Selection criteria for internal rectal prolapse repair by Delorme's transrectal excision.

PURPOSE: The aim of this study was to review our results of Delorme's transrectal excision for internal rectal prolapse, with a view to determining preoperative selection criteria associated with a satisfactory outcome. METHODS: Between 1992 and 1998, 20 patients with internal rectal prolapse underwent Delorme's transrectal excision. The last patient was excluded from the study because of a follow-up period shorter than six months. The remaining 19 patients were prospectively followed up and classified into two groups according to their preoperative selection criteria. Group I consisted of eight patients operated on between January 1992 and October 1993 who were selected for surgery after medical treatment during a three-month period failed to improve symptoms. Initial results were reviewed, with a follow-up of at least six months, to assess predictive criteria correlating with poorer surgical outcome. These adverse criteria were used to exclude patients from selection into Group II, which included 11 patients operated on between June 1994 and June 1997. In each group the degree of improvement of symptoms was graded: Grade 1 = complete improvement with resolution of all symptoms; Grade 2 = significant improvement with resolution of dyschezia but not of other symptoms; Grade 3 = no improvement; and Grade 4 = worsened condition or reoperation. The two groups were compared according to ultimate outcomes. RESULTS: Of the Group I patients, three had preoperative chronic diarrhea, one had proximal internal rectal prolapse with rectosacral separation at defecography, and the other two were incontinent to liquid stool. An additional patient had incontinence to liquid stool but no diarrhea. Three other patients had major perineal descent (>9 cm). Results were Grade 1 for one patient, Grade 2 for one patient, Grade 3 for five patients, and Grade 4 for one patient (subsequent abdominal rectopexy). Data review showed that proximal internal prolapse with rectosacral separation at defecography, preoperative chronic diarrhea, fecal incontinence, and descending perineum (>9 cm on straining) were associated with a poorer outcome (Grades 3 and 4). These adverse criteria were used to exclude patients from selection into Group II. In this group results were Grade 1 for seven patients and Grade 2 for four patients. During the course of follow-up (mean, 43; standard deviation, 19; range, 8-73 months), outcome was better in Group II (P = 0.007). CONCLUSION. These data suggest that a favorable outcome can be achieved after Delorme's transrectal excision for internal rectal prolapse by applying stringent patient-selection criteria.

[Is there a correlation between dietary habits and hemorrhoidal disease?]. / Y a-t-il une corrélation entre les habitudes alimentaires et la maladie hémorroïdaire?

OBJECTIVES: It is empirically accepted that certain foods play a role in the pathogenesis of hemorrhoids or their acute exacerbation. The aim of this work was to determine whether there is a relationship between hemorrhoids and certain food-related or common toxin-related factors. PATIENTS AND METHODS: Two groups of 50 subjects were compared. Group I was composed of 50 patients with hemorrhoid symptoms. Fifty volunteers with no proctologic abnormality were included in group II. We used a diet survey to compare total calorie, protein, carbohydrate, fat, food fiber, water, alcohol, salt, pepper, pimento, tea, and coffee intake was well as smoking habits. Episodes of constipation were also noted. RESULTS: Overall calorie intake, as well as protein, carbohydrate and fiber intake were similar in the two groups as were use of salt, coffee and tea. Dietary intake in group I was higher for fat (p = 0.02), alcohol (p = 0.01), pepper (p = 0.04, and pimento (p = 0.001). Subjects in group I drank less water (p = 0.008), smoked more (p = 0.01) and were more often constipated (p < 0.001) than those in group II. CONCLUSION: Our findings provide further arguments suggesting that dietary imbalance or smoking could be involved in the development of hemorrhoids. These factors should be evaluated in appropriate dietary inquiries. Epidemiological surveys would be required to confirm their possible causal effect.

[Early postoperative morbidity after hemorrhoidectomy using the Milligan-Morgan technic. A retrospective studies of 1,134 cases]. / Morbidité post-opératoire précoce après hémorroïdectomie selon la technique de Milligan et Morgan. Une étude rétrospective de 1,134 cas.

