Jeong Seok Choi

Outcome and management of patients with large rectoanal intussusception

OBJECTIVES:Rectoanal intussusception is the funnel-shaped infolding of the rectum, which occurs during evacuation. The aims of this study were to evaluate the risk of full thickness rectal prolapse during follow-up of patients with large rectoanal intussusception, and whether therapy improved functional outcome.METHODS:Between September 1988 and July 1997, patients diagnosed with a large rectoanal intussusception by cinedefecography (intussusception ≥ 10 mm, extending into the anal canal) were retrospectively evaluated. Patients with full thickness rectal prolapse on physical examination or cinedefecography were excluded, as were patients with colonic inertia or a history of surgery for rectal prolapse. The patients were divided into three groups according to the treatment received: group I, conservative dietary therapy; group II, biofeedback; and group III, surgery. Outcomes were obtained by postal questionnaires or telephone interviews. Parameters included age, gender, past medical and surgical history, change of bowel habits, fecal incontinence score, and development of full thickness rectal prolapse.RESULTS:Of the 63 patients, 18 were excluded (seven patients had confirmed full thickness rectal prolapse, four had previous surgery for rectal prolapse, three had colonic inertia, and four died). Follow-up data were obtained in 36 (80%) of the remaining 45 patients. The mean follow-up of this group was 45 months (range, 12–118 months). There were 34 women and two men, with a mean age of 72.4 yr (range, 37–91 yr). The mean size of the intussusception was 2.2 cm (range, 1.0–5.0 cm). The patients were classified as follows: group I, 13 patients (36.1%); group II, 13 patients (36.1%); and group III, 10 patients (27.8%). Subjectively, symptoms improved in five (38.5%), four (30.8%), and six (60.0%) patients in the three groups (p > 0.05). Among the patients with constipation, the decrease in numbers of assisted bowel movements per week (time of diagnosis to present) was significantly greater in group II compared to group I (8.1 ± 2.8 vs 0.8 ± 0.5, respectively, p = 0.004). Among the patients with incontinence, incontinence scores improved more in group II as compared to either group I or group III (time of diagnosis to present, 3.7 ± 4.2 to 1.1 ± 5.4 vs 1.4 ± 2.2, respectively, p > 0.05). Six patients (two in group I, three in group II, and one in group III) had the sensation of rectal prolapse on evacuation; however, only one patient in group I developed full thickness rectal prolapse.CONCLUSIONS:This study demonstrated that the risk of full thickness rectal prolapse developing in patients medically treated for large intussusception is very small (1/26, 3.8%). Moreover, biofeedback is beneficial to improve the symptoms of both constipation and incontinence in these patients. Therefore, biofeedback should be considered as the initial therapy of choice for large rectoanal intussusception.

Intraobserver and interobserver measurements of the anorectal angle and perineal descent in defecography.

PURPOSE: Anorectal angle and perineal descent can be measured either by drawing a line defined by the impression of the puborectalis muscle and the tangential of the posterior rectal wall (Method A) or by drawing a straight line at the level of the posterior rectal wall parallel to the central longitudinal axis of the rectum (Method B). The aim of this study was to assess the reproducibility of measuring anorectal angle and perineal descent by two different methods according to intraobserver and interobserver measurement and to evaluate which method yields more consistent results. METHODS: Five physicians who have had an average of 1.3 years (range, 6 months to 1.5 years) experience in defecographic measurement drew both lines on 63 randomly selected defecographic films and measured anorectal angle and perineal descent by the two methods. The defecographic parameters were measured twice by each observer during a three-week interval. To avoid potential bias, one physician who did not participate in either measurement of perineal descent or anorectal angle performed all data collection. Intraobserver and interobserver agreement was quantified using Shrout and Fleiss intraclass correlation coefficients. RESULTS: The mean and range of intraclass correlation coefficients for intraobserver agreement of measuring anorectal angle and perineal descent by Method A were 0.71 (0.6–0.78) and 0.89 (0.74–0.97), respectively, whereas with Method B the coefficients were 0.81 (0.73–0.89) and 0.93 (0.89–0.99), respectively. Regarding the interobserver agreement of the five observers, the mean coefficients for measurement of both anorectal angle and perineal descent by both methods showed similar agreement levels (0.88 and 0.98 by Method A and 0.89 and 0.97 by Method B). The mean (± standard deviation) values of anorectal angle and perineal descent found by Method B were significantly larger than those found by Method A (103.3°±19.6 and 6.56±3.20 cm and 91.1°±25.6 and 5.64±3.42 cm, respectively;P<0.001). CONCLUSION: Intraobserver and interobserver intraclass correlation coefficients of anorectal angle and perineal descent, which were measured by both methods, were more than 0.60, indicating that both methods are reliable and consistent for measurement of anorectal angle and perineal descent. However, centers should consistently use the same line for measurement of anorectal angle and perineal descent because of the statistically significant differences between the two methods and the possibility of inconsistent results.

