Michael Oberwalder

Meta-analysis to determine the incidence of obstetric anal sphincter damage

The reported incidence of anal sphincter injury after first (11·5–35·0 per cent) and subsequent (3·4–12·1 per cent) vaginal deliveries varies widely. In addition, the reported incidence of associated faecal incontinence ranges from zero to 68·2 per cent. The aim of this study was to perform a meta‐analysis of reported incidences of postpartum anal sphincter defect diagnosed by endoanal ultrasonography (EAUS) and associated incidences of faecal incontinence.

Assessment of long-term quality of life after laparoscopic and open surgery for Crohn's disease

Objective  Surgery for Crohns disease (CD) is associated with a high recurrence rate and quality of life (QOL) in these patients is controversial. The aim of this study was to assess QOL in patients after laparoscopic and open surgery for CD by two different validated instruments, a generic nonspecific score and a specific gastrointestinal QOL index.

Quality of life after colectomy for colonic inertia

AbstractBackgroundTotal abdominal colectomy (TAC) with ileorectal anastomosis represents the procedure of choice in patients with colonic inertia and relieves constipation in the majority of patients. The aim of this study was to assess postoperative long–term health related quality of life in these patients in relation to their functional outcome.MethodsA consecutive series of patients with isolated colonic inertia who underwent TAC between 1993 and 1999 was identified from a clinical database and investigated in a cohort outcome study. Functional variables including the weekly number of bowel movements (BM), abdominal pain, bloating and distension, fecal incontinence, and the use of medications for BM assistance were assessed preoperatively and postoperatively. Main outcome measure was healthrelated quality of life assessed at follow–up using the SF–36 Health Survey.ResultsA total of 17 women with a mean age of 47.8 years (SD=14.3 years) were assessed and were followed postoperatively for 58.3±27.3 months. Preoperatively, all patients were constipated with less than one bowel movement per week, used laxatives, and experienced abdominal pain, bloating and distension. Postoperatively, all patients had some relief of constipation symptoms, with 3.7±2.8 bowel movements/day; 41% complained of abdominal pain, 65% of bloating, 29% required BM assistance, and 47% had occasional incontinence to gas or liquid stool. The SF–36 scores were significantly lower than those of the general population (p<0.005). In univariate regression analysis, postoperative abdominal pain was predictive for lower scores in general health and vitality and the need for BM assistance for lower scores in physical role functioning, social functioning, and emotional role limitations.ConclusionsAfter TAC, quality of life is significantly reduced in patients with colonic inertia despite successful relief of symptoms of constipation. Postoperative pain and functional impairment are predictive of lower quality of life scores.

Outcome of Patients With Indeterminate Colitis Undergoing a Double-Stapled Ileal Pouch-Anal Anastomosis

INTRODUCTIONThe aim of this study was to assess the outcome of patients with indeterminate colitis undergoing double-stapled ileal pouch anal anastomosis.METHODSA retrospective review of demographic, disease-related, and outcome variables of all patients undergoing double-stapled ileal pouch anal anastomosis from August 1988 to January 2000 was undertaken. All patients were evaluated using the validated American Society of Colon and Rectal Surgeons Fecal Incontinence Severity Index. Patients with familial adenomatous polyposis, those who had undergone pouch revision or had S-configured pouches, and patients with a follow-up of less than three months were excluded from analysis.RESULTSThree hundred ninety-five patients underwent the double-stapled ileal pouch anal anastomosis; of these 303 patients were included for analysis. The mean duration of follow-up was 40 months. Fifty-six (18.1 percent) had a preoperative diagnosis of indeterminate colitis. Postoperatively, indeterminate colitis was diagnosed in 13 (4.3 percent), mucosal ulcerative colitis in 285 (94 percent), and Crohn’s disease in 5 (1.6 percent). The overall complication rate was 37.7 percent, 60 percent, and (30.7) percent in patients with mucosal ulcerative colitis, Crohn’s disease, and indeterminate colitis, respectively. Postoperative hemorrhage, abscess, and fistula occurred in 2.4 percent, 6.3 percent, and 3.9 percent, respectively, in patients with mucosal ulcerative colitis, and 0 percent, 15.3 percent, and 7.7 percent, respectively, in patients with indeterminate colitis. Small-bowel obstruction occurred in 8.5 percent, 20 percent, and 7.7 percent of patients with mucosal ulcerative colitis, Crohn’s disease, and indeterminate colitis, respectively. Pouchitis occurred in 4.6 percent of patients with mucosal ulcerative colitis but in none of the patients with indeterminate colitis. Dysplasia of the anal transition zone was seen in one patient each with mucosal ulcerative colitis and indeterminate colitis. These patients had consistent follow-up and neither showed any sign of evolution to neoplastic disease. None of the patients with indeterminate colitis had a postoperative diagnosis of Crohn’s disease during the follow-up period. Functional outcome was comparable in all three patient groups.CONCLUSIONThe outcome of the double-stapled ileal pouch anal anastomosis in patients with indeterminate colitis is similar to that of patients with mucosal ulcerative colitis. Therefore, it is a safe option in patients with indeterminate colitis.