Milligan and Morgan's procedure is commonly used for the surgical management of haemorrhoids. The aim of our study was to evaluate short term postoperative morbidity. Between 1975 and 1990, 1,134 patients were operated on. Two patients died after operation. The most frequent complications were pain (71%) and urinary retention (16.4%). Hemorrhages (7.6%) resulting in a re-operation occurred in 1% of cases. Other complications were rare and always cured by a specific treatment (stenosis: 2.9%, anal fissure: 0.5%, abscess: 0.6%, fistula in ano: 1.2%). Two patients had anal incontinence partially improved by biofeedback. Hemorrhoidal was 2%. Short term postoperative morbidity is generally low after Milligan and Morgan hemorrhoidectomy, with careful supervision in a surgical department and repeated postoperative care.

Gracilis muscle transposition in the treatment of faecal incontinence.

Between 1965 and 1994 eight selected patients with faecal incontinence for solid stool (Grade 4) were operated on by the original procedure described by Pickrell (1952), combined with biofeedback training postoperatively. No postoperative complication occurred. All patients were improved by this procedure. Five had normal continence and there were 3 incontinence for flatus. Anal manometry showed an increase in postoperative squeeze pressure (p < 0.05). Long term results (48.5 months) remained the same in five cases. One patient became incontinent following an anal dilatation at 108 months, and two required excision of mucosal ectropion at 7 and 78 months with restoration of continence. One patient died of unrelated disease at 31 months.

[Result of surgical treatment of exteriorized rectal prolapse in adults. Experience of 21 years]. / Résultats du traitement chirurgical du prolapsus rectal extériorisé de l'adulte. Une expérience de 21 ans.

Between 1971 and 1992, 89 patients (57 women, 32 men; mean age: 61 years) underwent surgical treatment for total rectal prolapse. 68.5% were constipated, and 12.3% had a solitary rectal ulcer, 46% were incontinent (3 grades 2, 11 grades 3, 27 grades 4). Twelve patients (21%) had been previously, but unsuccessfully operated. Manometry showed low resting pressures in the upper part of the anal canal, particularly in incontinent patients. Voluntary contraction was lower in incontinent patients. The resting anorectal angle was obtuse (113 degrees). Orr-Loygue operation (n = 53), modified rectopexy (n = 22), rectopexy to the left inguinal ligament (n = 6), Delorme operation (n = 4), and posterior rectopexy (n = 4) were performed. There was no operative mortality. Intraoperative and postoperative morbidity rates were 3.4% (n = 3) and 29%. Rectal prolapse recurred in 3 cases (3.4%). Solitary rectal ulcer healed in all patients. Only 8 patients were incontinent after operation, but control was better in 6 cases; in other both patients, preoperative electromyography showed grade III denervation. Bowel habit was postoperatively better (68.5% of patients were constipated before operation, 51.7% after operation). Resting pressures increased in preoperatively incontinent patients in the upper part of the anal canal; resting external sphincter pressures always increased. There was no change in the resting anorectal angle (112 degrees).

[Anorectal asynchronism. Clinical, manometric and therapeutic data]. / Dyssynergie anorectale. Données cliniques, manométriques et thérapeutiques.

OBJECTIVES: Anorectal asynchronism is a frequent and unrecognized cause of terminal constipation. The aim of this study was to describe clinical and instrumental findings, and results of biofeedback therapy. METHODS: From 1987 to 1991, 18 patients with anorectal asynchronism were studied then treated by biofeedback training. RESULTS: We found high rates of pelvic and perineal trauma (77.7%), of psychogenic factors (6.5%), of urinary incontinence (27.8%). The manometrical study confirmed puborectalis paradoxical contraction during defecation straining, and all the patients could not expel a rectal balloon containing 50 ml of air; non-specific manometrical abnormality was found in 44.5% patients. Excessive stamp of puborectalis muscle was always found at defecography; 77.7% of the patients had incomplete rectal evacuation, and 61.1% had an associated pelvic floor disorder. Biofeedback training was successful, and 88.9% of the patients were cured by 5 or 6 sessions. There was no predictive parameter in our study, but recovery rate seemed to be lower for patients from 45 to 55 years old. CONCLUSION: The diagnosis of the anorectal asynchronism is easily made with manometry and defecography. Treatment with biofeedback gives very good results in almost all patients.

