Operative management of severe constipation.

This report investigates the concept that severe constipation requiring major abdominal surgery may result from one of three common causes: 1) colonic inertia, 2) pelvic hiatal hernia, or 3) both colonic inertia and pelvic hernia. This study evaluates the symptoms, anatomy and outcome in 201 patients with severe surgical constipation treated by a single surgeon. In 2042 patients with constipation referred to one colon and rectal surgeon, 211 major abdominal surgical procedures were performed on 201 patients for severe constipation between 1989 and 1999. There were 187 women and 14 men. Mean age was 49 years (range, 9-84). Five high-risk patients had ileostomy; 196 had major colonic surgery for anatomic or physiologic causes of constipation, excluding malignancy, diverticular disease, and inflammatory bowel disease. Pelvic hiatal hernia was defined as the herniation of bowel through the hiatus of the pelvic diaphragm seen on pelvic videofluoroscopy or physical examination. Of these 196 patients, 44 per cent had pelvic hiatal hernia repair (PHHR), 27 per cent had total abdominal colectomy and ileorectal anastomosis for colonic inertia, and 29 per cent had surgery for both colonic inertia and pelvic hiatal hernia. Of the 144 patients undergoing PHHR, 95 had Gore-Tex patch (W. L. Gore and Associates, Inc., Phoenix, AZ) sacral colpopexy. PHHR for pelvic hiatal hernia without colonic inertia included sigmoid resection, rectopexy, and Gore-Tex patch sacral colpopexy. Mean duration of follow-up was 20 months. Symptoms noted preoperatively included abdominal pain (84%), straining at stool (90%), incomplete rectal emptying (85%), painful bowel movements (74%), pelvic pain (69%), vaginal bulge (55%), digital assistance with evacuation (35%), and incontinence of stool (38%). Outcome assessed by symptom relief was successful in 89.1 per cent of patients. 8.6 per cent of patient conditions were unchanged, and 2.3 per cent were unsatisfied with the outcome. There were no postoperative deaths. The complication rate was 6.1 per cent (small bowel obstruction, 7; anastomotic leak, 2; ureteral stenosis, 2; and patch erosion, 1). In our experience, severe surgical constipation can be due to colonic inertia, pelvic hiatal hernia, or both. Careful preoperative evaluation identifies these disorders, and surgical therapy aimed at correction of anatomic and physiologic defects results in high patient satisfaction and improvement in bowel function.

Local staging of anal and distal colorectal tumors with the magnetic resonance endoscope.

BACKGROUND: We prospectively assessed the feasibility and accuracy of endoscopic magnetic resonance (EMR) scanning in the local staging of anal and colorectal cancer as compared to endosonography. METHODS: Fifteen patients with biopsy-proven anal (n = 2), rectal (n = 11), and distal colonic (n = 2) cancer underwent endosonography followed by EMR imaging. Scans were acquired using the magnetic resonance receiver coil incorporated into the tip of the non-ferromagnetic endoscope. Blinded to endosonography results, two radiologists interpreted the EMR images using the TNM system. Staging results were compared to endosonography in all patients and to histopathology in the 13 colorectal cases. RESULTS: EMR imaging, well tolerated in all patients, correlated with endosonography in 10 of 15 and 12 of 15 cases for T- and N-staging, respectively. In the 13 colorectal patients with available histopathology, accuracy of EMR and of endosonography in T-staging was 77% and 85%, respectively; N-staging accuracy was 62% for both. CONCLUSIONS: For anal and distal colorectal neoplasms, EMR imaging is feasible and provides local staging comparable to endosonography.

Balloon sphincterography. Clinical findings after 200 patients.

There are two muscular mechanisms of fecal continence. The anal sphincter squeezes the anal canal, thus lengthening it and increasing its resistance. The puborectalis kinks the distal rectum, preventing the transmission of intra-abdominal pressures into the anal canal. Balloon sphincterography simultaneously records the shape of the anal canal and distal rectum and measures the strength of the puborectalis and anal sphincter muscles. This allows the physician to evaluate the function of these important muscles in patients with symptomatic defecation disorders such as constipation, incontinence, and rectal prolapse. A cylindrical balloon is connected by a hose to a fluid reservoir filled with liquid barium. The deflated balloon is placed into the anal canal and inflated by raising the fluid reservoir in increments. Fluoroscopy visualizes the balloon's shape and video records the results. Quantitative sphincterogram measurements in patients with defecation disorders include (the three measurements in each category refer respectively to incontinent patients [N = 87], prolapse patients without incontinence [N = 26], and constipated patients [N = 65]); anorectal angle (degrees + S.D.): 114 + 28, 103 + 18, 95 + 19; anal canal length (mm + S.D.): 33 + 11, 38 + 10, 39 + 10; squeeze pressure (cm H2O + S.D.): 68 + 23, 80 + 16, 91 + 22, and opening pressure (cm H2O + S.D.): 52 + 25, 67 + 22, 81 + 24. The method is useful in identifying specific defects, such as paradoxic puborectalis contractions, that can cause constipation, and injuries to the sphincters that can cause incontinence. In over 280 patients with a wide variety of defecation disorders, sphincterography has yielded information not available by standard manometric techniques. It augments the findings of defecography.

