M. R. B. Keighley

Audit of sphincter repair

PURPOSE: This study was designed to critically analyze the outcome of sphincter repair and, if possible, to identify high-risk factors. METHODS: Clinical and physiologic assessment was made of all sphincter repairs (42 patients) performed in one unit by two surgeons during five years. RESULTS: Forty-two patients (10 men, 32 women) underwent sphincter repair. Only three of five men with anterior defects of the anorectum from perineal trauma were rendered continent. Only three of five men with defects from fistula operations became continent, but one improved by later graciloplasty. All six women with fistula-related injuries eventually achieved continence, but two required repeat sphincter repairs because of early breakdown from sepsis. The worst results were in 26 women with third-degree obstetric injuries, of whom 11 remain incontinent; poor results in this group were associated with gross perineal descent, obesity, and age older than 50 years; two or more of these factors indicated a poor outcome. Preoperative anorectal physiology did not identify a poor-risk group. CONCLUSIONS: Poor results were identified in women with anterior defects from obstetric trauma, especially if they were obese, older than 50 years of age, and had perineal descent.

Manual dilatation of the anus vs. lateral subcutaneous sphincterotomy in the treatment of chronic fissure-in-ano: results of a prospective, randomized, clinical trial

The results of a prospective randomized trial in 111 patients were recorded to compare manual dilatation of the anus with lateral subcutaneous sphincterotomy performed under general anesthesia. There was no significant difference in the clinical results nor in the incidence of complications. Persistent or recurrent fissure occurred in three of 59 patients after manual dilatation of the anus and two of 39 patients after lateral subcutaneous sphincterotomy, an incidence of 5.1 percent in each group. Only one patient developed serious impairment of continence, and this occurred following lateral subcutaneous sphincterotomy (5.1 percent).

Randomized trial to determine the optimum level of pouch-anal anastomosis in stapled restorative proctocolectomy

PURPOSE: This study was undertaken to identify the optimum level of stapled ileal pouch-anal anastomosis. METHOD: A prospective, randomized trial was completed to compare double-stapled ileoanal anastomosis placed at the top of anal columns (high, n=26) with anastomosis at the dentate line (low, n=21). RESULTS: There was no significant difference in the overall complication rate between operations (high, n=7,vs.low, n=8;P<0.21). Pouchanal functional score (scale 0–12; 0=excellent, 12=poor) was significantly better in the high anastomosis group (median (range): 2 (1–9)vs.5.5 (1–12);P<0.05). Incontinence occurred in only two patients randomized to high anastomosis compared with six in the low anastomosis group. Nocturnal soiling was reported in three patients after high anastomosis and in six patients after dentate line anastomosis. Both operations caused a significant but comparable reduction of maximum anal resting pressure (31 percent after high anastomosis (P<0.05); 23 percent after low anastomosis (P<0.05)). However, a significant fall in functional length of the anal canal was only seen after a low pouch-anal anastomosis (P<0.05). CONCLUSION: Stapled pouch-anal anastomosis at the top of anal columns gives better functional results compared with a stapled anastomosis at the dentate line.

Loop ileostomy after ileal pouch-anal anastomosis--is it necessary?

Construction of a loop ileostomy is usually advised in patients having an ileal pouch-anal anastomosis to minimize the complication of chronic pelvic sepsis. Formation and closure of a loop ileostomy was associated with a 41 percent and 30 percent complication rate, respectively, in a prospective series of 34 patients. This morbidity must now be assessed in relation to the benefits of avoiding temporary fecal diversion in restorative proctocolectomy.

Manual dilatation of the anusvs. Lateral subcutaneous sphincterotomy in the treatment of chronic fissure-in-ano

The results of a rospective randomized trial in 111 patients were recorded to compare manual dilatation of the anus with lateral subcutaneous sphincterotomy performed under general anesthesia. There was no significant difference in the clinical results nor in the incidence of complications. Persistent or recurrent fissure occurred in three of 59 patients after manual dilatation of the anus and two of 39 patients after lateral subcutaneous sphincterotomy, and incidence of 5.1 percent in each group. Only one patient developed serious impairment of continence, and this occurred following lateral subcutaneous sphincterotomy (5.1 percent).

