D. C. C. Bartolo

Rectopexy is an ineffective treatment for obstructed defecation

The symptoms of obstructed defecation have been attributed to rectal intussusception, and thus rectopexy has been advocated in the surgical management. In this study, patients with obstructed defecation underwent manometry and proctography before and after rectopexy. Seventeen patients (16 females and one male, mean age 51.6 years) were studied. Eleven underwent anterior and posterior fixation of the rectum and six had posterior fixation only. Preoperatively five patients demonstrated rectoanal intussusceptions. Fifteen had significant pelvic descent. No significant change in maximum resting pressure, maximum voluntary contraction, pelvic descent, or anorectal angle was seen postoperatively. In the initial follow-up, many patients had significant amelioration of symptoms. However, on longer follow-up (mean 30.8 months) only two had long-term improvement. The remainder had a poor clinical result in spite of complete resolution of rectal intussusception. Many reported a worsening of symptoms as reflected by an increase in tenesmus and stool frequency. In the two cases with a satisfactory result, both could empty the rectum completely and demonstrated rectoanal intussusception on preoperative evacuation proctography. In those with poor results, four had complete emptying and three had rectoanal intussusception. In conclusion rectopexy is an ineffective treatment for obstructive defecation in most patients.

Surgical management of intestinal radiation injury

The management of 14 cases of radiation injury to the intestinal tract over a 4-year period is evaluated. The longest latent interval between radiation treatment and symptoms was 30 years. Eight patients were treated surgically; six were treated conservatively by laser therapy or application of formalin to the affected mucosa. The indications for surgery were rectovaginal fistula (four), rectal stricture (one), radiation proctitis (eight), and small bowel obstruction (one). Seven patients underwent large bowel resection. These consisted of four anastomoses with coloanal J-reservoirs, two low anterior resections, and one coloanal anastomosis without reservoir. There was no perioperative mortality. Morbidity occurred in one of the eight surgical cases. Radical resection of the radiation-damaged rectum has been shown to be a safe and reliable treatment for rectovaginal fistulas, rectal strictures, and proctitis unresponsive to medical measures. Coloanal J-reservoir is the procedure of choice to avoid urgency and frequency symptoms associated with coloanal sleeve anastomosis. Laser therapy for hemorrhagic proctitis can achieve an important place in the management of this problem without recourse to surgery.

Comparison of anterior sphincteroplasty and postanal repair in the treatment of idiopathic fecal incontinence

Both postanal repair and anterior sphincteroplasty with levatorplasty have been advocated in the treatment of idiopathic fecal incontinence. To assess the functional results of these procedures, physiologic and radiologic measurements were carried out prospectively in 33 patients with idiopathic incontinence undergoing operative treatment, and 12 age- and sex-matched controls. Sixteen patients had anterior sphincteroplasty and levatorplasty and 17 had postanal repair. A satisfactory postoperative outcome was defined as perfect continence or incontinence of flatus only. Ten patients in the anterior sphincteroplasty group had satisfactory results (64 percent) and 10 in the postanal repair group (59 percent). Preoperatively, both groups had decreased resting and squeeze pressures, impaired anal mucosal electrosensitivity, and marked pelvic descentvs.controls. Postoperatively, significant improvement in sphincter pressures and mucosal electrosensitivity was seen in both groups. No significant change in anorectal angle was demonstrated in the postanal repair group, whereas it was made significantly more obtuse in the anterior sphincteroplasty group. It is likely that the improved continence resulting from either of these two procedures is secondary to better anal sphincter muscle function and improved anal sensation. It would appear that the anorectal angle is not crucial in maintaining continence.

Improvement of anal sensation with preservation of the anal transition zone after ileoanal anastomosis for ulcerative colitis

One of the most important considerations in restorative proctocolectomy for ulcerative colitis is postoperative continence. Preservation of the anal transition zone has been associated with improved results after this procedure in the pediatric age group. This study was carried out to determine the effect of preservation of the amal transition zone in adult patients undergoing restorative proctocolectomy, comparing a group of patients with the anal transition zone preserved with a group of patients with the anal transition zone removed. Physiologic testing demonstrated improved sensation in those patients with a preserved anal transition zone. Functional results were not significantly improved, although there was a trend toward improved continence and discrimination in those with the anal transition zone preserved. Although the results are early and are not conclusive from the clinical standpoint, they are certainly encouraging and may justify continued use of this technique.

