Low anterior resection syndrome following rectal cancer surgery: are incidence and severity lower with long-term follow-up?

BACKGROUND: Low anterior resection syndrome (LARS) is a functional disorder that may follow restorative proctectomy. The aim of this study was to evaluate the long-term incidence and risk factors for LARS following surgery for rectal cancer. METHODS: A retrospective study was performed on patients from a prospectively maintained database, who underwent a restorative proctectomy between January 2014 and December 2019 at Hadassah Hebrew University Medical Center. The study cohort was divided into two groups: patients following partial proctectomy with a partial mesorectal excision and a colorectal anastomosis (PME group) and patients following total proctectomy with total mesorectal excision and a coloanal anastomosis (TME group). The incidence and severity of LARS were evaluated using the LARS questionnaire. Risk factors for LARS were also evaluated. RESULTS: A total of 240 patients (male: female ratio 134:106, median age 64 years [interquartile range 55-71 years]) were included in the analysis. There were 160 patients in the PME group and 80 patients in the TME group. The overall incidence of LARS was 37.4% (26.5% major LARS and 10.9% minor LARS). Major LARS was observed in 53.8% of patients who underwent TME and in 12.7% of patients who underwent PME (p < 0.001). On multivariate analysis, distance of the anastomosis from the anal verge, TME, and neoadjuvant radiotherapy were independent prognostic factors for LARS. The incidence and severity of LARS were significantly lower in patients with longer follow-up (p = 0.05). CONCLUSIONS: Significant improvement in LARS can be expected with longer follow-up. Distance of the anastomosis from the anal verge, TME and neoadjuvant radiotherapy are independent risk factors for LARS.

External sphincter-sparing anal fistulotomy (ESSAF): a simplified technique for the treatment of fistula-in-ano.

BACKGROUND: Fistula-in-ano due to cryptoglandular disease is a common condition. While a simple anal fistula can be treated successfully by a fistulotomy, the risk of potential damage to the anal sphincters and subsequent poor functional outcomes persist in a large portion of patients with complex fistulae. Several sphincter-preserving treatment procedures have been described for complex fistulae over the past 3 decades, with variable results and complication rates, and no procedure is proven to be superior to the others. We developed external sphincter-sparing anal fistulotomy (ESSAF), a reproducible simple modification of the ligation of intersphincteric fistula tract (LIFT) technique for the treatment of complex fistula-in-ano.. The aim of the present study was to describe the technique and our outcomes. METHODS: This was a retrospective review of all patients who underwent ESSAF for a complex anal fistula at our institution from January 2014 to December 2019. The primary outcome measure of this study was the primary fistula healing rate. Secondary outcome measures included fecal and/or gas incontinence and postoperative complications. During the ESSAF procedure, the mucosa and skin overlying the fistula tract are incised to allow complete exposure of the sphincter complex. Then the internal sphincter muscle fibers overlying the tract are divided and the tract is meticulously curetted and debrided. Next, the internal opening of the tract traversing the external sphincter muscle is suture-ligated with absorbable sutures. Then, a minimal amount of mucosa is advanced and the incision is partially closed with absorbable sutures, while its external portion is left open for drainage. RESULTS: Fifty-nine patients [43 males, median age was 50 years (range 36-63 years)] underwent ESSAF for complex anal fistula during the study period. Mean follow-up was 12 ± 14.7 months. Of the 59 patients, 42 (71.2%) experienced fistula closure, with a median healing time of 8 weeks (IQR 4-16 weeks). None of the patients developed significant anal incontinence following the procedure. One patient (1.7%) suffered from soiling and another patient (1.7%) developed postoperative bleeding. There were no infectious complications. Of the 17 patients (28.8%) who failed to heal successfully, 9 (15.2%) did not heal primarily and 8 (16%) experienced recurrence after complete healing. Thirteen (76%) of these patients underwent reoperation with complete recovery after ESSAF (n = 4), fistulotomy (n = 8) or endorectal advancement flap (ERAF) (n = 1). Overall ESSAF initiated recovery in 93.2% of the patients. CONCLUSIONS: ESSAF is a feasible, safe, reproducible and effective sphincter-sparing procedure for the treatment of complex anal fistulae.

