Lucas W. M. Janssen

Selection criteria for anterior rectal wall repair in symptomatic rectocele and anterior rectal wall prolapse

PURPOSE: This study was undertaken to determine the outcome and changes produced by an endorectal anterior wall repair in objective functional parameters using anorectal manometry and defecography and to asses their usefulness in the selection of patients for the operation. METHODS: Between 1986 and 1990, we performed a prospective study of 76 consecutive patients with symptomatic rectocele and/or an anterior rectal wall prolapse. All patients were studied prospectively according to a fixed protocol. Standard questionnaire, defecation diary, clinical examination, defecography, and anal manometry were performed preoperatively and three to four months postoperatively. RESULTS: Three months postoperatively, 38 patients (50 percent) had no complaints at all (excellent result), 32 (42 percent) had only a minor complaint (good result), and in 6 patients (8 percent) the complaints were essentially unchanged (unsatisfactory result). After one year, similar figures were obtained. The postoperative mean stool frequency in all patients after three months was significantly increased (P<0.05) but not after one year. Postoperative defecographies showed a complete absence or significant diminution of the rectocele at three months and were significantly correlated with relief of symptoms. An inverse correlation was found between improvement in incontinence grade after operation and (larger) preoperative volume at which urge to defecate was elicited, making it a good predictor of improvement in incontinence by the operation. CONCLUSIONS: The anterior rectal wall repair positively influences rectal sensation in patients with incontinence and/or obstructed defecation caused by a rectocele and/or an anterior rectal wall prolapse. Anorectal manometry was useful in studying the beneficial physiologic effects of the endorectal repair. In patients with no previous pelvic surgery, a large urge to defecate volume is a good predictor of a good clinical outcome.

The anal fistula plug treatment compared with the mucosal advancement flap for cryptoglandular high transsphincteric perianal fistula: a double-blinded multicenter randomized trial.

BACKGROUND: The anal fistula plug was developed as an alternative treatment for perianal fistulas. OBJECTIVE: This study aimed to compare the anal fistula plug with the mucosal advancement flap for the treatment of high transsphincteric fistulas. DESIGN: This study was a double-blinded, multicenter, randomized trial. PATIENTS: Sixty patients with perianal fistulas were randomly assigned to receive an anal fistula plug or a mucosal advancement flap and were blinded for the type of treatment. MAIN OUTCOME MEASURES: The outcome measures comprised the closure rate, postoperative pain, continence (colorectal functional outcome, Vaizey, and Wexner scores), and quality of life. Closure was determined by clinical examination by a surgeon blinded for the intervention. RESULTS: At a follow-up of 11 months the recurrence rates were 71% (n = 22) in the anal fistula plug group and 52% (n = 15) in the mucosal advancement flap group, which was not significantly different. There were no significant differences in postoperative pain, in pre- and postoperative incontinence scores, soiling, and quality of life. CONCLUSIONS: The results of the anal fistula plug and advancement flap procedures are disappointing in the multicenter setting. There were no significant differences in recurrence, functional outcome, and quality of life between the plug and the advancement flap. Because the plug is simple to apply and minimally invasive, it can be considered as an initial treatment option for high transsphincteric fistulas.

Robot-Assisted Endoscopic Surgery: A Four-Year Single-Center Experience

Background: Robotic systems were introduced in the late 1990s with the objective to overcome the technical limitations of endoscopic surgery. In this prospective cohort study the potential safety, feasibility, pitfalls and challenges of robotic systems in gastrointestinal endoscopic surgery are assessed and our vision on future perspectives is presented. Methods:Between August 2000 and December 2004, 208 procedures were performed with support of the Intuitive Surgical da Vinci™ robotic system. We started with cholecystectomies (40) and Nissen fundoplications (41) to gain experience with robot-assisted surgery. In the following years more complex procedures were carried out, i.e. colorectal procedures (7), type III/IV paraesophageal hernia repair (32), redo Nissen fundoplications (9), Heller myotomies (24), esophageal resections (22), rectopexies (16) and aortobifemoral bypasses (3). Results:The median robotic set-up time was 13 min, and 7 min in the last 50 procedures. The median operating time for the total of procedures was 120 min (45–420) and the median blood loss was 30 ml (0–800). Fourteen procedures were converted to open surgery (6.7%). Equipment-related problems, such as start-up failures and positioning difficulties of the robotic arms, were encountered in 11 cases (5.3%). Postoperative complications were seen in 11 patients (11/176, 6.3%) after robot-assisted laparoscopic procedures. Pulmonary complications occurred in 11 patients, cardiac in 3, anastomic leakage in 3, chylous leakage in 3 and vocal cord paralysis in 3 after thoracoscopic esophagolymphadenectomy for esophageal cancer. One patient died 12 days after esophageal resection (0.5%). Conclusion:During the implementation of this robotic system, we experienced an obvious learning curve, particularly with regard to the positioning of the robot cart and communication between the surgeon and operating team. After 4 years, we have experienced that the merits of the current generation of this technology probably is preserved to complex endoscopic procedures with delicate dissection and suturing. In the nearby future we will focus on the treatment of motility disorders and malignancies of the esophagus and stomach. The position of the robot in the endoscopic operating room will have to be clarified by the outcome of prospective research. Furthermore, priorities have to be acclaimed on technical sophistication and cost reduction of these systems.

Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence

BackgroundAnal inspection and digital rectal examination are routinely performed in fecal incontinent patients but it is not clear to what extent they contribute to the diagnostic work-up. We examined if and how findings of anal inspection and rectal examination are associated with anorectal function tests and endoanal ultrasonography.MethodsA cohort of fecal incontinent patients (n=312, 90% females; mean age 59) prospectively underwent anal inspection and rectal examination. Findings were compared with results of anorectal function tests and endoanal ultrasonography.ResultsAbsent, decreased and normal resting and squeeze pressures at rectal examination correlated to some extent with mean (±SD) manometric findings: mean resting pressure 41.3 (±20), 43.8 (±20) and 61.6 (±23) Hg (p<0.001); incremental squeeze pressure 20.6 (±20), 38.4 (±31) and 62.4 (±34) Hg (p<0.001). External anal sphincter defects at rectal examination were confirmed with endoanal ultrasonography for defects <90 degrees in 36% (37/103); for defects between 90-150 degrees in 61% (20/33); for defects between 150-270 degrees in 100% (6/6). Patients with anal scar tissue at anal inspection had lower incremental squeeze pressures (p=0.04); patients with a gaping anus had lower resting pressures (p=0.013) at anorectal manometry. All other findings were not related to any anorectal function test or endoanal ultrasonography.ConclusionsAnal inspection and digital rectal examination can give accurate information about internal and external anal sphincter function but are inaccurate for determining external anal sphincter defects <90 degrees. Therefore, a sufficient diagnostic work-up should comprise at least rectal examination, anal inspection and endoanal ultrasonography.

The Anal Fistula Plug versus the mucosal advancement flap for the treatment of Anorectal Fistula (PLUG trial)

BackgroundLow transsphincteric fistulas less than 1/3 of the sphincter complex are easy to treat by fistulotomy with a high success rate. High transsphincteric fistulas remain a surgical challenge. Various surgical procedures are available, but recurrence rates of these techniques are disappointingly high. The mucosal flap advancement is considered the gold standard for the treatment of high perianal fistula of cryptoglandular origin by most colorectal surgeons. In the literature a recurrence rate between 0 and 63% is reported for the mucosal flap advancement. Recently Armstrong and colleagues reported on a new biologic anal fistula plug, a bioabsorbable xenograft made of lyophilized porcine intestinal submucosa. Their prospective series of 15 patients with high perianal fistula treated with the anal fistula plug showed promising results.The anal fistula plug trial is designed to compare the anal fistula plug with the mucosal flap advancement in the treatment of high perianal fistula in terms of success rate, continence, postoperative pain, and quality of life.Methods/designThe PLUG trial is a randomized controlled multicenter trial. Sixty patients with high perianal fistulas of cryptoglandular origin will be randomized to either the fistula plug or the mucosal advancement flap. Study parameters will be anorectal fistula closure-rate, continence, post-operative pain, and quality of life. Patients will be followed-up at two weeks, four weeks, and 16 weeks. At the final follow-up closure rate is determined by clinical examination by a surgeon blinded for the intervention.DiscussionBefore broadly implementing the anal fistula plug results of randomized trials using the plug should be awaited. This randomized controlled trial comparing the anal fistula plug and the mucosal advancement flap should provide evidence regarding the effectiveness of the anal fistula plug in the treatment of high perianal fistulas.Trial registrationISRCTN: 97376902

Relationship between external anal sphincter atrophy at endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence

PurposeExternal anal sphincter atrophy at endoanal magnetic resonance imaging has been associated with poor outcome of anal sphincter repair. We studied the relationship between external anal sphincter atrophy on endoanal magnetic resonance imaging and clinical, functional, and anatomic characteristics in patients with fecal incontinence.MethodsIn 200 patients (mean Vaizey score, 18 (±2.9 standard deviation)) magnetic resonance images were evaluated for external anal sphincter atrophy (none, mild, or severe) by radiologists blinded to anorectal functional test results and details from medical history. Subgroups of patients with and without atrophy were compared for medical history, anal manometry, pudendal nerve latency testing, anal sensitivity testing, external anal sphincter thickness, and external anal sphincter defects. Whenever significant differences were detected, we tested for differences between patients with mild and severe atrophy.ResultsExternal anal sphincter atrophy was demonstrated in 123 patients (62 percent): graded as mild in 79 (40 percent), and severe in 44 patients (22 percent). Patients with atrophy were more often female (P < 0.001) and older (P = 0.003). They had a lower maximal squeeze (P = 0.01) and squeeze increment pressure (P < 0.001). Patients with severe atrophy had a lower maximal squeeze (P = 0.003) and squeeze increment pressure (P < 0.001) than patients with mild atrophy. These effects were not attenuated by potential confounding variables. Patients with atrophy could not be identified a priori by other characteristics.ConclusionsExternal anal sphincter atrophy at endoanal magnetic resonance imaging was depicted in 62 percent of patients, varying from mild to severe. Because increasing levels of atrophy were associated with impaired squeeze function, further studies are needed to evaluate whether grading atrophy is clinically valuable in selecting patients for anal sphincter repair.

Can the outcome of pelvic-floor rehabilitation in patients with fecal incontinence be predicted?

PurposePelvic-floor rehabilitation does not provide the same degree of relief in all fecal incontinent patients. We aimed at studying prospectively the ability of tests to predict the outcome of pelvic-floor rehabilitation in patients with fecal incontinence.Materials and methodsTwo hundred fifty consecutive patients (228 women) underwent medical history and a standardized series of tests, including physical examination, anal manometry, pudendal nerve latency testing, anal sensitivity testing, rectal capacity measurement, defecography, endoanal sonography, and endoanal magnetic resonance imaging. Subsequently, patients were referred for pelvic-floor rehabilitation. Outcome of pelvic-floor rehabilitation was quantified by the Vaizey incontinence score. Linear regression analyses were used to identify candidate predictors and to construct a multivariable prediction model for the posttreatment Vaizey score.ResultsAfter pelvic-floor rehabilitation, the mean baseline Vaizey score (18, SD ± 3) was reduced with 3.2 points (p < 0.001). In addition to the baseline Vaizey score, three elements from medical history were significantly associated with the posttreatment Vaizey score (presence of passive incontinence, thin stool consistency, primary repair of a rupture after vaginal delivery at childbed) (R2, 0.18). The predictive value was significantly but marginally improved by adding the following test results: perineal and/or perianal scar tissue (physical examination), and maximal squeeze pressure (anal manometry; R2, 0.20; p = 0.05).ConclusionAdditional tests have a limited role in predicting success of pelvic-floor rehabilitation in patients with fecal incontinence.

The Role of Endoluminal Imaging in Clinical Outcome of Overlapping Anterior Anal Sphincter Repair in Patients with Fecal Incontinence

OBJECTIVE Anterior sphincter repair has become the operation of choice in patients with fecal incontinence who have defects of the external anal sphincter (EAS), but not all patients benefit from surgery. The aim of this study was to investigate whether endoluminal imaging can identify determinants that play a role in the outcome of sphincter repair. SUBJECTS AND METHODS Thirty fecal incontinent patients with an EAS defect were included. The severity of incontinence was evaluated pre- and postoperatively using the Vaizey incontinence score. Patients underwent endoanal MRI and endoanal sonography before and after sphincter repair. We evaluated the association between preoperatively assessed EAS measurements with outcome and postoperatively depicted residual defects, atrophy, tissue at overlap, and sphincter overlap with clinical outcome. RESULTS After surgery, the mean Vaizey score in 30 patients (97% females; mean age, 50 years) had improved from 18 to 13 (p < 0.001). MRI showed that baseline measurement of preserved EAS thickness correlated with a better outcome (r = 0.42; p = 0.03). Clinical outcome did not differ between patients with and those without a persistent EAS defect (p = 0.54) or EAS atrophy (p = 0.26) depicted on MRI. Patients with a visible overlap and less than 20% fat tissue had a better outcome than patients with nonvisible, fatty overlap (decrease in Vaizey score, 7 vs 2 points, respectively; p = 0.04). Sonography showed that patients with a persistent EAS defect had a worse outcome than those without an EAS defect (17 vs 10 points, respectively; p = 0.003). CONCLUSION Endoanal MRI was useful in determining EAS thickness and structure, and endoanal sonography was effective in depicting residual EAS defects.

