W. Rudolph Schouten

Eradication of Pathogenic Bacteria and Restoration of Normal Pouch Flora: Comparison of Metronidazole and Ciprofloxacin in the Treatment of Pouchitis

PURPOSE:Pouchitis is the major long-term complication after ileal pouch-anal anastomosis for ulcerative colitis. Metronidazole and ciprofloxacin are commonly used for treatment; however, nothing is known about the effects on the pouch flora during and after pouchitis episodes. This study was designed to evaluate the effect of both antibiotics on eradication of pathogens and the restoration of normal pouch flora.METHODS:The fecal flora obtained from 13 patients with ulcerative colitis was examined at the beginning of a pouchitis episode before treatment, during treatment with metronidazole or ciprofloxacin, and during pouchitis-free periods. Some patients experienced more than one pouchitis episode. Therefore, a total of 104 samples was obtained. Each sample was cultured under aerobic and anaerobic conditions and the isolated bacteria were identified. Furthermore, the clinical response to both antibiotics was compared using the Pouchitis Disease Activity Index score.RESULTS:During pouchitis-free periods, the patients had a flora characterized by high numbers of anaerobes and no or low numbers of pathogens. This flora resembles normal colon flora. During pouchitis episodes, we found a significant decrease of anaerobes (P = 0.01), a significant increase of aerobic bacteria (P = 0.01), and significantly more numbers of pathogens, such as Clostridium perfringens (in 95 percent of the samples; P < 0.01) and hemolytic strains of Escherichia coli (in 57 percent of the samples; P = 0.05). Treatment with metronidazole resulted in a complete eradication of the anaerobic flora, including C. perfringens. However, no changes in the numbers of E. coli were found. In contrast, when the patient was treated with ciprofloxacin, not only C. perfringens, but also all coliforms including hemolytic strains of E. coli disappeared. The larger part of the anaerobic flora was left undisturbed during the administration of ciprofloxacin. Patients treated with ciprofloxacin experienced significant larger reductions in Pouchitis Disease Activity Index score compared with patients treated with metronidazole (P = 0.04).CONCLUSIONS:This study strongly suggests a role of pathogenic bacteria (C. perfringens and/or hemolytic strains of E. coli) in pouchitis. From a microbiologic and a clinical point of view, ciprofloxacin is preferable to metronidazole, because treatment with ciprofloxacin eradicates both pathogens and results in an optimal restoration of normal pouch flora.

Detection of anal sphincter defects in female patients with fecal incontinence: a comparison of 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound.

BACKGROUND: Endoanal ultrasound is widely used for the detection of external and internal anal sphincter defects in patients with fecal incontinence. Recently, 3-dimensional transperineal ultrasound has been introduced as a noninvasive imaging method for the detection of these sphincter defects. OBJECTIVE: This study was designed to assess agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects in women with fecal incontinence. DESIGN: This study was designed as a prospective observational study. SETTINGS: The study took place in a university hospital. PATIENTS: Between October 2008 and June 2009, all women with concerns of fecal incontinence underwent 2-dimensional endoanal ultrasound as well as 3-dimensional transperineal ultrasound. MAIN OUTCOME MEASURES: The main outcome measures are the presence of external and internal anal sphincter defects. RESULTS: Fifty-five patients were included. External and internal anal sphincter defects were observed with 2-dimensional endoanal ultrasound in 27 (49%) and 15 (27%) patients. Three-dimensional transperineal ultrasound detected an external and internal sphincter defect in 19 (35%) and 16 (29%) patients. The Cohen &kgr; coefficient for the detection of external (&kgr; = 0.63) and internal (&kgr; = 0.78) anal sphincter defects was good. LIMITATIONS: This study’s limitations include the absence of a surgical examination as the reference standard in the determination of sphincter defects. CONCLUSION: This study shows good agreement between 3-dimensional transperineal ultrasound and 2-dimensional endoanal ultrasound regarding the detection of anal sphincter defects. Based on these data, 3-dimensional transperineal ultrasound might be considered as a valuable alternative noninvasive investigation method.