Does caffeine enhance bowel recovery after elective colorectal resection? A prospective double-blinded randomized clinical trial.

BACKGROUND: Postoperative ileus is a common condition following abdominal surgery. Previous studies have shown the positive effects of coffee on gastrointestinal motility. The aim of this study was to assess whether caffeine is the stimulatory agent in coffee that triggers bowel motility and thus may reduce the duration of postoperative ileus. METHODS: This was a single-centered, prospective, randomized controlled, double-blinded clinical trial. Patients scheduled to undergo elective laparoscopic colectomy between November 2017 and March 2019 were randomly assigned to receive either oral caffeine (100 mg three times daily) or placebo following the procedure. Primary endpoints were time to first flatus and time to first bowel movement. Secondary endpoints were time to tolerate a solid, low-residue diet and length of hospital stay. Registration number: NCT03097900. RESULTS: Seventy patients were included, [35 males, median age 56 years (range 19-79 years)]. After the exclusion of 12 patients, there were 30 patients in the caffeine group and 28 patients in the placebo group. The first passage of stool in the caffeine group occurred 18 h earlier than in the placebo group (p = 0.012); other endpoints did not reach statistical significance. No caffeine-related adverse events were observed. CONCLUSION: Caffeine consumption following colectomy is safe, leads to a significantly shorter time to first bowel movement, and may thus potentially lead to a shorter postoperative hospital stay.

Predictors for Adherence to Multidisciplinary Follow-Up Care after Sleeve Gastrectomy.

INTRODUCTION: A considerable proportion of patients who undergo bariatric surgeries (BS) do not attend routine postoperative follow-up despite recommendations for such. Data are sparse regarding the various aspects of patient adherence to consultations following sleeve gastrectomy (SG). OBJECTIVES: To examine predictors of adherence to SG follow-up, reasons for attrition from follow-up, and the relationship between adherence to follow-up and weight loss results. METHODS: A retrospective cohort study was performed with a mean follow-up of 3 years. Data were collected from electronic medical records and telephone questionnaires. Adherence was defined both as a numerical variable (ranking 0-9 according to the number of pre-scheduled postoperative visits) and as a dichotomous variable (adherent and non-adherent groups). RESULTS: Of 178 patients, 46.63% were defined as "adherent," according to the dichotomous definition. Compared to the "non-adherent group," patients in the "adherent group" more regularly used vitamin D after the surgery, had fewer rehospitalizations, and reported a lower intake of sweetened beverages. The main reasons for attrition were work-related and difficulties in mobility. Adherence to postoperative follow-up was not found to be correlated to weight loss. Older age (OR = 1.04; p = 0.026) and postoperative side effects (OR = 2.33; p = 0.035) were found to be positive predictors for adherence, whereas rehospitalizations (OR = 0.08; p = 0.028) and ethnical minority status were negative predictors (OR = 0.42; p = 0.019). CONCLUSION: Adherence to postoperative follow-up was found to be associated with positive lifestyle behaviors; however, no correlation was found to mid-term weight loss outcomes.

Herpes simplex virus delivery to orthotopic rectal carcinoma results in an efficient and selective antitumor effect.

Cancer of the rectum poses a complex therapeutic challenge because of its proximity to adjacent organs and anal sphincters. The addition of radiotherapy before surgical resection has been shown to confer good survival rates while preserving sphincter function. Nevertheless, radiation is associated with significant side effects. On the basis of our previous work showing that herpes simplex virus type-1 (HSV-1) preferentially infects human colon cancer, we set out to examine the oncolytic effect of HSV-1 on orthotopic rectal tumors in mice. Two vectors were compared for oncolytic activity, HSV-1(Gbeta) with wild-type replication and an attenuated HSV-1 vector (HSV-G47Delta). Intratumoral injection of HSV-1(Gbeta) and HSV-G47Delta resulted in a significant reduction or disappearance of the tumors and increased survival of mice. Although the use of HSV-1(Gbeta) was associated with systemic toxicity, HSV-G47Delta appears to possess a selective oncolytic activity. Moreover, infection with HSV-G47Delta resulted in the activation of the double-stranded RNA-dependent protein kinase (PKR) pathway. A significant improvement in viral replication and the antitumor effect was observed when the PKR inhibitor 2-aminopurine was coadministered with HSV-G47Delta to the tumor. In conclusion, the efficacy of local delivery of HSV-G47Delta combined with a specific chemical inhibitor of antiviral activity points to a novel therapeutic modality for rectal cancer and other solid tumors.

Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty.

BACKGROUND: The management of full thickness rectal prolapse remains controversial. Although abdominal approaches have a lower recurrence rate than do perineal operations, they are associated with a higher morbidity. The aim of this study was to compare the outcomes of perineal rectosigmoidectomy with and without levatorplasty. METHODS: Between 1989 and 1999, a total of 109 consecutive patients (10 men) underwent 120 perineal procedures. These patients were retrospectively evaluated in two groups on the basis of the type of surgery received: perineal rectosigmoidectomy (PRS) or perineal rectosigmoidectomy with levatorplasty (PRSL). Subsequent functional outcome and physiological parameters were assessed. RESULTS: The patients had a mean age of 75.7 years (range, 23.0-94.8 years) and they were followed for an overall mean (in both groups combined) of 28.0 months (range, 0.4-126.4 months) after surgery. Mean duration of surgery was 78.1 min (SD=25.9) and 97.6 min (SD=32.3) in PRS and PRSL, respectively ( p=0.002, unpaired t test). There was no significant difference between the two groups in terms of hospital stay, morbidity or mortality. Recurrence rates and mean time interval to recurrence were, respectively, 20.6% and 45.5 months in PRS compared to 7.7% and 13.3 months in PRSL ( p=0.049, chi-square test; p=0.001, unpaired t test). Both groups had significant improvements in postoperative incontinence score ( p<0.0001, Wilcoxon's matched-pairs signed-ranks test), however, there were no significant changes in anorectal manometric findings and pudendal nerve terminal motor latency assessment. CONCLUSIONS: Perineal rectosigmoidectomy with levatorplasty is associated with a lower recurrence rate and a longer time to recurrence than perineal rectosigmoidectomy alone. Levatorplasty should be offered to patients when a perineal approach for rectal prolapse is selected.

Intraoperative endoscopy in laparoscopic colectomy.

BACKGROUND: The localization of focal colonic pathologies is problematical in laparoscopic surgery because it is difficult to palpate the colon. The aim of this study was to evaluate the use of intraoperative lower endoscopy in laparoscopic segmental colectomy. METHODS: We did a retrospective review of the charts of patients who had undergone laparoscopic segmental colectomy. Patients in whom intraoperative lower endoscopy had been used were compared to a group of 250 patients who had colectomy by laparotomy. The patients were matched by type of surgery and operating surgeon. RESULTS: Between 1991 and 2000, 233 patients underwent laparoscopic segmental colectomy at our clinic. Lower endoscopy was employed in 57 of them (24%), as compared to 42 patients (17%) in the laparotomy matched group ( p = 0.042). The diseased segment was successfully identified in all of the patients in whom the main indication for endoscopy was localization (65% of cases). Endoscopy was judged to have changed the surgical management in 66% of the 57 cases in whom it was employed, and especially in 88% of the 37 patients for whom the main indication had been localization. There were no endoscopy-related complications. CONCLUSION: Intraoperative lower endoscopy is a useful and safe tool for the localization of pathologies and the assessment of the intracorporeal anastomosis in laparoscopic segmental colectomy.

Is obesity a high-risk factor for laparoscopic colorectal surgery?

