Anthony A. Eyers

Successful overlapping anal sphincter repair: Relationship to patient age, neuropathy, and colostomy formation

BACKGROUND: Fecal incontinence from single anal sphincter defects are surgically remedial and commonly the result of obstetric injuries. Overlapping anal sphincter repair has previously been associated in small series with good results in 69 to 97 percent of patients. OBJECTIVES: The aims of this study were to assess the results of overlapping anal sphincter repair in one institution and to assess the effects of age, presence of a neuropathy, and addition of a temporary colostomy on the success of surgery. METHODS: A study of 57 overlapping anal sphincter repairs in 56 (54 females) patients at the Royal Prince Alfred Hospital during a six-year period was performed. All patients were investigated preoperatively with endoanal ultrasound and concentric needle electromyography. Patients have been assessed prospectively since 1994 with a questionnaire, including a four-point Likert scale of continence level, the St. Marks incontinence scoring system (range, 0–13), the Pescatori incontinence scoring system (range, 0–6), and patient assessment of success or failure of the overlapping anal sphincter repair. A colostomy was selectively formed in conjunction with an overlapping anal sphincter repair in 21 patients (8 preoperatively, 13 simultaneously), and 18 patients had a concomitant neuropathy (3 unilateral, 15 bilateral). RESULTS: After a median follow-up of 18 months, median continence scores overall had improved from St. Marks incontinence scoring 13 to 3 (P<0.0001) and Pescatori incontinence scoring 6 to 2 (P<0.0001). Forty-nine of 57 (86 percent) repairs have been successful, and 8 are considered to be failures. Twenty-one of 27 (78 percent) repairs in patients younger than 40 years of age were successful, as were 28 of 30 (93 percent) repairs in patients older than 40 years of age (P=0.10). Four of 18 (22 percent) repairs associated with a neuropathy failed compared with 4 of 39 (10 percent) without a neuropathy (P=0.21). Improved or normal continence was achieved in 17 of 21 (81 percent) patients with a stoma and overlapping anal sphincter repair and in 32 of 36 (89 percent) patients with an overlapping anal sphincter repair alone (P=0.32). The presence of a stoma did not improve the rate of wound healing by primary intention (62 percent for stomavs. 64 percent for overlapping anal sphincter repair alone;P=0.55). CONCLUSIONS: Single anal sphincter defects can be successfully treated with an overlapping anal sphincter repair. There is no improvement in primary healing with selective stoma formation. Age of the patient and presence of a neuropathy should not detract from proceeding with overlapping anal sphincter repair when singular anal sphincter defects are detected on endoanal ultrasound in muscle that is still active.

Are special investigations of value in the management of patients with fecal incontinence

PURPOSE: The aim of this study was to determine whether special investigations significantly alter either the diagnosis or the management plan of patients with fecal incontinence assessed on the basis of a structured history and physical examination alone. METHODS: Fifty consecutive patients with fecal incontinence were prospectively studied in a tertiary referral clinic. Each patient was assessed by two clinicians who independently formulated a diagnosis and treatment plan based on the history and physical examination. The resulting 100 patient assessments were then compared with the final diagnosis and treatment plan formulated on completion of endoanal ultrasound, anal manometry, external sphincter electromyography, and defecating proctography. RESULTS: In the assessment of fecal incontinence, the addition of special investigations altered the diagnosis of the cause of incontinence based on history and examination alone in 19 percent of cases. The management plan was altered in 16 percent of cases. Special investigations were most useful in separating neuropathy from rectal wall disorders and in demonstrating the unexpected presence of internal sphincter defects and neuropathy. CONCLUSIONS: Even experienced colorectal surgeons will misdiagnose up to one-fifth of patients presenting with fecal incontinence if assessment is based on the history and physical examination alone. However surgically correctable causes of incontinence are rarely missed on clinical assessment.

