Experimental internal anal sphincter replacement with demucosated colonic plication.

BACKGROUND: Selective re-creation of a new internal anal sphincter could be indicated when the natural one is irreversibly damaged or excised. METHODS: In this preliminary experimental work, surgical techniques of internal anal sphincter replacement in pigs were investigated. After preoperative anorectal manometry, surgical procedure was done in two phases: abdominal, mobilization of the colon-rectum to the pelvic floor; and perianal, dissection of the anal canal from the external anal sphincter through the intersphincteric space. The fully mobilized anorectal segment, including the internal anal sphincter, was pulled down through the anus and resected. The distal colonic stump was then demucosated and two types of plications of the demucosated segment were accomplished, each type in three animals. The plicated segment was then returned into the anal canal, inside the external sphincter. Short-term follow-up with clinical and manometric evaluations was performed and, subsequently, histological analysis of the plicated segment, after the animals were sacrificed. RESULTS: None of the animals became incontinent. Anal manometry identified a high-pressure zone and relaxation reflex in the new anal canal. Histologic studies showed hypertrophy of smooth muscle layers without degenerative changes. CONCLUSION: This study indicates that a plication of colonic smooth muscle wall can re-create a high-pressure zone in the anal canal after the internal anal sphincter has been excised.

Associations of defecography and physiologic findings in male patients with rectocele.

This study evaluated the incidence and physiological findings in male patients with rectoceles. All defecographic studies were evaluated by a single colorectal surgeon. After diagnosis of rectocele in male patients, the patient's history, symptoms, and physiologic tests (anal manometry, pudendal nerve terminal motor latency [PNTML], assessment and electromyography [EMG]) were studied. A prominent rectocele was defined as one that did not empty during defecography and was associated with outlet obstructive syndrome. Forty (17%) rectoceles were diagnosed in 234 male patients with evacuatory disorders who underwent defecography. Rectoceles were anterior in 19 (48%) and posterior in 21 (52%) patients. The main complaint was constipation with difficult defecation in 33 (83%), followed by rectal pain in 5 (13%), rectal prolapse in 1 (3%), and incontinence in 1 (3%). Previous prostatic surgery had been performed in 16 (40%) patients. The mean age and duration of symptoms were 72.4 years (range, 30-88) and 10.3 years (range, 0.5-70), respectively. Excessive straining during evacuation was noted in 73%, unilateral or bilateral pudendal neuropathy in 24.5%, paradoxical puborectalis contraction in 49% and abnormal EMG in 11% of patients. Higher resting pressures with a mean 3.9 cm high pressure zone were noted in 29% of patients. The accompanying findings in defecography were, non-relaxing or partially relaxing puborectalis muscle (66%), perineal descent (65%), intussusception (23%), and sigmoidocele (15%). None of the patients underwent surgery for rectocele alone. In conclusion, rectocele is uncommon in males; it rarely appears as an isolated dysfunction as it is often associated with functional disorders of the pelvic floor. There is a frequent association between rectocele and prostatectomy. Clinical significance and therapeutic strategy remain unknown.

Recurrent rectal prolapse: what is the next good option?

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 +/- 7.8 vs. rectal prolapse, 12.7 +/- 7.2; range, 0-20) or manometric or electromyography findings, and there were no significant differences in mortality (0 vs. 3.7 percent), mean hospital stay (5.4 +/- 2.5 vs. 6.9 +/- 2.8 days), anastomotic complications (anastomotic stricture (0 vs. 7.4 percent), anastomotic leak (3.7 vs. 3.7 percent) and wound infection (3.7 vs. 0 percent), postoperative incontinence score (2.8 +/- 4.8 vs. 1.5 +/- 2.7), or recurrence rate (14.8 vs. 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.

Prognostic significance of rectocele, intussusception, and abnormal perineal descent in biofeedback treatment for constipated patients with paradoxical puborectalis contraction.

