Linda L. Jensen

Endorectal ultrasound in the preoperative staging of rectal tumors : a learning experience

The preoperative staging of rectal cancer has important implications for treatment as local therapies become increasingly utilized. Seventy-seven patients underwent preoperative staging using endorectal ultrasonography. All patients had complete pathologic staging and none had preoperative radiotherapy. Depth of invasion of the tumor was accurately predicted in 75 percent of cases in the entire group, with 22 percent overstaged and 3 percent understaged. Accuracy improved greatly over the study period, and in the past six months, 95 percent have been accurately staged for depth of invasion with 5 percent overstaged. Lymph nodes have been properly classified into positive and negative groups in 88 percent of cases in the past year, with a specificity of 90 percent and a sensitivity of 88 percent. Endorectal ultrasound is an accurate preoperative staging modality. Accuracy is improved greatly with increased experience and it has been found that the 5-layer anatomical model facilitates accurate staging. Introduction of the ultrasound probe through a previously placed proctoscope ensures complete scanning of the entire lesion and should be used for the majority of examinations.

Supplementation with dietary fiber improves fecal incontinence.

BackgroundHuman studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful. ObjectiveTo compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined. MethodsThirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment. ResultsIn the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by non-significant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods. ConclusionsSupplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.

Long-term cost of fecal incontinence secondary to obstetric injuries.

INTRODUCTION: Anal incontinence is eight times more frequent in females than in males because of injuries sustained at childbirth. The aim of the present study was to determine the long-term costs associated with anal incontinence related to obstetric injuries. METHODS: Sixty-three patients with anal incontinence caused by obstetric sphincter injuries answered questionnaires regarding previous treatments, symptoms, and use of protective products. Of the patients, 31 were treated surgically, 11 with biofeedback, 6 with a combination of surgery and biofeedback, and 15 conservatively. Treatments and their respective costs were obtained from patient records, patient questionnaires, billing database, and Health Care Financing Administrations 1996 inpatient database. Costs were expressed in 1996 dollars. RESULTS: The mean incontinence score changed from 26 at evaluation to 16 at follow-up (P<0.001). The average cost per patient was

Incontinence after lateral internal sphincterotomy: Anatomic and functional evaluation

17,166. Evaluation and follow-up charges totaled

Biofeedback improves functional outcome after sphincteroplasty

65,412, and physiologic assessment accounted for 64 percent of these costs. Treatment charges totaled

Incontinence and rectal prolapse: A prospective manometric study

559,341, and physician charges accounted for 18 percent of these charges. CONCLUSIONS: Fecal incontinence after childbirth results in substantial economic costs, and treatment is not always successful. New treatment modalities, such as artificial bowel sphincter or dynamic graciloplasty, should be assessed to determine their cost-effectiveness.

Effect of delivery on anal sphincter morphology and function.

PURPOSE: This study was designed to evaluate the anatomic and functional consequences of lateral internal sphincterotomy in patients who developed anal incontinence and in matched controls. METHODS: The study includes 13 patients with anal incontinence after lateral internal sphincterotomy and 13 controls who underwent the same operation and were continent and satisfied with the results of the procedure. Patients underwent clinical evaluation, anorectal manometry, pudendal nerve terminal motor latency testing, and endoanal ultrasonography. RESULTS: Sphincterotomies were longer in incontinent patients (75vs. 57 percent), but the resting pressure and length of the high-pressure zone were not different between groups. Surprisingly, maximum voluntary contraction was higher in incontinent patients than in continent controls (136vs. 100 mmHg). Rectal sensation and pudendal nerve terminal motor latency were similar in both groups. The defect in the internal sphincter was wider in incontinent patients than in continent controls (17.3vs. 14.4 mm), but these differences were not statistically significant. The thickness of the internal sphincter measured by endoanal ultrasound was identical in both groups, but the external sphincter was thinner in incontinent patients both at the site of the sphincterotomy (6.8vs. 8.1 mm) and in the posterior midline (7.1vs. 8.6 mm). CONCLUSIONS: Anal incontinence after lateral internal sphincterotomy is directly related to the length of the sphincterotomy. Whether secondary to preoperative sphincter abnormality or the result of lateral internal sphincterotomy, the external sphincter is thinner in incontinent patients than in continent controls.

