Graeme S. Duthie

Sustained internal sphincter hypertonia in patients with chronic anal fissure

PURPOSE: This study was designed to determine whether functional variations of internal sphincter activity occur in order to differentiate between patients with anal fissures from those with hemorrhoids. METHODS: Thirty patients with chronic anal fissure (median age, 28 years; 12 females), 22 patients with hemorrhoids (median age, 37 years; 7 females), and 33 control volunteers (median age, 48.5 years; 21 females) underwent ambulatory anal sphincter fine-needle electromyography and anorectal manometry. RESULTS: The median internal sphincter electromyography frequency was similar: fissure group, 0.49 Hz; hemorrhoid group, 0.46 Hz (P>0.05), and control group, 0.44 Hz (P>0.05). Median anal resting pressures were similar in the fissure group (132 cm. H2O) and the hemorrhoids group (116 cm of H2O) (P>0.05), but significantly greater than those in the control group (94 cm. H2O) (P<0.05). The median number of transient relaxations of the internal anal sphincter with an associated rise in rectal pressure and fall in anal pressure was 1 (range, 0–4) per hour in the fissure group, 6 (range, 4–7) per hour in the hemorrhoid group, and 4 (range, 3–6) per hour in the control group. Six patients with fissures were reassessed following lateral internal sphincterotomy. Median anal pressure was 102 cm of H2O (P>0.1vs.controls) and the number of internal sphincter relaxations increased to 4 per hour (P<0.01vs.preoperative number). CONCLUSIONS: Internal anal sphincter relaxation occurs on fewer occasions in patients with chronic anal fissures that have failed to heal in comparison to patients with hemorrhoids and normal controls. This evidence further supports the hypothesis that internal sphincter hypertonia may be relevant to the pathogenesis of this disorder.

Sacral nerve neuromodulation is effective treatment for fecal incontinence in the presence of a sphincter defect, pudendal neuropathy, or previous sphincter repair.

PURPOSE: To assess the effectiveness of sacral nerve neurostimulation in the setting of sphincter defects, previous sphincter repair, or pudendal neuropathy. METHODS: A total of 55 patients underwent insertion of a sacral nerve neurostimulator for fecal incontinence. There were 52 female and 3 male patients, with a mean age of 51 (range, 25–65) years and a median follow-up of 37 (range, 15–41) months. RESULTS: There was a significant improvement in the median Cleveland Clinic continence score for all of the patients, from a median of 15 (13–18) before insertion of the neurostimulator, to a median of between 4 and 7 during the follow-up period of up to 48 months. (P < .001–.008). Patients with a sphincter defect on endoanal ultrasound, a pudendal neuropathy, or a previous sphincter repair did not show any significant differences in continence scores during the follow-up period (P = .46, .25, and .81, respectively). The Fecal Incontinence Quality of Life score also showed a significant improvement on all 4 scales, Lifestyle (median 2.00 baseline to 3.00–3.70 P = .001–.008), Coping/Behavior (median 1.56 baseline to 2.89–3.22 P = .001–.007), Depression/Self-Perception (median 2.29 baseline to 2.93–3.71 P = .001–.005), and Embarrassment (median 1.50 baseline to 2.17–3.00 P = .001–.013) after insertion at all time intervals up to 36 months. The Fecal Incontinence Quality of Life score was higher than the baseline at 48 months but only statistically significant for Lifestyle (median 3.10, P = .04) and Coping/Behavior (median 2.63, P = .03) scores. There were 6 device-related complications. CONCLUSIONS: Sacral nerve neuromodulation results in a significant improvement in fecal incontinence and Fecal Incontinence Quality of Life scores after medium-term follow-up, even when there is a sphincter defect or pudendal neuropathy.

Rectal prolapse and rectal invagination

Solitary rectal ulcer, internal rectal intussusception, and complete rectal prolapse are a range of defaecatory disorders that may have a common aetiology, namely chronic straining. If the pelvic floor is weak, external prolapse is often complicated by faecal incontinence. Few patients, a lack of randomised trials, and difficulties in the interpretation of studies of anorectal physiology (the results of which often seem conflicting) have made the understanding of these disorders difficult. The basis for treatment is clear, however--patients who have symptomatic defaecatory disorders associated with an internal intussusception, or solitary rectal ulcer, or both should have a course of training of pelvic floor muscles, dietary advice, and should use fibre supplements as primary treatment. Operation should be reserved for those patients in whom medical treatment has failed, and it may be expected to relieve symptoms in above two thirds of patients. Defaecating proctography may be useful in assessing which patients may not benefit from operation. Operation is the primary treatment for external prolapse. The choice of surgical approach should be tailored according to the expertise available, the medical condition of the patient, and the presence or absence of pre-existing constipation or incontinence.