Long-term results of total pelvic floor repair for postobstetric fecal incontinence

PURPOSE: This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD: Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18–78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS: Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION: Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.

Recurrent small bowel Crohn's disease is more frequent after subtotal colectomy and ileorectal anastomosis than proctocolectomy

The cumulative probability of reoperation for recurrent ileal Crohns disease at five years was: 17 percent following ileocecal resection, 19 percent following proctocolectomy, and 28 percent after ileorectal anastomosis. At ten years, the rate of ileal recurrence was significantly less after proctocolectomy; 24 percent as compared with 43 percent for ileorectal anastomosis (P<0.01), whereas ileocecal resection assumed an intermediary position with 35 percent.

Randomized trial of internal anal sphincter plication with pelvic floor repair for neuropathic fecal incontinence

PURPOSE: This study was designed to examine the role of adjuvant internal anal sphincter plication in women with neuropathic fecal incontinence undergoing pelvic floor repair. METHODS: We completed a randomized trial with symptomatic and physiologic assessment before and after surgery. RESULTS: There was no symptomatic advantage of adding internal sphincter plication; the mean improvement of functional score was 3.61±1.82 (standard deviation;P<0.01) following pelvic floor repair alone compared with 2.80±1.66 (standard deviation;P<0.01) when adjuvant internal anal sphincter plication was added. The addition of internal sphincter plication was associated with a significant fall in maximum anal resting and squeezing pressures (P<0.01). CONCLUSIONS: Addition of internal sphincter plication is not advised in women with neuropathic fecal incontinence treated by pelvic floor repair.

Indications and outcome of reoperation for ileostomy complications in inflammatory bowel disease

Indications for ileostomy revision in 49 patients with inflammatory bowel disease operated upon between January 1975 and December 1984 were obstruction (15), retraction (10), parastomal hernia (9), prolapse (8), and fistula (4). Recurrent Crohns disease was an important factor in the pathogenesis of ileostomy complications particularly obstruction, retraction and fistula. Local revision without laparotomy was successful in seven of eight patients with an ileostomy prolapse, but in only four of eight patients with a retracted stoma. Results of local repair without laparotomy and resiting were successful in five of six patients with a parastomal hernia. Laparotomy was usually necessary in patients with obstruction especially if there was underlying Crohns disease and in patients with peristomal fistula. Resiting of the stoma after laparotomy was used only if the stoma site was outside the rectus muscle or if the original stoma site was infected.

Gastroduodenal fistulas in Crohn's disease

PURPOSE: The aim of this study was to assess the clinical features and management of fistulas involving the stomach and duodenum (gastroduodenal fistulas) in patients with Crohns disease. METHODS: The medical records of 14 patients with a gastroduodenal fistula complicating Crohns disease treated in this unit between 1958 and 1997 were reviewed. RESULTS: In six patients a gastroduodenal fistula was diagnosed before surgery, whereas eight gastroduodenal fistulas were discovered during surgery for distal Crohns disease. In six patients, the fistula originated from Crohns disease in the transverse colon, and in six patients, it originated from a recurrent disease at an ileocolonic anastomosis; these patients had no gross evidence of gastroduodenal Crohns disease. In one patient, the ileocolonic-duodenal fistula closed on medical treatment. The other 11 patients underwent resection of the diseased bowel and closure of the gastric or duodenal fistulas. The two remaining fistulas were from the duodenum to the abdominal wall; both had primary Crohns duodenitis. One duodenocutaneous fistula was treated by debridement of the duodenal fistula and simple closure of the defect; the other was treated by limited duodenal excision around the fistula and by duodenojejunostomy. In all patients, gastroduodenal fistulas were cured, and there have been no fistula recurrences. CONCLUSIONS: Simple closure of the gastroduodenal component of the fistula is generally advised for gastroduodenal fistulas. However, when the duodenal defect after excision around the fistula is large, duodenojejunostomy is recommended, provided there is no evidence of jejunal Crohns disease.