BACKGROUND: The aim of this study was to assess the outcome of laparoscopic colorectal surgery in obese patients and compare it to that of a nonobese group of patients who underwent similar procedures. METHODS: All 162 consecutive patients who underwent an elective laparoscopic or laparoscopic-assisted segmental colorectal resection between August 1991 and December 1997 were evaluated. Body mass index (BMI; kg/m2) was used as an objective index to indicate massive obesity. The parameters analyzed included BMI, age, gender, comorbid conditions, diagnosis, procedure, American Society of Anesthesiologists classification score, operative time, estimated blood loss, transfusion requirements, intraoperative complications, conversion to laparotomy, postoperative complications, length of hospitalization, and mortality. RESULTS: Thirty-one patients (19.1%) were obese (23 males and 8 females). Conversion rates were significantly increased in the obese group (39 vs 13.5%, p = 0.01), with an overall conversion rate of 18%. The postoperative complication rate in the obese group was 78% versus 24% in the nonobese group (p <0.01). Specifically, rates of ileus and wound infections were significantly higher in the obese group [32.3 vs. 7.6% (p <0.01) and 12.9 vs 3.1%. (p = 0.03), respectively]. Furthermore, hospital stay in the obese group was longer (9.5 days) than in the nonobese group (6.9 days, p = 0.02). CONCLUSION: Laparoscopic colorectal segmental resections are feasible in obese patients. However, increased rates of conversion to laparotomy should be anticipated and the risk of postoperative complications is significantly increased, prolonging the length of hospitalization when compared to that of nonobese patients.

Current attitudes in laparoscopic colorectal surgery.

BACKGROUND: In this study, we set out to examine the current attitudes among surgeons toward laparoscopic colorectal surgery (LCS). METHODS: A total of 3628 questionnaires were sent to all North American members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society of Colon and Rectal Surgeons (ASCRS); 40% of the members of each society responded (B15 respondents). RESULTS: Currently, 85% of the respondents perform laparoscopic surgery; LCS was performed by 48% of the respondents in 21% of their patients. Although 35% of the members of SAGES have increased the number of laparoscopic colorectal operations they perform in the last 3 years, only 26% of ASCRS members did so. Our findings showed that 74% of the surgeons who perform LCS do so for diverticular disease, 68% for colonic polyps, 61% for villous adenoma, and 36% for ileal Crohn's disease. However, only 15% operate for the cure of carcinoma of any stage (16% of SAGES members and 11% of ASCRS members), whereas 8.5% and 7% operate for the cure of all upper and lower rectal carcinomas, respectively. Thirty-six percent of the surgeons who perform LCS for cancer have done between one and 10 curative resections, 8% have done 11-20 procedures, and 14% have done >20 procedures. There were 80 cases of port site recurrence reported by 4.4% of surgeons. Although 56% of the respondents would themselves undergo laparoscopic colorectal surgery for a rectal villous adenoma, only 9% would do so for a distal-third rectal carcinoma (12% of SAGES and 5% of ASCRS respondents). CONCLUSIONS: The overall percentage of respondents performing LCS has decreased over the last 3 years; moreover, surgeons are more hesitant to perform laparoscopic surgery for the cure of colonic cancer. Due to the overall low response rate, the fact that 4.4% of those surgeons who did respond have seen port site recurrences does not allow any conclusions to be drawn about the prevalence of this problem.

Laparoscopic total mesorectal excision.

After total mesorectal excision for rectal cancer was introduced in 1982, local recurrence rates decreased to 5%. These results were found to be reproducible; therefore, the technique became standard for the treatment of rectal cancer. Laparoscopic surgery for curable colorectal malignancy is still considered investigational. Indeed, the United States National Cancer Institute (NCI) trial excludes rectal carcinoma. The application of laparoscopy to rectal carcinoma must compete with total mesorectal excision, which has obtained favorable results in the last decade. In this review, we assess the adequacy of laparoscopic total mesorectal excision, describe the techniques (both anterior resection and abdominoperineal resection), and discuss their potential advantages.

Update on prospective randomized trials of laparoscopic surgery for colorectal cancer.

Cosmetic improvement is perhaps the only conclusive advantage of laparoscopic colectomy for cancer. Previous retrospective studies repeatedly have demonstrated the feasibility and safety of this procedure. Although short-term prospective studies showed adequate cancer resection, comparable complication rates, and no increase in recurrence, issues of port site implantation, immune response and cost-efficiency remain unsolved. The ongoing clinical trials mentioned currently are evaluating the benefits and the potential risks of this technique as a cancer operation. Four trials will have completed accrual and three will be able to offer early analysis of the results by the year 2001. Until then, laparoscopic surgery for colorectal cancer should be considered investigational to be performed only as part of these above-mentioned trials.