Long-Term Functional Outcomes After Laparoscopic and Open Rectopexy for the Treatment of Rectal Prolapse

PurposeLaparoscopic rectopexy to treat full-thickness rectal prolapse has proven short-term benefits, but there is little long-term follow-up and functional outcome data available.MethodsPatients who had abdominal surgery for prolapse during a ten-year period were identified and interviewed to ascertain details of prolapse recurrence, constipation, incontinence, cosmesis, and satisfaction. Additional details on recurrences that required surgery and mortality were obtained from chart review and the State Death Registry.ResultsOf 321 prolapse operations, laparoscopic rectopexy was performed in 126 patients, open rectopexy in 46, and resection rectopexy in 21 patients. At a median follow-up of five years after laparoscopic rectopexy, there were five (4 percent) confirmed full-thickness recurrences that required surgery. Actuarial recurrence rates of laparoscopic rectopexy were 6.9 percent at five years (95 percent confidence interval, 0.1–13.8 percent) and 10.8 percent at ten years (95 percent confidence interval, 0.9–20.1 percent). Seven patients underwent rubber band ligation for mucosal prolapse and seven required other surgical procedures. There was one recurrence after open rectopexy (2.4 percent) and one after resection rectopexy (4.7 percent), and there was no significant difference between groups. Overall constipation scores were not increased after laparoscopic rectopexy, with no significant difference to open rectopexy or resection rectopexy.ConclusionsThis study has demonstrated that laparoscopic rectopexy has reliable long-term results for treating rectal prolapse, including low recurrence rates and no overall change in functional outcomes.

Laparoscopic rectopexy using mesh fixation with a spiked chromium staple

Abdominal rectopexy for patients with rectal prolapse is well suited for performance laparoscopically because no resection or anastomosis is necessary, with potential benefits being a decrease in postoperative pain, better cosmesis, and an earlier return to normal activity. PURPOSE: Objectives of this study were to determine the feasibility of laparoscopic abdominal rectopexy using a solitary spiked chromium staple to fix the mesh to the sacrum and to compare initial results with consecutive previous abdominal rectopexies (historical control study). METHODS: Duration of operation (anesthetic plus surgery), the day a solid diet was first tolerated, day of discharge, and patient morphine requirements in the first 48 hours were documented prospectively for the laparoscopic group and retrospectively from medical records for an open abdominal rectopexy group. RESULTS: Laparoscopic rectopexy group had lower morphine requirements when using patient-controlled analgesia (mean, 38.2vs.100.6 mg;P<0.02), an earlier tolerance of solid diet (mean, 2.7vs.5.8 days;P< 0.001), and an earlier discharge from the hospital (mean, 6.3vs.11.0 days;P<0.01). Operating time was longer for the laparoscopic group (mean, 198vs.130 minutes;P< 0.001). CONCLUSIONS: Laparoscopic rectopexy is feasible, may have benefits in reducing postoperative pain, and may aid earlier return to normal diet and activity. Given the inherent bias of a historical control study, a randomized controlled study has commenced to confirm these results.

Multicenter Randomized Trial of Centralized Nurse-Led Telephone-Based Care Coordination to Improve Outcomes After Surgical Resection for Colorectal Cancer: The CONNECT Intervention

PURPOSE To investigate the effectiveness of a centralized, nurse-delivered telephone-based service to improve care coordination and patient-reported outcomes after surgery for colorectal cancer. PATIENTS AND METHODS Patients with a newly diagnosed colorectal cancer were randomly assigned to the CONNECT intervention or usual care. Intervention-group patients received standardized calls from the centrally based nurse 3 and 10 days and 1, 3, and 6 months after discharge from hospital. Unmet supportive care needs, experience of care coordination, unplanned readmissions, emergency department presentations, distress, and quality of life (QOL) were assessed by questionnaire at 1, 3, and 6 months. RESULTS Of 775 patients treated at 23 public and private hospitals in Australia, 387 were randomly assigned to the intervention group and 369 to the control group. There were no significant differences between groups in unmet supportive care needs, but these were consistently low in both groups at both follow-up time points. There were no differences between the groups in emergency department presentations (10.8% v 13.8%; P = .2) or unplanned hospital readmissions (8.6% v 10.5%; P = .4) at 1 month. By 6 months, 25.6% of intervention-group patients had reported an unplanned readmission compared with 27.9% of controls (P = .5). There were no significant differences in experience of care coordination, distress, or QOL between groups at any follow-up time point. CONCLUSION This trial failed to demonstrate substantial benefit of a centralized system to provide standardized, telephone follow-up for postoperative patients with colorectal cancer. Future interventions could investigate a more tailored approach.

