Biofeedback therapy for rectal intussusception.

BACKGROUND: Surgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception. METHODS: We retrospectively evaluated the results of electromyography (EMG)-based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder. RESULTS: A total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean+/-SD) was 2.0+/-6.8 before and 4.1+/-4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8+/-3.5 before to 1.5+/-2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty-three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were constipated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0+/-0.7 before to 0.07+/-0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1+/-4.2 before to 4.6+/-3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group. CONCLUSIONS: Biofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long-standing constipation is less effectively cured by biofeedback.

Accuracy of hydrogen peroxide enhanced endoanal ultrasonography in assessment of the internal opening of an anal fistula complex.

BACKGROUND: The aim of this study was to evaluate the accuracy of hydrogen peroxide-enhanced ultrasound in localizing the internal opening of the anal fistula. METHODS: A retrospective review of all patients with anal fistula who underwent hydrogen peroxide-enhanced ultrasound was performed. The results of hydrogen peroxideenhanced ultrasound and intraoperative findings on the basis of operative reports were correlated. RESULTS: A total of 57 patients (47 men) of mean age of 45.7 (range, 21-77) years underwent hydrogen peroxide-enhanced ultrasound with a diagnosis of anal fistula; 36 patients underwent surgery. The intraoperative internal opening correlated with the hydrogen peroxide-enhanced ultrasound report in 22 of 36 patients (61.1%). In 5 patients, the hydrogen peroxide-enhanced ultrasound yielded false-positive information with a positive predictive value of 84%. Four of the 7 patients with falsenegative hydrogen peroxide-enhanced ultrasound findings had supra- and extrasphincteric fistulas. CONCLUSIONS: There is a 61.1% correlation between hydrogen peroxide-enhanced ultrasound and surgical findings of the internal opening with a positive predictive value of 84%. If no internal opening was seen on hydrogen peroxide-enhanced ultrasound, it strongly suggests the possibility of a supralevator or extrasphincteric fistula.

Double stapled ileal pouch anal anastomosis (DS-IPAA) for mucosal ulcerative colitis (MUC): is there a correlation between the tissue type in the circular stapler donuts and in follow-up biopsy?

PURPOSE: This study aims to assess the correlation between the tissue types found in the circular stapler donut at the time of initial double-stapled ileal pouch-anal anastomosis (DS-IPAA) and during subsequent periodic routine random biopsy. Secondarily, we sought to assess the risk of dysplasia, carcinoma or mucosal ulcerative colitis (MUC) recurrence in the retained mucosa. METHODS: The pathology reports of 91 patients (48 males, 43 females) who were operated upon for MUC from September 1988 to June 1997 and were reviewed and had two follow up visits for biopsy. The histological features of the distal donuts and biopsies of retained mucosa obtained at yearly interval follow-up were assessed in order to determine the epithelial tissue type (columnar, transitional and squamous), inflammation, recurrence of MUC and presence of dysplasia or malignancy. RESULTS: Median age at surgery was 43 (range 15-71) years and duration of MUC was 9.6 (range 0.3-42) years prior to surgery. The anastomosis was performed at a median height of 1.0 (range 0-2.5) cm cephalad to the dentate line and biopsy follow-up was undertaken at median 34 (range 2-110) months after DS-IPAA. The distal donuts were analysed in all cases, as were 305 follow-up biopsies (median 3.4; range 1-7 per patient). Although columnar epithelium (CE) was found in 62 (68%) donuts, it was absent on follow-up biopsy in 16 (26%) of these patients. Conversely, although no CE was identified in 29 (32%) donuts, it was identified in 11 (38%) of these patients during follow-up biopsy. CE in the donut was a significant predictor of CE in subsequent biopsies (P = 0.0012). The histological features consistent with MUC were seen in the biopsies from the retained mucosa in 15 (16%) patients from 0.3 to 7.6 years after DS-IPAA. While eight (9%) patients exhibited dysplasia or adenocarcinoma in the excised colon or rectum, none of the patients had either dysplastic changes or carcinoma within the retained mucosal biopsies. CONCLUSION: The correlation between CE in the circular stapler donut and at follow-up biopsy was high. However since CE developed in some patients in whom no CE was present in the distal donuts, regardless of the epithelial tissue type finding at the time of DS-IPAA, periodic follow-up biopsy should be obtained.

