Predictive factors for faecal incontinence after third or fourth degree obstetric tears: a clinico-physiologic study.

OBJECTIVE: This is a prospective study to review the natural history of anorectal dysfunction after primary repair for third or fourth degree obstetric tear and to identify the predictive factors for significant faecal incontinence. METHOD: From January 2003 to December 2005, 121 consecutive women (mean age 29.9 +/- 4.7) who sustained third or fourth degree obstetric tears were assessed. All had primary repair by obstetricians. They were assessed using anorectal physiology testing and endoanal ultrasound. Short-term (3-month postpartum) and medium-term (mean 18.8 +/- 7.7 months) Wexner's continence scores were obtained. RESULTS: Among the 121 women, seven were excluded because of incomplete follow-up. At short-term assessment, 25 out of 114 women were incontinent. One of them underwent another sphincter repair for significant faecal incontinence. Twenty-one and three patients respectively, had mild (Wexner's score 1-4) and moderate (Wexner's score 5-8) symptoms. At medium-term assessment, 24 patients remained incontinent; of these, 20 had mild symptoms (Wexner's score 1-4) and four had moderate incontinence (Wexner's score 5-8). The parity (P = 0.04), degree of obstetric tear (P = 0.036) and short-term Wexner's scores at 3 months postpartum (P < 0.0001) were significantly related to the change in Wexner's scores at medium-term assessment. However, the short-term Wexner's score was the only identifiable predictive factor for significant faecal incontinence. CONCLUSION: Most women suffering from third or fourth degree obstetric tear were continent or mildly incontinent. Poor Wexner's score at short-term assessment at 3 months postpartum was predictive of faecal incontinence in the medium-term.

Rectogesic (glyceryl trinitrate 0.2%) ointment relieves symptoms of haemorrhoids associated with high resting anal canal pressures.

OBJECTIVE: Some haemorrhoids are associated with high resting anal canal pressures. The aim of this study was to assess if Rectogesic, a topical glyceryl trinitrate 0.2% ointment was effective in relieving symptoms of early grade haemorrhoids associated with high resting anal canal pressures. METHOD: This was a prospective, two-centre, open label study of 58 patients with persistent haemorrhoidal symptoms. Patients with first or second degree haemorrhoids and a maximum resting anal canal pressure > 70 mmHg were included. Rectogesic was applied three times a day for 14 days. Anorectal manometry was performed 30 min after the first application of Rectogesic. A 28-day diary was completed during 14 days of therapy and for 14 days after cessation of treatment. This recorded the incidence of rectal bleeding, and visual analogue scales for anal pain, throbbing, pruritus, irritation and difficulty in bowel movement. RESULTS: Maximum resting anal canal pressures were reduced after application of Rectogesic (115.0 +/- 40.4 mmHg vs 94.7 +/- 34.1 mmHg, P < 0.001). In the study period and at 14 days after cessation of Rectogesic, there was significant reduction in rectal bleeding (P = 0.0002), and significant improvement of anal pain (P = 0.0024), throbbing (P = 0.0355), pruritus (P = 0.0043), irritation (P = 0.0000) and difficulty in bowel movement (P = 0.001). The main adverse event was headache in 43.1% of patients. CONCLUSION: Rectogesic is a safe and feasible treatment for patients with early grade haemorrhoids associated with high resting anal canal pressures.

Laparoscopic surgery for ulcerative colitis - a meta-analysis.

OBJECTIVE: To assess the safety and feasibility of laparoscopic surgery for patients with ulcerative colitis. METHODS: A search of published studies in English between January 1992 and September 2005 was obtained, using the MEDLINE and PubMed databases and the Cochrane Central Register of Controlled Trials. Two independent assessors reviewed the studies using a standardized protocol. Where raw data, means and standard deviations were available, meta-analysis was performed using the Forest plot review. Studies where medians and ranges were presented were separately analysed. RESULTS: The duration of surgery for laparoscopic and open procedures were similar (weighted mean difference 62.92 min, P = 0.19). Patients were able to tolerate oral intake significantly earlier, with a weighted mean difference of 1.39 days (P = 0.002), but recovery of bowel function was similar (weighted mean difference 0.73 days, P = 0.36). The length of hospital stay was shorter for patients who had undergone laparoscopic surgery, with a weighted mean difference of 2.64 days (P = 0.003). The complication rate was higher in open colectomy, compared to laparoscopic colectomy (67.6%vs 39.7%, P = 0.005). For restorative proctocolectomy, complication rates were comparable between the laparoscopic and open groups (P = 0.25). CONCLUSIONS: The time taken to perform laparoscopic surgery is similar to open surgery. Patients are able to tolerate oral intake earlier, and have a shorter hospitalization. Laparoscopic colectomy was safer compared to the open procedure, but both were equally safe for patients who had restorative proctocolectomy. Thus, laparoscopic surgery for ulcerative colitis is both safe and feasible.

Which is the optimal bowel preparation for colonoscopy - a meta-analysis.

OBJECTIVE: To assess which bowel preparation agent is most effective. METHODS: A search of randomized trials between January 1990 and July 2005 was obtained, using MEDLINE and PubMed databases, and the Cochrane Central Register of Controlled Trials. Meta-analysis was performed using the Forest plot review. RESULTS: Sodium phosphate (NaP) was more effective in bowel cleansing than polyethylene glycol (PEG) - odds ratio 0.75 (95%CI: 0.65-0.88; P = 0.0004); and sodium picosulphate (SPS) - odds ratio 0.52 (95%CI: 0.34-0.81; P = 0.004). PEG and SPS were comparable in bowel cleansing ability, odds ratio 1.69 (95%CI: 0.92-3.13; P = 0.09). NaP was more easily completed by patients compared to PEG, odds ratio 0.16 (95%CI: 0.09-0.29; P < 0.00001). More patients were able to complete SPS than PEG, but this was not statistically significant - odds ratio 0.56 (95%CI: 0.28-1.13; P = 0.11). NaP and PEG were comparable in terms of adverse events, odds ratio 0.98 (95%CI: 0.82-1.17; P = 0.81), although NaP resulted in more asymptomatic hypokalaemia and hyperphosphataemia. NaP and SPS appeared to have similar incidence of adverse events. PEG resulted in more adverse events than SPS, odds ratio 3.82 (95%CI: 1.60-9.15; P = 0.003). CONCLUSIONS: NaP was more effective in bowel cleansing than PEG or SPS and was comparable in terms of adverse events. Patients have more difficulty completing PEG than NaP and SPS. Biochemical changes associated with a small-volume preparation like NaP, albeit largely asymptomatic, mandate caution in patients with cardiovascular or renal impairment.