Claes Johansson

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.

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.

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.

Growth-Regulatory Effects of Sensory Neuropeptides, Epidermal Growth Factor, Insulin, and Somatostatin on the Non-Transformed Intestinal Epithelial Cell Line IEC-6 and the Colon Cancer Cell Line HT 29

A non-transformed small-intestinal cell line from the rat (IEC-6) and a human colon cancer cell line (HT 29) were examined for their trophic response to sensory neuropeptides. Substance P, neurokinin A (NKA), calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP), and peptide YY (PYY) were tested. Epidermal growth factor (EGF), insulin, and somatostatin-14 were also used. Interaction studies were performed on IEC-6 cells by combining EGF or insulin with somatostatin-14. The sensory neuropeptides had no effect either on IEC-6 cell growth and DNA synthesis or on HT29 cell growth. EGF and insulin stimulated cell growth and DNA synthesis in IEC-6 cells and cell growth in HT 29 cells in a dose-dependent fashion. Somatostatin-14 had no effect either alone or in combination with EGF or insulin on IEC-6 cell growth and DNA synthesis. HT 29 cell growth was inhibited by somatostatin-14 only in the presence of serum with a maximal and significant response at 10(-7) M. Our observations suggest that the sensory neuropeptides do not exert a direct growth-regulatory effect either on IEC-6 cells or on HT 29 cells. Somatostatin, however, inhibits serum-induced HT 29 cell growth but does not interfere directly with the proliferative effect of serum, EGF, or insulin on IEC-6 cells in this model.

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.

Disturbances in the defecation mechanism with special reference to intussusception of the rectum (internal procidentia)

Anorectal disorders that disturb normal defecation are described, especially intussusception of the rectum (internal procidentia). A review of 190 patients, half of whom were treated operatively and the other half conservatively, is presented. Diagnostic procedures, symptoms, and indications for operations are evaluated. We believe that intussusception of the rectum is a relatively common cause of difficult emptying of the rectum and, when the correct diagnosis is established, operation presents a fair chance for improvement.

Effects of short-time somatostatin infusion on the gastric and intestinal propulsion in humans.

The effect of short-time somatostatin infusion on gastric and intestinal propulsion of an oral glucose load was examined in healthy subjects by means of a multiple indicator dilution technique. The early gastric emptying rate was enhanced by somatostatin, indicating delayed gastric inhibition. After withdrawal of the somatostatin infusion, the late gastric emptying rate was decreased and the intestinal propagation rate markedly slowed. The effect of long-time somatostatin infusion has to be examined to analyse the nature of the events described.

Diverticular disease and migration – the influence of acculturation to a Western lifestyle on diverticular disease

Diverticular disease of the colon is more common in the Western world, compared with non‐Western countries.

Continence is improved after the Ripstein rectopexy: Different mechanisms in rectal prolapse and rectal intussusception?

PURPOSE: This study was undertaken to evaluate anal manometric changes after Ripsteins operation for rectal prolapse and rectal intussusception and to study the clinical outcome following the operation, with special reference to anal incontinence. METHODS: Forty-two patients with rectal prolapse or rectal intussusception were subjected to anorectal manometry preoperatively and seven days and six months postoperatively. A detailed history was obtained from each patient preoperatively and six months postoperatively. RESULTS: Preoperatively, patients with rectal intussusception had higher maximum resting pressure (MRP) (52±23 mmHg) than patients with rectal prolapse (34±20 mmHg;P<0.01). In the group of patients with rectal prolapse, there was a postoperative increase in MRP after six months (P<0.001) but not after seven days. Maximum squeeze pressure (MSP) did not increase. Neither MRP nor MSP increased postoperatively in patients with internal rectal procidentia. Continence was improved postoperatively both in patients with rectal prolapse (P<0.01) and rectal intussusception (P<0.01). There was no postoperative increase in rectal emptying difficulties. CONCLUSION: Ripsteins operation often improved anal continence in patients with rectal prolapse and rectal intussusception. This improvement was accompanied by increased MRP in patients with rectal prolapse, indicating recovery of internal anal sphincter function. No postoperative increase in MRP was found in patients with rectal intussusception. This suggests an alternate mechanism of improvement in patients with rectal intussusception.