Overlapping sphincteroplasty: does preservation of the scar influence immediate outcome?

BACKGROUND: The importance of the overlapping scar in an anterior sphincteroplasty is often emphasized. The aim of this study was to identify the tissue type used in overlapping sphincter repair based upon ultrasound images, and to correlate these results with the immediate clinical outcome. METHODS: Data were collected prospectively on all patients with faecal incontinence who underwent anterior overlapping sphincteroplasty between June 1998 and May 1999. Continence was assessed by a standardized incontinence score ranging from 0 to 20. Pre-operative ultrasound images were compared to intraoperative ultrasound findings for each patient. In each case the surgeon performed an overlap of what was grossly felt to represent scar after which a single blinded observer performed intraoperative ultrasound. The degree of overlap was measured and classified as hyperechoic over hyperechoic (muscle over muscle; Type 1), hyperechoic over or under hypoechoic (muscle over or under scar; Type 2), hypoechoic over hypoechoic (scar over scar; Type 3). The patient follow-up included incontinence score that was obtained by telephone interview; suboptimal outcome was considered as an incontinence score >/= 6. Statistical analysis was performed using the Mann-Whitney test and Wilcoxon matched-pairs test. RESULTS: Fourteen female patients with a mean age of 51.6 (range 28-79) years were evaluated. The mean pre-operative incontinence score was 17.1 (range 7-20) and 13 of the 14 (93%) patients had an incontinence score >/= 15. All pre-operative ultrasound images were hypoechoic which correlated with the surgeon's intraoperative findings of scar. The operative appearance included two Type 1, four Type 2, and eight Type 3 images. Larger pre-operative ultrasound image defects were statistically significantly related to intraoperative Type 3 ultrasound images. At a mean follow up of 7.5 (range 2-16) months the mean postoperative incontinence score was 4.5 (range 0-12). In patients with Type 1 and Type 2 images, the mean postoperative score was 8.6 (range 4-12) whereas in patients with Type 3 it was 1.3 (range 0-5) (P < 0.003); 7 of the 8 patients in Type 3 (87.5%) had an incontinence score

Percutaneous postoperative intra-abdominal abscess drainage after elective colorectal surgery.

Intra-abdominal abscesses are a frequent source of morbidity and mortality following both elective and emergent surgery of the alimentary tract. CT-guided percutaneous drainage of intra-abdominal abscess is an alternative to immediate surgical intervention. We studied the clinical characteristics and outcomes of patients undergoing percutaneous drainage of intra-abdominal abscesses arising after elective colorectal procedures. We retrospectively identified 40 patients with postoperative intraabdominal abscess following elective colorectal surgery who underwent CT-guided percutaneous drainage with a Von Sonnenberg sump drain between 1990 and 1998. The most common presenting symptoms were pyrexia in 39 (97%), abdominal tenderness in 32 (80%), guarding in 1 (2.5%) and abdominal mass in 3 (7.5%); no patient had generalized peritonitis. The most common index procedure was proctocolectomy with ileoanal anastomosis and ileal Jpouch in 12 (30%) patients. Drainage was performed using an anterior approach in 32 (80%) and a transgluteal window in 8 (20%) patients. Thirty-five (87.5%) patients had a single collection, while 2 (5.0%) patients had 2 collections and 3 (7.5%) patients had 3 collections. Thirteen (32.5%) patients had perioperative steroids, 30 (75%) had preoperative antibiotics, and 40 (100%) had postoperative antibiotics. Follow-up at a mean of 35.8 days revealed complete resolution of abscess in 26 (65%) patients; 14 (35%) patients had residual or recurrent abscess successfully treated by repeat drainage in 8 patients and requiring laparotomy in 6. Percutaneous CT-guided abscess drainage is an effective method for treating intra-abdominal abscess following elective colorectal surgery. The primary success was 65% after the first and 85% after a second drainage. In conclusion, this technique should be considered as the treatment of choice in patients with localized intra-abdominal abscess without signs of generalized peritonitis.

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.

A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines.

BACKGROUND: The aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines. METHODS: A prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed. RESULTS: Between April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001). CONCLUSIONS: This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe" colonoscopies.

