D. K. Thekkinkattil

Surgical Management of Pelvic Organ Prolapse in Females: Functional Outcome of Mesh Sacrocolpopexy and Rectopexy as a Combined Procedure

PurposeUrogenital prolapse is relatively common compared with rectal prolapse and the combination of urogenital prolapse and rectal prolapse is still more infrequent. This study was designed to evaluate the functional outcome of a series of patients who have undergone open mesh sacrocolporectopexy surgery for combined vaginal and rectal prolapse.MethodsConsecutive patients from June 2000 to June 2004 with confirmed vaginal and rectal prolapse subsequently underwent open mesh sacrocolporectopexy. The Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory questionnaire with Urinary Distress Inventory, Pelvic Organ Prolapse Distress Inventory, and Colorectal-Anal Distress Inventory subscales was completed by all patients preoperatively and at six months postoperatively.ResultsThere were 29 patients with a median age of 66 (interquartile range, 59–73) years. Median period of follow-up was 26 (interquartile range, 15–33) months. Median global pelvic floor distress inventory scores were lower postoperatively compared with preoperatively (96.4 (interquartile range, 50.8–149.7) vs. 182.3 (interquartile range, 140.6–208.6; P = 0.001). All three median subscales scores also were significantly lower postoperatively compared with preoperatively.ConclusionsIn patients with concurrent vaginal and rectal prolapse, open mesh sacrocolporectopexy confers good symptomatic improvement for urinary-, vaginal-, and rectal-related symptoms.

A classification system for faecal incontinence based on anorectal investigations

Faecal incontinence is a socially disabling condition that affects a heterogeneous population of patients. There is no standardization of investigations, and treatment outcomes are variable. The major limitation for comparing the results from different studies is the lack of a pretreatment classification of incontinence. The aim of this study was to review the anorectal investigation findings and propose a simple, repeatable classification for faecal incontinence.

Measurement of anal cushions in idiopathic faecal incontinence

Faecal incontinence affects a heterogeneous population and aetiology can be multifactorial. In a subset of patients the aetiology remains idiopathic despite standard investigations. Anal cushions are important in normal continence, but have rarely been studied. The aim of this study was to measure the size of the anal cushions and to evaluate their role in patients with idiopathic faecal incontinence.

Awareness of investigations and treatment of faecal incontinence among the general practitioners: a postal questionnaire survey

Objective  Faecal incontinence is a distressing condition that can result in significant embarrassment and limitation of routine activities. General practitioners (GP) are the primary carers of such patients. There are recent developments in the surgical treatment options for this under‐reported condition. Awareness of these changes is required to make the best use of them. To the best knowledge of the authors, no studies have examined the awareness of investigations and treatment options for faecal incontinence amongst GPs. This is the focus of our study.

The assessment of a rapid noninvasive immunochromatographic assay test for fecal lactoferrin in patients with suspected inflammation of the ileal pouch.

PurposePouchitis is a common complication after ileal pouch-anal anastomosis. Diagnosis is based on the Pouch Disease Activity Index, which comprises clinical symptoms, endoscopic appearance, and histologic confirmation. A Pouch Disease Activity Index ≥ 7 confirms pouchitis. Fecal lactoferrin is a marker of intestinal inflammation, which can aid in the diagnosis of pouchitis. The IBD EZ VUE™ test is a simple, rapid, noninvasive test for fecal lactoferrin. Our goal was to study the sensitivity and specificity of this test in the diagnosis of pouchitis.MethodsConsecutive patients with pouch dysfunction were recruited from October 2005 to July 2006. A fecal sample was collected before calculation of the Pouch Disease Activity Index. An IBD EZ VUE™ test was performed on each fecal sample and the results correlated with the diagnosis of pouchitis to calculate sensitivity and specificity of the IBD EZ VUE™ test.ResultsThere were 32 patients (21 healthy and 11 inflammed pouches). The IBD EZ VUE™ test was positive in 14 patients. It had a sensitivity of 100 percent and a specificity of 86 percent in diagnosing pouchitis. The positive predictive value was 76 percent. There were three false-positive results.ConclusionsThe IBD EZ VUE™ test is a sensitive method that may remove the need for invasive pouch investigations and lead to greater confidence when antibiotic therapy is commenced. Further investigations may be reserved for those patients who have a positive lactoferrin test and fail to respond to antibiotic treatment.

