W. R. Schouten

Transanal advancement flap repair of transsphincteric fistulas

OBJECTIVE: The purpose of this study was to evaluate the healing rate of transsphincteric perianal fistulas after transanal advancement flap repair and to examine the impact of this procedure on fecal continence. METHODS: Between January 1992 and January 1997, 44 consecutive patients with a transsphincteric perianal fistula passing through the middle or upper third of the external anal sphincter underwent transanal advancement flap repair. There were 34 male patients, and the median age was 44 (range, 19–72) years. Twenty-four patients (55 percent) had previously undergone one or more prior attempts at repair. With the patient in prone jackknife position, the internal opening of the fistula was exposed using a Parks retractor. The crypt-bearing tissue around the internal opening and the overlying anoderm was excised. A layer of mucosa, submucosa, and internal sphincter fibers was mobilized 4 to 6 cm proximally. The base of the flap was approximately twice the width of its apex. The flap was advanced and sutured to the anoderm below the level of the internal opening. The median follow-up was 12 months. Fecal continence was evaluated in 43 patients by means of a questionnaire. RESULTS: Transanal advancement flap repair was successful in 33 patients (75 percent). Success was inversely correlated with the number of prior attempts. In patients with no or only one previous attempt at repair the healing rate was 87 percent. In patients with two or more previous repairs the healing rate dropped to 50 percent. In 15 patients (35 percent) continence deteriorated after transanal advancement flap repair. Twenty-six patients (59 percent) had a completely normal continence preoperatively. Ten of these patients (38 percent) encountered soiling and incontinence for gas after the procedure, whereas three subjects (12 percent) complained of accidental bowel movements. Eighteen patients (41 percent) had continence disturbances at the time of admission to our hospital. In two of these patients (11 percent), incontinence deteriorated. CONCLUSIONS: The results of transanal advancement flap repair in patients with no or only one previous attempt at repair are good. In patients who have undergone two or more previous attempts at repair the outcome is less favorable. Remarkably, the number of previous attempts did not adversely affect continence status.

Relationship between anal pressure and anodermal blood flow

PURPOSE: The aim of this study was to investigate the relationship between anal pressure and anodermal blood flow. METHODS: We performed Doppler laser flowmetry of the anoderm combined with anorectal manometry in 178 subjects (87 males and 91 females; median age, 55 (range, 17–87) years). This group consisted of 31 healthy volunteers, 23 patients with fecal incontinence, 17 patients with hemorrhoids, and 9 patients with anal fissure. The remaining 98 patients had other colorectal disorders. In 16 controls we examined anodermal blood flow in the four quadrants of the anal canal. RESULTS: Perfusion of the anoderm at the posterior midline was significantly lower than in the other three segments of the anal canal (posterior midline: 0.74±0.26 V; left lateral side: 1.68 ±0.81 V; right lateral side: 1.57±0.52 V; anterior midline: 1.48±0.69 V,P<0.001). In the overall group, we found a significant correlation between maximum anal resting pressure and anodermal blood flow at the posterior midline (r=−0.616,P<0.001). In the nine patients with chronic anal fissure, the mean maximum anal resting pressure was 125±26 mmHg, which was significantly higher than in patients with hemorrhoids (82±15 mmHg), controls (66±19 mmHg), and patients with fecal incontinence (42±14 mmHg,P<0.001), whereas the blood flow at the base of the fissure was significantly lower (0.43±0.10 Vvs.0.57±0.19 Vvs.0.75±0.26vs.1.03±0.34 V). In ten patients we also studied the influence of anesthesia on both anal pressure and anodermal blood flow. During the administration of anesthesia, anal pressure dropped from 63±21 mmHg to 32±15 mmHg (P<0.001), whereas anodermal blood flow at the posterior midline increased from 0.79±0.22 V to 1.31±0.35 V (P<0.001). CONCLUSION: Anodermal blood flow at the posterior midline is less than in the other segments of the anal canal. The perfusion of the anoderm at the posterior commissure is strongly related to anal pressure. The higher the pressure, the lower the flow. Our findings support the hypothesis that anal fissures are ischemic ulcers.

Smoking affects the outcome of transanal mucosal advancement flap repair of trans-sphincteric fistulas

The aim of the study was to identify variables affecting the outcome of transanal advancement flap repair (TAFR) for perianal fistulas of cryptoglandular origin.

Prospective comparison of hydrogen peroxide-enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging of perianal fistulas.

AbstractPURPOSE: This study was conducted to determine agreement between hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in the preoperative assessment of perianal fistulas and to compare these results with the surgical findings. nMETHODS: Twenty-one patients (aged 26–71 years) with clinical symptoms of a cryptoglandular perianal fistula and a visible external opening underwent preoperative hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography, endoanal magnetic resonance imaging, and surgical exploration. The results were assessed separately by experienced observers blinded as to each other’s findings. Each fistula was described with notice of the following characteristics: classification of the primary fistula tract according to Parks (intersphincteric, transsphincteric, extrasphincteric, or suprasphincteric), horseshoe, or not classified; presence of secondary tracts (circular or linear); and location of an internal opening. nRESULTS: The median time between hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging was 66 (interquartile range, 21–160) days; the median time between the last study (hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography or endoanal magnetic resonance imaging) and surgery was 154 (interquartile range, 95–189) days. Agreement for the classification of the primary fistula tract was 81 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 90 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. For secondary tracts, agreement was 67 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 57 percent for endoanal magnetic resonance imaging and surgery, and 71 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging in case of circular tracts and 76 percent, 81 percent, and 71 percent, respectively, in case of linear tracts. Agreement for the location of an internal opening was 86 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and surgery, 86 percent for endoanal magnetic resonance imaging and surgery, and 90 percent for hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging. nCONCLUSIONS: For evaluation of perianal fistulas, hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging have good agreement, especially for classification of the primary fistula tract and the location of an internal opening. These results also show good agreement compared with surgical findings. Therefore, hydrogen peroxide–enhanced three-dimensional endoanal ultrasonography and endoanal magnetic resonance imaging can both be used as reliable methods for preoperative evaluation of perianal fistulas.