Anterior sphincteroplasty for fecal incontinence: A single center experience in the era of sacral neuromodulation

PURPOSE: Anterior sphincteroplasty is the surgical treatment of choice for patients with fecal incontinence associated with an external anal sphincter defect. Recently it has been reported that patients with such a defect may also benefit from sacral neuromodulation. The success of this technique raises the question whether anterior sphincteroplasty still deserves a place in the surgical treatment of fecal incontinence. This study investigated the outcome of anterior sphincteroplasty in a large cohort of patients. METHODS: A consecutive series of 172 patients underwent anterior overlapping sphincteroplasty. A standardized questionnaire concerning current continence status, overall satisfaction, and quality of life was used to assess the outcome. RESULTS: Follow-up data were obtained from 75% of the 160 patients who were still alive at the time of the survey. After a median follow-up of 111 (range, 12–207) months, the outcome was still good to excellent in 44 patients (37%). In 28 patients (23%), the outcome was classified as moderate because these patients still experienced regular incontinence for stool. However, they were satisfied with their outcome because their incontinence episodes had been reduced by 50% or more. The outcome was poor in 40% of the patients. Predictors of worse outcome were older age (≥50 years) at surgery, deep wound infection, and isolated external anal sphincter defects. Patients with follow-up of five or more years had the same outcome as patients with follow-up of fewer than five years. CONCLUSION: Anterior sphincteroplasty results in an acceptable to excellent long-term outcome in 60% of patients, especially in those under the age of 50 years at surgery.

Integrity of the Anal Sphincters After Pouch-Anal Anastomosis: Evaluation With Three-Dimensional Endoanal Ultrasonography

PURPOSEThe aim of the present study was to assess the integrity of the anal sphincters after handsewn pouch-anal anastomosis performed with the help of a Scott retractor. For this purpose the anal sphincters were visualized with three-dimensional endoanal ultrasonography.METHODSPatients undergoing a colonic pouch-anal anastomosis or an ileal pouch-anal anastomosis were included. Before and six months after the procedure, the length and volume of both sphincters were assessed with three-dimensional endoanal ultrasonography, and anal manometry was performed. Continence scores were determined using the Fecal Incontinence Severity Index (FISI).RESULTSFifteen patients with a colonic pouch and 13 patients with an ileal pouch were examined. Six months after the procedure, three-dimensional endoanal ultrasonography showed significant alterations of the internal anal sphincter in eight patients with a colonic pouch-anal anastomosis (53 percent) and in eight patients with an ileal pouch-anal anastomosis (62 percent). These alterations were characterized by asymmetry or thinning. No defects were seen in the colonic pouch group, but, in two patients with an ileal pouch, a small defect in the internal anal sphincter was found. A decrease in internal anal sphincter volume was seen only in patients with a colonic pouch-anal anastomosis (P = 0.009). In both groups the length of the internal anal sphincter and the length, thickness, and volume of the external anal sphincter remained the same. After the procedure a reduction of maximum anal resting pressure was found in both groups (colonic pouch: P < 0.001, ileal pouch: P = 0.001). Maximum anal squeeze pressure was reduced in only patients with an ileal pouch-anal anastomosis (P = 0.006). The observed alterations of the internal anal sphincter and the manometric findings showed no correlation with the postoperative Fecal Incontinence Severity Index scores.CONCLUSIONHandsewn pouch-anal anastomosis, performed with the help of a Scott retractor, only rarely leads to internal anal sphincter defects, but three-dimensional endoanal ultrasonography shows alterations of the internal anal sphincter in 57 percent of the patients. No correlation was observed between these alterations and the functional outcome.

Is the outcome of transanal advancement flap repair affected by the complexity of high transsphincteric fistulas

BACKGROUND: Transanal advancement flap repair for the treatment of high transsphincteric fistulas fails in 1 of every 3 patients. Until now no definite risk factors for failure have been identified. The question is whether the more complex fistulas, such as those with horseshoe extensions and associated abscesses, have a less favorable outcome. OBJECTIVE: Aim of the present study was to indentify whether more complex fistulas have a less favorable outcome. DESIGN: This study is a retrospective case series review. PATIENTS: Between 1995 and 2007 a series of 162 patients underwent endoanal MR imaging before transanal advancement flap repair. Two investigators, without prior knowledge of the surgical findings, reviewed all MR images. RESULTS: Lateral fistulas were identified in 5 patients. Because of the small number, these patients were excluded from further analysis. Posterior fistulas were identified in 119 patients (76%). These fistulas had 3 types of extensions: a direct course (36%), a classic horseshoe extension (23%), or an intersphincteric horseshoe extension (41%). The corresponding healing rates were 37%, 81%, and 73%. Anterior fistulas were observed in 23% of the patients. These fistulas had 2 types of extensions: a direct course (61%) or a classic horseshoe extension (39%). The corresponding healing rates were 60% and 52%. The healing rate of fistulas with a direct course was significantly lower than the healing rate of fistulas with a classic or intersphincteric horseshoe extension. Associated abscesses were found in 47% of the posterior fistulas and 5% of the anterior fistulas. Once adequately drained, these abscesses did not affect the outcome of transanal advancement flap repair. CONCLUSION: The complexity of high transsphincteric fistulas does not affect the outcome of transanal advancement flap repair.

