Outcome and Prognostic Factors Associated with Poor Outcome of Biofeedback Therapy for Constipated Patients with Non- relaxing Puborectalis Syndrome

PURPOSE: Biofeedback is a major treatment method for constipated patients with non-relaxing puborectalis syndrome. However a significant percent of patients still showed poor outcome, and little has been known about the predictors associated with outcome of biofeedback. The aim of this study was to determine the outcome and identify predictors associated with poor outcome of biofeedback therapy for constipated patients with non- relaxing puborectalis syndrome. METHODS: Fifty-two constipated patients with non-relaxing puborectalis syndrome (median age, 47 years) who had more than one biofeedback session after defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were analyzed. Any differences in demographics, clinical symptoms, and parameters of anorectal physiological study were evaluated between success group (patients felt improvement in symptoms at follow-up) and failure group (patients felt no improvement). RESULTS: Follow up (mean follow-up; 17 months) results were evaluated by an independent observer in 45 patients. At post-biofeedback, 42 (81 percents) patients felt improvement in symptoms, including 7 (13 percents) with complete symptom relief. At follow-up, 25 (56 percents) patients felt improvement in symptoms, including 1 (2 percents) with complete symptom relief. There was a significant reduction in difficult defecation (from 81 to 44, 53 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.005, P<0.01), sensation of incomplete defecation (from 90 to 50, 40 percent; P< 0.00001, P<0.000005), laxative use (from 25 to 10, 11 percent; P<0.05), and enema use (from 13 to 0, 2 percent; P<0.01, P<0.05). Normal spontaneous bowel movement was increased from 42 percent pre-biofeedback to 81 percent post-biofeedback (P<0.0001), 80 percent at follow up (P<0.0005). Pre-biofeedback presence of symptoms of bowel habit change predict poor outcome (15 vs. 0 percent; failure vs. success, P<0.05). High pressure zone in prebiofeedback manometry was longer in failure group than in success group (2.80 vs 2.01 cm, P<0.05). In the success group, 11 (44 percent) had a rectocele, 1 (4 percent) had a rectal intussussception, 18 (72 percent) had a descending perineal syndrome, and 3 (12 percent) had a sigmoidocele. In the failure group, 4 (20 percent) had a rectocele, and 1 (5 percent) had a rectal intussusception, 14 (70 percent) had a descending perineal syndrome, and a sigmoidocele was not accompanied (P<0.05). Accompanied rectocele, rectal intussusception, descending perineal syndrome, and sigmoidocele did not influence outcome. CONCLUSIONS: Biofeedback is an effective option and should be considered as the first line therapy. Bowel habit change and long high pressure zone in pre-biofeedback manometry were predictors associated with poor outcome of biofeedback therapy for constipated patients with non-relaxing puborectalis syndrome.

Outcome and Predictors of Biofeedback Therapy for Patients with Internal Rectal Intussusception

PURPOSE: The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for patients with internal rectal intussusception. METHODS: Twenty-one patients (median age. 54 years, 15 female, 6 male) diagnosed with internal rectal intussusception by using cinedefecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed. RESULTS: Follow up (median: 15, range 2~24 months) results were evaluated by an independent observer in 20 patients. At post-biofeedback, 20 (95%) patients felt improvement in symptoms, including 7 (33%) with complete symptom relief. At follow-up, 17 (85%) patients felt improvement in symptoms, including 7 (35%) with complete symptom relief. There was a significant reduction in difficult defecation (from 90 to 29, 10 percent, from pre-biofeedback to post-biofeedback, and at follow up respectively; P<0.001), sensation of incomplete defecation (from 90 to 24, 35 percent; P<0.001), enema use (from 29 to 0, 0 percent; P<0.01), and anal pain (from 19 to 0, 0 percent; P<0.05). Digitation (from 19 to 0 percent, from pre- biofeedback to at follow up; P<0.05) and laxative use (from 29 to 5 percent; P<0.05) were also decreased. Normal spontaneous bowel movement was increased from 52 percent, at pre-biofeedback to 86 percent, at post- biofeedback (P<0.05), 95 percent at follow up (P<0.005). Low bowel frequency, at pre-biofeedback (P<0.01), and hard stool (P<0.05) predicted poor outcome. Long puborectalis length during push (P<0.05) and dynamic descent (P<0.05) on defecography also predicted poor outcome. Low electrical activities of puborectalis and anal sphincter muscle during rest (P<0.001), squeeze (P<0.01) and push (P<0.005) on pre-biofeedback electromyography were related to poor outcome. No patient developed full rectal prolapse during follow up. CONCLUSIONS: Biofeedback is an effective option and should be considered as the first line therapy especially for patients that don't have low bowel frequency, long puborectalis during push, and dynamic descent before treatment.