Palliation for rectal cancer. Resection? Anastomosis?

There is no agreement regarding the proper management of patients with advanced carcinoma of the rectum. We performed a study to clarify whether palliative resection with or without primary anastomosis is worthwhile and safe. Among 679 patients managed for cancer of the rectum, 125 were considered incurable and underwent palliative procedures. High and low anterior resections were performed in nine and 57 cases, respectively, abdominoperineal resection in 26, Hartmann's procedure in three, simple diverting colostomy in 17, and transanal excision in 13. The overall postoperative mortality rate was 0.8%. Postoperative morbidity was 18% in abdominal operations and none in local excisions. Among patients treated by abdominal resections, only one required subsequent reoperation for colonic obstruction secondary to local recurrence. The median survival was 6.4 months for patients treated by diverting colostomy, 14.8 months for abdominally resected cases, and 14.7 months for transanal excisions. We conclude that palliative resection, often with primary anastomosis or local transanal excision, can be done safely in patients with incurable rectal cancer. We believe this approach improves the quality of the remaining life for these patients.

Surgical treatment of early-stage carcinoma of the oral tongue--wound adjuvant treatment be beneficial?

A group of 97 patients with clinical stage I and stage II squamous carcinoma of the oral tongue, treated by partial glossectomy alone, has been reviewed to define prognostic indicators. Sixty-seven patients were staged T1N0 and 30 were T2N0. Disease recurred in 28 patients (27%) and the most common site of failure was the ipsilateral neck (21%). The incidence of initial recurrence did not vary significantly with patient age, sex, T-stage, or when tumor size was examined in other subdivisions. The presence of perineural invasion significantly increased recurrence rate (P = 0.003) and decreased survival (P = 0.002). Disease-free survival at 5 yr was 73% for patients with T1 tumors, and 62% for T2 tumors. This difference was not significant. In this low-risk patient population with early stage carcinoma of the oral tongue, partial glossectomy is adequate treatment in most cases. However, we recommend postoperative radiation therapy to the primary site and ipsilateral neck for patients with perineural invasion. No evidence could be found to support adjuvant local therapy or elective neck treatment in the remaining patients.

Balloon topography. A simple method of evaluating anal function.

Balloon topography was developed to simultaneously measure anal canal pressure, anal canal length, and anorectal angle. It is performed using a cylindrical flexible balloon placed into the anal canal and rectum and filled with liquid radiopaque contrast dye under low pressure. The pressure of the dye inside the balloon is controlled by the investigator, and does not vary with changes in balloon volume. The shape of the balloon within the anal canal is recorded using fluoroscopy and plain radiopaques. The patient receives less radiation than he would receive during a single contrast barium enema. We have performed the test on 27 subjects including a normal control, rectal prolapse patients, and incontinent patients. Early results demonstrate the usefulness of the test in examining anal sphincter and pelvic floor function in maintaining fecal continence in health and disease. The test measures multiple aspects of anopelvic function simultaneously that previously required separate investigations.

A multifactorial analysis of prognostic factors in patients with liver metastases from colorectal carcinoma.

A multifactorial analysis was used to identify the dominant prognostic variables predicting survival rates of 175 patients with hepatic metastases from colorectal carcinoma. Seven of 22 parameters examined simultaneously were found to independently influence the median survival rate in these patients: (1) elevated alkaline phosphatase (p = 0.0004), (2) elevated serum bilirubin level (p = 0.0005), (3) location of hepatic metastases (unilateral or bilateral, p = 0.0022), (4) number of metastatic nodes involved (0, 1-5, greater than 5; p = 0.0148), (5) depressed serum albumin (p = 0.0217), (6) whether or not the primary colorectal tumor was resected (p = 0.0013), and (7) chemotherapy (given or withheld, p = 0.0439). The prothrombin time, serum lactic dehydrogenase, and the number of hepatic metastases also correlated with survival, but they did not independently predict survival rates after other more dominant factors were accounted for. A mathematical equation for predicting an individual patient's clinical course once they developed hepatic metastases was derived from this statistical analysis. In addition, a simple and clinically useful guide for predicting outcome was developed that integrated the two most important risk factors, alkaline phosphatase and bilirubin.