Anterior sphincteroplasty for fecal incontinence: is the outcome compromised in patients with associated pelvic floor injury?

INTRODUCTION: It has been shown that vaginal delivery may result not only in sphincter defects, but also in pelvic floor injury. However, the influence of this type of injury on the etiology of fecal incontinence and its treatment is unknown. The present study was aimed to assess the prevalence of pelvic floor injury in patients who underwent anterior sphincteroplasty for the treatment of fecal incontinence and to determine the impact of this type of injury on the outcome of this procedure. METHODS: Women who underwent anterior sphincteroplasty in the past were invited to participate in the present study. With transperineal ultrasound, which has been developed recently, pelvic floor integrity was examined in 70 of 117 patients (60%). Follow-up was obtained from a standardized questionnaire. RESULTS: The median time period between anterior sphincteroplasty and the current assessment was 106 (range, 15–211) months. Pelvic floor injury was diagnosed in 43 patients (61%). Despite the prior sphincteroplasty, an external anal sphincter defect was found in 20 patients (29%). Outcome did not differ, neither between patients with and those without pelvic floor injury, nor between patients with and those without an adequate repair. However, patients with an adequate repair and an intact pelvic floor did have a better outcome than patients with one or both abnormalities. CONCLUSION: The majority of female patients with incontinence who were eligible for anterior sphincteroplasty have concomitant pelvic floor injury. Based on the present study, it seems unlikely that this type of injury itself has an impact on the outcome of anterior sphincteroplasty.

The Anal Fistula Plug as an Adjunct to Transanal Advancement Flap Repair

To the Editor—We read with interest the editorial of Christoforides. He presents a good overview of the current status of the anal fistula plug in the treatment of complex anal fistulas. Although the plug has gained wide popularity, the transanal advancement flap (TAFR) is considered the standard for the treatment of high transsphincteric fistulas by most colorectal surgeons. In our institution more than 300 patients have undergone TAFR. This procedure fails in 1 of 3 patients. In almost all patients in whom TAFR has failed, we have observed that the flap was completely healed except at the spot of the original internal opening. A possible explanation for this remarkable finding might be persistent inflammation in the remaining fistulous tract. Based on this hypothesis we wondered whether obliteration of the fistulous tract might enhance the outcome of TAFR. First, we started a pilot study with BioGlue in 8 patients. Fistula healing was observed in only 1 patient. All other patients experienced one or more of the following complications: prolonged severe pain (n 5), discharge of great amounts of purulent liquid from the external opening (n 3), and abscess formation (n 2), necessitating incision and drainage. An advantage of the anal fistula plug is that it occludes the internal opening but preserves a route for external drainage through the external opening of the tract. Therefore, we conducted a pilot study to assess the role of the plug as an adjunct to TAFR. A consecutive series of 8 patients underwent TAFR after placement and fixing of the plug in the anal fistula. Fistula healing was observed in only 2 of these patients. In 3 patients abscess formation was observed shortly after the operation, necessitating incision and drainage. Because of these poor results we decided to terminate our pilot study prematurely. Even though this pilot study comprised only a limited number of patients, we do not advocate the use the anal fistula plug as an adjunct to TAFR. Based on both small pilot studies, it seems obvious that obliteration of the fistula tract deteriorates the outcome of TAFR.

