Sven Nilsson

Does surgical repair of a rectocele improve rectal emptying

PURPOSE: This study was undertaken to assess results of surgical repair of rectocele and to identify possible determinants of outcome from patients history and preoperative defecography. Another aim was to evaluate how surgery affects rectal evacuation. METHOD: Thirty-four women with constipation and rectal emptying difficulties underwent surgery with a transanal technique. A preoperative defecography was performed in each patient. They were followed up after a median of 10 (range, 2–60) months with a questionnaire (n=34) and a defecography (n=31). Computer-based image analysis of defecographies was used to evaluate rectal evacuation. RESULTS: In 27 patients (79 percent), the result of surgery was good with subjectively improved emptying. The need for vaginal or perineal digitation preoperatively was related to a good result (P<0.05), whereas a previous hysterectomy (P<0.01) and a large rectal area on defecography (P<0.01) related to a poor result. Preoperative use of enemas, motor stimulants, or several types of laxatives also related to a poor outcome (P<0.05). Surgical treatment resulted in reduction of the rectocele (P<0.001), an elevated position of the anorectal junction (P<0.05), and improved rectal evacuation on defecographies (P<0.001). CONCLUSIONS: Surgical repair reduces the size of the rectocele and improves rectal emptying. These changes are accompanied by a symptomatic improvement in the majority of patients. Preoperative patient data and defecography may help in selecting patients for surgery.

Diverticulitis of the sigmoid colon

Purpose: to evaluate the use of laparoscopy, CT, colonic enema (CE), and laboratory tests (white blood cell count (WBC), sedimentation rate (SR), and C-reactive protein (CRP)) in diagnosing diverticulitis of the sigmoid colon. Material and Methods: the diagnostic methods were prospectively evaluated in 88 patients, 30 of whom were referred for laparoscopy. Results: Fifty-two patients were found to have sigmoid diverticulitis: 20 patients by laparoscopy, 21 by CT, and 11 by CE combined with one positive laboratory test. Laparoscopy proved to be superior to the other diagnostic methods in diagnosing diverticulitis of the sigmoid colon. CT had a high specificity (1.0; 95% CI: 0.92–1.0) but low sensitivity (0.69; 95% CI: 0.56–0.79) in detecting diverticulitis. CE had a higher sensitivity (0.82; 95% CI: 0.71–0.90) but a lower specificity (0.81; 95% CI: 0.67–0.91) than CT. Conclusion: CT was the best method for diagnosing abdominal pathology outside the colon. CT can be recommended as the first examination in seriously ill patients where abscesses and other causes of the symptoms than diverticulitis must first be ruled out. Laparoscopy is probably the most accurate method in diagnosing diverticulitis.

Segmental colonic transit studies : Comparison of a radiological and a scintigraphic method

Objective  Colonic transit studies are used to diagnose slow transit constipation (STC) and to evaluate segmental colonic transit before segmental or subtotal colectomy. The aim of the study was to compare a single X‐ray radio‐opaque marker method with a scintigraphic technique to assess total and segmental colonic transit in patients with STC.

CT-colonography in the follow-up of acute diverticulitis: patient acceptance and diagnostic accuracy

Abstract Objective. The aim of this study was to assess CT-colonography (CTC) in the follow-up of diverticulitis regarding patient acceptance and diagnostic accuracy for diverticular disease, adenomas and cancer, with colonoscopy as a reference standard. Methods. A prospective comparative study where half of the patients underwent colonoscopy first, followed immediately by CTC. The other half had the examinations in the reverse order. Patient experiences and findings were registered after every examination, blinded to the examiner. Results. Of a total of 110 consecutive patients, 108 were included in the study, with a median age of 56 years (range 27–84). The success rate was 91% for colonoscopy and 86% for CTC. Examination time was 25 min for both methods. The mean time for CTC evaluation was 20 min. Eighty-three per cent of the patients received sedation during colonoscopy. Despite this, patients experienced colonoscopy as more painful (p < 0.001) and uncomfortable (p < 0.001). Diverticulosis and polyps were detected in 94% and 20% with colonoscopy and in 94% and 29% with CTC, respectively. Sensitivity and specificity for CTC in the detection of diverticulosis was 99% and 67%, with a good agreement (κ = 0.71). Regarding detection of polyps, the sensitivity and specificity were 47% and 75%, with a poor agreement (κ = 0.17). No cancer was found. Conclusion. CTC was less painful and unpleasant and can be used for colonic investigation in the follow-up of diverticulitis. CTC detected diverticulosis with good accuracy while the detection accuracy of small polyps was poor. CTC is a viable alternative, especially in case of incomplete colonoscopy or in a situation with limited colonoscopy resources.

