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Annals of The Royal College of Surgeons of England 12/2008; 90(8):696. · 1.23 Impact Factor
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ABSTRACT: With advances in diagnostic technology, it is now accepted that in the field of functional bowel disorders, symptom-based assessment is unsatisfactory as the sole means of directing therapy. A robust taxonomy based on underlying pathophysiology has been suggested, highlighting a crucial role for physiologic testing in clinical practice. A wide number of complementary investigations currently exist for the assessment of anorectal structure and function, some of which have a clinical impact in patients with functional disorders of evacuation and continence by markedly improving diagnostic yield and altering management. The techniques, limitations, measurements, and clinical use of manometric, sensorimotor, and neurophysiologic tests of anorectal function are presented.
Gastroenterology Clinics of North America 10/2008; 37(3):511-38, vii. · 2.62 Impact Factor
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ABSTRACT: Patients with constipation and fecal incontinence usually come to the attention of the surgeon when conservative measures have failed to alleviate sufficiently severe symptoms. Following detailed clinical and physiologic assessment, the surgeon should tailor the procedure to specific underlying physiologic abnormalities to restore function. This article describes the rationale, indications (including patient selection), results, and current position controversies of surgical procedures for constipation and fecal incontinence, dividing these into those regarded as historical, contemporary, or evolving. Reported surgical outcome data must be interpreted with caution because for most studies the evidence is of low quality, making comparison of different procedures problematic and emphasizing the need for better designed and conducted clinical trials.
Gastroenterology Clinics of North America 10/2008; 37(3):605-25, viii. · 2.62 Impact Factor
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Gastroenterology 06/2008; 134(5):1294, 1636. · 11.68 Impact Factor
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Gastroenterology 06/2008; 134(5):e4-6. · 11.68 Impact Factor
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ABSTRACT: Severe constipation may be subclassified on the basis of speed of colonic transit and efficacy of rectal evacuation. It is hypothesized that rectal evacuatory disorder (RED) may be associated with a secondary transit delay.
To determine whether scintigraphy can discriminate between slow transit constipation (STC) with or without coexistent RED on the basis of progression of isotope throughout the colon and by analyses of specific regions of interest.
One hundred ninety-six patients with STC (radio-opaque marker study) were subclassified according to results of proctography into those with a RED (STC-RED N = 30) or normal (STC-ONLY N = 41) evacuation. Patients subsequently underwent colonic scintigraphy. Distribution of generalized or left-sided patterns of colonic transit was assessed. Severities of transit delay and regional transit at specific time points were also evaluated.
Time-activity curves and severity of global transit delay were similar between groups as were the incidences of generalized and left-sided patterns of delay. Percentage of radioisotope retention in the right colon at 18 h was higher for the STC-ONLY group (P < 0.05), but this was poorly discriminative. No differences were observed for the percentage of radioisotope retained in the left colon at later scans.
Global and regional assessment of colonic transit by scintigraphy failed to discriminate between patients with STC with or without coexistent RED. Thus, RED is not associated with a specific pattern of transit delay and scintigraphy alone cannot predict the presence or absence of RED, knowledge of which is important for management.
The American Journal of Gastroenterology 03/2008; 103(2):427-34. · 7.28 Impact Factor
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New England Journal of Medicine 12/2007; 357(22):2309; discussion 2309-10. · 53.30 Impact Factor
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New England Journal of Medicine 11/2007; 357(14):1431. · 53.30 Impact Factor
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ABSTRACT: Traditional methods of identifying patients with persistent dilation of the rectum, or megarectum, are associated with inherent methodologic limitations. The purpose of this study was to use a barostat to establish criteria for the diagnosis of megarectum and to assess rectal diameter during isobaric (barostat) and volumetric (barium contrast) distention protocols in constipated patients with megarectum on anorectal manometry.