Bowel preparation for colorectal surgery.

PURPOSE: The aim of this study was to assess recent literature regarding bowel preparation for colonoscopy and surgery. METHODS: The study was conducted by an Index Medicus English-language search of articles relevant to both oral mechanical and parenteral and oral antibiotic preparation for elective colorectal surgery and mechanical bowel preparation for colonoscopy. The study period was from 1975 to 2000. In addition, studies of elective colorectal surgery without mechanical bowel preparation were also considered. RESULTS: Although several recent prospective, randomized trials have suggested that elective colorectal surgery can be safely performed without any mechanical bowel preparation, mechanical bowel preparation remains the standard of care, at least in North America at the present time. A recent survey of the members of The American Society of Colon and Rectal Surgeons revealed that the majority currently use sodium phosphate for bowel preparation and use a dual oral antibiotic regimen before elective colorectal surgery, combined with two doses of parenteral antibiotics. Although some of the use patterns are based on prospective, randomized study, others seem founded strictly on habit and theory. CONCLUSIONS: The current methods of bowel cleansing for both colonoscopy and surgery include sodium phosphate and polyethylene glycol; colorectal surgeons practicing in North America currently prefer sodium phosphate. Additional preparation for colorectal surgery includes perioperative parenteral antibiotics and, to a slightly lesser degree, preoperative oral antibiotic preparation. Although some recent prospective, randomized studies have suggested that omission of mechanical bowel preparation for elective colorectal surgery is not only feasible but potentially preferable, caution is recommended before routinely omitting these widely practiced measures, because data to support such routine omission are limited.

Adenocarcinoma arising from along the rectal stump after double-stapled ileorectal J-pouch in a patient with ulcerative colitis: the need to perform a distal anastomosis. Report of a case.

Patients treated with restorative proctocolectomy for ulcerative colitis occasionally develop neoplasia from the rectal mucosal remnants. We report a case of a 65-year-old male who developed an adenocarcinoma from the rectal stump after a double-stapled ileorectal J-pouch for ulcerative colitis. We emphasize the need to perform the anastomosis either at the level of the dentate line or just cephalad to the anal transitional zone. Furthermore, when high-grade dysplasia at the rectum is evident, either an ileal pouch-anal anastomosis with mucosectomy or completion proctectomy with an end Brooke ileostomy should be offered. This is the second report in the literature of a carcinoma arising after use of the double-stapled ileal pouch-anal anastomotic technique.

Are complications of subtotal colectomy with ileorectal anastomosis related to the original disease?

The aim of this study was to compare the morbidity of subtotal colectomy with ileorectal anastomosis performed for colonic inertia, Crohn's disease, familial adenomatous polyposis, and colorectal neoplasia. A retrospective review of all patients who underwent elective colectomy with ileorectal anastomosis between June 1988 and November 1996 was performed. The patients were divided into three groups: Group I, colonic inertia; Group II, Crohn's disease; and Group III, Familial Adenomatous Polyposis or other neoplasia. Outcome factors studied included the frequency of bowel movements, the incidence of small bowel obstruction, and the incidence of anastomotic leakage. Other factors assessed included operative time, intraoperative blood loss, length of hospitalization, level of ileorectal anastomosis, time of first bowel movement, and whether the operation was undertaken in one or two stages. Statistical analysis was undertaken by using the chi-square test and the Mann-Whitney U exact test. All 48 patients in Group I were operated on in one stage. In Group II (30 patients) 15 patients were operated on in one stage, eight patients had a preliminary Hartmann's operation and then ileorectal anastomosis, and seven patients underwent subtotal colectomy with both an ileorectal anastomosis and a proximal loop ileostomy. In Group III (22 patients) 20 patients underwent a one-stage operation whereas two patients underwent a subtotal colectomy with ileorectal anastomosis and proximal loop ileostomy. The median ages were 47.0 years in Group I, 43.8 in Group II, and 53.3 in Group III. Small bowel obstruction occurred in five patients (10%) in Group I, four patients (13.3%) in Group II, and four patients (18%) in Group III. The anastomotic leak rate was 4.2% (two patients) in Group I, 1% (three patients) in Group II, and 0% in Group III (P < 0.05). At the follow up interview after surgery, the mean number of bowel movements per day 6 months after surgery was 5.4 in Group I, 7.2 in Group II, and 5.6 in Group III, (P < 0.05, Group II vs Group I or Group III). Operative time in Group III was significantly longer than in the other two groups (P = 0.004). No statistically significant differences were found among the three groups relative to blood loss, hospitalization, or timing of first bowel movement. This study failed to identify any differences in either immediate perioperative outcome or morbidity or intermediate-term function in patients undergoing ileorectal anastomosis regardless of diagnosis. The overall rate of small bowel obstruction was 13 per cent with no significant differences among the three groups. Lastly although the anastomotic leak rate was not significantly higher in patients with Crohn's disease it was higher in the group with ileostomy and ileorectal anastomosis, which highlights a potential advantage of performance of this procedure in two stages in selected patients of this patient population.