Fast and robust semi-automatic liver segmentation with haptic interaction

We present a method for semi-automatic segmentation of the liver from CT scans. True 3D interaction with haptic feedback is used to facilitate initialization, i.e., seeding of a fast marching algorithm. Four users initialized 52 datasets and the mean interaction time was 40 seconds. The segmentation accuracy was verified by a radiologist. Volume measurements and segmentation precision show that the method has a high reproducibility.

The Accuracy of Clinical Examination in the Diagnosis of Rectal Intussusception

PURPOSE:This study was designed to compare routine clinical examination and defecography in the diagnosis of rectal intussusception in constipated patients and study relationships between rectal intussusception and symptoms.METHODS:A total of 127 consecutive patients with functional constipation were examined in the left-lateral position with rectal palpation and rectoscopy according to a protocol. An overall clinical judgment was made if the patient had intussusception, unclear finding, or no intussusception. Defecography was performed without knowledge of the results of the clinical evaluation. Symptom duration varied between 0.5 to 60 (median, 10) years. All patients fulfilled a bowel questionnaire and all had a full physiologic workup.RESULTS:A diagnosis by digital examination (P = 0.002) and by rectoscopy (P = 0.002) as well as the overall judgment (P = 0.0002) was clearly related to a longer intussusception as measured by defecography. Five of six intra-anal intussusceptions were correctly assessed by clinical examination, whereas the correlation to defecography was poor in the group with short intussusceptions. Neither clinical nor defecographic diagnosis of rectal intussusception were related to the main symptoms of constipation but both were associated with a tendency toward lower anal resting pressures (P = 0.04 and P = 0.06) and an obtuse anorectal angle (during evacuation, P = 0.01 and P = 0.01).CONCLUSIONS:There is no clear relationship between rectal intussusception and constipation. However, intussusception is related to sphincter function and may be of clinical relevance. A normal clinical examination will exclude most long intussusceptions, whereas a positive finding needs further evaluation with defecography.

Accurate and reproducible semi-automatic liver segmentation using haptic interaction

In this work, we describe and evaluate a semi-automatic method for liver segmentation in CT images using a 3D interface with haptic feedback and stereo graphics. Recently, we reported our fast semi-automatic method using fast marching segmentation. Four users performed initialization of the method for 52 datasets by manually drawing seed-regions directly in 3D using the haptic interface. Here, we evaluate our segmentation method by computing accuracy based on newly obtained manual delineations by two radiologists for 23 datasets. We also show that by performing subsequent segmentation with an interactive deformable model, we can increase segmentation accuracy. Our method shows high reproducibility compared to manual delineation. The mean precision for the manual delineation is 89%, while it is 97% for the fast marching method. With the subsequent deformable mesh segmentation, we obtain a mean precision of 98%. To assess accuracy, we construct a fuzzy ground truth by averaging the manual delineations. The mean sensitivity for the fast marching segmentation is 93% and the specificity is close to 100%. When we apply deformable model segmentation, we obtain a sensitivity increase of three percentage points while the high specificity is maintained. The mean interaction time for the deformable model segmentation is 1.5 minutes. We present a fully 3D liver segmentation method where high accuracy and precision is efficiently obtained via haptic interaction in a 3D user interface. Our method makes it possible to avoid time-consuming manual delineation, which otherwise is a common option prior to, e.g., hepatic surgery planning.