During fluoroscopic screening, rectal diameter was measured at minimum distending pressure of the rectum, achieved using a barostat. It was also measured during evacuation proctography (volumetric distention). Having established a normal range in 25 healthy volunteers, 30 constipated patients with evidence of megarectum on anorectal manometry (elevated maximum tolerable volume on latex balloon distention) were studied. A further 10 constipated patients without evidence of megarectum were studied (normal rectum).
Megarectum was diagnosed when the rectal diameter was greater than 6.3 cm at minimum distending pressure. Rectal diameter at minimum distending pressure was increased in 20 patients (67 percent) with megarectum on anorectal manometry, but was normal in the remaining 10 patients (33 percent) and all patients with a normal rectum on anorectal manometry. Rectal diameter was increased at evacuation proctography in only 15 patients (50 percent) with evidence of megarectum on anorectal manometry.
The prevalence of megarectum is overestimated and underestimated when rectal diameter is assessed using anorectal manometry and contrast studies, respectively. Controlled (pressure-based) distention combined with fluoroscopic imaging allowed accurate identification of patients with megarectum on the basis of a rectal diameter greater than 6.3 cm at the minimum distention pressure. Measurement of rectal diameter at minimum distention pressure may be useful in those patients with an elevated maximum tolerable volume on anorectal manometry when surgery is being contemplated.
Diseases of the Colon & Rectum 06/2007; 50(5):621-9. · 3.13 Impact Factor
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ABSTRACT: Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only "apparent" identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although "sensory-retraining biofeedback" appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.
The American Journal of Gastroenterology 06/2006; 101(5):1140-51. · 7.28 Impact Factor
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ABSTRACT: Rectal intussusception (RI) is a significant cause of morbidity amongst those with a rectal evacuatory disorder. The pathophysiology is unknown, but may involve abnormal biomechanics of the rectal wall similar to that previously demonstrated in patients with overt rectal prolapse (RP). Using an electromechanical barostat, this study aimed to investigate the biomechanics and visceroperception of the rectal wall in patients with RI.
Twenty consecutive patients (12 females, median age 46 yr (range 24-66)) with symptomatic, full-thickness RI were studied. Patients underwent assessment of rectal compliance, visceroperception, adaptive response to isobaric distension at urge threshold, and assessment of the postprandial response. Results were compared with those obtained in 28 asymptomatic volunteers, 10 with RI (6 females, median age 29 yr (range 21-36)) and 18 (9 females, median age 33 yr (range 21-62)) without.
In the absence of the clinical finding of solitary rectal ulcer syndrome (SRUS), patients with symptomatic RI have normal rectal wall biomechanics, as do asymptomatic volunteers with RI (p < 0.05). Patients with the clinical finding of SRUS had reduced compliance and adaptation. In all three groups, there was a linear relationship between rectal pressure and visceroperception. The postprandial contractile response was similar between groups.
Patients with RI have normal rectal wall biomechanics. This is in contrast to patients with RP, and suggests that while they may represent different stages of the same disease process, they are physiologically distinct. In patients with RI and SRUS, rectal wall inflammation and fibrosis, perhaps arising secondary to the intussusception, may explain the physiological changes observed.
The American Journal of Gastroenterology 07/2005; 100(7):1578-85. · 7.28 Impact Factor
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ABSTRACT: A subgroup of patients with intractable constipation has persistent dilatation of the bowel, which in the absence of an organic cause is termed idiopathic megabowel (IMB). The aim of this systematic review was to evaluate the published outcome data of surgical procedures for IMB in adults.
Electronic searches of the MEDLINE (PubMed) database, Cochrane Library, EMBase, and Science Citation Index were performed. Only peer-reviewed articles of surgery for IMB published in the English language were evaluated. Studies of all surgical procedures were included, providing they were performed on 3 or more patients, and overall success rates were documented. Studies were critically appraised in terms of design and methodology, inclusion criteria, success, mortality and morbidity rates, and functional outcomes.
