Irwin R. Berman

Sutureless laparoscopic rectopexy for procidentia

Procedures for treating rectal prolapse may constitute some of the best applications for colorectal laparoscopic techniques. Although the condition is benign, rectal prolapse is often debilitating and frequently progressive in terms of functional limitations. Moreover, many patients are elderly, medically unfit, or both. A technique that afforded relief of prolapse and of incontinence by laparoscopic rectal sacropexy, performed without sutures, using a newly designed laparoscopic sacral tacker and laparoscopic staples, is described. Indications, contraindications, technical details, and surgical implications are discussed. Laparoscopic pelvic suspension procedures are presented as realistic and appropriate objectives for colon and rectal surgeons.

Delorme's transrectal excision for internal rectal prolapse

Surgical therapy of functional outlet obstruction in patients with internal rectal intussusception may include abdominal, perineal, or transrectal procedures. Because abdominal procedures often result in significant physiologic impact but unrelieved constipation, the authors have elected Delormes transrectal excision for management of these patients. Since a short-term “placebo” effect attends many therapies, this report describes results of transrectal excision only after a threeyear postoperative period. Delormes transrectal excision of internal intussusception accomplished sustained symptomatic relief in over 70 percent of otherwise refractory constipated patients. The association of internal intussusception with other abnormalities underscores the importance of defining both anatomic and functional components when selecting patients whose constipation may require surgical therapy. Critical technical elements, surgical pitfalls, and potential complications of the procedure are discussed.

Manometric study of topical sildenafil (Viagra) in patients with chronic anal fissure: sildenafil reduces anal resting tone.

PURPOSE:Topical therapies for anal fissure have largely focused on nitric-oxide donors (e.g., nitroglycerin), sometimes with undesirable side effects or inconsistent benefits. Topical phosphodiesterase inhibitors have theoretical merit but have never been reported in treatment of anal fissure. This article describes manometric analysis of the effects of a phosphodiesterase-5 inhibitor, topical sildenafil (Viagra®) in 19 consecutive patients with chronic anal fissure with no previous treatment history.METHODS:Station pullthrough manometry was performed with patients in the left-lateral position. Maximum resting pressure (MRP1) was recorded, and 0.75 ml of 10 percent sildenafil was then instilled in the anal canal. Maximum resting pressure was repeated at the same distance from the anal verge. Thereafter, pressure was measured continuously. Time for initial relaxation (T1) and time to maximal relaxation (T2) were recorded. Average resting pressure (MRP2) was calculated. Results were analyzed by Student’s t-test.RESULTS:Topical administration of 10 percent sildenafil was accompanied by significant reduction in anal sphincter pressure (18 percent; P < 0.01). Only one patient failed to respond. Average onset of action was less than three minutes, with maximum effect one minute later. MRP1: 119.3 ± 18.7 cmH2O. MRP2: 97.8 ± 21.3 cmH2O. MRP2 < MRP1, P < 0.01. MRP M vs. F, ns. T1: 168 ± 67 seconds (M = 210 ± 72, F = 130 ± 53, P < 0.02). T2: 230 ± 78 seconds (M = 271 ± 63, F = 183 ± 75, P < 0.02). Mild-to-moderate anal discomfort was reported by 26 percent of patients. No headaches or other side effects were reported.CONCLUSIONS:Topical administration of a phosphodiesterase-5 inhibitor (sildenafil, Viagra®) significantly reduces anal sphincter pressure in patients with chronic anal fissure. A beneficial effect of nitric oxide on the spastic anal sphincter has been demonstrated previously. This study confirms that this effect need not be derived solely from nitric oxide donors. New therapeutic avenues for treatment of anal fissure through indirect enhancement of nitric oxide activity are suggested.

Sleeve advancement anorectoplasty for complicated anorectal/vaginal fistula.

Transanal flap-advancement procedures for complicated anorectal or rectovaginal fistula may include vertically incised flaps, horizontal flaps, and tubal flaps. Anatomic and pathologic considerations affecting choice of the three major techniques are examined in the context of their historical development over the last century. Application of the tubal (or sleeve) advancement principle is described in a woman whose combined rectovaginal and cryptogenic fistulas encompassed more than one-third of her anal circumference, necessitating surgical modifications beyond those afforded by previously documented techniques. Obliteration of disease and preservation of sphincteric competence were the achieved objectives of the procedure. Rationale for the procedure and technical details of the sleeve advancement anorectoplasty are described, mindful of the surgical antecedents of this therapeutic option.

Streamlining the management of defecation disorders

Obstinate constipation is a frequent but elusive gastrointestinal symptom. Increased understanding of defecation physiology and recent availability of simple, ready-to-use tools have increased specificity of both diagnosis and treatment. This patient series includes over 700 severely constipated patients with over 70 percent overall therapeutic success. Cinedefecography, pelvic floor electromyography, and determination of rectoanal inhibitory reflex were performed with simple and readily available equipment to document outlet anatomy and dynamics. Colonic transit time was examined in patients whose defecography and electromyography results were nondiagnostic and/or whose response to medical management was suboptimal, using a commercially available marker capsule, followed by abdominal x-rays. Retention of markers throughout the colon suggested colonic hypomotility or “inertia”; rectosigmoid retention confirmed functional outlet obstruction. With careful history, physical examination, and exclusion of organic causes, orderly application of readily available techniques can afford rapid, objective, and anatomically specific evidence upon which treatment of disordered defecation may be based.