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Abstract

Laparoscopic surgery has demonstrated advantages over conventional open procedures. Specifically, avoiding an abdominal incision and allowing the complete inspection of the abdominal cavity, as well as the ability to obtain a biopsy sample, are some of the reasons that made this method of stoma creation advantageous. The creation of stomas by laparoscopy is one of the simpler laparoscopic procedures and is associated with a shorter learning curve compared with other colorectal procedures. This section discusses the indications, methods, and complications associated with the laparoscopic creation of stomas.

Abstract

PURPOSE:

Patients with idiopathic or neurogenic incontinence without an isolated sphincter defect may be suitable candidates for a postanal repair. The aim of this study was to assess the results of postanal repair in patients with idiopathic or neurogenic fecal incontinence and to evaluate the role of various parameters, including preoperative physiologic testing on outcome.

METHODS:

Postanal repair was offered by a single surgeon to patients meeting the following criteria: incontinence score of at least 12 of 20, absence of an isolated anterior external anal sphincter defect, and failed conservative, medical, and biofeedback management. Physiologic investigation and clinical findings of female patients who had postanal repair for fecal incontinence between 1992 and 1998 were reviewed. Physiologic investigation included anorectal manometry, pudendal nerve terminal motor latency, concentric needle electromyography, and endoanal ultrasonography. Follow-up was obtained by telephone questionnaire; moreover, patients were asked to grade the outcome of their surgery as excellent or good (success) or as fair or poor (failure).

RESULTS:

Twenty-one patients of median age 68 (range, 40-80) years had a mean duration of fecal incontinence before postanal repair of 6.8 (range, 0.5-22) years. Twenty patients (95 percent) were available for at least one year of follow-up. Seventeen patients (80.9 percent) had at least one prior vaginal delivery, and prior sphincteroplasty had been performed in 10 patients (47.6 percent). The morbidity and mortality rates were 5 and 0 percent, respectively. After a mean follow-up period of three (range, 1-7.5) years, seven patients (35 percent) considered surgery to be successful and had a statistically significant decrease in their incontinence score. Neither prolongation of pudendal nerve terminal motor latency nor external sphincter damage as noted on electromyography or any of the preoperative manometric parameters correlated with outcome. Furthermore, patients’ ages at surgery did not correlate with the degree of postoperative improvement in continence scores nor did the duration of the patients’ symptoms, number of vaginal deliveries, or a history of previous surgery for fecal incontinence.

CONCLUSION:

None of the factors assessed was demonstrated to be predictive of outcome after postanal repair; moreover, the currently available preoperative testing has not altered the success rate, which remains low (35 percent). Despite the low success rate, the absence of any mortality and the low morbidity suggest that postanal repair may be a valid therapeutic approach. However, it should be offered only to selected patients with persistent, severe fecal incontinence despite an anatomically intact external anal sphincter who are not candidates for or refuse all other operative modalities.

Abstract

PURPOSE:

This study assessed the efficacy of anterior overlapping sphincteroplasty and parameters predictive of a successful outcome.

METHODS:

Clinical findings and physiologic investigations of female patients who underwent anterior overlapping sphincteroplasty for fecal incontinence between 1988 and 1996 were reviewed. The extent of sphincter damage was assessed at needle electromyography as the number of quadrants exhibiting decreased motor unit potentials. Prolonged pudendal nerve terminal motor latencies were those of greater than 2.2 ms. The size of the endoanal ultrasound defect was assessed as degrees circumference of the external sphincter in which viable muscle was absent. Patients were reviewed by telephone questionnaire and were asked to grade the outcome of their surgery as excellent or good (success) or fair or poor (failure). Incontinence was graded using a scoring system of 0 (perfect continence) to 20 (complete incontinence).

RESULTS:

There were 100 patients who had an overlapping sphincteroplasty; complete follow-tip information was obtained for 77 patients at a median of 24 (range, 2-96) months. The median age was 47 (range, 25-80) years and they had a median duration of incontinence of four (range, 0.1-39) years. Prior sphincteroplasty had been performed in 30 patients with a median of one (range, 1-7) operations. Investigations performed included electromyography (n = 49), pudendal nerve terminal motor latency (n = 71), endoanal ultrasound (n = 49), and manometry (n = 67). Sixty percent of patients had improved continence and 42 (55 percent) considered their surgery to have been successful as attested to by a significant decrease in their incontinence score (from 15.1 +/- 4.5 to 4.3 +/- 4.2; P < 0.0001). Neither patient age, parity, prior sphincteroplasty, cause or duration of incontinence, extent of electromyography damage, size of the endoanal ultrasound defect, nor any manometric parameter correlated with outcome. However, 62 percent of 59 patients with bilaterally normal pudendal nerve terminal motor latencies had a successful outcome compared with only 16.7 percent of 12 patients with unilateral or bilateral prolonged pudendal nerve terminal motor latencies (P < 0.01).