Does rectal mucosal blood flow affect the outcome of transanal advancement flap repair

INTRODUCTION: Transanal advancement flap repair provides a useful tool for the treatment of high transsphincteric fistulas. Recent studies indicate that transanal advancement flap repair fails in one of every three patients. Until now no definite risk factors for failure have been identified. A previous pilot study, conducted in our own institution, revealed a significant decrease in rectal mucosal blood flow after creation of the advancement flap. We postulated that impaired blood flow might result in breakdown of the distal part of the flap. This study was designed to evaluate the effect of rectal mucosal blood flow on the outcome of transanal advancement flap repair. METHODS: Between August 2004 and June 2007 a series of 54 patients with a high transsphincteric fistula underwent transanal advancement flap repair. The present series comprised 34 males and 20 females. Median age at the time of repair was 45 (range, 25–68) years. Rectal mucosal blood flow was determined by laser Doppler flowmetry before and after creation of the flap. The flow was expressed in arbitrary units. RESULTS: Transanal advancement flap repair was successful in 34 patients (63%). Median healing time was 2.2 months. Median mucosal blood flow before and after transanal advancement flap repair was 145 arbitrary units and 94 arbitrary units, respectively. This decrease was statistically significant. In a comparison of patients with and patients without a successful repair, no differences were found in mucosal blood flow before and after creation of the flap (146 vs. 138 arbitrary units and 83 vs. 104 arbitrary units). CONCLUSION: Rectal mucosal blood flow does not affect the outcome of transanal advancement flap repair.

Is sacral neuromodulation for fecal incontinence worthwhile in patients with associated pelvic floor injury

PURPOSE: It has been shown that vaginal delivery may result in pelvic floor injury. Until now it is unknown whether this type of injury plays a role in the etiology of fecal incontinence and whether it affects the outcome of treatment. The aim of the present study was to assess the prevalence of pelvic floor injury in patients with fecal incontinence who were eligible for sacral neuromodulation and to determine whether sacral neuromodulation is worthwhile in patients with pelvic floor injury. METHODS: All women with fecal incontinence who were eligible for sacral neuromodulation in the past were invited to participate in the present study. With transperineal ultrasound, which has been developed recently, pelvic floor integrity was examined in 46 of the 66 patients (70%). Follow-up was obtained from a standardized questionnaire. RESULTS: Pelvic floor injury was found in 29 of the 46 participants (63%). No differences regarding the efficacy of sacral neuromodulation were found between patients with and those without pelvic floor injury. Successful test stimulation was obtained in 86% of the patients with pelvic floor injury and in 71% of the patients without pelvic type injury. After implantation of a definitive pulse generator, a successful outcome was found in 84% of the patients with pelvic floor injury and in 75% of the patients with an intact pelvic floor. CONCLUSION: Pelvic floor injury is present in the majority of incontinent patients who were eligible for sacral neuromodulation. This type of injury seems to have no detrimental effect on the treatment outcome.

Primary Cystic Lesions of the Retrorectal Space: MRI Evaluation and Clinical Assessment

OBJECTIVE The purpose of this study was to assess the a priori chance that primary cystic lesions of the retrorectal space are malignant and to investigate MRI characteristics that indicate malignancy. MATERIALS AND METHODS Patients referred to a center for colorectal surgery were recruited from 2000 to 2014. Lesions were proven by clinical assessment and histopathology. MRI was performed at 1.5 T with examinations evaluated by two radiologists. Interobserver agreement was assessed (Cohen kappa) and differences between malignant and benign lesions calculated (Fisher exact test). RESULTS Twenty-eight patients (22 women, six men; age range, 18-70 years) with 31 lesions were included. Lesions were categorized as tailgut cysts (n = 16, 52%), teratomas (n = 9, 29%), lesions of colorectal origin (n = 4, 13%), or neurogenic lesions (n = 2, 6%). Five patients (18%) had malignant lesions. Colorectal lesions had the highest percentage of malignancy (3/4, 75%). A solid tissue component was found in all five (100%) malignant lesions and two (8%) of the benign lesions, which were both teratomas (p < 0.05). Sensitivity and specificity for malignancy according to the presence of a solid tissue component was 100% (5/5) and 92% (24/26). For unilocularity, multilocularity, debris, septa, and wall thickening, differences were not significant. Interobserver agreement was excellent (κ = 1) for all characteristics except debris (κ = 0.795). CONCLUSION The majority of retrorectal cystic lesions are benign. The presence of a solid tissue component should raise suspicion for malignancy.