Is there an association between fecal incontinence and lower urinary dysfunction

BACKGROUND: Urinary and fecal incontinence in females are both common and distressing conditions. Because common pathophysiologic mechanisms have been described, an association between the two would be expected. The aim of this study was to determine whether patients with lower urinary tract dysfunction have concomitant fecal incontinence when compared with age and gender matched community controls and, second, to determine whether they have predisposing factors that have led to lower urinary tract symptoms and concomitant fecal incontinence. METHODS: A case-control study was performed by means of detailed questionnaire and review of investigation results. One thousand consecutive females presenting for urodynamic investigation of lower urinary tract dysfunction, were compared with 148 age and gender matched community controls. RESULTS: Frequent fecal incontinence was significantly more prevalent among all cases than among community controls (5vs. 0.72 percent,P=0.023). Occasional fecal incontinence was also more prevalent (24.6vs. 8.4 percent,P<0.001). Fecal incontinence was not significantly more prevalent among females with genuine stress incontinence (5.1 percent) when compared with females with detrusor instability (3.8 percent) or any other urodynamic diagnosis. Symptoms of fecal urgency and fecal urge incontinence were significantly more prevalent among those with a urodynamic diagnosis of detrusor instability or sensory urgency than among females with other urodynamic diagnoses or community controls. Multivariate analysis comparing cases with fecal incontinence with other cases and also with community controls did not indicate that individual obstetric factors contributed significantly to the occurrence of fecal incontinence in these patients. CONCLUSIONS: There is an association between genuine stress incontinence, lower urinary tract dysfunction, and symptoms of fecal incontinence, but the exact mechanism of injury related to childbirth trauma is questioned.

Biofeedback for fecal incontinence using transanal ultrasonography

PURPOSE: Neosphincter procedures may prove to be the treatment of choice for patients with neuropathic fecal incontinence but are rarely proposed for milder forms of the disease. Biofeedback may prove beneficial to these patients but is yet unproven. The objectives of this study were to develop a method of performing biofeedback using transanal ultrasound to teach the patient to contract repetitively and to determine biologic measures of sphincter function using transanal ultrasound in healthy and incontinent patients. METHODS: Initial uncontrolled studies were performed to determine the compliance, normal values, biologic measures of external sphincter strength (isotonic and isometric fatigue times), and early efficacy data using continence scores and visual analog scale scores. RESULTS: Forty-four patients were assessed during three months, with relative improvements in continence scores (St. Marks Hospital, 40 percent; Pescatori, 20 percent) and patient and investigator visual analog scale scores (38 percent for both) and measurable increase in biologic fatigue times measured by transanal ultrasound. CONCLUSIONS: Transanal ultrasound seems to be a method of teaching external sphincter contraction and measuring sphincter strength with good initial compliance. Clinically and statistically significant improvements in incontinence scores, visual analog scale scores, and biologic strength of the external sphincter were detected in the short-term follow-up with uncontrolled data. The randomized, controlled trial that we have begun will either confirm or refute these results.

