The effect of abdominal ventral rectopexy on faecal incontinence and constipation in patients with internal intra-anal rectal intussusception.

AIM: Optimal treatment of anal incontinence in a patients with a normal anal sphincter is controversial, as is the role of intra-anal rectal intussusception in anal incontinence. We evaluated the results of abdominal ventral rectopexy on anal continence in such patients. METHOD: Forty consecutive patients with incontinence and intra-anal rectal intussusception without a sphincter defect were treated by abdominal ventral mesh rectopexy without sigmoidectomy. The Cleveland Clinic Incontinence Score (CCIS), patient satisfaction and constipation before and after surgery and recurrence were recorded. RESULTS: The mean CCI scores were 13.2 (=/-4.25) preoperatively and 3 (±3.44) postoperatively (P<0.0001). Patient assessment was reported as 'cured' in 26 (65%), 'improved' in 13 (32.5%) and 'unchanged' in one (2.5%) patient. Constipation was induced in two (5%) patients and was cured in 13 of 20 (65%) patients who were constipated before surgery. One case of recurrent prolapse occurred after a mean follow-up of 38 months. CONCLUSION: Intra-anal rectal intussusception may be associated with anal incontinence. For these patients, abdominal ventral mesh rectopexy appears to be an adequate treatment.

Efficacy of synthetic glue treatment of high crypoglandular fistula-in-ano.

OBJECTIVES: In France, seton drainage followed by fistulotomy is currently the standard treatment for high cryptoglandular fistula-in-ano. Biological or synthetic glues, such as Glubran(®) 2, have been recently proposed for sealing the fistula tract. The purpose of this study is to determine the healing rate with glubran 2 and to assess the functional outcome after cure of fistula-in-ano. PATIENTS AND METHODS: From July 2006 to July 2008, 34 patients (20 males; median age 48.5 years, range 22-55 years) with high cryptoglandular anal fistulas were treated with glubran 2. Patients were seen for physical examination at 1, 3 and 6 months, then interviewed by telephone at 1 and 2 years, and in September 2009. The Fecal incontinence severity index (FISI) score was used to assess continence. RESULTS: The healing rate at 1 month was 67.6% (23 patients); the fistula failed to heal in 11 patients. All 23 patients with a healed fistula remained recurrence-free, with no continence disorders noted, during the median 34-month follow-up period (range 21-43 months). One patient was lost to follow-up after 6 months. CONCLUSION: Glubran 2 provides an effective treatment for high fistula-in-ano, with no change in continence. In future, a randomized comparison of this agent with fibrin glues should be useful.

Benefits of perineal colostomy on perineal morbidity after abdominoperineal resection.

PURPOSE: Abdominoperineal resection has a high rate of postoperative morbidity of the perineal wound. This study aimed to determine the effects of perineal colostomy on perineal morbidity after abdominoperineal resection. METHODS: All patients who underwent an abdominoperineal resection for rectal adenocarcinoma between 1993 and 2007 were studied. Two groups were identified and compared who had undergone either an iliac colostomy or a perineal colostomy. RESULTS: The analysis included 110 patients (iliac colostomy group, n = 41; perineal colostomy group, n = 69). There were fewer instances of pelviperineal morbidity (P = .008) and fewer instances of wound dehiscence (P = .02) in the perineal colostomy group, which resulted in a shorter time to healing (35.3 vs 45.1 d, respectively; P = .04). There was no specific postoperative morbidity in any patient and no difference between the 2 groups regarding long-term perineal morbidity. The benefits from perineal colostomy were statistically significant in patients who received radiation therapy in terms of pelviperineal morbidity (P = .01) and healing time (50.8 vs 35.9 days, respectively; P = .02), whereas no difference was found in patients who had not received radiation therapy. CONCLUSION: Perineal colostomy is a safe and functionally acceptable procedure for perineal reconstruction after abdominoperineal resection for rectal adenocarcinoma. In the present study, there was no additional morbidity related to perineal colostomy, and this procedure was associated with a decrease in perineal morbidity and healing time compared with primary perineal closure, in particular, after radiotherapy treatment.

Oncological outcome of ultra-low coloanal anastomosis with and without intersphincteric resection for low rectal adenocarcinoma.