Use of bioresorbable membrane (sodium hyaluronate + carboxymethylcellulose) after controlled bowel injuries in a rabbit model.

PURPOSE: Patients in whom enterolysis is performed are at high risk for recurrence of adhesions and for injury during adhesiolysis. Therefore, the aim of this study was to assess the safety of sodium hyaluronate-based bioresorbable membrane (Seprafilm®) after myotomy and enterotomy. METHODS: A total of 60 rabbits underwent laparotomy with equal distribution to one of three groups: creation of either three repaired, or three unrepaired myotomies, or three repaired enterotomies. Thus, a total of 180 defects were created in the same anatomic positions. One-half of the animals in each group had the surface of the myotomies or enterotomies covered by Seprafilm®. Fourteen days later, after complete absorption of Seprafilm®, the presence of intra-abdominal abscess, adhesions, and the integrity of the suture line were evaluated by a surgeon blinded to the use of Seprafilm® and by a standard radiographic isobaric contrast study. Statistical analysis was done by use of Fishers exact test; significance was set atP<0.05. RESULTS: The incidence of adhesions in the repaired myotomy group were 2 (6.6 percent) and 9 (30 percent) in the Seprafilm® and control (nonSeprafilm®) groups, respectively (P<0.05); in the unrepaired myotomy group, 2 (6.6 percent) and 10 (33 percent) in the Seprafilm® and control groups, respectively (P<0.05); and in the enterotomy group, 28 (94 percent) and 29 (97 percent) in the Seprafilm® and control groups, respectively (P = not significant). A single phlegmon occurred in the myotomy group at a Seprafilm® site (1.6 (1/60)vs. 0 percent,P = not significant). There were no leaks in this group. In the enterotomy group, the incidence of phlegmons was 33 percent (10/30) in the Seprafilm® group, whereas it was 27 percent (8/30) in the nonSeprafilm® group (P = not significant). The incidence of leaks was 6.6 (2/30) and 10 percent (3/30) in the Seprafilm® and nonSeprafilm® group, respectively (P = not significant). CONCLUSION: The use of Seprafilm® at the sites of myotomies significantly reduced the incidence of adhesions. Effectiveness at the enterotomy site may have been attenuated by a greater inflammatory response. Importantly, Seprafilm® did not increase septic mortality in any group.