Evidence of electromechanical dissociation of the internal anal sphincter in idiopathic fecal incontinence.

PURPOSE: This study was designed to evaluate the relationship between internal sphincter electromyographic frequency and ambulatory anal pressures in order to clarify the pathophysiology of internal anal sphincter dysfunction in fecal incontinence. METHODS: Seventytwo patients of median age 55 years (range, 24–75; 63 females) with neurogenic fecal incontinence and 33 normal subjects of median age 48.5 years (range, 25–74; 21 females) underwent fine-wire anal sphincter electromyography and anal manometry. RESULTS: The median internal anal sphincter electromyographic frequency was incontinent 0.25 Hz (0.2–0.34) and the control was 0.44 Hz (0.36–0.55;P<0.03). Ambulatory resting pressures were incontinent median 54 cm of H2O (34–68 cm of H2O) and control 94 cm of H2O (72–102;P<0.01). Internal sphincter electromyographic frequency correlated with anal resting pressures in both groups (P<0.002). Internal sphincter electromyographic silence not attributable to electrode movement or the rectoanal inhibitory reflex, lasting 0.5 to 4 minutes occurred in all but two of the incontinent patients. The anal pressure during this period did not significantly change (P>0.1). No recruitment of the external sphincter or puborectalis was noted during these episodes. Such electromechanical dissociation was not seen in the control group. The frequency of transient internal sphincter relaxation was 4 (ranges 2–6) per hour in controls and 8 (ranges, 6–12) per hour in incontinent patients (P<0.01). Rectal pressures did not exceed midanal pressures in any of the controls but did in all of the incontinent patients on at least one occasion per hour in the incontinent group. CONCLUSION: Internal anal sphincter activity exhibits electromechanical dissociation and relaxes abnormally in incontinent patients.

Can photodynamic therapy be the preferred treatment option for anal intraepithelial neoplasia? Initial results of a pilot study

Anal intra-epithelial neoplasia (AIN) is a pre-malignant condition, which over time may progress to invasive anal squamous cell carcinoma. There is no standard treatment for AIN, but one of the therapeutic options available is photodynamic therapy (PDT). There are very few published studies of the efficacy of PDT, but it has been shown to produce downgrading of high-grade dysplasia in the anal region. The aim of the study was to evaluate the role of PDT in the treatment of AIN. Fifteen patients who received anal PDT between 2004 and 2013 were identified; twelve of these had AIN, two had intra-epithelial adenocarcinoma and one had dysplasia with high-risk human papillomavirus. After a median follow-up of nineteen months, ten of these have had at least one follow-up with aceto-white staining. Six of these ten patients had a complete response to PDT, although three subsequently had some recurrence. Three further patients had a partial response to PDT. There were no major therapeutic complications. Our findings suggest that PDT is a safe and feasible treatment option for AIN, associated with reasonable response rates and relatively little morbidity. Further research into the efficacy of PDT for AIN is required.

Laparoscopic Approaches to Malignant Disease

The recent application of laparoscopic surgical techniques to colorectal resection is controversial, and the value of this new treatment modality is, as yet, unclear. The laparoscopic approach may confer benefit to the patient in terms of reduced wound-related morbidity, shorter duration of ileus and decreased hospital stay [6, 7, 12, 17, 20, 29]. However, the oncological safety of laparoscopic techniques is unproven. Histological examination of resected specimens has provided data suggesting that the lymph node clearance and excision margins achieved laparoscopically may be comparable to those obtained using conventional surgical techniques [7, 8, 12, 24, 25]. However, the loco-regional recurrence rates consequent upon the laparoscopic approach are not yet known. There are also reports of wound recurrence following laparoscopic surgery, some of which have occurred after “curative excision” of early cancers, and these have yet to be adequately explained [18, 28],