A total of 27 suitable studies were identified, all evidence was low quality obtained from case series, and there were no comparative studies. The studies involved small numbers of patients (median 12, range 3-50), without long-term follow-up (median 3 years, range 0.5-7). Inclusion of subjects, methods of data acquisition, and reporting of outcomes were extremely variable. Subtotal colectomy was successful in 71.1% (0%-100%) but was associated with significant morbidity related to bowel obstruction (14.5%, range 0%-29%). Segmental resection was successful in 48.4% (12.5%-100%), and recurrent symptoms were common (23.8%). Rectal procedures achieved a successful outcome in 71% to 87% of patients. Proctectomy, the Duhamel, and pull-through procedures were associated with significant mortality (3%-25%) and morbidity (6%-29%). Vertical reduction rectoplasty (VRR) offered promising short-term success (83%). Pelvic-floor procedures were associated with poor outcomes. A stoma provided a safe alternative but was only effective in 65% of cases.
Outcome data of surgery for IMB must be interpreted with extreme caution due to limitations of included studies. Recommendations based on firm evidence cannot be given, although colectomy appears to be the optimum procedure in patients with a nondilated rectum, restorative proctocolectomy the most suitable in those with dilatation of the colon and rectum, and VRR in those patients with dilatation confined to the rectum. Appropriately designed studies are required to make valid comparisons of the different procedures available.
Annals of Surgery 05/2005; 241(4):562-74. · 7.49 Impact Factor
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ABSTRACT: The study looked at why women developed invasive cervical cancer during a 10-year period. It reviewed the hospital records of 66 patients with cervical cancer with an age range of 21-81 years. Screening non-attenders accounted for a disproportionate number of cases. The proportion of women who had never been screened did not vary during the study period. Attention needs to focus on reasons why these women do not attend.
European Journal of Obstetrics & Gynecology and Reproductive Biology 04/2005; 119(1):123-4. · 1.97 Impact Factor
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ABSTRACT: Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension. Diagnosis on the basis of abnormal threshold volumes on balloon distension alone may be inaccurate due to the influence of differing rectal wall properties. The aim of this study was to investigate whether RH was actually due to impaired afferent nerve function or whether it could be secondary to abnormalities of the rectal wall.
A total of 50 patients were referred consecutively to a tertiary referral unit for physiologic assessment of constipation (Rome II criteria), 25 of whom had associated fecal incontinence. Thirty patients had RH (elevated threshold volumes on latex balloon distension), and 20 patients had normal rectal sensation (NS). Results were compared with those obtained in 20 healthy volunteers (HV). All subjects underwent standard anorectal physiologic investigation, and assessment of rectal compliance, adaptive response to isobaric distension at urge threshold, and postprandial rectal response, using an electromechanical barostat.
Mean rectal compliance was significantly elevated in patients with RH compared to NS and HV (p < 0.001). However, 16 patients with RH (53%) had normal compliance. Intensity of the urge to defecate during random phasic isobaric distensions was significantly reduced in patients with RH compared to NS and HV (p < 0.001). The adaptive response at urge threshold was reduced in patients with RH compared to NS and HV (p < 0.001), although spontaneous adaptation at operating pressure was similar in all three groups studied (p= 0.3). Postprandially, responses were similar between groups.
In patients found to have RH on simple balloon distension, impaired perception of rectal distension may be partly explained in one subgroup by abnormal rectal compliance. However, a second subgroup exists with normal rectal wall properties, suggestive of a true impairment of the afferent pathway. The barostat has an important role in the identification of these subgroups of patients.
The American Journal of Gastroenterology 02/2005; 100(1):106-14. · 7.28 Impact Factor
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ABSTRACT: Traditionally, microbiological swabs are taken for culture during appendicectomy. However, the pathogens encountered are largely predictable, and sensitive to broad-spectrum antibiotics. Thus, we aimed to examine the clinical value of this practice, by determining the influence of microbiological results on postoperative outcome in patients undergoing appendicectomy.
