ABSTRACT: Vertical reduction rectoplasty (VRR) was devised specifically to address the physiological abnormalities present in the rectum of patients with idiopathic megarectum (IMR). This study evaluated the medium-term clinical and physiological results of VRR.
VRR and sigmoid colectomy was performed in ten patients with IMR and constipation (six women). Patients were evaluated before and a median of 60 (range 28-74) months after surgery by assessment of symptoms using scoring systems and anorectal physiological measurements. Independent, detailed postoperative evaluation of rectal diameter, compliance, and sensory and evacuatory function was performed.
There were no deaths or late complications. Symptoms recurred necessitating permanent ileostomy formation in two patients. Median (range) constipation scores improved from 22 (18-27) before to 10 (0-24) after surgery (P = 0.016). Median (range) bowel frequency increased from 1.5 (0.2-7) to 7 (0.5-21) per week (P = 0.016). Rectal diameter, compliance and sensory function were normal in seven of eight patients after surgery. Evacuatory function and colonic transit were each normalized in two of eight patients after VRR.
VRR corrected rectal diameter, compliance and sensory function in most patients, and clinical benefit was sustained in the medium term. The procedure was associated with a low morbidity, and no mortality and should be considered in the surgical management of IMR.
British Journal of Surgery 06/2005; 92(5):624-30. · 4.61 Impact Factor
ABSTRACT: Two different techniques have been developed to stimulate the gracilis muscle when it is used in anal neosphincter reconstruction. These are direct neural stimulation and intramuscular electrode stimulation. The aim of this study was to compare these techniques.
Comparison was made of gracilis anal neosphincter reconstruction using neural stimulation (Royal London Hospital in the United Kingdom) with the intramuscular muscular method (University Hospital Maastricht in the Netherlands). The United Kingdom data were obtained from a retrospective database, whereas the Netherlands data were gathered prospectively.
A successful outcome was achieved in 46 of 81 patients (57 percent) in London and 148 of 200 cases (74 percent) in the Maastricht study (chi-squared = 7.2; P < 0.01). There was no significant difference between the two techniques in voltage required for stimulation of the neosphincter muscle during a ten-year period. Reoperative surgery for electrode failure or dislocation was required in 21 (26 percent) patients in the London study, whereas only four (2.7 percent) of the Maastricht cases required such procedures (chi-squared = 37.8; P < 0.05). The high electrode plate failure rate in the London study was related to the source of manufacture.
Both neural and intramuscular nerve techniques provide effective long-term stimulation of the gracilis anal neosphincter.
Diseases of the Colon & Rectum 05/2001; 44(4):581-6. · 3.13 Impact Factor
ABSTRACT: The aim of this study was the development of a procedure which would successfully treat selected patients presenting with incapacitating urgency and fecal incontinence. Some patients presenting with urgency and fecal incontinence, with an intact anorectum but deficient sphincter mechanism, have low rectal compliance. Management is problematic, because correction of the sphincter defect does not abolish the incapacitating urgency caused by rectal hypersensitivity.
This was a prospective study of three female patients with urgency and fecal incontinence who underwent combined rectal augmentation using a segment of distal ileum and stimulated gracilis anal neosphincter. All patients had low rectal volumes and two exhibited a temporal relationship between high-amplitude (>60 mmHg) rectal pressure waves and urgency on prolonged ambulatory anorectal manometry.
Urgency was abolished and continence restored in all individuals. When the level of stimulation was not optimal or had been discontinued, patients experienced only passive incontinence with no urgency. Postoperative physiology revealed elevated thresholds to rectal distention and a reduction in the number of high-amplitude rectal pressure waves in all cases.
Combined rectal augmentation with stimulated gracilis anal neosphincter may be of benefit to some patients with distressing urgency and fecal incontinence not previously helped by current techniques.
Diseases of the Colon & Rectum 03/2001; 44(2):192-8. · 3.13 Impact Factor
ABSTRACT: The aetiology of idiopathic megarectum is unknown and the results of surgery are often unsatisfactory. Rectal hyposensation is common and poor perception of rectal filling may contribute to the poor evacuatory function. By reducing the capacity of the rectum, it was hypothesized that sensory thresholds to rectal distension and perception of urge to defaecate would be improved.
Vertical reduction rectoplasty (VRR) and concomitant sigmoid colectomy was performed on six patients with idiopathic megarectum. Patients were evaluated before and after operation by detailed questionnaire and anorectal physiology. Postoperative rectal compliance was also studied by means of a programmable electronic barostat. Where appropriate, physiological data were compared with those obtained in eight healthy volunteers.
Bowel frequency increased from a preoperative median of 2.5 to 16 per month after operation. Four patients reported improved rectal perception of the urge to defaecate. Thresholds for defaecatory urge and maximum tolerated volume were significantly reduced following VRR (P<0.05). Post-VRR rectal compliance was no different from that in healthy volunteers. Colonic transit time decreased significantly after VRR (P<0.05) and evacuation on proctography increased from a median of 30 per cent to 50 per cent. At a median of 57 weeks' follow-up five of the six patients expressed continued satisfaction with the results.
VRR is a new approach to the treatment of idiopathic megarectum. Clinical and physiological studies confirm that it can improve sensory feedback and defaecation. The procedure needs further evaluation as the number of patients undergoing the procedure increases.
British Journal of Surgery 09/2000; 87(9):1203-8. · 4.61 Impact Factor