PURPOSE: The findings of paradoxical puborectalis contraction, rectocele, sigmoidocele, intussusception, and abnormal perineal descent often coexist in constipated patients, as noted by defecographic study. Moreover, some of these conditions are often found in asymptomatic patients. Biofeedback is the treatment of choice for constipated patients with paradoxical puborectalis contraction; the main determinant of successful biofeedback is patient compliance. The significance of coexistent and highly prevalent variants, such as rectocele, intussusception, sigmoidocele, or abnormal perineal descent, on the success of biofeedback is unknown. This review was designed to assess whether these coexisting defecographic findings have any prognostic significance for the outcome of biofeedback. METHODS: From July 1988 to December 1996, 209 constipated patients with paradoxical puborectalis contraction underwent biofeedback treatment after defecography. A total of 173 patients (120 females) who had more than one biofeedback session after defecography formed the study group. Defecographic findings included concomitant rectoceles, 40 (23 percent); evidence of circumferential intussusception, 17 (10 percent); sigmoidocele, 13 (8 percent); and abnormal perineal descent, 109 (63 percent). RESULTS: Whereas 65 patients failed to complete the course of biofeedback therapy, 108 (62.4 percent) patients completed the course of biofeedback and were discharged by the therapist. Within the completed group 59 (55 percent) improved, and 49 (45 percent) patients failed biofeedback therapy. In the improved group 14 (23.7 percent) had a rectocele, 5 (8.5 percent) had intussusception, 5 (8.5 percent) had a sigmoidocele, and 37 (62.7 percent) had abnormal perineal descent. In the failure group 9 (18.4 percent) had a rectocele, 5 (10.2 percent) had an intussusception, 2 (4.1 percent) had a sigmoidocele, and 31 (63.3 percent) had abnormal perineal descent (P = not significant). The success of biofeedback was then analyzed relative to the number of coexisting conditions. Specifically, the outcome in patients with paradoxical puborectalis contraction alone and with one, two, and three other defecographic findings were compared. No statistically significant difference was found among these four groups. CONCLUSION: Although other defecographic findings frequently coexist with paradoxical puborectalis contraction, none of the concomitant findings adversely affected the outcome of biofeedback treatment. Therefore, biofeedback can be recommended to patients with coexistent defecographic findings, with expectation of success in over 50 percent of individuals who complete the course of therapy.

Laparoscopic colectomy compares favorably with colectomy by laparotomy for reduction of postoperative ileus.

PURPOSE: The aim of this study was to compare the length of postoperative ileus in patients undergoing colectomy by either laparotomy or laparoscopy. METHODS: A total of 166 patients were studied. These patients were divided into two groups: Group 1, in which colectomy was done laparoscopically, and Group 2, consisting of patients undergoing laparotomy. Both groups contained 83 patients who were matched for disease severity, indications for surgery, and procedure. Indications for surgery included sigmoid diverticulitis in 12 (14 percent) patients, polyps in 22 (27 percent), Crohn's disease in 21 (25 percent), colorectal cancer in 11 (13 percent), stoma reversal in 8 (10 percent), rectal prolapse in 3 (4 percent), and other indications in 6 (7 percent) in each group. Operations were colectomy with anastomosis (42 ileocolic, 26 colorectal, 6 colocolic, 4 ileorectal, and 2 ileal J pouch) or without anastomosis (3 abdominoperineal resections) performed by the same surgeons during the same time period January 1993 to October 1996). The nasogastric tube was removed from all patients immediately after surgery in both groups. All patients received a clear liquid diet on the first postoperative day, followed by a regular diet as tolerated. The nasogastric tube was reinserted if two or more episodes of emesis of more than 200 ml occurred in the absence of bowel movement. Patients were discharged from the hospital when tolerating a regular diet without evidence of ileus. Statistical analysis was performed using unpaired t-test and Fisher's exact probability test. RESULTS: The male-to-female ratio was 38 to 45 in both groups. A total of 10 (12 percent) and 23 (28 percent) patients in Group 1 and Group 2 had emesis (P = 0.02), and the rate of nasogastric tube reinsertion was 5 (6 percent) and 13 (16 percent), respectively (P > 0.05). There were significant differences between Groups 1 and 2 relative to the lengths of ileus (3.5 +/- 1.3 vs. 5.4 +/- 1.7 days, respectively; P < 0.001), hospitalization (6.6 +/- 3.3 vs. 8.1 +/- 2.5 days, respectively; P < 0.002), and operative time (170 +/- 60 vs. 114 +/- 46 minutes, respectively; P < 0.001). The morbidity rate was 16 (19.2 percent) and 18 (21.6 percent) in the laparoscopy and laparotomy groups, respectively. CONCLUSIONS: Although early oral intake is safe and can be tolerated by 84 percent of patients after colectomy by laparotomy, laparoscopic colectomy reduced the lengths of both postoperative ileus and hospitalization.

Comparison of laparoscopically assisted and conventional ileocolic resection for Crohn's disease.