[Place of ampullectomy in the surgical treatment of tumors in Oddi's sphincter]. / Place de l'ampullectomie dans le traitement chirurgical des tumeurs Oddiennes.

Ampoulectomy is rarely used for exeresis of tumours of the Oddi ampoula due to the risk of incomplete exeresis and postoperative complications. We performed 10 ampoulectomies between 1981 and 1990 (8 males, and 2 females: mean age 59 years). The operative procedure included wide resection followed by reimplantation of the biliary and pancreatic canals. The operative indications were based on converging evidence proficed by pathological examination of pre- and peroperative biopsies. There were 4 adenomas, 2 villous tumours, 2 ectopic pancreases, 1 somatostatinoma and 1 villous tumour with in situ carcinoma. Post-operative mortality was nil: the only post-operative complication was 1 stress ulcer. In one case, the benign nature of the tumour was infirmed by the pathological examination of the surgical specimen (invasive adenocarcinoma). This patient refused duodenopancreatectomy and died at recurrence 72 months later. For the other patients, mean post-operative follow-up was 60 months. Clinical, biological, endoscopic and pathological follow-up have not revealed relapse in any of the other patients. These results show that complete exeresis of benign Oddi tumors can be achieved by ampoulectomy without specific post-operative complications. Progress in echoendoscopy will probably lead to very precise evaluation of the local invasion of these tumours and thus to wider indications and better follow-up in operated patients.

Sphincter repair without overlapping for fecal incontinence.

Forty patients who had sphincter repair by one surgeon over the last 15 years were reviewed. The etiology of sphincter trauma was previous surgery (22), childbirth (14), and accidental trauma (4). Eleven patients had undergone at least one previous attempt at repair. Prior to operation, 12 patients were incontinent for liquid stool and 28 for formed stool. A technique of sphincter repair without overlapping was used. An associated diverting colostomy was carried out on seven patients who had had a previous failed repair. Follow-up was an average of 17 months after operation (range, 2-96 months). After operation, 25 patients were completely continent, 6 had occasional leaks of liquid stool, 4 were continent for solid stool only, and 5 showed no improvement. Neither diverting colostomy nor overlapping sutures appear to be mandatory for a successful repair of the anal sphincter after trauma.

Posterior approach to the rectum for treatment of selected benign lesions.

Access to lesions in the mid-rectum can be difficult. This report summarizes our experience with a posterior approach to the rectum in 22 men and 13 women, age range 21 to 96 years. Surgical indications included villous tumours, rectal prolapse, rectal strictures or rectal fistulae. No postoperative complications were observed in 20 patients, but fistulae developed in seven patients, of whom three required proximal colostomy and surgical treatment. Four healed spontaneously. Two patients developed sacrococcygeal hernia. Pathologic examination of villous tumour showed extensive malignant change in three cases requiring rectal resection with end-to-end colo-anal anastomosis. In two patients mild incontinence developed, treated by biofeedback. Residual peri-anal pain was reported by two patients. The posterior approach to the rectum is particularly useful for benign lesions too high for a transanal resection and too low for a transabdominal resection.

[Cancer of the rectum in elderly patients over the age of seventy-five years. Results of the surgical treatment]. / Le cancer du rectum chez les sujets âgés de plus de soixante-quinze ans. Résultats du traitement chirurgical.

The authors reviewed 122 rectal cancers observed over a period of 14 years in patients over the age of 75 years. Sixty-eight patients underwent extensive rectal resection, 17 were treated by local excision, and 28 only underwent a colostomy. Eight patients were excluded for surgery. The analysis of all of these groups showed that perioperative mortality was greater for large resections than for local resections, but with a lower recurrence rate and a higher survival at 3 years. Survival at 5 years after large resections was very close to the natural life expectancy for people of the same age. Moreover, survival was the quality of more comfortable than after local excision, and operative mortality was generally due to organ failure rather than to age itself. Radical surgery does not have to be systematically refused for very old patients, but he discussed in terms of the patients general status.

