good (score ≤ 4); class II, fair (score > 4 to ≤ 8); and class III, poor (score > 8). Results After rehabilitation, there was significant improvement in the overall mean ODS score (P < 0.001). Thirty (76.9%) patients were included as class I (good results), of whom eight (20.5%) were symptom free. Five (12.8%) patients were considered class III. A significant postrehabilitative direct correlation was found between ODS score and pelvic surgery (ρ_s = 0.54; P < 0.05). Significant differences were found between pre‐ and postrehabilitative manometric data from the straining test (P < 0.001), duration of maximal voluntary contraction (P < 0.001) and conscious rectal sensitivity threshold (P < 0.02). Conclusion After rehabilitation, some patients become symptom free and many had an improved ODS score.     

Character of the invasive margin in colorectal cancer

PURPOSE: The clinical significance and prognostic value of the histopathologic parameters used in both the Dukes and Jass classifications were evaluated to select those with an independent effect on survival after radical surgery for colorectal cancer. METHODS: The depth of local spread (limited to the bowel wall or extended beyond it), the number of metastatic lymph nodes (none, 1–4, more than 4), the character of the invasive margin (pushing or infiltrating), and the presence or absence of conspicuous peritumoral lymphocytic infiltration were assessed in 235 patients who had undergone radical resection for colorectal cancer. The influence of these variables on survival was studied by univariate and multivariate analysis. RESULTS: No significant difference in survival was found between patients with conspicuous peritumoral infiltrate and those without it; moreover, multivariate analysis failed to show any independent prognostic value for either lymphocytic infiltration or depth of local invasion. However, the character of the invasive margin and the number of metastatic lymph nodes were identified as the only variables with any independent importance on survival. Based on these data, a new prognostic model may be proposed; it uses the character of the infiltrative margin as a discriminating factor among patients within the lymph node-negative (Dukes A and B stages) and lymph node-positive (Dukes C1 and C2 subsets) groups. A good prognosis for Dukes A, B, and C1 patients was associated with pushing tumors; C1 and C2 patients with infiltrating tumors had a poor prognosis. On the whole, the new prognostic model has allowed for the placement of 59.6 percent of our patients into groups that provide a confident prognosis. The clinical outcome of Dukes A and B patients with infiltrating tumors is still uncertain. CONCLUSIONS: The character of the invasive margin is an important prognostic factor in colorectal cancer. The association of this parameter with the traditional Dukes classification may provide additional useful prognostic information and aid in the selection of those patients who could most benefit from adjuvant therapy.     

Self-perceived normality in defecation habits

BACKGROUND: Available information on normal bowel habits was mainly gathered by means of telephone interviews or mailed questionnaires. AIMS: We undertook a prospective study to evaluate the defecatory habits in subjects perceiving themselves as normal concerning this function. SUBJECTS AND METHODS: A questionnaire (4-week diary with "yes-no" daily answers to six questions concerning bowel habits) was distributed to 204 subjects perceiving their defecation behaviour as normal. RESULTS: The completed questionnaire was returned by 140 subjects. No significant differences were found between sexes or age groups for any variable, even though straining at stool and feeling of incomplete and/or difficult evacuation showed a trend to increase with age. No subject had less than three bowel movements per week or more than three per day. The percentage of symptoms linked to an abnormal defecatory behaviour was well below 10%. Fifty-five percent of subjects reported at least one parameter of abnormal functioning; the most frequent was straining at stool and the rarer was the manual manoeuvres to help defecation. CONCLUSIONS: In normal subjects the prevalence of symptoms considered in Rome II criteria as part of an abnormal defecatory behaviour (in more than 25% of defecations) is well below 10%, manual manoeuvres are almost never used to help defecation, and the frequency of defecations is at least three per week.     

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation(Part Ⅱ:Treatment)

The second part of the Consensus Statement of the Italian Association of Hospital Gastroenterologists and Italian Society of Colo-Rectal Surgery reports on the treatment of chronic constipation and obstructed defecation.There is no evidence that increasing fluid intake and physical activity can relieve the symptoms of chronic constipation.Patients with normal-transit constipation should increase their fibre intake through their diet or with commercial fibre.Osmotic laxatives may be effective in patients who do not respond to fibre supplements.Stimulant laxatives should be reserved for patients who do not respond to osmotic laxatives.Controlled trials have shown that serotoninergic enterokinetic agents,such as prucalopride,and prosecretory agents,such as lubiprostone,are effective in the treatment of patients with chronic constipation.Surgery is sometimes necessary.Total colectomy with ileorectostomy may be considered in patients with slow-transit constipation and inertia coli who are resistant to medical therapy and who do not have defecatory disorders,generalised motility disorders or psychological disorders.Randomised controlled trials have established the efficacy of rehabilitative treatment in dys-synergic defecation.Many surgical procedures may be used to treat obstructed defecation in patients with acquired anatomical defects,but none is considered to be the gold standard.Surgery should be reserved for selected patients with an impaired quality of life.Obstructed defecation is often associated with pelvic organ prolapse.Surgery with the placement of prostheses is replacing fascial surgery in the treatment of pelvic organ prolapse,but the efficacy and safety of such procedures have not yet been established.     

An extended assessment of bowel habits in a general population

AIM:Bowel habits are difficult to study, and most data on defecatory behaviour in the general population have been obtained on the basis of recalled interview. The objective assessment of this physiological function and its pathological aspects continues to pose a difficult challenge. The aim of this prospective study was to objectively assess the bowel habits and related aspects in a large sample drawn from thegeneral population.METHODS: Over a two-month period 488 subjects were prospectively recruited from the general population and asked to compile a daily diary on their bowel habits and associated signs and symptoms (the latter according to Rome Ⅱ criteria). A total of 298 (61%) participants returned a correctly compiled record, so that data for more than 8000 patient-days were available for statistical analysis.RESULTS:The average defecatory frequency was once per day (range of 0.25-3.25) and was similar between males and females.However, higher frequencies of straining at stool (P=0.001), a feeling of incomplete emptying and/or difficult evacuation (P=0.0001), and manual manoeuvres to facilitate defecation (P=0.046) were reported by females as compared to males.CONCLUSION:This study represents one of the first attempts to objectively and prospectively assess bowel habits in a sample of the general population over a relatively long period of time. The variables we analyzed are coherent with the criteria commonly used for the clinical assessment of functional constipation, and can provide a useful adjunt for a better evaluation of constipated patients.