Biofeedback therapy for rectal intussusception

BackgroundSurgery for isolated internal rectal intussusception is controversial due to high morbidity. Therefore, there is interest in other forms of treatment that are safe and effective. The aim of this study was to determine outcome and identify predictors for success of biofeedback therapy in patients with rectal intussusception.MethodsWe retrospectively evaluated the results of electromyography (EMG)–based biofeedback in 34 patients with rectal intussusception without any other major pelvic floor or colonic physiologic disorder.ResultsA total of 34 patients (7 men) had undergone at least 2 biofeedback sessions. The patients had a mean age of 68.5 years (SD=11.4 years). In the 27 patients with constipation, the frequency of weekly spontaneous bowel movements (mean±SD) was 2.0±6.8 before and 4.1±4.6 after biofeedback (p<0.05). The frequency of weekly assisted bowel movements decreased from 3.8±3.5 before to 1.5±2.2 after therapy (p<0.005). The number of patients who experienced incomplete evacuation decreased from 17 (63%) to 9 (33%) (p<0.05). Thirty–three percent of patients had complete resolution of the symptoms, 19% had partial improvement, and 48% had no improvement. Patients with constipation lasting less than nine years had a 78% success rate vs. 13% in patients who were consti– pated more than 9 years (p<0.01). In seven patients with incontinence, the frequency of daily incontinence episodes decreased from 1.0±0.7 before to 0.07±0.06 after biofeedback (p<0.05). The fecal incontinence score decreased from 13.1±4.2 before to 4.6±3.6 after treatment (p<0.005). Two patients (29%) were completely continent following biofeedback, 2 had partial improvement, and 3 (43%) had no significant improvement. There was no mortality in either group.ConclusionsBiofeedback is a safe and effective treatment option for constipation and fecal incontinence due to rectal intussusception in patients who are willing to complete the course of treatment. Long–standing constipation is less effectively cured by biofeedback.

Biofeedback therapy after perineal rectosigmoidectomy or J pouch procedure.

The aim of this study was to determine the outcome and to identify possible predictors of success for biofeedback therapy after perineal rectosigmoidectomy (PRS) or coloanal or ileoanal J pouch. A retrospective chart review of all patients with electromyography-based biofeedback therapy due to fecal incontinence after PRS or a J pouch procedure was undertaken. Follow-up was obtained by telephone survey. Fourteen patients (4 men and 10 women) were included in this study. In the 9 patients after PRS, the frequency of daily bowel movements was 3.6 2.8 preoperatively, 4.1 3.2 prebiofeedback, and 2.2 - 1.3 postbiofeedback (P < .05). The frequency of daily incontinent episodes was reduced from 2.4 2.2 preoperatively and 2.0 + 1.9 prebiofeedback to 0.26 0.3 postbiofeedback (P< .05). The incontinence scores decreased from 17 3.1 preoperatively to 16 + 2.1 prebiofeedback and to 8.2 5 postbiofeedback (P < .001). At a follow-up of 15.8 7.1 months, 5 patients after the J pouch had decreased daily bowel frequency from 6.6 4.2 prebiofeedback to 3.3 2 postbiofeedback and 3.1 2 at follow-up (P < .05). The frequency of daily incontinent episodes was reduced from 1.9 1.3 prebiofeedback to 0.9 0.7 postbiofeedback to 0.7 0.8 at followup (P < .05). The incontinence scores decreased from 13.4 2.7 prebiofeedback to 8.8 5.1 postbiofeedback to 6.8 5.5 at follow-up (P < 0.05). In both groups, the postbiofeedback incontinence score correlated with the prebiofeedback incontinence score. Furthermore, there was no correlation between outcome and age, interval between surgery and biofeedback therapy, frequency of biofeedback sessions, or manometry results in either group. Biofeedback therapy is an effective option for patients with fecal incontinence after perineal rectosigmoidectomy or colonic or ileal J pouch.

Physiologic and clinical assessment of patients with rectoanal intussusception

Abstract: The aims of this study were (1) to establish an objective baseline to assess the severity of rectoanal intussusception by the depth of rectal infolding and (2) to compare manometric and defecographic parameters in patients to validate this new objective classification of intussusception. Between July 1988 and September 1997, 224 patients with rectoanal intussusception confirmed by cinedefecography who underwent anal manometry were evaluated. These patients were classified into two groups based on the depth infolding: group I (n = 163), intussusception < 10 mm infolding seen on the rectal wall; and group II (n = 61), intussusception ≥ 10 mm infolding extending into the anal canal. There were 32 males and 192 females, of a mean age of 61 years (range, 19–88). Patients were subdivided into 5 groups according to their dominant complaint. Complaints were constipation with incomplete evacuation (n = 113, 69.3%), fecal incontinence (n = 28, 17.2%), rectal pain (n = 19, 11.7%) and others (n = 3, 1.8%) in group I and constipation (n = 34, 55.7%), sensation of prolapse (n = 14, 23.0%) and others (n = 13, 21.3%) in group II. There was a significant difference in the degree of intussusception relative to sensation of prolapse (p < 0.05). Manometry showed that the rectoanal inhibitory reflex was absent more often in patients in group II (19.7% vs. 8.5%) than in group I (p < 0.05). Moreover, group I patients had higher mean and maximum squeeze pressures when compared to group II (78.1 vs. 62.5, 105.9 vs. 88.8 mm Hg, respectively, p < 0.05). the incidences of combined cinedefecographic anomalies, such as rectocele, sigmoidocele and perineal descent, were high: 85.2% in group II and 79.1% in group I (p > 0.05). In conclusion, this study showed manometric and symptomatic differences relative to the size of the intussusception. The decreased pressure seen in patients with larger intussusception may auger for the subsequent development of incontinence in these patients.