Biofeedback Therapy for Patients with Rectocele

PURPOSE: The aim of this study was to determine the outcome and identify predictors of success of biofeedback therapy for rectocele. METHODS: Twenty four female patients (mean age 43.8 years) with rectal emptying difficulties and a rectocele greater than 2 cm at defecography were evaluated before hand with a standardized questionnaires, immediately after biofeedback therapy, and at follow up. Defecography, manometry, colon transit studies and electrophysiology were also analyzed. RESULTS: Follow up (mean 7.2; range 2~17 months) results were evaluated by an independent observer in 20 patients. At the end of biofeedback, 22 (92 percent) patients felt improvement in symptoms, including 13 (54 percent) with symptomatic relief. At follow-up, 14 (70 percent) patients felt improvement in symptoms, including 3 (15 percent) with complete relief of symptoms. There was a significant reduction in difficult defecation (from 79 to 29, 40 percent, from pre-biofeedback to post-biofeedback, at follow-up respectively; P<0.001, P<0.05), sensation of incomplete defecation (from 96 to 46, 60 percent; P<0.001, P<0.005), laxative use (from 54 to 25, 30 percent; P<0.05), enema use (from 21 to 0,0 percent; P<0.05), anal pain (from 21 to 0, 5 percent; P<0.05) and digitation (from 21 to 4, 5 percent). Normal spontaneous bowel movement was significantly increased from 50 percent pre-biofeedback to 83 post-biofeedback (P<0.05), 65 percent at follow-up. Abdominal pain (P<0.05) and digitation (P<0.05) related to poor results. High mean squeeze pressure (P<0.001) and high maximum squeeze pressure (P<0.05) on pre-biofeedback manometry were also related to a poor outcome. Age, duration of symptoms, parity, number of sessions of biofeedback, gynecologic surgery history, and rectocele size at defecography had no prognostic value. Anismus and colonic inertia did not influence the outcome of biofeedback. CONCLUSIONS: Biofeedback is an effective treatment option for patients with obstructed defecation due to rectocele.

Long Term Follow-up for Modified Whitehead Hemorrhoidectomy

PURPOSE: Walter Whitehead introduced new method for treating circumferential hemorrhoids with good results for the first time in 1882, but his procedure has been neglected by most surgeons because of complications, such as anal stricture, incontinence, ectropion, etc. METHODS: We retrospectively inves tigated and analyzed 52 cases involving modified Whitehead hemorrhoidectomies (WH) and 60 cases involving submucosal hemorrhoidectomies (SH) performed at Seoul Adventist Hospital from Jan. 1989 to Dec. 1994. We only selected patients whose follow-up durations were more than 5 years. The chi-square test and t-test were used for the statistical analysis. RESULTS: The results are as follows: 1) The sex ratio of males to females was 1.36 to 1 in the WH group and 1.31 to 1 in the SH group. 2) The peak age was in the 4th decade (40.0% in the WH group and 35.0% in the SH group), the mean age was 39.1 years in the WH group and 37.3 years in the SH group, and the age distribution ranged from 17 years to 75 years in both groups. 3) The average postoperative hospital stay was 9.83 days in the WH group and 8.43 days in the SH group (p=0.001). 4) The average follow up duration was 71.3 months in the WH group and 76.9 months in the SH group. 5) In the WH and the SH groups, the postoperative complications were, respectively, recurrence (1.9%:0%, p=0.281), defecation difficulty (7.7%:1.7%, p=0.124), incontinence (1.9%:3.3%, p= 0.645), ectropion (1.9%:0%, p=0.281), anal pain (15.4%:8.3%, p=0.245), and anal bleeding (9.6%: 13.3%, p=0.540). 6) Some patients complained about complications 7 years after the operation. These were 1 defecation difficulty and 1 incontinence in the WH group and 1 defecation difficulty and 2 incontinences in the SH group. CONCLUSIONS: The results of a long term follow-up for postoperative complications after a modified Whitehead operation were no worse than those for a submucosal hemorrhoidectomy. Thus, if one uses proper surgical technique, one should be able to get better results: fewer complications and more complete healing of the hemorrhoid.

A Modified Whitehead Hemorrhoidectomy for Circumferential Hemorrhoid

This report is a clinico-statistical review of our experience with 64 patients with circumferential hemorrhoids who were admitted to and treated at the Surgical Department of Seoul Adventist Hospital during 10 years from Jan. 1986 to Dec. 1995. 1) The indication for a modified Whitehead hemorrhoidectomy was third and or fourth degree circumferential hemorrhoid. 2) The sex ratio of male to female was 1.8 to 1. 3) The peak incidence was in the 3rd and the 5th decades(89.3%). 4) The frequent pre-operative anorectal symptoms were anal prolapse (81.5%), anal pain (52.3%), and anal bleeding (55.6%). 5) The mean average post-operative hospital stay was 9.9 days. 6) The early post-operative problems were urinary retention(35.4%), severe anal pain(21.5%), mild anal bleeding(8.9%) and constipation(1.5%). 7) The late post-operative complications were mild anal stenosis(3.3%), flatus incontinence(1.6%), fissure(3.3%) and a nonhealing wound(1.6%). 8) Attention to the proctologic anatomy and experience are essential for a good result and for prevention of anal stenosis or prolapse.