An analysis of rectal morphology in obstructed defaecation

Obstructed defaecation in the descending perineum syndrome has been attributed to anterior mucosal prolapse. Manometric and radiological measurements together with evacuation proctograms in 49 patients with obstructed defaecation and normal whole gut transit times were carried out and compared in a total of 25 controls. Proctography delineated four groups: (I) puborectalis accentuation,n=11; (II) rectal intussusception,n=25; (III) anterior rectal wall prolapse,n=11; (IV) rectocele,n=2. The anorectal angle at rest, maximum basal sphincter pressures and the rectoanal inhibitory reflex did not differ between the groups and controls. Group III achieved a greater increase in anorectal angle on straining than controls. Groups II and III exhibited significant perineal descent below the pubococcygeal line whereas group I did not. In perineal descent intussusception was the commonest morphological abnormality associated with obstructed defaecation. Isolated anterior mucosal prolapse was not observed, making local treatment aimed at reducing its bulk questionable.

Differences in anal sensation in continent and incontinent patients with perineal descent.

Neuropathic damage secondary to pelvic floor descent is considered to be an important aetiological factor in idiopathic faecal incontinence. Perineal descent however does not necessarily result in a loss of motor function or incontinence. To elucidate the role of anal sensation in the continence mechanism we measured mucosal electrosensitivity and thermal sensitivity in normal controls and in both continent and incontinent patients with perineal descent. A catheter carrying two platinum electrodes was used to assess mucosal electrosensitivity and a water perfused thermode 1 cm long to measure thermal sensory thresholds. In addition, routine anal manometry was performed. The degree of perineal descent and anorectal angle was assessed radiographically. Anal sensation was largely preserved in continent patients with perineal descent (Controls vs continent perineal descent, Mucosal electrosensitivity (ma), lower anal canal: 4 (2–7) vs 5 (2.6–8) ns; middle anal canal 4 (2–7) vs 4.2 (2–15) ns; upper anal canal 6.5 (4–13) vs 8.3 (3.6–16)P<0.05, thermal sensitivity, median threshold (°C), lower anal canal 0.92 (0.5–2.5) vs 0.95 (0.3–3.6) ns; middle anal canal 0.83 (0.4–1.5) vs 0.75 (0.2–2) ns; upper anal canal 0.98 (0.6–2.4) vs 2.2 (0.5–4.8)p<0.05). There was a severe impairment of anal sensation in the incontinent patients with perineal descent despite a greater degree of perineal descent in the continent group. Loss of anal sensation is associated with the development of incontinence and is likely to be involved in the pathogenesis of the condition.

Anal sensation and the continence mechanism

Thermal sensation is thought to be important in sensory discrimination between different substances. The aim of this study was to determine the thermal sensitivity in the anal canal in continent patients with hemorrhoids (N=20), a group that has been reported to have a sensory deficit, and to compare the results with control subjects (N=40) and patients with idiopathic fecal incontinence (IFI) (N=22). Anal manometry was performed and sensation to mucosal electrostimulation and temperature change in the lower, middle, and upper zones of the anal canal assessed. Thermal sensation was impaired in the hemorrhoid group as compared with controls, but not to the same degree as in IFI (e.g., median thermal sensitivity in mid anal canal, control 0.9°C, hemorrhoid 1.2°C, IFI 2.0°C,P<.05 and <.001, respectively). The correlation between the two tests of sensation was 0.54 (P<.001) and the reproducibility of thermal sensory thresholds was 0.82 (P<.001). In conclusion, patients with hemorrhoids have a mild anal sensory deficit, but continence in this group is likely to be augmented by other factors.

Psoas abscess in Bristol: a 10-year review

A consecutive series of 16 cases of psoas abscess managed over a 10-year period at the Bristol Royal Infirmary is presented. Tuberculosis accounted for 4 patients all normally resident in the United Kingdom. Intrabdominal inflammatory disorders accounted for 9 of the cases with Crohns disease being the commonest of these with 5 cases. The remaining patients comprised 3 with primary staphylococcal abscesses, one appendicitis, one diverticulitis and 2 with colonic carcinoma. Diagnostic delay was common. Ultrasonography together with guided aspiration of pus was the most useful investigation giving the diagnosis in cases due to tuberculosis and staphylococci. The presence of gut associated organisms was indicative of gastrointestinal pathology. Four patients died and significant morbidity occurred in a further 5. We recommend effective dependent drainage together with resection of diseased gut in the cases of gastrointestinal origin.

The relationship between perineal descent and denervation of the puborectalis in continent patients

It has been suggested that perineal descent causes puborectalis neuropathy. To elucidate this, perineal descent was measured on standard proctograms and prolongation of mean motor unit potential duration was used as the index of denervation of the external sphincter and puborectalis in 9 male and 18 female patients with perineal descent and obstructed defaecation. The findings were compared with 21 normal controls. There was no significant perineal descent below the pubococcygeal line at rest but both males and females had abnormal descent of the anorectal angle on straining and a similar degree of external sphincter neuropathy. Females, however, exhibited a significant degree of puborectalis denervation compared with controls (p<0.001) and with male patients (p<0.001). Thus external sphincter denervation was associated with perineal descent in both sexes whereas other causes, of which obstetric trauma is a possibility, must be implicated in the puborectalis neuropathy of the females studied.