Laparoscopic Suture Rectopexy for Rectal Prolapse

PURPOSE: This study was undertaken to eveluate the early results of the laparoscopic suture rectopexy in the treatment of rectal prolapse. METHODS: From May 1999 to July 2001, laparoscopic suture rectopexy (LSR) was successfully performed in 26 patients and the results were compared to those of 5 patients with open suture rectopexy (OSR) and 6 patients with open resection rectopexy (ORR). Preoperative and postoperative functional assessment included Wexner's incontinence score, constipation score, and anorectal manometry. RESULTS: Immediate postoperative morbidity was minimal in all groups. Bowel function was resumed significantly sooner (P=0.001), the numbers of the analgesics injection were significantly fewer (P<0.001) and postoperative hospital stay was significantly shorter (P<0.001) in the LSR than in the open groups. Postoperatively, the anal resting and squeezing pressures increased slightly and Wexner's incontinence score decreased significantly in all groups of patients. Constipation score decreased slightly in all groups of patients after surgery. There was one mucosal prolapse recurrence after surgery in the LSR. CONCLUSIONS: Laparoscopic suture rectopexy for rectal prolapse can be performed safely. Recovery is uneventful and of shorter duration after the laparoscopic than after the open approach. Functional results are obtained similarly with both approaches.

Factors Influencing Fecal Incontinence in Complete Rectal Prolapse: A Prospective Analysis

PURPOSE: This study was undertaken to identify factors influencing fecal incontinence in rectal prolapse. METHODS: The clinical and anorectal physiologic data (anal manometry, rectal sensitivity test, pudendal nerve terminal motor latency (PNTML)) of 42 complete rectal prolapse patients were collected in a prospective database and were analyzed according to Wexner's incontinence score (0-20). RESULTS: The mean Wexner's incontinence score was 10.6. Females (n=24) were more prone to be incontinent than males (n=18)(incontinence score 14.8 vs 5.1, p<0.001). A linear regression analysis showed that increased age (r= 0.497, p=0.001), decreased maximum resting pressure (MRP) (r= 0.686, p<0.001), decreased maximum squeezing pressure (MSP)(r= 0.789, p<0.001), decreased maximal rectal tolerable volume (MTV) (r= 0.386, p=0.012) influenced the incontinence score. An absent rectoanal inhibitory reflex (RAIR) was not related to incontinence, but was related to significantly low resting anal pressure. Delayed PNTML did not influence incontinence or the MSP. In a multiple regression analysis, decreased MRP (beta= 0.383; p=0.002), decreased MSP (beta= 0.345; p =0.007) and female gender (beta=0.343; p=0.006) influenced incontinence significantly. CONCLUSIONS: Major factors influencing fecal incontinence in complete rectal prolapse were decreased MRP and MSP. Female patients were more prone to fecal incontinence than males. RAIR and MTV were not significant factors. PNTML did not show any relation to incontinence score or the anal pressure.

Clinical and Physiologic Characteristics of Rectal Prolapse in Males

This study compares the sexual differences among rectal prolapse patients regarding the clinical and the physiologic characteristics with emphasis on males. METHODS: The clinical data, functional status and operative records of 43 patients, who had completed both clinical and functional evaluations were collected in a prospective database and were analyzed according to sex. The functional status of the patients was evaluated by Wexner's constipation score (0~30), Wexner's incontinence score (0~20), anorectal manometry, and pudendal nerve terminal motor latency (PNTML). RESULTS: The incidences of rectal prolapse in males (n=22) and in females (n=21) were similar. The age of onset for males was lower (mean standard deviation, 19.6 19.59 (50% in childhood) vs 52.0 20.75 years; p=0.001) and the duration of symptoms was longer (31.5+/-19.87 vs 12.5+/-14.31 years; p<0.001). Surgery in males was most commonly performed during the sexually active years (51.2+/-16.34 vs 64.5+/-13.19; p=0.006). The incidence of mucosal prolapse in males was higher (10/22 vs 4/17; p=0.065). The incidences and the severities of defecation difficulty in males and females were similar (n=12, mean Wexner score=8.4 vs n=12, mean Wexner score=9.9; p=NS) but, the incidences and the severities of fecal incontinence were lower in males (n=4, mean Wexner score=4.3 vs n=17, mean Wexner score= 14.2; p<0.001). The maximum resting pressure was higher in males (39.2+/-21.46 vs 26.3+/-19.98 mmHg; p=0.049), and the maximum squeezing pressure was better preserved (131.2+/-62.63 vs 67.5+/-37.99 mmHg; p<0.001). No significant difference existed in the PNTML. Female patients underwent abdominal resection rectopexy (n=6), perineal rectosigmoidectomy with lavatoroplasty (n=11), and Delorme's procedure (n=4), but all male patients preferred the perineal approach (rectosigmoidectomy with lavatoroplasty (n=8), Delorme's procedure (n=14)) for fear of sexual dysfunction after the abdominal approach. CONCLUSIONS: These findings suggest that the mechanism for developing rectal prolapse in male and female may be different and that surgical treatment should be tailored to the patient.

