Kari-Matti Hiltunen

Transanal or Vaginal Approach to Rectocele Repair: A Prospective, Randomized Pilot Study

PURPOSEThis study was designed to compare outcomes of transanal and vaginal techniques for rectocele repair.METHODSThirty females with symptomatic rectocele were enrolled in a prospective, randomized study. Fifteen underwent transanal rectoceleplasty, the other 15 underwent vaginal posterior colporrhaphy. Patients were assessed by clinical interview and examination, defecography, colon transit study, and anorectal manometry before randomization and 12 months postoperatively. Patients with compromised anal sphincter function or other symptomatic prolapse were excluded.RESULTSThe study groups were comparable in terms of demographic factors and rectocele-related symptoms and signs. Eleven (73 percent) patients in the vaginal group and 10 (66 percent) in the transanal group digitally assisted rectal emptying preoperatively. The mean depth of the rectocele was 6.0 ± 1.6 cm vs. 5.6 ± 1.8 cm (P = 0.53) in the respective groups. At follow-up, 14 (93 percent) patients in the vaginal group and 11 (73 percent) in the transanal group reported improvement in symptoms (P = 0.08). Need to digitally assist rectal emptying decreased significantly in both groups, to one (7 percent) for the vaginal group and four (27 percent) for the transanal group (P = 0.17 between groups). The respective recurrence rates of rectocele were one (7 percent) vs. six (40 percent) (P = 0.04), and enterocele rates were zero vs. four (P = 0.05). In the vaginal group defecography showed a significant decrease in rectocele depth whereas in the transanal group the difference did not reach statistical significance. None of the patients reported de novo dyspareunia, but 27 percent reported improvement.CONCLUSIONPatients’ symptoms were significantly alleviated by both operative techniques. The transanal technique was associated with more clinically diagnosed recurrences of rectocele and/or enterocele. Adverse effects on sexual life were avoided by use of both techniques.

Anal manometric findings in patients with anal incontinence

Anal manometric measurements were performed on 25 patients suffering from partial or total anal incontinence. Eleven patients were partially incontinent, and 14, totally incontinent. Compared with age- and sex-matched controls, both incontinent groups had significantly lower maximum basal pressure (MBP) and maximum squeeze pressure (MSP). Comparing the totally incontinent group with the partially incontinent group, the former had significantly lower MBP, but MSP did not differ significantly. The patients could also be grouped according to different manometric patterns, and it was shown that if both basal and squeeze pressures were low, the patients were prone to be totally incontinent. If only the voluntary function, MSP was low, the patients were most likely partially incontinent.

Frequency of hereditary nonpolyposis colorectal cancer

PURPOSE: Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant cancer syndrome characterized by early onset of colorectal carcinomas (CRC). Recently, two HNPCC genes have been mapped and cloned, one in the short arm of chromosome 2 and another in the short arm of chromosome 3. There has been a major controversy about the frequency of HNPCC. The few estimates available have been based on series selected by age or series representing local area. The purpose of the present study was to design a nonselected, prospective, multicenter study, taking into account the family background and other risk factors of CRC. METHODS: The proportion of HNPCC of all (N=406) CRC cases was evaluated in a prospective multicenter study. Family history and other risk factors were investigated over a 12-month period for all new CRC patients in ten hospitals. These cases constituted 23 percent of all CRCs diagnosed in Finland during the study period. RESULTS: Three (0.7 percent) cases of verified and seven (1.7 percent) cases of suspected HNPCC were identified, following the evaluation of all families with features indicative of susceptibility to cancer. The proportion of identifiable risk factors of CRC was 5.8–7.5 percent (HNPCC, 0.7-2.4 percent; previous CRC, 3.4 percent; ulcerative colitis, 1.0 percent; familial adenomatous polyposis coli, 0.7 percent). CONCLUSION. This prospective multicenter study revealed that the frequency of hereditary colorectal cancer is lower than in some previous studies, when diagnosis is based on extensive pedigree analysis. This result with recent findings of common ancestral founding mutation in Finnish HNPCC families indicates that there may be geographic differences in the occurrence of HNPCC. However, this does not change the fact that identification of HNPCC—perhaps one of the most common inherited diseases identified in humans—has become a question of vital importance now when diagnosis of the syndrome and largescale screening of gene carriers using specific tests are on the horizon.

Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse

We studied 27 patients with rectal prolapse (7 men and 20 women). Eight patients were continent, 8 were partially incontinent, and 11 were totally incontinent. Perineal descent and an absent anocutaneous reflex were common findings, implying damage to the external anal sphincter and the pelvic floor muscles. Both partially and totally incontinent patients had significantly lower basal and voluntary contraction pressures compared with those of control subjects, which is in accordance with previous reports on the subject. Our continent patients had normal voluntary contraction pressures, but basal pressures were lower than those of the control subjects (p less than 0.02). This suggests that there may be dysfunction of the internal anal sphincter before the development of clinical symptoms of incontinence. The internal anal sphincter reflex was present in 19 patients (70 percent). It was absent in patients with very little tone of the anal canal. It seems that absence of the internal anal sphincter reflex is not invariably connected with rectal prolapse. The results of this study indicate that rectal prolapse is often associated with dysfunction of the anal sphincters, leading to incontinence.

