Göran Brodén

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.

A combined electromyographic and cineradiologic investigation in patients with defecation disorders

Records from 20 patients on whom defecography and electromyography were performed simultaneously because of defecation disorders were analyzed. According to the electromyographic investigation, the patients could be divided into three main groups: 1) normal sphincter reaction; 2) paradoxical sphincter reaction; and 3) combined reaction. Group A was characterized by a marked reduction of muscular activity during emptying and a pronounced closing reflex after emptying. This was followed by return of normal tonic activity. Patients in group B had no relaxation of the sphincters during emptying but a pronounced increased activity in the external sphincter and the puborectalis muscle. They also had severe emptying difficulties at defecography. No closing reflex was seen. In group C the electrical activity in the sphincters increased during moderate straining and when emptying was complete a clear closing reflex was seen. In this study, a dynamic visualization of the defecation together with a registration of electromyographic activity in the striated anal sphincters was performed. It was shown that patients with paradoxical sphincter reaction were lacking a closing reflex after emptying was complete. This has not been reported previously and is important evidence for the paradoxical defecation pattern. It was also shown that the patients with rectoceles had paradoxical sphincter reaction.

Slow transit chronic constipation (Arbuthnot Lane's disease)

Seven patients (6 women, 1 man) with severe idiopathic chronic constipation, who underwent surgery with subtotal colectomy and ileorectal anastomosis, were investigated for the occurrence and density of nerve fibres, immunoreactive to different neuropeptides in the mucosa, submucosa, ganglia and smooth muscle in fresh specimens from the colon ascendens, the colon transversum and the colon descendens-sigmoideum. The following substances were studied: enkephalin, substance P, somatostatin, neuropeptide Y, vasoactive intestinal polypeptide, calcitonin gene-related peptide, bombesin, motilin, tyrosine hydroxylase, dynorphin and galanin. Nerve fibres immunoreactive to CGRP occurred in large numbers in the myenteric ganglia of the patients with severe idiopathic chronic constipation, whereas in the myenteric ganglia of the control cases they only occurred in low numbers. In two patients there was no detectable motilin immunoreactivity and in one patient only sparse in the mucosa and the smooth muscle. The other neuropeptides investigated occurred in the density and distribution previously reported in the normal gut. With the present technique there were indications that patients with severe idiopathic chronic constipation have a significant difference in the occurrence of immunoreactive nerve fibres to CGRP and motilin compared to control patients.

Evacuation difficulties and other characteristics of rectal function associated with procidentia and the Ripstein operation

Twenty-one patients with rectal prolapse (N=15) or internal rectal procidentia (N=6) were investigated clinically and by anorectal manometry prior to and six months following rectopexy. Symptoms such as urgency, rectal pain, blood, and mucous discharge were markedly relieved by the operation. Rectal evacuation and number of bowel motions seemed to be unaffected. Rectal volume, sensibility, and compliance did not change following surgery. Rectal sensibility was reduced in these patients compared with 15 controls, but there was no difference in rectal volume or rectal compliance.

Increased anal resting pressure following the Ripstein operation

To investigate the physiology of improvement in continence following the Ripstein operation for procidentia, preoperative and postoperative anorectal manometry was performed on 11 patients. The mean maximum anal resting pressure increased from 39 to 55 mm Hg (P=0.01). This probably reflects improved function of the internal anal sphincter, which might contribute to better continence by increasing the closing capacity of the anal canal

Rectal anatomy following ripstein's operation for prolapse studied by cineradiography

SummaryEleven patients operated on for rectal prolapse, according to the method described by Ripstein, were examined pre- and postoperatively with cineradiography of the rectum. The patients were asked to fill in a questionnaire to evaluate their histories of constipation. There is no apparent anatomic explanation for postoperative constipation. One patient had a rectal stricture and another, a recurrence in the shape of an intussusception.

Voluntary relaxation of the external anal sphincter

In this study five volunteers with special training in anal sphincter exercise (Scandinavian Yoga School) managed voluntarily to reduce anal pressure. The mean reduction of anal pressure was 20 mm Hg. In one of the subjects, this was shown by manometry during low spinal anesthesia and electromyography to be caused by relaxation of the external anal sphincter.