Long-term follow-up of patients undergoing colectomy for colonic inertia.

PURPOSE: Total abdominal colectomy with ileorectal anastomosis has been the procedure of choice for patients with the established diagnosis of colonic inertia. Previous studies with a limited follow-up of only one to two years have shown acceptable results and a high rate of patient satisfaction. The aim of this study was to evaluate the long-term results of total abdominal colectomy in these patients in terms of complications, bowel function, and overall patient satisfaction. METHODS: Access to the colorectal registry at the Cleveland Clinic Florida identified all patients who underwent total abdominal colectomy for colonic inertia between 1988 and 1993, with a minimum of five-year follow-up. Telephone interviews were designed to assess bowel function, concomitant use of any antidiarrheal medications, postoperative complications, persistence or development of preoperative symptoms such as pain or bloating, and overall satisfaction. Patients were asked to rate their outcome as excellent, good, fair, or poor. RESULTS: Fifty patients underwent total abdominal colectomy for the diagnosis of colonic inertia. Three patients died of unrelated causes and 30 (60 percent) were available for follow-up. The mean follow-up was 106 months, ranging from 61 to 122 months. All 30 patients reported the outcome of surgery as "excellent." The average frequency of spontaneous bowel movements was 2.5 (range, 1-6) per day. During the period of follow-up, six patients (20 percent) required admission for small-bowel obstruction, three of whom (10 percent) required laparotomy. Four patients complained of mild pelvic pain, only one of whom had the onset of pelvic pain postoperatively that persisted until the time of interview. In the other three patients the pain was present preoperatively but had decreased in intensity since the operation. Two patients (6 percent) still required assistance with bowel movements, one by laxatives and the other by enemas. Only two patients (6 percent) needed antidiarrheal medications to reduce bowel frequency. CONCLUSION: This long-term follow-up revealed a high degree of patient satisfaction and very good bowel habits, with an acceptable long-term rate of bowel obstruction. Based on these results, total abdominal colectomy can be recommended to patients with well-established colonic inertia with expectations of sustained benefit up to ten years after surgery.

Outcome and management of patients with large rectoanal intussusception.

OBJECTIVES: Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome. METHODS: Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception > or = 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse. RESULTS: Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12-118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37-91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0-5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group 1 (8.1+/-2.8 vs 0.8+/-0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7+/-4.2 to 1.1+/-5.4 vs 1.4+/-2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse. CONCLUSIONS: This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.

The efficacy of chemoradiation therapy in HIV seropositive patients with squamous cell carcinoma of the anus.