Die Genauigkeit der klinischen Untersuchung bei der Diagnose der rektalen Invagination

ZusammenfassungZiel:Diese Studie wurde durchgeführt, um die routinemäßige klinische Untersuchung und die Defäkographie in der Diagnose der rektalen Invagination bei obstipierten Patienten zu vergleichen und um die Beziehungen zwischen rektaler Invagination und Symptomen zu untersuchen.Methodik: Insgesamt 127 konsekutive Patienten mit funktioneller Obstipation wurden gemäß einem vorher festgelegten Untersuchungsprotokoll in linkslateraler Position mit rektaler Palpation und Proktoskopie untersucht. Eine ausführliche klinische Bewertung erfolgte, wenn der Patient an einer Invagination litt, unklare Befunde zeigte oder keine Invagination aufwies. Die Defäkographie wurde ohne Kenntnis der Ergebnisse der klinischen Bewertung durchgeführt. Die Dauer der Symptome variierte zwischen 0,5 und 60 (durchschnittlich 10) Jahren. Alle Patienten füllten einen Darmfragebogen aus und unterzogen sich einer vollständigen physiologischen Untersuchung. Ergebnisse: Eine Diagnose mittels digitaler Untersuchung (p = 0,002) und Proktoskopie (p = 0,002) sowie die Gesamtbewertung (p = 0,0002) zeigten einen deutlichen Zusammenhang mit einer längeren Invagination als defäkographisch gemessen. Fünf der sechs intraanal gemessenen Invaginationen wurden durch die klinische Untersuchung richtig bewertet, während die Korrelation in der Defäkographie in der Gruppe mit kurzer Invagination schlecht war. Weder die klinische noch die defäkographische Diagnose der rektalen Invagination stand in Zusammenhang mit den Hauptsymptomen der Obstipation, aber beide waren mit einer Tendenz zu geringeren analen Ruhedruckwerten (p = 0,04 und p = 0,06) und einem stumpfen anorektalen Winkel (während der Entleerung, p = 0,01 und p = 0,01) assoziiert.Schlussfolgerungen: Es besteht keine eindeutige Beziehung zwischen rektaler Invagination und Obstipation. Allerdings steht die Invagination in Zusammenhang mit der Sphinkterfunktion und kann klinische Bedeutung erlangen. Eine normale klinische Untersuchung kann die meisten langen Invaginationen ausschließen, während ein positiver Befund mittels Defäkographie weiter abgeklärt werden muss.AbstractPurpose: This study was designed to compare routine clinical examination and defecography in the diagnosis of rectal intussusception in constipated patients and study relationships between rectal intussusception and symptoms.Methods:A total of 127 consecutive patients with functional constipation were examined in the left-lateral position with rectal palpation and rectoscopy according to a protocol. An overall clinical judgment was made if the patient had intussusception, unclear finding, or no intussusception. Defecography was performed without knowledge of the results of the clinical evaluation. Symptom duration varied between 0.5 to 60 (median, 10) years. All patients fulfilled a bowel questionnaire and all had a full physiologic workup.Results: A diagnosis by digital examination (p = 0.002) and by rectoscopy (p = 0.002) as well as the overall judgment (p = 0.0002) was clearly related to a longer intussusception as measured by defecography. Five of six intraanal intussusceptions were correctly assessed by clinical examination, whereas the correlation to defecography was poor in the group with short intussusceptions. Neither clinical nor defecographic diagnosis of rectal intussusception were related to the main symptoms of constipation but both were associated with a tendency toward lower anal resting pressures (p = 0.04 and p = 0.06) and an obtuse anorectal angle (during evacuation, p = 0.01 and p = 0.01).Conclusions: There is no clear relationship between rectal intussusception and constipation. However, intussusception is related to sphincter function and may be of clinical relevance. A normal clinical examination will exclude most long intussusceptions, whereas a positive finding needs further evaluation with defecography.