Investigation of Skip Lesion at the Appendiceal Orifice in Ulcerative Colitis

BACKGROUND: Generally ulcerative colitis has a character that has a continuous pathological lesion from the rectum toward the cecum. Ulcerative appendicitis with a skipped appendiceal orifice lesion, which is unusual in ulcerative colitis, has been infrequently reported, and its clinical characteristics have not been identified. PURPOSE: This study was carried out to evaluate the incidence rate and the clinical characteristics of ulcerative appendicitis. METHODS: One hundred consecutive patients with ulcerative colitis who had been treated from Jan. 1997 to Aug. 1998 at Song-Do Colorectal Hospital were used for the study. Data evaluated included age, sex, involved site, clinical type, clinical severity of the disease, and endoscopic severity of the disease. RESULTS: Nineteen (19%) of the 100 patients had skipped lesions around the appendiceal orifice; the other 81 did not. There were no significant differences between these two groups with respect to the age and the sex distributions, the involved site, the clinical type, and the clinical severity. There was a correlation between the endoscopic grades, based on the Riley classification, of the lesions at the rectum and at the appendiceal orifice. Seven patients (36.8%) of the 19 patients with appendiceal orifice lesions showed an extended lesion from the appendiceal orifice to the cecum. CONCLUSIONS: We suggest that appendiceal lesions in ulcerative colitis are not infrequent. Even though no significant differences in the clinical characteristics of ulcerative colitis with ulcerative appendicitis, compared with those of ulcerative colitis without ulcerative appendicitis, were found, we suggest that more profound study of ulcerative appendicitis probably contribute to understand the pathophysiology of ulcerative colitis.

Submucosal Invasive Cancer in the Colon / 대한소화기내시경학회지

BACKGROUND AND AIMS: A superficially invasive cancer in the colon is considered a candidate for an endoscopic resection. Therefore, detecting a superficially invasive cancer and differentiating it from a massively invasive cancer is an important key in selecting proper treatment. In order to accomplish this purpose, exact knowledge of the characteristics of submucosal invasive cancers is required. In this study, attempts to define those endoscopic features and draw guidelines for treatment were made. METHODS: Recently, 23 submucosal invasive cancers were experienced. All of them were detected by an endoscopic examination, and were treated by endoscopic therapy and/or surgical resection. These cancers were reviewed and analyzed with emphasis on size, configuration, differentiation, and treatment. RESULTS: The most common sizes ranged from 10 mm to 19 mm (47.8%). There were two minute lesions below 5 mm. The most common type of lesions was sessile (43.5%). Most lesions showed redness and 60.9% showed hardness. Many cases had characteristic features such as nodules (47.8%), bleeding easily upon touch (39.1%), erosion (39.1%), and white spots (34.8%). Other characteristic features were expanded figures, depressions, and mucosal convergence. Moderately-differentiated adenocarcinomas were predominant (8/15, 53.3%), and there were four polypoid cancers (4/17, 23.5%). In 43.5% of the lesions, only endoscopic treatment was enough. Forty-four percent of all patients treated endoscopically needed additional surgical resections because of uncertainty with respect to complete excision of the cancer and/or a poorly-differentiated adenocarcinoma with lymphatic invasion. There was no lymph node metastasis in any of the patients who underwent surgical resections, and three of them had no residual tumors, as the endoscopic treatment had completely excised the cancer. CONCLUSIONS: Accurate information on submucosal invasive cancers and recognition of the endoscopic characteristics of submucosal invasive cancers are necessary for their detection and management in an early stage. Moreover, it is possible to differentiate superficially invasive cancers from massively invasive ones by their characteristic features. Therefore, in selected patients with superficially invasive cancers, surgical resections can be avoided.

Repair of Rectovaginal Fistulas

Thirteen women with rectovaginal fistulas unrelated to inflammatory bowel disease or previous radiotherapy were operated on during Jan. 1993 - Jul. 1997 at Song-Do Colorectal Hospital. The mean age was 36.9 (range, 25~56) years. The mean follow-up after operation was 33 (range, 8~62) months. The etiology of the fistula in the majority of patients was obstetric injury and operative trauma (10/13). Seven patients were referred after attempts at repair elsewhere. Eleven patients were managed with a mucosal flap advancement and a 3-layered repair of the rectovaginal septum: 4 without and 7 with a perineal body reconstruction or sphincter repair. Two patients were managed with a mucosal flap advancement only without a repair of rectovaginal septum. In all cases, a concomitant colostomy was not performed. Postoperative complications were noticed in 3 of the patients managed by a mucosal flap advancement and 3-layered repair of the rectovaginal septum with perineal body reconstruction or sphincter repair and all were perineal wound infections. All of these infections were cured, without recurrence, by simple rubber seton drainage. Recurrence occurred in one case managed by a mucosal flap advancement only. Three patients with liquid incontinence became continent after a sphincter reconstruction. We conclude that most rectovaginal fistulas unrelated to inflammatory bowel disease or previous radiotherapy can be managed with a mucosal flap advancement and 3-layered reconstruction of the rectovaginal septum. If any signs or symptoms of sphincter injury are noticed preoperatively while taking the patient's history or during manometry and endorectal ultrasonography, a perineal body reconstruction or sphincter repair should be performed.