The relation between seborrheic keratoses and malignant solid tumours. A case-control study.

In order to establish whether or not here is an association between cancer and intense growth of seborrheic keratosis, the so-called Leser-Trelat sign, we conducted a case control study in which the number and features of seborrheic keratosis in 82 patients with recent solid tumours, were compared with 82 age- and sex-matched controls. Neither numbers nor features of seborrheic keratosis differed significantly in patients and controls. Eruptive seborrheic keratosis was noted in only one patient and one control. This study showed that solid malignancies are not generally associated with an increase in the number or size of seborrheic keratosis lesions, thus suggesting that they are not controlled by a hypothetical secretion of growth factors by tumours. Our results suggest that Leser-Trelat is either a coincidence, or at most a very rare sign of unusual types of cancer. We also showed that multiple cherry angiomas, previously reported to be a paraneoplastic sign, are not regularly associated with solid tumours.

[Hydatid cyst of the pancreas. Apropos of 2 cases]. / Kyste hydatique du pancréas. A propos de deux observations.

Two new cases of pancreatic hydatidosis are reported. The diagnosis of a cystic lesion of the pancreas has been easily established owing to the modern imaging techniques, especially to computed tomography. The hydatid nature has also been recognized before surgery on the basis of the epidemiological data, the existence of a calcified shell in one case, and positive serology in the other. Retrograde endoscopic cholangiowirsungography allowed specifying the relationships between the cyst and the pancreatic duct in one case. The treatment consisted in the resection of the protruding dome and in total cystectomy. There were no postoperative complications. The preoperative diagnosis of the lesion must no longer be regarded as difficult. The treatment does not raise any specific difficulties when there is no fistula into the pancreatic duct. Retrograde endoscopic cholangiowirsungography is a good means of recognizing a possible fistula and makes a scheduled surgical treatment possible.

[Rectoceles. Diagnosis and treatment]. / Rectocèles. Diagnostic et traitement.

Rectocele generally considered as a gynaecological lesion, may express only by rectal signs. A study conducted on 202 patients with rectal statics disorders allows to observed 49 cases of isolated rectocele. It was 49 women with a mean age of 48 years (24-73). Many of them complained of terminal constipation necessitating digital vaginal assistance. Medical treatment of constipation was always inefficiency. 39 patients underwent a surgical treatment by endo-anal procedure. Results were good in 95% of the cases with only 1 failure. Rectocele with rectal signs must in every case be operated on by endo-anal way.

[Urinary disorders following anorectal surgery]. / Les troubles urinaires après chirurgie ano-rectale.

Troubles of micturition are common after anorectal surgery. They range from transient slight dysfunction to protracted retention necessitating catheterization. Surgical procedures for hemorrhoids are the main cause regardless of technique. Anesthesia and age of the patient are of minor importance. Men are more often affected than women. Innervation of the vesical sphincter is connected to that of the anorectal region be it by common innervation or by shared reflexes. Two mechanisms prevail: surgical trauma can lead to early sphincter contraction and atonia of the bladder or constipation after surgery may play a role. Psychologic environment and administration of sedatives play an important role in the treatment of postoperative micturition disorders. Parasympathomimetics are often successful. Catheterization can not always be avoided. It should not be used within first 18 hours after surgery. Rapid institution of intestinal motility has a preventive effect.

[Biofeedback as a complementary treatment in surgery for anal incontinence]. / Biofeedback como tratamiento complementario de la cirugía de la incontinencia anal.

Anal incontinence is a severe condition which may be treated by surgery, with unpredictable results. Biofeedback technique is designed to re-educate the function of the anal sphincter; it employs a probe for anorectal manometry, connected to the screen of an oscilloscope. The use of this technique in 43 patients with incontinence, treated with surgery resulted in 48.1% of total continence, 39.53% of partial continence and 11.62% of null response.