BACKGROUND: The value of ultra-low coloanal anastomosis (CAA) for rectal cancer is dependent on the oncological and functional results. The aim of this comparative study was to evaluate the long-term oncological outcome of CAA with or without intersphincteric resection (ISR) for low-lying rectal tumours. METHODS: The study population comprised consecutive patients with low rectal cancer who underwent CAA in a single institution between 1977 and 2004. Patients were divided into two groups according to whether or not a partial ISR had been performed. Cox multivariate models were used for survival analysis. RESULTS: Some 278 patients underwent CAA with curative intent; 173 had ISR and 105 had CAA without ISR. Mean follow-up was 66.8 months. The 5-year actuarial rate for local recurrence, regardless of tumour stage, was 10.6 per cent in the ISR group versus 6.7 per cent for CAA alone (P = 0.405), and the 5-year actuarial overall survival rate was 86.1 and 80.0 per cent respectively (P = 0.318). Cox multivariable analysis revealed that resection of the anal canal was not a prognostic factor for local or metastatic recurrence. CONCLUSION: Sphincter-preserving surgery appears to be oncologically adequate for very low-lying rectal tumours.

Preliminary results of peripheral transcutaneous neuromodulation in the treatment of idiopathic fecal incontinence.

PURPOSE: Few therapeutic tools are available for treating idiopathic anal incontinence. Sacral neuromodulation appears to be effective in selected patients but requires surgical implantation of a permanent electrical stimulator. The aim of this work was to assess the efficiency of posterior tibial nerve (PTN) transcutaneous electrical nerve stimulation (TENS) in the treatment of anal idiopathic incontinence. METHODS: Ten women were treated by PTN TENS, 20 min a day for 4 weeks. Functional results were evaluated by Wexner's incontinence score and anorectal manometry. RESULTS: Eight of the ten patients showed a 60% mean improvement of their incontinence score after 4 weeks. This improvement remained stable over the 12-week follow-up period. Manometric parameters did not differ before and after stimulation. CONCLUSION: PTN neuromodulation without surgically implanted electrode could represent a safe and low-cost alternative to permanent sacral neuromodulation for idiopathic anal incontinence.

Rectal excision with coloanal anastomosis for superficial distal third rectal cancer: survival and local recurrence.

OBJECTIVE: Appropriate surgical treatment of distal third rectal cancer limited to bowel wall (i.e. T1 or T2) in medically operable patients is controversial. Transanal excision can deprive some patients of accurate pathological staging, prognosis and cure. In contrast abdominoperineal resection has considerable practical and psychosocial problems largely related to a permanent colostomy. We hypothesize that superficial distal rectal tumours can be effectively treated with rectal excision and coloanal anastomosis. SUBJECTS AND METHODS: Prospective oncological study of 80 patients with distal third superficial rectal carcinomas treated by complete rectal excision with coloananl anastomosis from December 1977 to January 1993 was carried out. The resected specimens were examined for depth of spread and number of histologically positive nodes. The actuarial local recurrence and survival rates for superficial node-negative and node-positive tumours were analysed independently. RESULTS: Seventy-eight patients had complete postoperative assessment. Thirty-one percent had received low-dose preoperative neo-adjuvant radiotherapy (3500 rads). Mean follow-up time in all patients was 70 months on average. The lymph node involvement rate for T1 and T2 tumours was 12.5 and 15.6%, respectively. The local recurrence rates for patients with (T1/T2) N0 and (T1/T2) N1 were 1.5 and 16.7%, respectively, and the five year actuarial survival rates were 96.6 and 90%, respectively. The overall local recurrence was 3.8% with five-year actuarial survival of 95.8%. CONCLUSIONS: Lymph node involvement in superficial tumours is not rare. Rectal excision with coloanal anastomosis results in a high cure rate especially for node-positive superficial tumours. This treatment strategy avoids the psychological trauma of colostomy following abdominoperineal resection and the potential risk of undertreatment by local excision.

[Rectal prolapse]. / Le prolapsus du rectum.

Rectal prolapse and rectal intussuception correspond to two stages of the same disease. Rectal prolapse is unusual but requires surgical treatment. Abdominal rectopexy is the most effective procedure but increases the risk of postoperative constipation. This risk decreases when the lateral sides are not touched during rectal dissection. The Delorme procedure is associated with a higher rate of recurrence and must be reserved for patients presenting a high risk of postoperative complications. Rectal intussuception is more frequent and is pathological only when arising in the anal sphincter. Rectal intussuception may lead to solitary rectal ulcer and has in this case to be treated by rectopexy. Rectal intussuception involvement in terminal constipation is not yet proved. Internal mucosectomy seems to be the best treatment for terminal constipation.