Visceral neuropathy in slow transit constipation: An immunohistochemical investigation with monoclonal antibodies against neurofilament

PURPOSE: The aim of this study was to investigate neuropathologic changes in the colonic wall of patients with slow transit constipation using monoclonal antibodies raised against neurofilament. METHODS: In a prospective study, 227 patients with severe, long-standing constipation and intractable defecation disorders were analyzed according to a standard protocol. Slow transit constipation was diagnosed in 65 patients (29 percent). Fortythree patients (7 men and 36 women; mean age, 46 years; range, 16–76 years) underwent a partial (n=20) or subtotal (n=23) colectomy. In 39 patients (5 with megacolon and 34 with normal-sized colon) the cause of their constipation remained unexplained (idiopathic slow transit constipation). All resected colon specimens were investigated with the monoclonal antineurofilament antibody NF2F11 and compared with those of 20 control patients. RESULTS: In all controls the myenteric plexus revealed a moderate and diffuse axonal staining. In 29 of 39 patients with “idiopathic” slow transit constipation, the apparently normal axon bundles in the myenteric plexus stained markedly less than normal or failed to stain at all with the monoclonal antibody. In 17 patients this reduced or absent neurofilament expression was found along the entire length of the colon, whereas in 12 patients only a portion of the colon was affected. CONCLUSION: These findings indicate that a visceral neuropathy seems to be present in the majority of patients with severe, so-called idiopathic slow transit constipation.

Relationship between sphincter morphology on endoanal MRI and histopathological aspects of the external anal sphincter

Abstractu2002Atrophy of the external anal sphincter can be shown only on endoanal magnetic resonance imaging (MRI). Until now no study has compared the morphological endoanal MRI findings with histopathological aspects of the external anal sphincter. The aim of this study was to validate the MRI interpretation of the external anal sphincter using histology as a ”gold standard.” In this prospective study 25 consecutive unselected women (median age 48 years, range 27–72) with fecal incontinence due to obstetric trauma were assessed preoperatively with endoanal MRI. All patients underwent anterior sphincteroplasty within 6 months of the preoperative assessment. During sphincter repair, a biopsy specimen was taken both from the left and right lateral parts of the external anal sphincter. Interpretation of MRI was performed by one of the radiologists (J.S.), and biopsy specimens were evaluated by the pathologist (W.J.M.). Both were blinded to the interpretation of the other. MRI revealed external anal sphincter atrophy in 9 of the 25 patients (36%). Histopathological investigation confirmed these findings in all but one. In one additional patient atrophy was detected on histological investigation while the morphology of the external anal sphincter was classified as normal on MRI. In detecting sphincter atrophy endoanal MRI showed 89% sensitivity, 94% specificity, 89% positive predictive value, and 94% negative predictive value. MRI correctly identified sphincter morphology in 23 of 25 cases (92%). This study demonstrates that endoanal MRI accurately identifies normal and abnormal external anal sphincter morphology. Endoanal MRI is therefore a valuable preoperative diagnostic tool.

Quality of life after transanal endoscopic microsurgery and total mesorectal excision in early rectal cancer

Objectiveu2002 Total mesorectal excision (TME) is the gold standard in rectal cancer, if curation is intended. Transanal endoscopic microsurgery (TEM) is a much safer technique and seems to have comparable survival in early rectal cancer. The impact of both procedures on quality of life has never been compared. In this study we compared quality of life after TEM and TME.

Long-term follow-up of retrograde colonic irrigation for defaecation disturbances

Objectiveu2003 Irrigation of the distal part of the large bowel is a nonsurgical alternative for patients with defaecation disturbances. In our institution, all patients with defaecation disturbances, not responding to medical treatment and biofeedback therapy, were offered retrograde colonic irrigation (RCI). This study is aimed at evaluating the long‐term feasibility and outcome of RCI.

Quality of life after total mesorectal excision for rectal cancer

Backgroundu2002 After total mesorectal excision for rectal cancer, many surgeons try to avoid an abdominoperineal resection (APR) by performing a transanally double stapled low colo‐rectal anastomosis (LRA), frequently without a pouch. This policy is mainly based on the assumption that the quality of life after such LRA is higher than after APR. It has been suggested that a better functional outcome and therefore a higher quality of life might be achieved by a colo‐anal J‐pouch anastomosis (CPA). The aim of this study was to assess quality of life among disease‐free survivors after APR, LRA and CPA.

Assessment of posterior compartment prolapse: a comparison of evacuation proctography and 3D transperineal ultrasound.

Introductionu2002 Evacuation proctography (EP) is considered to be the gold standard investigation for the diagnosis of posterior compartment prolapse. 3D transperineal ultrasound (3DTPUS) imaging of the pelvic floor is a noninvasive investigation for detection of pelvic floor abnormalities. This study compared EP with 3DTPUS in diagnosing posterior compartment prolapse.