CONCLUSION:

Bilateral normal pudendal nerve terminal motor latencies are the only factors predictive of long-term success after overlappingsphincteroplasty.

Abstract

Laparoscopic colorectal procedures have been accepted for a variety of conditions. We present two cases of HIV-positive who underwent laparoscopic sigmoid colectomy and creation of a stoma for the treatment of sigmoid cancer and disseminated colorectal kaposi sarcoma, respectively. Laparoscopy may be a good option in selected HIV-positive patients.

Abstract

BACKGROUND:

Some indications for laparoscopic bowel surgery are still controversial. However, the use of laparoscopic techniques for the treatment of benign disorders is less often challenged. Moreover, the morbidity of nonresectional procedures is less than that encountered with resectional cases. Therefore, stoma creation seems ideally suited to laparoscopy. The aim of our study was to assess the outcome of laparoscopic stoma creation.

METHODS:

All patients who underwent laparoscopic intestinal diversion were evaluated; parameters included age, gender, indication for the procedure, history of previous surgery, operative time, length of hospitalization, recovery of bowel function, and postoperative complications.

RESULTS:

Between March 1993 and January 1996, 32 patients of a mean age of 42.2 (range 19-72) years (14 males, 18 females) underwent elective laparoscopic fecal diversion (25 loop ileostomy, four loop colostomy, three end colostomy). Indications for fecal diversion were fecal incontinence (n = 11), Crohn’s disease (n = 6), unresectable rectal cancer (n = 4), pouch vaginal fistula (n = 3), rectovaginal fistula (n = 2), colonic inertia (n = 2), radiation proctitis (n = 1), anal stenosis (n = 1), Kaposi’s sarcoma of the rectum (n = 1), and tuberculous fistula (n = 1). Conversion was required in five patients (15.6%) due to the presence of adhesions (three), enterotomy (one), or colotomy (one). All of these five patients had undergone previous abdominal surgery and were operated on early in our experience. Major postoperative complications occurred in two patients (6%) and in both cases consisted of stoma outlet obstruction after construction of a loop ileostomy. One of the two patients had undergone prior surgery. This patient required reoperation, at which time a rotation of the terminal ileum at the stoma site was found. The other patient had a narrow fascial opening which was successfully managed with 2 weeks of self-intubation of the stoma. The mean operative time was 76 (range 30-210) min; mean length of hospitalization was 6.2 (range 2-13) days; stoma function started after a mean of 3.1 (range 1-6) days. Patients with previous abdominal surgery had a longer mean operative time (14/32; 117 min) compared to patients who had no previous surgery (18/32; 55 min) (p < 0.0002). These longer operative times and hospital stay were attributable to extensive enterolysis, which was required in some cases.

CONCLUSION:

In conclusion, laparoscopic creation of intestinal stomas is safe, feasible, and effective. Although the length of the procedure is longer in patients who have had prior surgery, previous surgery is not a contraindication, and even in these cases, a laparotomy can be avoided in the majority of patients. Lastly, care must be taken to ensure adequate fascial opening and correct limb orientation.

Abstract

Video defecography is a dynamic investigation which can influence surgical decision making in constipated patients. A study was therefore undertaken to assess the inter and intraobserver variability in video defecography. Specifically, we sought to assess the interpretation of video defecographies by a group of observers with the same training, guidelines and standards. To determine interobserver variation, four independent observers, two blinded to the patient’s history, reviewed 100 randomly sequenced video defecographies performed in constipated patients. The presence or absence of sigmoidocele, rectocele, intussusception or prolapse was noted. Adequate or improper function of the puborectalis, anal canal opening, anorectal angle (ARA) and grade of emptying of the rectum were also assessed. Two weeks after the initial assessment, intraobserver variation was determined by a repeat blinded review of unlabelled randomly sequenced studies. The results of interobserver accuracy for sigmoidoceles, rectoceles, intussusception, rectal prolapse, rectal emptying, opening of the anal canal, puborectalis contraction and straightening of the ARA and rectal emptying were 89.5%, 46.0%, 87.5%, 97.5%, 86.5%, 88.5%, 83.0%, and 80.0%, respectively. The intraobserver variations were 88.5%, 83.8%, 80.5%, 94.5%, 77.0%, 84.8%, 80.5% and 85.5%, respectively. Prior knowledge of the patient’s history did not significantly influence the outcome. In summery, video defecography has an overall accuracy of 83.3% and as such is a valid tool in assessing constipated patients.