Contribution of Posture to Anorectal Manometric Measurements: Are the Measurements in Left-Lateral Position Physiologic?

PurposeAnorectal manometry is commonly used to investigate fecal incontinence. Traditional practice dictates that measurements are performed with the patient in the left-lateral position however, episodes of fecal incontinence usually occur in the erect position. The influence of erect posture on anorectal manometry has not been studied.MethodsWe examined the contribution of posture to commonly measured variables during manometry by performing assessment in the left-lateral position and the erect posture. Maximum mean resting pressure, vector volumes, and resting pressure gradient were compared.ResultsComplete data were available for 172 patients. Median age was 55 (interquartile range, 44–65) years. Thirty-seven (22 percent) patients were continent, and 135 (78 percent) were incontinent. Both resting pressure and vector volume increased significantly in the erect position for both continent (P = 0.008 and 0.001, respectively) and incontinent (P = 0.001 for both) patients. A significant negative correlation was seen between severity of incontinence and resting pressure in the erect posture and amount of change in maximum mean resting pressure from left-lateral to erect posture (Spearman coefficients = −0.203, −0.211, and P = 0.013, 0.017, respectively) but not with maximum mean resting pressure in the left-lateral position (Spearman coefficient = −0.119; P = 0.164).ConclusionsOur study shows significant increase in measurements of manometric variables in the erect position. The increase may be related to anal cushions, which have a significant role in this position. The measurements in erect posture are better correlated with severity of incontinence and may be a more physiologic method of performing anorectal manometry.

Measurement of anal cushions in continent women

Aim  Anal cushions are connective tissue complexes thought to be involved in anal continence. This study aimed to assess them in continent subjects.

Accuracy of the Surgeons’ Clinical Prediction of Postoperative Major Complications Using a Visual Analog Scale

Background. Although the risk factors that contribute to postoperative complications are well recognized, prediction in the context of a particular patient is more difficult. We were interested in using a visual analog scale (VAS) to capture surgeons’ prediction of the risk of a major complication and to examine whether this could be improved. Methods. The study was performed in 3 stages. In phase I, the surgeon assessed the risk of a major complication on a 100-mm VAS immediately before and after surgery. A quality control questionnaire was designed to check if the VAS was being scored as a linear scale. In phase II, a VAS with 6 subscales for different areas of clinical risk was introduced. In phase III, predictions were completed following the presentation of detailed feedback on the accuracy of prediction of complications. Results. In total, 1295 predictions were made by 58 surgeons in 859 patients. Eight surgeons did not use a linear scale (6 logarithmic, 2 used 4 categories of risk). Surgeons made a meaningful prediction of major complications (preoperative median score 40 mm for complications v. 22 mm for no complication, P < 0.001; postoperative 46 mm v. 21 mm, P < 0.001). In phase I, the discrimination of prediction for preoperative (0.778), postoperative (0.810), and POSSUM (Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity) morbidity (0.750) prediction was similar. Although there was no improvement in prediction with a multidimensional VAS, there was a significant improvement in the discrimination of prediction after feedback (preoperative, 0.895; postoperative, 0.918). Conclusion. Awareness of different ways a VAS is scored is important when designing and interpreting studies. Clinical assessment of major complications by the surgeon was initially comparable to the prediction of the POSSUM morbidity score and improved significantly following the presentation of clinically relevant feedback.