OBJECTIVE: To compare safety, outcome, and feasibility of laparoscopic assisted and conventional laparotomy for ileocolic resection in Crohn's disease. DESIGN: Retrospective study. SETTING: Private clinic, USA. SUBJECTS: 74 patients who had ileocolic resection and anastomosis for Crohn's disease between August 1991 and July 1996, 48 through conventional laparotomy and 26 in whom it was laparoscopically assisted. MAIN OUTCOME MEASURES: Age, operating time, duration of hospital stay, early and late morbidity, and patients' subjective assessment. RESULTS: The mean age was 42 (+/- 17) in the conventional group and 40 (+/- 15) in the laparoscopically assisted group. The mean operating time was significantly shorter in the conventional group, 90.5 +/- 3.7 minutes, compared with 150 +/- 1.2 minutes in the laparoscopic-assisted group (p < 0.0001), but they stayed in hospital significantly longer, 9.6 +/- 0.6 days in the conventional group, compared with 7 +/- 0.8 days in the laparoscopic-assisted group (p < 0.0001). There were no differences between the groups in the incidence of early complications or the cost of admission, but at a mean follow up of 30 months (range 2-59) significantly more patients in the conventional group had developed symptomatic bowel obstruction (15/48 compared with 2/26, p = 0.02). 31 patients in the conventional group (65%) and 16 in the laparoscopically assisted group (62%) returned their subjective assessments. There were no differences between the groups in the number with changed bowel habits, use of drugs for bowel movement, or restricted diet, but patients in the laparoscopically assisted group returned to work more quickly (3.7 +/- 1.2 weeks) compared with 8.2 +/- 1.1 weeks in the conventional group, had better cosmetic results (14/16 compared with 13/31, p = 0.004), and were more likely to have improved social and sexual lives (8/16 compared with 5/31, p = 0.02). CONCLUSION: Laparoscopically assisted ileocolic resection for Crohn' s disease is safe and has less morbidity than conventional laparotomy.

Laparoscopic colectomy yields similar morbidity and disability regardless of patient age.

This study compared the outcome factors of morbidity and the length of disability in older and younger patients following laparoscopic colorectal surgery. All patients undergoing laparoscopic segmental resection during the study period were included. Morbidity was determined by reviewing the medical records, and disability by a patient-administered questionnaire. The series was divided into two age cohorts (/=65 years), which did not differ significantly in gender or type of procedure. Between these two groups we found no significant differences in mean duration of ileus (3.3 days in both groups), the mean length of hospitalization (5.7 vs. 6.3 days, respectively), morbidity rate (18% vs. 21%), or time until returning to partial activity (1.6 vs. 1.6 weeks) or to full activity (3 vs. 2 weeks). Our findings demonstrate that neither the morbidity rate nor the disability period after laparoscopic techniques differ between elderly and younger patients. We therefore endorse the use of laparoscopy regardless of patient age.

Adult colonic intussusception caused by malignant tumor of the transverse colon.

Adult colonic intussusception is rare and often originates from neoplasms. In emergency situations it can be difficult to diagnose. Our aim was to show how the integration of readily available diagnostic means in emergency situations can help in making a correct diagnosis of this disease. A 68-year old male patient presented with vomiting and abdominal pain. The abdomen was distended, with pain to palpation in the left quadrants without a mass. Plain radiographs of the abdomen showed a large amount of gas in the small bowel and in the right and transverse colon. A barium enema demonstrated an endoluminal filling defect in the descending colon. Abdominal ultrasonography revealed the presence of intraperitoneal fluid and thickened left colonic wall at the site of the lesion, with an aspect of a "double ring" consistent with intussusception. A solid formation was also revealed at a point distal to the thickened colonic wall. At emergency laparotomy an approximately 8-cm-long mass was palpable through the left colon. A colostomy was fashioned, and subsequently colonoscopy revealed the presence of a left colon tumor. At the subsequent operation an invagination of the left transverse colon into the descending colon was confirmed. The left transverse and descending colon were resected with high ligation of the left colic artery. Macroscopic examination of the invaginating head showed a vegetating transverse colon neoplasm. We conclude that in emergency settings the association of readily available diagnostic means such as plain abdominal radiography, water soluble contrast enema and ultrasonography may yield reliable information for diagnosing colonic intussusception.

Laparoscopic colectomy is superior to laparotomy for reduction of disability in patients with colorectal adenoma.