Elektrostimulation und Biofeedback-Beckenbodenmuskeltraining bei Patienten mit Stuhlinkontinenz

ZusammenfassungFragestellung und Hintergrund:Das Beckenbodentraining ist eine attraktive Behandlung für Patienten mit Stuhlinkontinenz, die berichteten Ergebnisse unterscheiden sich jedoch. Diese Studie wurde durchgeführt, um das Ergebnis einer Beckenbodenrehabilitation in einer großen Serie konsekutiver Patienten mit fäkaler Inkontinenz unterschiedlicher Ätiologie zu beurteilen.Patienten und Methodik:Die Studie umfasste insgesamt 281 Patienten (252 Frauen). Es wurden Daten zur Krankengeschichte, zur analen Manometrie, zur rektalen Kapazitätsmessung sowie zur endoanalen Sonographie gesammelt. Auf der Basis von Integrität und Art des analen Sphinkterkomplexes sowie möglicher zugrundeliegender Ursachen der Stuhlinkontinenz wurden Patientenuntergruppen gebildet. Anschließend wurden die Patienten zum Beckenbodentraining überwiesen, das aus neun Sitzungen für Elektrostimulation und Beckenbodenmuskeltraining mit Biofeedback bestand. Das Ergebnis der Beckenbodenrehabilitation wurde mit dem Vaizey-Score, analer Manometrie und den Befunden rektaler Kapazitätsmessungen dokumentiert.Ergebnisse:Im Vergleich zum Ausgangswert verbesserte sich der Vaizey-Score bei 143 von 239 Patienten (60%), bei 56 Patienten (23%) blieb er unverändert, und bei 40 Patienten (17%) verschlechterte er sich. Der mittlere Vaizey-Score reduzierte sich um 3,2 Punkte (p < 0,001). Eine ≥ 50%ige Reduktion des Vaizey-Scores wurde bei 32 Patienten beobachtet (13%). Der mittlere Kneifdruck (+5,1 mmHg; p = 0,04) sowie das maximal tolerierte Volumen (+11 ml; p = 0,01) verbesserten sich gegenüber dem Ausgangswert. Ruhedruck (p = 0,22), Perzeptionsschwelle (p = 0,52) und Dranggefühl (p = 0,06) blieben unverändert. Die Untergruppenanalysen zeigten keine wesentlichen Unterschiede in den Auswirkungen des Beckenbodentrainings zwischen den Untergruppen.Schlussfolgerung:Das Beckenbodentraining führt insgesamt zu einer moderaten Verbesserung der Schwere der fäkalen Inkontinenz, des Kneifdrucks und des maximal tolerierten Volumens. Nur bei wenigen Patienten wurde eine wesentliche Verbesserung gegenüber dem Ausgangswert des Vaizey-Scores beobachtet. Weitere Studien sind erforderlich, um Patienten zu identifizieren, die höchstwahrscheinlich von einem Beckenbodentraining profitieren werden.AbstractPurpose:Pelvic floor rehabilitation is an appealing treatment for patients with fecal incontinence but reported results vary. This study was designed to assess the outcome of pelvic floor rehabilitation in a large series of consecutive patients with fecal incontinence caused by different etiologies.Methods:A total of 281 patients (252 females) were included. Data about medical history, anal manometry, rectal capacity measurement, and endoanal sonography were collected. Subgroups of patients were defined by anal sphincter complex integrity, and nature and possible underlying causes of fecal incontinence. Subsequently patients were referred for pelvic floor rehabilitation, comprising nine sessions of electric stimulation and pelvic floor muscle training with biofeedback. Pelvic floor rehabilitation outcome was documented with Vaizey score, anal manometry, and rectal capacity measurement findings.Results:Vaizey score improved from baseline in 143 of 239 patients (60 percent), remained unchanged in 56 patients (23 percent), and deteriorated in 40 patients (17 percent). Mean Vaizey score reduced with 3.2 points (p < 0.001). A Vaizey score reduction of ≥ 50 percent was observed in 32 patients (13 percent). Mean squeeze pressure (+5.1 mmHg; p = 0.04) and maximal tolerated volume (+11 ml; p = 0.01) improved from baseline. Resting pressure (p = 0.22), sensory threshold (p = 0.52), and urge sensation (p = 0.06) remained unchanged. Subgroup analyses did not show substantial differences in effects of pelvic floor rehabilitation between subgroups.Conclusions:Pelvic floor rehabilitation leads overall to a modest improvement in severity of fecal incontinence, squeeze pressure, and maximal tolerated volume. Only in a few patients, a substantial improvement of the baseline Vaizey score was observed. Further studies are needed to identify patients who most likely will benefit from pelvic floor rehabilitation.