Circulating cell-free DNA in plasma of locally advanced rectal cancer patients undergoing preoperative chemoradiation: A potential diagnostic tool for therapy monitoring

Circulating cell-free DNA opens up an interesting field for therapy monitoring, in particular during multimodal therapy protocols. The objective of this proof of principle study was to evaluate whether the amount of circulating plasma DNA has the potential to serve as a marker for therapy monitoring during the treatment course of locally advanced rectal cancer patients. We especially focused on kinetics of circulating DNA to assess whether variances in kinetics have the potential to discriminate between therapy responders and nonresponders. The amount of circulating DNA in plasma of rectal cancer patients undergoing preoperative chemoradiation was determined using real-time PCR before chemoradiation, after the end of chemoradiation and at the end of treatment. The study population was divided into responders (ypT0-T2 stage) and nonresponders (ypT3-T4 stage). Both groups showed comparable median plasma DNA values before and after the end of chemoradiation. At the end of treatment responders showed a further decrease in circulating DNA, whereas in nonresponders the circulating DNA manifestly increased (P = 0.006). This study demonstrates that circulating DNA in plasma of rectal cancer patients undergoing preoperative chemoradiation might serve as a surrogate marker to discriminate between responders and nonresponders. Therefore, we hypothesize that quantification of plasma DNA could be of use as an easily accessible tool for therapy monitoring in these patients.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair

AbstractBackgroundAnatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects.MethodsThe medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0–10 were interpreted as success whereas scores of 11–20 indicated failure.ResultsA total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3–131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups.ConclusionA pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

Anal submucosal carbon bead injection for treatment of idiopathic fecal incontinence: a preliminary report.

PURPOSE: Submucosal injection of bulking agents is a treatment option for idiopathic fecal incontinence. This study sought to assess whether the injection of carbon beads can significantly improve anal continence. METHODS: Consecutive patients presenting with fecal incontinence were evaluated with standardized incontinence grading and quality-of-life grading scores, by anoproctoscopy, endoanal ultrasound, and anomanometry before, 3, 6, 12, and 24 months after injection. Injection therapy was performed in patients with anatomically intact anal sphincters. Patients kept a two-week incontinence diary. Data were obtained from a two-year follow-up period. RESULTS: Eleven women with a mean age of 66 (range, 56 to 74) years met the inclusion criteria. Mean incontinence score was 12.27 ± 0.97 at baseline, 6.82±1.64 at three-month, 6.73 ± 1.47 at six-month, 5.91 ± 0.95 at one-year, and 4.91 ± 0.87 at two-year follow-up (P = 0.003). Quality-of-life items like coping and embarrassment improved significantly from baseline 2.3 to 3 at three months and 2.8 at six months (P < 0.05). Anomanometry showed a trend toward increase in measured pressures. No major complications occurred. CONCLUSIONS: The injection of carbon beads via an intersphincteric approach is a promising new treatment option for old patients with idiopathic fecal incontinence.

Timing of restorative proctectomy following subtotal colectomy in patients with inflammatory bowel disease

Background  There is no general consensus regarding the timing of restorative proctocolectomy (RPC) in patients who have undergone subtotal colectomy with end ileostomy (STC). The aim of this study was to determine the impact of timing of RPC in patients who have undergone subtotal colectomy and end ileostomy for inflammatory bowel disease (IBD).

Imbrication of the external anal sphincter may yield similar functional results as overlapping repair in selected patients

Objective  Overlapping external anal sphincter repair is the preferred procedure for incontinent patients with functional yet anatomically disrupted anterior external anal sphincter. When incomplete disruption, thinning or technically difficult mobilization of the external anal sphincter occurs, imbrication without division may be the more feasible surgical option. The aim of the study was to assess retrospectively the indications for external anal sphincter imbrication in patients who underwent either overlapping external anal sphincter repair or external anal sphincter imbrication, and to compare the success rates.

Endosonographic image of a retrorectal bowel duplication

PURPOSE: Endosonographic image and surgical therapy of a retrorectal bowel duplication are described. METHODS, RESULTS, AND CONCLUSIONS: Compared with standard investigations, the most accurate information about a retrorectal mass in a 35-year-old woman could be obtained by means of endorectal ultrasound. Guided by endorectal ultrasound, the mass was excised using a transanal-transrectal approach, and Kraskes operation could be avoided. Additionally, histopathologic analysis of this rare disease is presented.