Defunctioning of the anorectum

BACKGROUND: Creating a defunctioning stoma for anorectal disease in patients in whom no resection or anastomosis is required appears eminently suited for laparoscopic techniques, with the intended advantages of early recovery, reduced pain, and avoidance of a laparotomy. OBJECTIVES: The study contained herein was undertaken to determine the feasibility of laparoscopic defunctioning stoma formation using a three-port technique (including one at the stoma site) and to compare initial results with a historical control group. METHODS: Duration of operation (anesthetic plus surgery), the time to tolerance of a liquid and then a solid diet, time to passage of flatus and feces, patient morphine requirements in the first 48 hours, and day of discharge were documented. RESULTS: Nineteen laparoscopic stomas were attempted (3 converted to open) and 23 open stomas were formed in the control group. The laparoscopic stoma group had lower morphine requirements (mean, 47.7vs. 89.9 mg;P<0.01), an earlier tolerance of both liquid (mean, 2.1vs. 3.7 days; P<0.01) and solid diets (mean, 3.6vs. 5.5 days;P<0.001), and an earlier time to passage of both flatus (mean, 2.2vs. 3.6 days;P<0.001) and feces (mean, 3.7vs. 5.6 days;P<0.001). Operating time was longer for the laparoscopic group (mean, 176vs. 104 minutes;P<0.001), whereas median time to discharge from hospital was shorter (median, 8vs. 11 days;P=0.014). Postoperative 30-day morbidity occurred in 1 of 19 laparoscopic group patients and 4 of 23 open group patients. CONCLUSIONS: In this select group of patients requiring defunctioning stoma only, laparoscopic surgery is feasible and safe and may have advantages over open procedures of less pain, earlier tolerance of diet, earlier return of bowel function, and a shorter median length of stay.

A new classification of hepatic territories using intraoperative ultrasound

Intraoperative ultrasonography is now established as the most accurate technique for detecting and localizing hepatic tumors, be they primary or metastatic. A major problem is the accurate placement of any lesions found by intraoperative ultrasound and, hence, the correlation of the lesions found by ultrasound to the current classification of hepatic segments and to lesions seen by other imaging techniques. This paper outlines an objective and reproducible method of mapping hepatic lesions into territories defined solely by the major hepatic veins and their tributaries. It is a simple technique that can be readily used by any surgeon, which accurately determines the presence, number, size, and site of hepatic metastases.

Extranodal plasmablastic lymphoma arising in mantle cell lymphoma

the advantage that they are more easily applicable in routine diagnostic histopathology compared with mutational analysis of HNF1a and b-catenin genes and real time RT-PCR of b-catenin target genes. We studied resected liver tumours in which the diagnosis of hepatocellular adenoma had been made. Analogous to the study of Zucman-Rossi et al., cases previously diagnosed as typical focal nodular hyperplasia (FNH) or typical HCC were excluded. The archives of our institution contained 33 such tumours that occurred in 30 patients. After review by two liver pathologists, 21 tumours were diagnosed as hepatocellular adenomas, six as HCC arising in hepatocellular adenoma, two as borderline between hepatocellular adenoma and HCC and four as telangiectatic adenoma (formerly designated as telangiectatic FNH). Steatosis was assessed on a H&E-stained section (0–10%, 10– 30%, 30–60% or >60%) and activation of b-catenin was considered present when immunohistochemistry for b-catenin (with a mouse monoclonal antibody; clone 14; dilution 1:10; BD Transduction Laboratories, Lexington, KY, USA) showed nuclear positivity in the neoplastic cells. Appropriate positive internal controls (membranous hepatocyte and cholangiocyte staining) and negative controls (omission of primary antibody) were performed. Twenty-nine of 30 patients were female and 17 (missing data for six patients) had taken oral contraceptives for up to 20 years. The mean age at resection was 37 years and the mean size of the tumours 74 mm (range 8–180). None of these variables was associated with a diagnosis of borderline lesion or HCC in hepatocellular adenoma (P ‡ 0.0529). In contrast, b-catenin activation was seen only in cases of borderline lesions or HCC in hepatocellular adenoma and this type of tumour was also characterized by a complete or almost complete absence of steatosis (Figure 1, Table 1). We were able to confirm the most important conclusions of Zucman-Rossi et al. on an independent set of tumours using methods that are easily applicable in routine diagnostic histopathology. Assessment of steatosis on H&E-stained sections and immunohistochemistry for b-catenin may be powerful tools for detecting those adenomas with an increased risk of malignancy.