OBJECTIVE: The aim was to assess the efficacy of chemoradiation therapy for squamous cell carcinoma of the anal canal in HIV seropositive patients. PATIENTS AND METHODS: A retrospective review of all patients with squamous cell carcinoma of the anus treated primarily with combined chemotherapy (5-fluorouracil and mitomycin) and radiotherapy or local excision was undertaken comparing HIV seropositive to HIV seronegative patients. RESULTS: Thirteen HIV seronegative patients were compared with 6 HIV seropositive patients. The HIV positive group included a higher proportion of males and a significantly greater history of prior treatment for condyloma. There was no difference in the median radiation dose (5020 cGy vs 4500 cGy, P=0.10). There was a trend towards higher local tumour recurrence in the HIV seropositive patients although this was not statistically significant (30% vs 66%). The CD4 count of HIV positive patients did not correlate either with their ability to complete the prescribed treatment regimen or with subsequent recurrence. CONCLUSION: Combined chemoradiation is feasible in HIV positive patients, however, local recurrence rates in HIV positive patients may be higher. Tolerance of this therapy in HIV seropositive patients or recurrence after therapy are not related to the patient's CD4 cell count.

Effect of age on the functional outcome of total abdominal colectomy for colonic inertia.

OBJECTIVE: Colonic inertia (CI) usually presents in women in the third decade of life; however, elderly patients are at times diagnosed with the disease. Total abdominal colectomy (TAC) is considered the preferred surgical treatment for patients with well established CI refractory to conservative and medical management. Surgeons are reluctant to proceed with colectomy in aged patients because of anticipated high morbidity and poor functional outcome. MATERIALS AND METHODS: We retrospectively reviewed the outcome in 14 patients over the age of 65 years (range 65-80) (Group I) who underwent TAC for CI between 1988 and 1996. The functional and clinical outcome was compared with that of 41 patients under the age of 65 (range 21-61) (Group II) operated upon during the same time period. Functional outcome was assessed by postal and telephone questionnaires at least 12 months following surgery. RESULTS: There was no major postoperative morbidity in either group. Three (21%) patients in Group I developed small bowel obstruction postoperatively and, of them, 2 required surgical treatment. In Group II the rate of obstruction was 7% (3 patients), with one patient requiring surgery. One patient in Group I subsequently underwent completion proctectomy and creation of an end ileostomy due to continued panenteric hypomotility. Three patients in Group I died during follow-up from causes unrelated to surgery. The mean frequency of spontaneous bowel movements following surgery was 3.8 (range 1-10)/day in Group I and 2.9 (range 1-8)/day in Group II (P=NS). 'Excellent' outcome was reported by 7 patients (64%) in Group I and 39 patients (95%) in Group II (P=0.01). CONCLUSION: TAC can be performed in elderly patients with established CI with acceptable functional results and no increase in morbidity, resulting in lifestyle improvement. Complete physiological evaluation with increased emphasis on small bowel and gastric motility studies is required in this patient population.

Reproducibility of colonic transit study in patients with chronic constipation.

PURPOSE: Major therapeutic decisions are rendered based on a single colonic transit study. Therefore, the aim of this study was to assess the reproducibility of colonic transit time in patients with chronic constipation. MATERIALS AND METHODS: Fifty-one patients with chronic idiopathic constipation were randomly selected to undergo two separate colonic transit tests. All clinical conditions, methodology, and patients' instructions were identical on both occasions. The gamma rate (linear correlation analysis) was undertaken between the first and second colonic transit times. Groups were divided according to the diagnoses of colonic inertia (slow-transit constipation), paradoxical puborectalis contraction, and chronic idiopathic constipation (normal-transit constipation). RESULTS: In 35 of 51 patients (69 percent), the results were identical between the two studies; however, in 16 patients (31 percent), the results were disparate (gamma correlation coefficient = 0.53; P < 0.01). The specific correlation coefficients for patients with colonic inertia, paradoxical puborectalis contraction, and chronic idiopathic constipation were 0.12, 0.21, and 0.60 (P < 0.01), respectively. Moreover, the success rate of colectomy for colonic inertia was significantly higher in patients who underwent a repeat transit study confirming inertia than in patients who underwent colectomy based on a single study. CONCLUSIONS: Overall, colonic transit time is reproducible in patients with chronic constipation. The correlation coefficient is best for patients with idiopathic constipation and worst for patients with colonic inertia. This new finding suggests that suboptimal surgical outcome may be attributable to inaccurate diagnosis. Because of this poor correlation coefficient, in patients with colonic inertia, consideration should be given to repeating the colonic transit study before colectomy to help secure the diagnosis and improve outcome.