Fecal continence following partial resection of the anal canal in distal rectal cancer: long-term results after coloanal anastomoses.

BACKGROUND: The aim of the study was to assess the influence of partial excision of the superior portion of the anal canal (AC) when necessary for tumor margin clearance in distal rectal cancer on fecal continence after coloanal anastomoses. METHODS: Between 1977 to 1993, 209 patients with middle and lower third rectal cancers underwent complete rectal excision and coloanal anastomoses. For very low tumors, located at or below 5 cm from the anal verge (AV), varying portions of the superior segment of the AC were excised for tumor margin clearance. The magnitude of resections was inversely proportional to the height of the anastomosis from the AV. The patients were categorized into 3 groups according to their level of anastomoses from AV: group 1, patients with anastomoses from 0.5 to less than 2 cm from AV (1 to 2.5 cm of AC resected, i.e., major resection); group 2, anastomoses at 2 to less than 3 cm from AV (less than 1 cm of AC resected, i.e., minor resection); group 3, with anastomoses at 3 to 3.5 cm from AV (AC completely preserved). A standard questionnaire, physical examination, and anal manometry at intervals of 3, 6, 12, 24, 36, and 48 months were performed prospectively to assess anal continence. RESULTS: The patients in the 3 categories were matched for age, gender, stage, presence or absence of a colonic J-pouch, preoperative neoadjuvant radiotherapy and surgical technique. Fourteen patients with postoperative radiotherapy were excluded from the clinical assessment. Mean follow-up was 33.5 months. There were 43 patients in group 1, 75 in group 2, and 73 in group 3 for clinical assessment. In the first year, there was progressive improvement in anal continence in all 3 groups. At 2 years, 50% in group 1, 73% in group 2, and 62% in group 3 were fully continent. The proportion of patients fully continent in group 1 remained unchanged as compared to continued improvement for groups 2 and 3 following the first year. At 4 years, 50% in group 1, 80% in group 2, and 68% in group 3 were completely continent. The difference among the 3 groups was not statistically significant. CONCLUSIONS: For distal rectal cancer, where tumor margin clearance necessitates partial resection of the superior portion of the AC, when limited to less than 1 cm, the proportion of patients remaining fully continent is similar to those with complete AC preservation. More substantial excisions of the AC can still result in satisfactory anal continence, such that following the fourth year, one half of the patients can expect to be fully continent.

Coloanal anastomosis for distal third rectal cancer: prospective study of oncologic results.

PURPOSE: Jeopardizing cure and risking high local recurrence have served as arguments against sphincter-saving resection for patients with distal third rectal cancer. This prospective study examines and compares the local recurrence and survival rates in patients with distal third rectal cancer treated by either coloanal anastomosis or abdominoperineal resection. METHODS: Between 1977 and 1993, 174 patients underwent coloanal anastomoses and 38 patients underwent abdominoperineal resection. All tumors were located 4 to 7 cm from the anal verge. One hundred ninety-three patients (91 percent) underwent rectal excision with a curative intent. Mean follow-up was 66 months after sphincter-saving resection and 65 months after abdominoperineal resection. RESULTS: Mean anastomotic height from the anal verge was 2.3 cm after sphincter-saving resection. Overall local recurrence rate was 7.9 percent after sphincter-saving resection and 12.9 percent after abdominoperineal resection. The five-year actuarial survival rate was 78 percent after sphincter-saving resection and 74 percent after abdominoperineal resection. CONCLUSION: Local recurrence and survival are not compromised in patients with distal third rectal cancer when treated by sphincter-saving resection, provided that oncologic principles are not violated. Coloanal anastomosis can be performed with an acceptable morbidity.

Continent perineal colostomy after abdominoperineal resection: outcome after 63 cases.

