Bo Holmström

Results of rectocele repair. A prospective study.

PURPOSE: This study was designed to evaluate the results of rectocele repair and parameters that might be useful in selecting patients for this operation. METHODS: Twentyfive patients with symptom-giving rectoceles were prospectively evaluated with a standardized questionnaire, physical examination, defecography, colon transit studies, anorectal manometry, and electrophysiology. Patients underwent posterior colporrhaphy and perineorrhaphy. They were followed postoperatively (mean, 1.0 year) with the same questionnaire, physical examination, defecography, anorectal manometry, and electrophysiology. RESULTS: Constipation had improved postoperatively in 21 of 24 constipated patients (88 percent). At postoperative follow-up 13 patients (52 percent) had no constipation symptoms, 8 (32 percent) had occasional symptoms, and 4 (16 percent) had symptoms more than once per week. Four patients with rectocele at preoperative defecography, but not at physical examination, had favorable outcomes following surgery. The majority of patients not using vaginal digitalization preoperatively had improved with respect to constipation. All patients with pathologic transit studies had various degrees of constipation postoperatively. Constipation was not improved in two of five patients with preoperative paradoxic sphincter reaction. CONCLUSIONS: Rectocele is one cause of constipation that can be treated with good results. Preoperative use of vaginal digitalization is not mandatory for a good postoperative result. Defecography is an important complement to physical examination. Patients with pathologic transit study might have a less favorable outcome of rectocele repair with respect to constipation. More studies about the significance of paradoxic sphincter reaction in these patients are indicated.

Anal sphincter tears at vaginal delivery: risk factors and clinical outcome of primary repair.

OBJECTIVE To determine risk factors for obstetric anal sphincter tears and to evaluate symptomatic outcome of primary repair. METHODS Obstetric-procedure, maternal, and fetal data were registered in 845 consecutive vaginally delivered women. Risk factors for anal sphincter tears were calculated by multiple logistic regression. All 808 Swedish-speaking women who delivered vaginally were included in a questionnaire study regarding anal incontinence in relation to the delivery. Questionnaires were distributed within the first few days postpartum, and at 5 and 9 months postpartum. RESULTS Six percent of the women had a clinically detected sphincter tear at delivery. Sphincter tears were associated with nulliparity (odds ratio [OR] 9.8, 95% confidence interval [CI] 3.6, 26.2), postmaturity (OR 2.5, 95% CI 1.0, 6.2), fundal pressure (OR 4.6 95% CI 2.3, 7.9), midline episiotomy (OR 5.5 95% CI 1.4,18.7), and fetal weight in intervals of 250 g (OR 1.3 95% CI 1.1, 1.6). Fifty-four percent of women with repaired sphincter tears suffered from fecal or gas incontinence or both at 5 months and 41% at 9 months. Most of the symptoms were infrequent and mild. CONCLUSION Several risk factors for sphincter tear were identified. Sphincter tear at vaginal delivery is a serious complication, and it is frequently associated with anal incontinence. Special attention should be directed toward risk factors for this complication. Symptoms of anal incontinence should explicitly be sought at follow-up after delivery.

Defecography : results of investigations in 2,816 patients

PURPOSE: This study was designed to analyze the frequency of different findings at defecography in patients with defecation disorders and see in what way the evaluation could be improved. METHODS: The reports of investigations in 2,816 patients were analyzed. RESULTS: Twenty‐three percent of the investigations were considered normal. Thirty‐one percent of the patients had rectal intussusception, 13 percent had rectal prolapse, 27 percent had rectocele, and 19 percent had enterocele. Twenty‐one percent of the patients had a combination of two or three of these diagnoses. The combination of rectocele and enterocele was rare. The majority of patients with enterocele had other concomitant findings. Patients with or without abnormal perineal descent had similar frequencies of rectal prolapse, rectal intussusception, and enterocele. Rectocele was more common in patients with abnormal perineal descent. CONCLUSIONS: Defecography is valuable when investigating patients with defecation disorders. Pathologic findings were found in 77 percent of the patients. A standardized protocol should ensure a complete evaluation of defecography.

Late adverse effects of short-course preoperative radiotherapy in rectal cancer.

Preoperative radiotherapy improves local control and survival in rectal cancer, but there are few reports on long‐term morbidity. The aims of this study were to compare long‐term morbidity and quality of life in patients undergoing rectal cancer surgery with or without preoperative radiotherapy.

Conservative treatment of acute colonic diverticulitis: Are antibiotics always mandatory?