Does limited placement of bioresorbable membrane of modified sodium hyaluronate and carboxymethylcellulose (Seprafilm) have possible short-term beneficial impact?

PURPOSE: The aim of the study was to assess the impact of sodium hyaluronate and carboxymethylcellulose membrane (Seprafilm) on postoperative intestinal obstruction as judged by the rates of bowel obstruction and laparotomy for bowel obstruction. A secondary aim was to assess early postoperative morbidity. METHODS: All patients who had Seprafilm placed during colorectal surgery between June 1993 and October 1998 were included in the study group and compared with a matched group of patients without Seprafilm. All patients were assessed for intestinal obstruction and complications by telephone interview and chart review. Statistical tests for independence were used where appropriate; alpha was 0.05 for all tests, and the two groups were tested for case matching. Fisher's exact test was used to compare gender distribution, nature of diagnosis (inflammatory vs. noninflammatory), and urgency of surgery (elective vs. emergency). The age distribution, number of prior abdominal surgeries, and operative time were compared by Student's t-test. Approximation of Katz test was used for independent proportions to compare the two groups for early postoperative morbidity and overall incidence of intestinal obstruction and surgical enterolysis. The incidence of intestinal obstruction between the two groups was also compared with Kaplan-Meier product limit method and log-rank test. RESULTS: Two hundred fifty-nine patients in whom Seprafilm was placed were compared with a well-matched control cohort of 179 patients. The two groups did not differ in gender or age. One-half of each group had inflammatory conditions, and approximately 90 percent of each group underwent elective operations. The operative times were similar. Both groups had a similar number of abdominal operations before inclusion (mean = 1.2, both groups). Early morbidity rates were 17.8 percent for the Seprafilm group and 15.6 percent for the controls, with mortality rates of 0.8 percent and 0.0 percent, respectively. There were 12 intestinal obstructions in 12 patients in the Seprafilm group and 12 intestinal obstructions in 11 patients in the control group at a follow-up period of 65 months in the Seprafilm group and 81 months in the control group. Eight of the 12 intestinal obstructions in the Seprafilm group resolved with conservative management while only 5 of 12 in the control group responded without surgery. Thus the enterolysis rate was 1.5 percent in the Seprafilm group and 3.9 percent in the control group, demonstrating a trend in favor of Seprafilm. There were no statistically significant differences in the incidence of either overall or abdominopelvic septic complications between the Seprafilm (3.4 percent) and control (1.1 percent) groups. CONCLUSION: During short-term follow-up in this nonprospective, nonrandomized study, limited placement of Seprafilm did not significantly reduce the need for surgical enterolysis for intestinal obstruction or significantly adversely affect the morbidity rate. However, a long-term, prospective, randomized trial is underway to elucidate these issues.

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.

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.

Enterochromaffin and serotonin cells are abnormal for patients with colonic inertia.