PURPOSE: For patients with distal rectal or anal tumors, quality of life can be compromised after abdominoperineal resection and iliac colostomy. This study examines our experience with a continent perineal colostomy constructed from a colonic smooth-muscle cuff wrap. METHODS: Between 1987 and 1996, 63 patients with distal rectal or anal tumors (0-5 cm from the anal verge) underwent abdominoperineal resection and construction of a colonic smooth-muscle cuff at the site of the perineal colostomy. Postoperatively, all patients required colonic irrigations daily or every two days. The complications, continence at 6 and 12 months, and degree of satisfaction were prospectively evaluated using a standard questionnaire. RESULTS: Early complications included partial perineal dehiscence in 14 (22.5 percent) patients, pelvic abscess in 2 (3 percent) patients, and colostomy necrosis in 1 (1.6 percent) patient. Late complications were colostomy stricture in 7 (11.8 percent) patients, perineal sinus tract in 4 (6.7 percent) patients, and mucosal prolapse in 12 (20 percent) patients. Satisfactory continence (complete continence to stool and incontinence to gas) at 6 and 12 months was achieved in 30 (55.6 percent) and 27 (59 percent) patients, respectively. Patient satisfaction was noted in 85 percent. CONCLUSION: Continent perineal colostomy can serve as an alternative to conventional iliac colostomy. Most patients were satisfied. The modest complication rate can be minimized with patient selection.

[Surgery of rectal cancer: total exeresis of the mesorectum]. / Chirurgie du cancer du rectum: l'exérèse totale du mésorectum.

The authors review the recent literature about total mesorectal excision for rectal cancer. They report the actual management of such patients.

Fournier's gangrene: an unusual presentation for rectal carcinoma.

We report a case of a large perforated adenocarcinoma of the rectum manifesting as an ischiorectal abscess progressing to Fournier's gangrene in an insulin-dependent diabetic man. Recognition and management of this rare syndrome in the setting of a common disease is discussed.

Is rectal intussusception a cause of idiopathic incontinence?

PURPOSE: The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence. METHODS: Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals. RESULTS: Continence was improved after rectopexy (P < 0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant. CONCLUSIONS: Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.

Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis.

BACKGROUND: Functional outcome after rectal excision with coloanal anastomosis is improved by construction of a colonic J pouch. Present prospective randomized studies lack follow-up beyond 1 year. The aim of this study was to assess the clinical outcome at both short- and long-term follow-up. METHODS: Forty patients with low rectal cancer were randomized prospectively to either J colonic pouch-anal anastomosis or a straight coloanal anastomosis. Clinical assessments were performed 3, 12 and 24 months after colostomy closure using a standard questionnaire and physical examination. RESULTS: There was no significant difference in the complication rate between the two groups. There was a significant (P < 0.01) improvement in frequency of defaecation at 3, 12 and 24 months for patients with a reservoir. Similarly, fragmentation (clustering of stools) was significantly less at 3 and 12 months (P < 0.01) in the reservoir group, and incontinence occurred less frequently in the first year (P = 0.09). By 24 months no patient in either group suffered from major or minor incontinence. CONCLUSION: The functional improvement gained from a colonic reservoir in coloanal anastomosis continues to benefit the patient for at least 2 years.

[Preservation of sexual innervation in the surgery of rectal cancers]. / Préservation de l'innervation sexuelle dans la chirurgie du cancer du rectum.

Eighteen out of 55 rectal resections for cancer included preservation of sexual innervation, which was complete in 17 cases and partial in one case. Fourteen patients were evaluated by questionnaire one year after resection; 10 out of 14 (71.4%) did not report any sexual disorders.

[Local treatment of "small cancers" of the rectum: excision is preferable to electrocoagulation]. / Traitement local des "petits cancers" du rectum: l'excision est préférable à l'électro-coagulation.

From 1973 to 1990, 50 patients with a "small cancer" of the rectum were treated locally either by electrocoagulation or by local excision using an electrical scalpel. 20 patients were treated by electrocoagulation. Their 5-year actuarial survival was 78.3% and the local recurrence rate was 16.5%. 4 treated patients by local excision had a lesion which invaded the serosa and should have been amputated as primary procedure. Three of them relapsed. 26 patients were treated by local excision for a lesion confined to the rectal wall. Their 5-year actuarial survival was 94.4% and the local recurrence rate was 4.5%. The difference in survival and recurrence was significant between electrocoagulation and excision of a lesion confined to the rectal wall. These results suggest that excision is preferable to electrocoagulation as it allows prediction of the result by pathological examination of the operative specimen.

[Surgical treatment of cancer of the pancreas]. / Traitement chirurgical du cancer du pancréas.

Resection of the pancreas is still the only way to cure patients with pancreatic cancer. Morbidity and mortality rates following pancreatico-duodenectomy for adenocarcinoma of the pancreas have decreased. Survival has improved during the past several decades.