The study population comprised 721 consecutive patients undergoing appendicectomy for suspected acute appendicitis in a single district general hospital. Microbiological culture results and sensitivities of isolates were recorded in relation to histopathological findings and infective morbidity, to establish whether they influenced postoperative outcome.
Swabs were taken during 463 (64%) appendicectomies. Only 113 (24%) yielded positive cultures ('coliforms', anaerobes and Streptococcus milleri were most frequently isolated). Organisms resistant to broad-spectrum antibiotics were encountered in only 11 of 463 patients (2%) where swabs were taken. Overall, 39 patients (5%) developed significant infective complications postoperatively. Neither the presence of a positive intra-operative culture, nor the isolation of resistant organisms were significant in predicting infective complications (P = 0.11 and 0.17, respectively).
In the population studied, the results of intra-operative culture did not influence clinical outcome in patients undergoing appendicectomy. The practice of taking routine microbiological swabs for culture must be seriously questioned.
Annals of The Royal College of Surgeons of England 06/2004; 86(3):196-201. · 1.23 Impact Factor
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ABSTRACT: Acquired faecal incontinence arising in the non-elderly population is a common and often devastating condition. We conducted a retrospective cohort analysis in 629 patients (475 female) referred to a tertiary centre, to determine the relative importance of individual risk factors in the development of faecal incontinence, as demonstrated by abnormal results on physiological testing. Potential risk factors were identified in all but 6% of patients (7 female, 32 male). In women, the principal risk factor was childbirth (91%), and in most cases at least one vaginal delivery had met with complications such as perineal injury or the need for forceps delivery. Of the males, half had undergone anal surgery and this was the only identified risk factor in 59%. In many instances, assignment of cause was hampered by a long interval between the supposed precipitating event and the development of symptoms. Abnormalities of anorectal physiology were identified in 76% of males and 96% of females (in whom they were more commonly multiple). These findings add to evidence that occult damage to the continence mechanism, especially through vaginal delivery and anal surgery, can result in subsequent faecal incontinence, sometimes after an interval of many years.
Journal of the Royal Society of Medicine 04/2004; 97(3):111-6. · 1.41 Impact Factor
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ABSTRACT: Blunted rectal sensation, or rectal hyposensitivity, has been reported anecdotally in patients with functional disorders of evacuation and continence. The purpose of this study was to determine the prevalence of rectal hyposensitivity and whether the finding of such an abnormality was associated with any clinical impact.
One thousand three hundred fifty-one patients, referred for anorectal physiologic investigation, were divided according to presenting symptoms into the following categories: constipation (subdivided into infrequency of and/or obstructed defecation), fecal incontinence (subdivided into passive, postdefecation, and urge incontinence), fecal incontinence and constipation, or "other." Rectal hyposensitivity was judged to be present when at least one of the sensory threshold volumes was elevated beyond the normal range (mean plus 2 standard deviations). The prevalence of rectal hyposensitivity was then calculated in each group and in relation to other investigations.
Rectal hyposensitivity was present in 16 percent of patients, with males and females equally affected. Twenty-three percent of patients with constipation, 10 percent of patients with fecal incontinence, 27 percent of patients with incontinence associated with constipation, and only 5 percent of patients with other symptoms were found to have rectal hyposensitivity. In patients with obstructed defecation, rectal hyposensitivity was present in 33 percent with rectocele, 40 percent with intussusception, and 53 percent with no mechanical obstruction evident on evacuation proctography.
Rectal hyposensitivity is common in patients with constipation and/or fecal incontinence and may thus be important in the etiology of such conditions. Although the clinical relevance of this physiologic abnormality is unknown, its presence may have implications regarding the management of hindgut dysfunction and particularly the selection of patients for surgery.
Diseases of the Colon & Rectum 03/2003; 46(2):238-46. · 3.13 Impact Factor