PURPOSE: In recent studies, serotonin and several gut peptides have been shown to serve as regulators of colonic transit. Thus, the distribution, density, and intensity of cells secreting serotonin or certain gut peptides could be abnormal in patients with colonic inertia. The aim of this study was to evaluate the distribution, density, and staining intensity of enterochromaffin and serotonin cells in the colonic mucosa of patients with colonic inertia compared with a control group. METHODS: Between 1993 and 1998 tissue blocks from the right and left side of the colon were obtained in 19 consecutive patients (18 females; mean age, 43.7 +/- 11.5 years) who underwent subtotal colectomy for colonic inertia. The control group consisted of colonoscopic biopsies from the right and left colon of 15 patients (all females; mean age, 52.7 +/- 16.5 years) for indications other then constipation, inflammatory bowel diseases, or carcinoma. Immunocytochemical staining of enterochromaffin and serotonin cells were performed on 4 microm tissue sections with the primary rabbit antibody against chromogranin A or serotonin, and the biotinylated secondary antibody and enzyme-labeled-streptavidin. The average cell number per microscopic field (x200) was calculated and the proportion of cells with various staining distribution was expressed as the percentage of the entire positive cell population as low, moderate, and high intensity. Student's t-test and chi-squared test were used for statistical analysis, with significance level set at P < 0.05. RESULTS: The quantity of both enterochromaffin cells (16.8 +/- 10.2) and serotonin cells (12.1 +/- 6.4) in the mucosa of the left colon in patients with colonic inertia was significantly higher when compared with the right side of the colon (enterochromaffin cells, 9.4 +/- 6.0; serotonin cells, 7.8 +/- 3.6; P < 0.01). The percentage of both types of cells with low staining intensity was increased, whereas the cells with high and moderate staining intensity were decreased (P < 0.01) in the left colon as compared with the right. The number of enterochromaffin cells in left-sided colonic mucosa was significantly higher in the colonic inertia group than in the control group (16.8 +/- 10.1 vs. 10.4 +/- 6.0; P < 0.05). Moreover, the numbers of serotonin cells in both the right and left colon was also significantly higher in the colonic inertia group than in the control group (right, 7.8 +/- 3.6 vs. 4.1 +/- 2.4; left, 12.1 +/- 6.4 vs. 5.8 +/- 3.7; P < 0.01). In both sides of the colon, the percentage of enterochromaffin and serotonin cells with low staining was significantly higher, whereas percentage of those cells with high or moderate staining was significantly lower in the colonic inertia group than in the control group. In the colonic inertia group there was a significantly positive correlation between numbers of enterochromaffin and serotonin cells (right side, P < 0.01; left side, P < 0.05). CONCLUSION: In patients with colonic inertia, the number of both enterochromaffin and serotonin cells are significantly increased in the colonic mucosa, especially in the left colon. As indicated by staining distribution, enterochromaffin and serotonin cells contain significantly less hormone than do the same cells in the control group.

Simple rectovaginal fistulas.

In regard to the causes of simple rectovaginal fistulas (RVF) we examined the methods of diagnosis and the efficacy and outcome of surgical procedures. The study included all of our patients diagnosed with simple RVF between December 1988 and July 1998 (n = 19). Medical charts of these patients were reviewed regarding diagnostic investigations, operative procedure, outcome, and follow-up. The most common cause was obstetric trauma (n = 15, 79%) followed by infection (n = 4, 21%). Eight patients (42%) had undergone anal surgery prior to the development of RVF; two of these had undergone more than one procedure. Endoanal ultrasound was performed in 15 patients and identified the fistula in 11 (73%). A concomitant sphincter injury was visualized in 9 of 15 patients (60%). The most common initial operation performed was an endoanal advancement flap in 12 patients (63%). This operation was performed in combination with a sphincteroplasty in 4 patients, while 3 had sphincteroplasty alone. The mean hospital stay was 3 days (range 1-5). Postoperative morbidity was noted in 5 patients (26%) of and consisted of recurrent fistula and passage of gas per vagina. Surgery was successful in complete resolution of symptoms in 14 cases (74%). Two of the three recurrences were successfully repaired with a repeat endoanal advancement flap, and one is awaiting repair. The mean follow-up for the entire group was 35.8 months (range 6-84). Endoanal advancement flap should be the initial treatment of choice for simple, low rectovaginal fistulas. The procedure can also be employed with expectations of success even after a failed primary repair and should be combined with sphincteroplasty if a coexistent anteriorly based anal sphincter defect is noted either by clinical examination or endoanal ultrasonography.

Stable expression of human inducible nitric oxide synthase in V79 Chinese hamster cells.

A recombinant expression vector containing the full-length cDNA for human inducible nitric oxide (NO) synthase was constructed for constitutive expression in V79 Chinese hamster cells. Expression was followed by Western analyses using three different NO synthase antisera. Activity remained stable during 4 months of continued cultivation. Activities were 25 pmol min-1 mg-1 cytosolic protein with L-arginine and 47 pmol min-1 mg-1 cytosolic protein with NG-hydroxy-L-arginine as substrates. Activity was concentration-dependently inhibited by inhibitors such as NG-methyl-L-arginine, NG-nitro-L-arginine, NG-nitro-L-arginine methyl ester, aminoguanidine, and S-methyl-isothiourea. The rank order of inhibitor potencies was different from published results obtained with rodent inducible NOS. Parental V79 cells do not express and cannot be induced for NO synthase activity. Therefore, the genetically engineered V79 cell line is defined for the cDNA-encoded human inducible NO synthase. The new cell line may serve as a useful tool to study human inducible NO synthase.