Functional outcomes in patients with mucosal ulcerative colitis after ileal pouch-anal anastomosis by the double stapling technique

PURPOSE: The aim of this study was to evaluate any differences in functional outcome in patients with mucosal ulcerative colitis after restorative proctocolectomy and ileal pouch-anal anastomosis with use of the double stapling technique relative to the type of tissue in the stapled doughnut. METHODS: Between September 1988 and June 1997, the pathology of all patients with mucosal ulcerative colitis who underwent ileal pouch-anal anastomosis with use of the double stapling technique were reviewed. Information was obtained regarding the tissue types in the distal tissue rings (doughnuts) obtained from the stapled ileal pouch-anal anastomosis. The level of anastomosis was classified according to the type of tissue in the distal doughnut: Group I—patients in whom the anal transitional zone was removed and the distal doughnut included squamous epithelium or transitional epithelium and Group II—patients in whom the anal transitional zone was preserved because the distal doughnut revealed only columnar epithelium. Functional outcomes were assessed and compared by detailed questionnaires mailed to all patients at least one year after ileal pouch-anal anastomosis surgery. RESULTS: Distal doughnuts were obtained from the stapled ileal pouch-anal anastomosis in 222 patients with mucosal ulcerative colitis. Follow-up data at a mean of 38 (range, 12–132) months were obtained in 138 (62.2 percent) patients, including 72 males, with a mean age of 46.9 (range, 13–79) years. Group I consisted of 40 patients (29 percent; 35 (25.4 percent) who had squamous epithelium and 5 (3.6 percent) who had transitional epithelium in the distal tissue rings). Group II consisted of 98 patients (71 percent) with columnar epithelium in the distal tissue rings. Age at diagnosis and operation, duration of disease, length of follow-up, and stage of pouch surgery were similar in the two groups. Incontinence scores, frequency of bowel movement, use of a protective pad, discrimination between gas and stool, use of antidiarrheals, life-style alteration, and patient satisfaction showed similar functional results between the two groups. CONCLUSIONS: The tissue type in the stapler distal doughnut did not greatly influence functional outcome. Failure to identify a relationship may attest to the variable height and composition of the anal transitional zone.

Secondary reconstruction of an ileal reservoir in patients with failed straight ileoanal pull-through: report of two cases

Abstract. The ileoanal reservoir is a widely accepted option for the treatment of mucosal ulcerative colitis and familial adenomatous polyposis. Function of an ileoanal anastomosis without the reservoir may be unacceptable. The aim of this study was to assess the technical feasibility of conversion of a straight ileoanal anastomosis to an ileoanal reservoir anastomosis. Two patients underwent straight ileoanal anastomosis and then underwent subsequent conversion to an ileoanal reservoir anastomosis. A 16-year-old girl with mucosal ulcerative colitis and a 38-year-old woman with familial adenomatous polyposis presented with 20–25 bowel movements per day and severe diarrheal-related symptoms within 11 months of ileoanal anastomosis. In each case, the anastomosis was reversed and an ileal Jpouch was fashioned and anastomosed to the dentate line; there was no postoperative morbidity. The 38-year-old patient reported 4–5 bowel movements per day without the need for any medication at 1–8 months after ileostomy closure. The 16-year-old patient is waiting ileostomy closure. In conclusion, it is technically possible to convert a straight ileoanal anastomosis to an ileoanal reservoir anastomosis with expectations of improvement in function.