Der Einfluss präoperativer Immunmodulation auf pouchbezogene septische Komplikationen nach ileopouchanaler Anastomose

ZusammenfassungFragestellung:Untersucht wurden prä- und perioperative Faktoren; dabei wurde der Rolle der immunmodulatorischen Medikation besondere Aufmerksamkeit gewidmet, die sich auf die Inzidenz pouchbezogener septischer Komplikationen auswirken kann.Patienten und Methodik:Es wurde eine retrospektive Datenuntersuchung von Patienten durchgeführt, die sich während eines Zeitraums von 20 Jahren, zwischen 1985 bis 2005, einer Ileumpouchoperation unterzogen hatten. Der präoperative Einsatz immunmodulatorischer Medikation wurde zusammen mit perioperativen klinischen, operativen und krankheitsspezifischen Variablen dokumentiert. Die Patienten wurden während der frühen (innerhalb von 30 Tagen nach der Operation) und späten (mehr als 30 Tage nach der Operation) postoperativen Zeit auf pouchbezogene Entzündungen hin überwacht. Es wurden eine uni- und eine multivariate logistische Regressionsanalyse durchgeführt.Ergebnisse:Zur Verfügung standen 445 Patienten (206 Frauen; 46,4%). Das mediane Alter lag bei 36 Jahren (interquartile Streuung 27–46 Jahre). Der mediane Nachbeobachtungszeitraum betrug 52 Monate (interquartile Streuung 26–86 Monate). Für 335 Patienten waren komplette Datensätze verfügbar. Bei 58 Patienten (17,3%) traten frühe postoperative Entzündungen auf. Weitere 22 Patienten (6,5%) entwickelten späte postoperative Entzündungen. Bei der multivariaten Analyse erwies sich nur noch der Einsatz von Steroiden als prognostischer Faktor für höhere Raten früher postoperativer Entzündungen (Odds-Ratio 1,81; 95%-Konfidenzintervall 1,02–3,45; p = 0,002). Gleichermaßen blieben bei der multivariaten Analyse sowohl die Faktoren männliches Geschlecht (Odds-Ratio 0,24; 95%-Konfidenzintervall 0,09–0,71; p = 0,007) als auch eine 5-Aminosalicylsäure-Anwendung (Odds-Ratio 0,22; 95%-Konfidenzintervall 0,08–0,76; p = 0,023) als prognostische Faktoren für niedrigere Entzündungsraten übrig.Schlussfolgerung:Die präoperative Anwendung von Steroiden ist mit höheren Raten von frühen, aber nicht späten pouchbezogenen entzündlichen Komplikationen assoziiert. Die Autoren empfehlen, vor Ileumpouchoperationen einen Steroidentzug durchzuführen oder die Patienten auf das erhöhte Risiko einer postoperativen Sepsis hinzuweisen.AbstractPurpose:We studied preoperative and perioperative factors with particular attention to the role of immunomodulatory medication, which may impact the incidence of pouch-related septic complications.Methods:A retrospective review of data from patients who underwent ileal pouch surgery during a 20-year period from 1985 to 2005 was performed. Preoperative use of immunomodulatory medication along with perioperative clinical, surgical, and disease variables were recorded. Patients were monitored for pouch-related sepsis in the early (within 30 days of surgery) and late (after 30 days of surgery) postoperative periods. Univariate and multivariate logistic regression analysis was performed.Results:There were 445 patients (206 females; 46.4 percent). Median age was 36 (interquartile range, 27–46) years. Median follow-up period was 52 (interquartile range, 26–86) months. Complete data were available for 335 patients. Early sepsis was seen in 58 patients (17.3 percent). Another 22 patients (6.5 percent) developed late sepsis. On multivariate analysis, only steroid use remained predictive of higher rates of early sepsis (odds ratio, 1.81; 95 percent confidence interval, 1.02–3.45; P = 0.002). Likewise on multivariate analysis, both male gender (odds ratio, 0.24; 95 percent confidence interval, 0.09–0.71; P = 0.007) and 5-aminosalicylic-acid use (odds ratio, 0.22; 95 percent confidence interval, 0.08–0.76; P = 0.023) remained predictive of lower rates of sepsis.Conclusions:Preoperative steroid use is associated with higher rates of early but not late pouch-related septic complications. We recommend that patients be weaned of steroids before ileal pouch surgery or be warned of the higher risk of postoperative sepsis.