BACKGROUND: This study was to evaluate disability after laparoscopic colectomy in patients with colorectal adenomas as compared to disability after laparotomy. METHODS: Patients who underwent laparoscopic colectomy for colorectal adenoma were compared to patients who underwent laparotomy for the same problem by the same surgeons during the same time period in Cleveland Clinic Florida. A standard questionnaire was used to assess disability which included the number of days to return to partial activity, full activity, and work. RESULTS: Twenty-nine patients who underwent laparoscopy were compared with 31 patients who underwent laparotomy. There were no significant differences in age (70.4 vs 72.5 years) (p = 0.405) or gender (M:F 13:16 vs 20:11) (p = 0.126) between the laparoscopy and laparotomy groups. The operative time was longer for the laparoscopy group than the laparotomy group: 170 vs 131 minutes (p = 0.014). However, the duration of postoperative ileus, hospitalization, time until return to partial activity, time until return to full activity, and time off of work were significantly shorter in the laparoscopy group than in the laparotomy group: 3.3 vs 5.2 days, 6.2 vs 8.7 days, 2.3 vs 4.2 weeks, 4.4 vs 9.3 weeks, and 3.7 vs 7.3 weeks, respectively (p < 0.041 for all). Although the incidence of postoperative complications was not significantly different (24% for laparoscopy vs 29% for laparotomy, p = 0.325), the incidence of postoperative prolonged ileus was statistically significantly lower in the laparoscopy group (3% vs 26%, p = 0.027). CONCLUSION: Laparoscopic colectomy for patients with colorectal adenoma can reduce postoperative ileus, postoperative hospitalization, and disability in terms of a quicker return to partial activity, full activity, and employment. Laparoscopic colectomy should be considered for all patients who have colorectal adenomas which require resection.

Laparoscopic colectomy for benign colorectal disease is associated with a significant reduction in disability as compared with laparotomy.

BACKGROUND: The aim of this study was to evaluate disability after laparoscopic colectomy in patients with benign colorectal disease. METHODS: Patients who underwent laparoscopic colectomy for benign colorectal diseases were matched with patients who underwent laparotomy for the same diseases by the same surgeons during the same time period. A standardized questionnaire used to assess disability included days until return to partial activity, full activity, and work. RESULTS: Seventy-one patients who underwent laparotomy were compared with 71 patients who underwent laparoscopy. Pathology included 26 patients with adenoma, 23 with Crohn's disease, 13 with diverticulitis, and 9 with reversal of Hartmann's procedure in each group. Procedures were partial colectomy with ileocolostomy, colocolostomy, or colorectostomy. There were no significant differences (p > 0.05) in age (55.8 vs. 59.7 years) or in the incidence of perioperative complications (25% vs. 29%) between the laparoscopy and laparotomy groups, respectively. The operative time was longer in the laparoscopic group than in the laparotomy group: 165 versus 122 min (p < 0.001). However, length of hospitalization, return to partial and full activity, and time off of work were significantly shorter in the laparoscopy than in the laparotomy group: 6.3 versus 9.0 days, 2.1 versus 4.4 weeks, 4.2 versus 10.5 weeks and 3.8 versus 7.5 weeks, respectively (p < 0.01 for all). CONCLUSIONS: Laparoscopic colectomy for benign colorectal diseases was associated with significantly less disability than was laparotomy in terms of length of hospitalization as well as return to baseline partial and full activity and employment.

Laparoscopic abdominoperineal resection for anorectal cancer.

The use of the laparoscopic technique in treating colorectal malignancies for cure is still a controversial issue. The aim of this study was to evaluate the outcome of laparoscopic abdominoperineal resection (APR) in treating malignancies of the lower rectum and anus and to compare the results with patients of matched age and diagnosis treated by conventional open APR by the same surgeon during the same time period. Between August 1991 and December 1996, we performed 235 laparoscopic colorectal procedures, including 8 laparoscopic APRs for malignancies of the lower rectum or anus. There were 6 female and 2 male patients of a mean age of 67 years. Pathologies included 4 adenocarcinomas, 2 melanomas, 1 leiomyosarcoma, and 1 squamous cell carcinoma. Four procedures were laparoscopically completed, and 3 were laparoscopic-assisted. One was converted to an open procedure due to dense adhesions. Five procedures were performed with palliative intent, whereas 3 were performed with curative intent. These patients were evaluated for procedural safety, distal and lateral resection margins, number of lymph nodes harvested, operative time, postoperative ileus, length of hospital stay, morbidity, and mortality. Results were compared with 7 conventional APRs performed between 1991 and 1996, 5 of which were performed for palliation. Histologic studies of the specimen demonstrated free lateral resection margins in all cases in both groups. No differences were noted in the mean free distal resection margins among the four groups: laparoscopic, 2.5 cm; laparoscopic-assisted, 3 cm; converted, 6 cm; and open, 3.6 cm. Mean lymph node harvest was 9, 9, 9, and 10 nodes, respectively. Mean length of surgery was 181, 198, 240, and 131 minutes, respectively. The length of postoperative ileus was 3.2, 7, 3, and 5.9 days, respectively. Mean postoperative length of stay was 6.5, 7, 6, and 12.5 days, respectively. Morbidity was 25 per cent in the laparoscopy group and 43 per cent in the open group. There was no 30-day postoperative mortality recorded in any group. Laparoscopic APR is associated with a 50 per cent reduction in the length of hospitalization without any compromise to lateral or distal resection margins, number of lymph nodes harvested, or morbidity.