A Modified Whitehead Hemorrhoidectomy for Circumferential Hemorrhoid

This report is a clinico-statistical review of our experience with 64 patients with circumferential hemorrhoids who were admitted to and treated at the Surgical Department of Seoul Adventist Hospital during 10 years from Jan. 1986 to Dec. 1995. 1) The indication for a modified Whitehead hemorrhoidectomy was third and or fourth degree circumferential hemorrhoid. 2) The sex ratio of male to female was 1.8 to 1. 3) The peak incidence was in the 3rd and the 5th decades(89.3%). 4) The frequent pre-operative anorectal symptoms were anal prolapse (81.5%), anal pain (52.3%), and anal bleeding (55.6%). 5) The mean average post-operative hospital stay was 9.9 days. 6) The early post-operative problems were urinary retention(35.4%), severe anal pain(21.5%), mild anal bleeding(8.9%) and constipation(1.5%). 7) The late post-operative complications were mild anal stenosis(3.3%), flatus incontinence(1.6%), fissure(3.3%) and a nonhealing wound(1.6%). 8) Attention to the proctologic anatomy and experience are essential for a good result and for prevention of anal stenosis or prolapse.

Reflux Esophagitis Following a Loop Esophagojejunostomy with a Braun Anastomosis after a Total Gastrectomy for Gastric Cancer

BACKGROUNDS: Reflux esophagitis has been known to be a frequent complication after a total gastrectomy. Reflux esophagitis is very annoying to the patients, so various types of reconstructions has been introduced to eliminate this complication. METHODS: This study is a retrospective clinical analysis of 34 patients with gastric cancer who were treated with a total gastrectomy from January 1989 to December 1997 at the Department of Surgery, Seoul Adventist Hospital. RESULTS: During 9 years, the operation was performed on 194 patients with gastric cancer, amomg which 34 (17.3%) were total gastrectomies. The peak age was in the 5th and the 6th decades (58.8%), and the sex ratio of males to females was 1.6:1. The sites of the stomach cancer were the cardia (C) in 10 cases (29.4%), the body (M) in 19 cases (55.9%), and the cardia and body in 5 cases (14.7%). The TNM classification was stage I in 15.6% of the cases, stage II in 15.6% of the cases, stage III in 62.5% of the cases, and stage IV in 6.3% of the cases. Three methods of alimentary tract reconstruction were used:a loop esophagojejunostomy with a Braun anastomosis (27), a Roux-en-Y esophagojejunostomy (6), and an uncut Roux procedure (1). The reflux esophagitis rates for patients treated with a loop esophagojejunostomy with a Braun anastomosis and for patients treated with a Roux-en-Y esophagojejunostomy were 25.9% and 16.7%, respectively. The perioperative mortality was 5.8%, and the causes of death were pneumonia and anastomotic leakage. The most common recurrent site was the anastomotic site. CONCLUSIONS: Reflux esophagitis developed more often after a loop esophagojejunostomy with a Braun anastomosis than after a Roux-en-Y anastomosis. This finding was not significant statistically. Thus, further study of more cases is needed.

A Clinical Study of Colorectal Cancer

This is a retrospective clinical analysis of 156 patient with colorectal cancer who were surgically treated from January 1988 to June 1996 at the Department of Surgery, Seoul Adventist Hospital. The results are as follows: 1) The peak age incidence was in the 7th decade (31.4% of the cases), and the sex ratio of males to females was 1.03 : 1. 2) The most common location of the tumor was the rectum in 77 cases (49.4%); next were the sigmoid colon in 25 cases (16.0%) and the ascending colon in 25 cases (16.0%). 3) In the right colon, the most frequent symptoms and signs were abdominal pain, a palpable mass, weight loss; in the left colon and rectum, bloody tarry stool and bowel- habit change were the most common symptoms and signs. 4) The duration of the symptoms and signs prior to admission was most commonly less than 3 month (46.8% of the cases). 5) The diagnostic methods were digital rectal examination, sigmoidoscopy, colonofiberoscopy, barium enema, and abdominal CT. In two cases,an exploratory laparotomy was done. Also, 2.8 studies were done per patient. 6) The operations performed included an abdominoperineal resection in 36 cases (24.0%) and a right hemicolectomy (18.7%). The operability was 96.2%, and the total resectability was 79.5%. 7) The staging of the tumor was performed during the initial operation according to the Aster Coller classification and the TNM classification. Stages C2 (33.8%) and B2 (29.1%) and T3N0M0 were the most frequent stages in both classification. 8) The most common histologic type was an adenocarcinoma (96.8%). 9) The most common macroscopic finding was of the annular type (59.6%) 10) The most common distant metastasis sites were the pelvic organs and the liver. 11) The most frequent postoperative complication was wound infection (14.7%). The complication rate and perioperative mortality were 32.7% and 2%, respectively.

A clinical study of reoperation for intrasbdominal abscess

No abstract available.

A clinical analysis of incisional hernia

No abstract available.

A clinical study of abdominal trauma

No abstract available.

Clinical review on surgical acute abdomen

No abstract available.

A clinical review of upper gastrointestinal bleeding

No abstract available.

A clinical study of peptic ulcer perforation

No abstract available.