Abstract

AIM:

The aim of this study was to compare the cleansing ability, patient compliance, and safety of two oral solutions for elective colorectal surgery.

METHODS:

All eligible patients were prospectively randomized to receive either 4 l of standard polyethylene glycol (PEG) solution or 90 ml ofsodium phosphate (NaP) as mechanical bowel preparation for colorectal surgery. A detailed questionnaire was used to assess patient compliance. In addition, the surgeons, blinded to the preparation, intraoperatively evaluated its quality. Postoperative septic complications were also assessed. The calcium serum level was monitored before and after bowel preparation. Statistical analysis was performed using the Wilcoxon’s rank-sum test and Fisher’s exact test.

RESULTS:

Two hundred patients, well matched for age, gender, and diagnosis, were prospectively randomized to receive either PEG or NaPsolutions for elective colorectal surgery. All patients completed all phases of the trial. There was a significant decrease in serum calcium levels after administration of both NaP (mean, 9.3-8.8 mg/dl) and PEG (9.2-8.9 mg/dl), respectively (P < 0.0001), with no clinical sequelae. However, patient tolerance to NaP was superior to PEG: less trouble drinking the preparation (17 vs. 32 percent; P < 0.0002), less abdominal pain (12 vs. 22 percent; P = 0.004), less bloating (7 vs. 28 percent), and less fatigue (8 vs. 17 percent), respectively. Additionally, 65 percent of patients who received the NaP preparation stated they would repeat this preparation again compared with only 25 percent for the PEG group (P < 0.0001). Ninety-five percent of patients who received the NaP solution tolerated 100 percent of the solution compared with only 37 percent of the PEG group (P < 0.0001). For quality of cleansing, surgeons scored NaP as "excellent" or "good" in 87 compared with 76 percent after PEG (P = not significant). Rates of septic and anastomotic complications were 1 percent and 1 percent for NaP and 4 percent and 1 percent for PEG, respectively (P = not significant).

CONCLUSION:

Both oral solutions proved to be equally effective and safe. However, patient tolerance of the small volume of NaP demonstrated a clear advantage over the traditional PEG solution.

Comment in

Abstract

A total of 55 women underwent sphincteroplasty for the treatment of faecal incontinence related to anterior defects. Patients were followed prospectively for a mean of 29 months to evaluate the outcome overall and according to age. All patients were evaluated clinically by means of a questionnaire and graded using an incontinence scoring system ranging from 0 (perfect continence) to 20 (complete incontinence). Some 52 patients (95 per cent) had had a previous vaginal delivery and 30 (55 per cent) had a history of previous anal sphincter repair. Physiological and functional parameters in patients with a successful outcome (n = 39) were compared with those in patients with a poor outcome (n = 16). The results were also compared in patients under (n = 39) and over (n = 16) 60 years of age. Overall, patients with a successful outcome had a significant change in mean and maximal resting and squeeze pressures. These changes correlated well with the increase in the high-pressure zone (HPZ) length from 1.0-2.2 cm (P = 0.0002) and with functional outcome (change in incontinence score from 15.3 to 5.8; P < 0.0001). In patients over 60 years of age, a significant change in mean squeeze pressure (P = 0.03) and HPZ length (P = 0.01) was noted and correlated with functional outcome (change in incontinence score from 14.3 to 6.4; P < 0.0001). A successful outcome after anterior sphincteroplasty is related to improvement in sphincter function even in an older population. These results demonstrate that age itself does not seem to be a predictor of poor outcome. Patients should not be denied a repair exclusively on grounds of age.

Abstract

Laparoscopic colorectal procedures have been accepted for a variety of conditions. We present two cases of HIV-positive who underwent laparoscopic sigmoid colectomy and creation of a stoma for the treatment of sigmoid cancer and disseminated colorectal kaposi sarcoma, respectively. Laparoscopy may be a good option in selected HIV-positive patients.