Functional results of operative treatment of rectal prolapse over an 11-year period

PURPOSE: A variety of surgical procedures have been developed to treat rectal prolapse, but there is still no consensus on the operation of choice. The aim of this study was to evaluate the functional results of operative treatment of rectal prolapse during an 11-year period in our department. METHODS: All patients treated for complete rectal prolapse during an 11-year period, from 1985 to 1995, in a single university hospital were included. Of the 123 patients, 22 were men, and the mean age was 59 (range, 15–88) years. The medical records of all patients were reviewed retrospectively, and a questionnaire on bowel symptoms before and after surgery was sent to all 95 living patients. RESULTS: The majority of the procedures (91 percent) were performed by abdominal approach, and the most frequently used open technique was posterior rectopexy with mesh (78 percent). Of the incontinent patients, 35 (63 percent), all those less than 40 years of age and 64 percent of those 40 years or older, were continent postoperatively (P=0.0001) after a median follow-up of five (range, 1–72) months. According to the questionnaire, after a median follow-up of 85 (range, 16–144) months, only 38 percent of the incontinent patients in the mesh or suture group, 78 percent of patients less than 40 years of age (n=18), and 52 percent of those 40 years or older (n=47) claimed to be continent postoperatively. The proportion of patients with constipation was greater after the operation than preoperatively (P=0.02) and more patients used medication for constipation after than before the operation (P=0.0001). The overall complication rate was 15 percent, and the mortality rate was 1 percent (1/123). In the mesh or suture group there were 6 (6 percent) recurrent complete prolapses and 11 (12 percent) mucous prolapses. CONCLUSION: Posterior rectopexy with mesh gave good results in our hands. Older age and longer follow-up seem to have a negative effect on the functional outcome of the operation and on the recurrence rate.

Anal manometric findings in symptomatic hemorrhoids

Anal manometric findings were studied in 50 patients with symptomatic hemorrhoids and an equal number of age- and sex-matched control subjects. Manometry was performed with a continuously perfused catheter by the continuous pull-through technique. Both the control subjects and patients had significant negative collerations between age and basal pressure;i.e., basal pressure was lower with advancing age. Patients with symptomatic hemorrhoids had significantly higher maximal basal pressure (P<0.02) and maximal voluntary contraction pressure (P<0.05) as compared to controls. There was no correlation between the anal manometric findings and the degree of hemorrhoids or duration of symptoms. Those patients who had bleeding as the predominant symptom had higher basal pressures; (P<0.05) than those who had prolapsing hemorrhoids as the predominant symptom.

Simplified solid sphere test to investigate anal sphincter strength in patients with anorectal diseases.

PURPOSE: The solid sphere test has not gained general acceptance to investigate anal sphincters, despite its simplicity and low cost. We studied continent and incontinent patients to evaluate whether the solid sphere test is suitable in assessment of anal sphincter function. METHODS: Seventy colorectal patients with anal incontinence of varying severity were studied by means of incontinence grading, solid sphere test, and anal manometry. RESULTS: Anal sphincter strength, studied using the solid sphere test, declined gradually with increasing severity of anal incontinence from 1,186 (±334, SD) g in 28 continent patients to 619 (±256, SD) g in 13 patients with daily soiling (P<0.001). The test also correlated with anal manometry; there was positive correlation with maximum basal pressure (tr=0.643,P<0.001) and maximum voluntary contraction pressure (r=0.393,P<0.01). CONCLUSION: The solid sphere test is useful in the primary assessment of patients with anal incontinence as a screening test, but alone it is too inaccurate for clinical decision making.

Studies on the Biological and Chemical Nature of a Component in Transfer Factor with Immunologically Nonspecific Activity

Publisher Summary This chapter focuses on the studies of the biological and chemical nature of a component in transfer factor with immunologically nonspecific activity. Fractionation of human leucocyte dialysate on Sephadex G-10 yielded seven fractions and fractions I, III and VI induced skin reactivity to oidiomycin in negative recipients. Fraction VI had therapeutic effect in various immune deficiency states, characteristically its skin conversion effect was not associated with increase in the in vitro blastogenic response to antigenic stimulus in the recipients, but low PHA responses as well as low E rosette values normalized occasionally. In order to purify the active component dialyzates were fractionated on three consecutive columns of Sephadex G-10, resulting in two new fractions and several subs fractions. The UV absorbing spot in fraction via had the same RF value as uracil and IB-spectra, mass spectra as well as NMR-FT analysis indicated that uracil was the major, but not only component in this fraction. Adjacent fraction VII contained hypoxanthine, but again this was not the only component present.

Trimethoprim and sulfadiazine penetration into bile and gallbladder in acute cholecystitis

The concentrations of trimethoprim (TMP) and sulfadiazine (SDZ) in serum, bile and gallbladder wall of 9 patients with acute cholecystitis were measured after b.i.d. treatment with 160 mg of TMP + 500 mg of SDZ. The samples were collected 2-4 h after the last dose. Mean TMP concentrations were 1.71 +/- (SE) 0.51 micrograms/ml, 4.53 +/- 5.26 micrograms/ml and 2.31 +/- micrograms/g in serum, bile and gallbladder, respectively. Mean SDZ concentrations were 22.2 +/- 14.9 micrograms/ml in serum, 9.37 +/- 8.99 micrograms/ml in bile and 16.1 +/- 10.1 micrograms/g in gallbladder. The average ratios of bile-serum and gallbladder-serum concentrations were 2.64 and 1.35 for TMP and 0.42 and 0.73 for SDZ. There was a significant correlation between serum and gallbladder concentrations of both TMP and SDZ. No correlation existed between serum and bile levels.