Clinical Presentation and Surgical Outcome in Patients with Solitary Rectal Ulcer Syndrome

PURPOSE:Solitary rectal ulcer syndrome (SRUS) is a poorly understood clinical condition and its scheme of treatment has not been defined yet. The aim of this investigation was to review the clinical spectra and outcome of various surgical treatments in patients with SRUS, thus to define more rational approach to the management of this ambiguous condition. METHODS:The study population was composed of 49 patients, among whom 20 patients (18 females and 2 males; median age, 55) were diagnosed primarily as SRUS histopathologically (=primary SRUS). Reviewing all pathologic reports and slides from specimens resected surgically in patients with rectal prolapse, another 20 cases were diagnosed to be combined with SRUS. Other 9 patients included those who were diagnosed histologically as or to be combined with SRUS after the operation for an indication other than SRUS. The latter 29 cases (26 females and 3 males; median age, 72) were defined as secondary SRUS, and then differences in clinical features and outcome of surgical treatment between 2 groups were reviewed retrospectively. The median follow-up was 24 months (range, 5-49 months). RESULTS:Ulcerative morphology was predominant in primary SRUS (70 percent), whereas erythematous (45 percent) and polypoid (34 percent) in the secondary ones. This difference in morphologic distribution between two groups was significant statistically (P=0.0025). No statistical difference was observed for symptomatologic distributions between two groups. The most common problem associated with evacuation was rectal bleeding in both groups (85 percent and 76 percent, respectively). In primary SRUS, clinical and defecographic studies revealed a rectal prolapse in 5 patients (25 percent), intussusception in 11 patients (55 percent), sigmoidocele (2 degrees) in 4 (20 percent), and paradoxical puborectalis contraction (PPC) in 3 (15 percent) to be combined. Beside rectal prolapse in secondary group, other defecographic findings associated with possible evacuatory problem included sigmoidocele (2 degrees) in 5 (25 percent), rectocele and intussusception in 2 (10 percent), respectively. Clinical improvement after surgery was obtained in 14 of 19 procedures (74 percent) in 17 patients with primary SRUS and 23 of 29 (79 percent) in secondary SRUS, the difference of which was not significant. Though statistically not significant, transabdominal rectopexy was superior to local excision for symptomatic relief in primary SRUS without overt prolapse (86 percent vs. 33 percent). Neither of changes in the percentage of symptoms before and after the operation between two groups showed significance. Clinical and pathologic variables were compared between two treatment result groups of 'improvement' and 'no improvement' and manifestations as tenesmus and digitation correlated with a poorer outcome after surgery (P=0.0065 and 0.02, respectively). CONCLUSIONS:SRUS is rather a clinical condition associated with functional anorectal evacuatory disorders than an independent disorder. This study shows optimistic role of a surgical treatment against underlying functional disorders in the improvement of secondary SRUS. Proper surgical option, however, for treatment in variable clinical spectra of primary SRUS is still not established, which awaits a conclusion from extensive prospective randomized trials.

Is the Level of Anastomosis within the Anal Canal Pertinent to Physiologic and Functional Outcome in the Double-stapled Ileoanal Reservoir?

PURPOSE: The aims of this investigation were to access the relative ratio of epithelial types within the anal canal after a double-stapled ileoanal reservoir (DSIAR) and to review physiologic and functional differences based on this diversity in epithelial types. METHODS: According to types of the epithelium present at histologic sections of the distally excised tissue ring ("donut") after the stapling for restorative proctocolectomy with construction of a DSIAR, one hundred thirty-eight patients with ulcerative colitis were stratified into two groups: 40 patients (22 males and 18 females) were categorized to be of lower anastomosis (group I), where squamous, squamous mixed with columnar, or squamocuboidal component was reported to be present, and 98 patients (50 males and 48 females) to be of higher one (group II), which was evidenced by columnar epithelium at the "donut". Physiologic and functional parameters were appraised between 2 groups to define whether this difference in epithelial types is associated with a significant difference in postoperative anorectal functional outcome. RESULTS: None of preoperative parameters reflecting resting and squeeze pressures showed significant differences between 2 groups. Postoperative mean and maximal resting pressures (MRP and MxRP) were declined to 48.8 16.9 mmHg and 67.1 21.3 mmHg in group I, and 61.1 22.7 mmHg and 90.0 38.6 mmHg in group II, differences of which were significant (P=0.046 and 0.031, respectively). Neither postoperative mean nor maximal squeeze pressure was, however, statistically different between 2 groups. Mean length of the high pressure zone was decreased in both groups postoperatively, but there were no intergroup differences. Rectoanal inhibitory reflex decreased significantly from 97.4% to 50% in group I and from 86.5% to 53.9% in group II, respectively (P<0.0001 in both). However, there was no significant intergroup difference postoperatively. Maximal tolerance volume and compliance of the reservoir were significantly improved postoperatively in both groups; from 52.2 26.1 ml and 2.8 3.3 to 163.3 115.7 ml and 14.7 15.3 in group I (P=0.0001, and <.0001, respectively), and from 77.0 59.5 ml and 4.4 6.8 to 167.3 87.9 ml and 28.7 44.0 in group II (P<0.0001, both). But there was no intergroup difference in either parameters postoperatively. There were no significant differences between groups relative to functional outcome except the diurnal incontinence to solid stool (P<0.011). CONCLUSIONS: Although epithelial types were shown to be variable at the anal side of the anastomosis after a DSIAR, these differences were not associated with physiologic and functional differences. Therefore, if technically feasible, this procedure can be performed with safety without fear of significant functional derangement.