Objective. Most patients admitted for acute colonic diverticulitis (AD) are managed conservatively and receive antibiotics, although it is uncertain whether all patients with AD benefit from this treatment. The aim of this study was to evaluate the influence of antibiotic treatment on outcome in the conservative management of patients with mild AD. Material and methods. A retrospective audit of 311 patients (64% F, mean age 60 years) hospitalized for AD was carried out. All patients were initially treated conservatively with observation and restriction of oral intake. Patients receiving antibiotics (n=118) were compared with patients treated with observation and restriction of oral intake only (n=193). Mean follow-up time (FU) was 30 months. Results. Inflammation in patients treated with antibiotics was more pronounced (laboratory parameters (C-reactive protein, white blood cell count) were higher (p<0.01), fever was more common (p<0.01) and CT grading of inflammation was classified as severe in a higher proportion (p<0.01)) compared with patients treated without antibiotics. When initially treated with antibiotics, 3 patients (3%) failed to respond to treatment and had to undergo surgery. There were 7 (4%) failures in patients initially treated without antibiotics, and antibiotics were then added. During FU, 29% of patients treated with antibiotics had further events (recurrent AD and/or subsequent surgery) compared with 28% (NS) among those treated without antibiotics. In a multivariate analysis, the risk of a further event was not influenced by antibiotic treatment (OR 1.03, CI 95% 0.61–1.74). Conclusions. Our results indicate that antibiotics are not mandatory in mild AD. Treatment without antibiotics appears to be safe and seems not to change the rate of further events. These results warrant further randomized prospective studies.

Association between rectocele and paradoxical sphincter response

Rectocele as well as paradoxical sphincter reaction may lead to rectal emptying difficulties and outlet obstruction. Forty-one patients with emptying disturbances and rectocele were investigated with defecography, anorectal manometry, colon transit time, and electromyography. Twenty-nine patients (71 percent) had concomitant paradoxical sphincter reaction, and 13 of these also had increased colon transit time. The functional results after surgical treatment of rectocele are not always satisfactory, probably because patients often have several causes for their emptying disturbances. It is emphasized that careful preoperative investigations are important before surgical treatment of rectocele in patients with emptying difficulties.

Results of the Ripstein operation in the treatment of rectal prolapse and internal rectal procidentia

Over 15 years 108 patients with either rectal prolapse or internal rectal procidentia were treated by the Ripstein operation. Postoperative evaluation was possible in 97 patients (mean observation time, 6.9 years). The mortality rate was 2.8 percent and surgical complications occurred in an additional 3.7 percent. The recurrence rate was 4.1 percent. Preoperative, and postoperative functional analysis was possible in 92 patients. The proportion of continent patients increased from 33 percent preoperatively to 72 percent postoperatively. Defection difficulties increased from 27 percent to 43 percent following surgery, and were a major cause of dissatisfaction.

Recovery of the internal anal sphincter following rectopexy: A possible explanation for continence improvement

Twenty-one patients suffering from rectal prolapse (n=15) or internal rectal procidentia (n=6) were investigated clinically and by anorectal manometry prior to and six months following rectopexy. Rectal prolapse was associated with incontinence in 67% (10/15) of the patients preoperatively. The moderately or severely incontinent patients had lower than normal maximum anal resting pressures (MAP) and those with severe incontinence also had lower than normal maximum squeeze pressure (MSP). Postoperatively only 20% (3/15) of the patients remained incontinent and none of them suffered severe incontinence. MAP values increased significantly indicating that improvement of the function of the internal anal sphincter may be one of the factors contributing to better continence. Rectal sensibility was impaired in patients with rectal prolapse as compared to 15 controls. There was no postoperative change. Patients with internal rectal procidentia had normal MAP and MSP and no postoperative change could be demonstrated.

Long-term results and functional outcome after Ripstein rectopexy

PURPOSE: The aim of this study was to evaluate operative mortality, morbidity, and functional results after Ripstein rectopexy for rectal prolapse and internal rectal intussusception. METHODS: Sixty-nine patients with rectal prolapse and 43 with internal rectal intussusception were included. All patient records were studied and complications registered. Long-term follow-up was possible in 105 patients and performed by clinical examination and standardized interview, telephone interview, or patient records. Seventy-six patients were prospectively evaluated, comparing bowel function before and after rectopexy. RESULTS: There was no operative mortality. Operative morbidity was 33 percent, and most complications were minor. Severe early complications included one large-bowel obstruction and one transient ureteric stenosis. Median time of follow-up was seven years in patients with rectal prolapse and 5.4 years in patients with internal rectal intussusception. Late complications included two rectovaginal fistulas and one lethal sigmoid fecaloma. Five patients underwent subtotal colectomy for severe constipation. There was one recurrent prolapse (1.6 percent). Functional evaluation showed that incontinence improved (P=0.049), whereas the number of bowel movements per week decreased (P<0.001). Frequency of emptying difficulties did not change significantly in patients with rectal prolapse but increased in patients with internal rectal intussusception (P=0.038). CONCLUSION: Ripstein rectopexy can be performed with low mortality and recurrence rate, but with a high early complication rate. There were also some serious late complications. Continence was improved, although increased constipation was a problem in some patients, especially among those with internal rectal intussusception.

Outcome of younger patients with acute diverticulitis

There is controversy over whether patients presenting with a primary attack of acute diverticulitis at a younger age are more prone to complications and recurrence than older patients.