Ileal pouch vaginal fistulas: Incidence, etiology, and management

The primary treatment for obstetric sphincter injury is overlapping sphincteroplasty. However, despite restoration of the anatomy, only 65 percent of patients are fully continent. PURPOSE: This study was undertaken to determine if postoperative biofeedback improved continence in patients with poor functional outcomes after sphincteroplasty. METHOD: Outcomes of 28 patients who underwent electromyographic biofeedback training after sphincteroplasty for obstetric sphincter injury were reviewed. Nine patients had an accompanying levatorplasty. Average age was 34 (range, 23–57) years. Patients began biofeedback a mean of 32 (range, 2–192) months postoperatively. Before beginning biofeedback, patients completed an incontinence questionnaire, bowel diary, and scored their incontinence. At the end of treatment, they were again asked to score their incontinence and rate their improvement. Using an incontinence scale with a maximum score of 30, the average incontinence score before biofeedback was 20 (range, 13–30). Incontinent episodes per week ranged from one to nine. Sixteen patients were incontinent to solid stool. RESULTS: Overall, the average posttreatment incontinence score decreased from 20 to 3 (P< 0.0001). Average number of incontinent episodes per week decreased from 5.4 to 1.4 (P< 0.0001) Twenty-five patients (89 percent) reported improvement in their continence. All had a posttreatment incontinent score of less than three. Three patients noted no improvement. Of those, one subsequently had a colostomy, one is waiting the implant of an artificial anal sphincter, and one has sought no further treatment. There were no complications reported. CONCLUSION: Biofeedback improves functional outcome after sphincteroplasty and is a reasonable option for patients with less than optimum outcome after sphincteroplasty.

Should patients with combined colonic inertia and nonrelaxing pelvic floor undergo subtotal colectomy

A prospective, manometric study has been performed on 23 female patients with rectal prolapse and varying degrees of incontinence. Seven of the 14 incontinent patients regained continence after surgery, and a further two patients improved. Improvement in internal and external sphincter function follows correction of rectal prolapse. Preoperative resting anal pressure was significantly higher in continent patients than in incontinent patients (P< 0.05), as was the maximum voluntary contraction pressure (P< 0.027). Postoperatively there was a significant increase in the resting anal pressure (P< 0.0001) and maximum voluntary contraction pressure (P< 0.003)in the whole group. The preoperative resting anorectal angle was significantly more acute (P< 0.028) in continent patients than in incontinent patients. There was no significant change in the resting anorectal angle following prolapse repair. Patients who remained incontinent had a significantly lower preoperative resting anal pressure (P< 0.01) than patients who improved or regained continence. Similarly, maximum voluntary contraction pressure was lower preoperatively in these patients (P< 0.02). Preoperative resting anal pressure below 10 mm Hg and maximum voluntary contraction pressure below 50 mm Hg are associated with persisting incontinence after surgery.

Balloon topography. A simple method of evaluating anal function.

PURPOSE: Anal sphincter injury is a serious complication of childbirth, which may result in persistent anal incontinence. Occult injuries, visualized with endoanal ultrasonography, have previously been reported in up to 35 percent of females in a British study. The aim of the present study was to study anal sphincter morphology and function before and after delivery in primiparous females in the United States. METHODS: Thirty-eight primiparous patients (mean age, 31 years) were evaluated with endoanal ultrasonography, anal manometry, and pudendal nerve terminal motor latency during pregnancy and after delivery. Bowel function before and after delivery was recorded according to set questionnaires. Cesarean section was performed in three patients. RESULTS: Clinical sphincter tears, requiring primary repair, occurred in 15 percent of the patients. After delivery endoanal ultrasonography revealed disruptions in the external anal sphincter in six patients, but no patient had disruption in the internal anal sphincter. One patient had slight scarring in the external sphincter. Of the seven patients with pathologic findings at endoanal ultrasonography, the left pudendal latency increased after delivery (P<0.05), and manometric results were reduced. Three of these seven patients had a third-degree or fourth-degree tear during delivery. All investigations were normal in the three patients who underwent cesarean section. CONCLUSIONS: The present study demonstrates a significant frequency of sphincter injuries (20 percent) after vaginal delivery. Obstetricians should be aware of this risk and explicitly inquire about incontinence symptoms at follow-up after delivery.