Laparoscopic surgery for anorectal malignancies other than carcinoma.

OBJECTIVE: Numerous concerns have been raised relative to the appropriateness of laparoscopic surgery for cure of rectal adenocarcinomas. However, because of their rarity, little information exists about the role of laparoscopy for other anorectal malignancies. We report the outcome of five patients who underwent laparoscopic surgery for other anorectal malignancies. METHODS: All patients who underwent laparoscopic surgery for treatment of non-carcinomatous anorectal malignancy were assessed by means of endoscopic, radiological and histopathologic diagnostic tests. RESULTS: Two patients with anorectal melanoma and one with anal leiomyosarcoma underwent laparoscopic abdominoperineal resection. A laparoscopic loop ileostomy was performed for an HIV-positive patient with rectal Kaposi's sarcoma. Another patient with anorectal melanoma had intraoperative identification of distant liver metastasis and therefore underwent diagnostic laparoscopy instead of an intended abdominoperineal resection. There were no intraoperative laparoscopic complications. During the follow-up period three patients who underwent abdominoperineal resection were alive, one of whom had rectal melanoma and developed liver metastasis without local recurrence. The two patients with distant liver metastasis and rectal Kaposi's sarcoma died 46 days and five months after surgery, respectively. There were no port-site or local recurrences. CONCLUSION: Laparoscopic abdominoperineal resection for non-carcinomatous anorectal malignancies is technically feasible and avoids many of the concerns associated with attempted curative laparoscopic resection of carcinoma.

Histopathological and prognostic evaluation of immunohistochemical findings in colorectal cancer.

Many immunohistochemical studies have investigated the relationship between immunohistochemical characteristics and histopathological findings in colorectal tumors. One of the most extensively studied markers has been tissue CEA, although the prognostic significance of this and other antigens is still uncertain. The authors report results relative to three tumoral antigens (carcinoembryonic antigen, CEA; tissue polypeptide antigen. TPA, and carbohydrate antigen 19-9, CA 19-9) determined by immunohistochemical methods in tissue samples of 52 colorectal carcinomas. The relationship between the immunohistochemical characteristics of the neoplasms and the clinicopathologic parameters, as well as their influence on the prognosis of the patients, were examined. Positive CEA reaction has a significant relationship with grade of differentiation of the tumor while diffuse cellular expression of this antigen often indicates neoplasms extending beyond the intestinal wall and invading the lymph vessels. The number of tissue antigens expressed is significantly related to the extent of tumor spread through the intestinal wall. A greater incidence of recurrence and shorter disease-free interval and survival were observed in neoplasms that expressed tissue TPA antigen or more than one tissue antigens. In the present study the latter parameter has demonstrated to have independent prognostic significance for the disease-free interval. Immunohistochemical evaluation of antigens in colorectal carcinoma tissue shows a possible independent prognostic value of the antigenic heterogeneity of tumors, which could be related to their different biological behavior.

[Prognostic aspects of esophageal ph-metry in infants with reflux]. / Aspetti prognostici nella pHmetria esofagea del lattante reflussore.

Gastroesophageal reflux (g.e.r.) is a very common event in children particularly in infants. Twenty-four-hour continuous esophageal pH monitoring has become the preferred test to quantify acid gastroesophageal reflux. It has a large sensitivity and specificity, but it does not allow a good prediction of esophagitis. The Authors show a computerized method to determine the area under the curve (a.u.c.) and the percentage of time at different pH levels. These parameters have shown the same sensitivity and specificity as DeMeester-Boix-Ochoa score. They directly relate the time of exposure and pH level in every reflux under pH 4 and so they suggest a better prognostic index. To improve this approach to g.e.r. we will need other studies with this method.