Evacuation Difficulties Research Articles

H-Pouch: New Isoperistaltic Colonic Pouch For Coloanal Anastomosis After Rectal Resection For Cancer. A Pilot Study

To date, there is a consensus to consider colonic J-pouch-anal anastomosis as the standard form of reconstruction after proctectomy for cancer. However, one drawback of colonic J-pouch is evacuation difficulties, which are observed at some degree in almost one-half of patients. To improve functional outcome after coloanal anastomosis, we describe a new technique of isoperistaltic colonic H-pouch. The functional results after construction of this pouch were assessed prospectively in ten patients and compared with those obtained in a control group of matched patients with a colonic J-pouch. At six months and one year, there were no differences between both pouches for bowel function, continence score, and evacuation difficulties. This preliminary study showed that the creation of a new isoperistaltic colonic H-pouch did not improve the functional results after coloanal anastomosis compared with colonic J-pouch. Because colonic H-pouch is technically more complex to fashion, it should not be performed routinely and the J-pouch remains the benchmark for routine clinical practice.

Transverse Coloplasty Pouch After Total Mesorectal Excision: Functional Assessment of Evacuation

Colon pouch reconstruction after total mesorectal excision is functionally superior to straight colorectal/ anal anastomosis. In the long-term, stool evacuation difficulties could jeopardize the functional benefit. The transverse coloplasty pouch presents an alternative to the standard J-pouch. This study was designed to analyze functional outcome and defecography findings after total mesorectal excision and transverse coloplasty pouch reconstruction. Thirty consecutive patients with cancer of the middle and lower third of the rectum underwent a total mesorectal excision and were examined in a prospective study. In all patients, reconstruction was performed with a transverse coloplasty pouch. Pouch and anastomosis were checked by Gastrografin enema postoperatively. Patients were examined within eight months by means of defecography, manometry, pouch volumetry, and a standardized continence questionnaire. Total mesorectal excision with transverse coloplasty pouch anastomosis was performed successfully in all patients. Symptomatic anastomotic leakage was observed in 2 of 30 patients and the radiologic leak rate was 4 of 30. All patients evacuated the pouch completely; none needed enemas or suppositories to facilitate defecation. Twenty-five of 27 patients had a maximum of three bowel movements per day, and all patients were continent for solid stools. Patients with abnormal findings on defecography proved more likely to have anal dysfunction. Transverse coloplasty pouch reconstruction after total mesorectal excision leads to good functional results and is not associated with stool evacuation problems. Urgency and incontinence correlate rather with impaired pelvic floor movement than with pouch size or anal sphincter tonus.

Belgian experience with dynamic graciloplasty for faecal incontinence.

Dynamic graciloplasty (DGP) is an option in patients with end-stage faecal incontinence. The aim of this retrospective multicentre study was to assess early and late outcome after DGP. Sixty consecutive patients with congenital (14) or acquired (40) faecal incontinence or who had undergone total anorectal reconstruction (six) underwent DGP. Patients were followed up for a median of 48 (range 13-117) months. There were no deaths; 75 complications that required 61 reoperations were observed in 44 patients. Loss of muscle stimulation occurred in 22 patients, more frequently after direct nerve stimulation. Evacuation difficulties occurred in 12 patients. Overall, DGP failed in 27 patients, of whom seven had stoma construction. At follow-up, continence to solid stool without stoma was obtained in 47 of 60 patients, although 26 required use of antegrade continence enemas or other measures. Functional outcome was related to the presence of a functioning DGP and a short delay (less than 50 days) of muscle training after transposition. DGP is a major operation with a high morbidity rate; it requires experience and early muscle training. The outcome after DGP should be compared prospectively with that after implantation of an artificial sphincter or other less expensive alternatives.

HYDRAULIC MODEL TEST OF INUNDATION WATER INTRUSION INTO COMPLICATED UNDERGROUND SPACE

A hydraulic model test is conducted by use of the undistorted hydraulic model with 1/30 scale. The studied underground space is the complex one comprising the shopping mall, the parking lot and the subway station. Inundation process there is studied in detail and evacuation possibility is examined based on the depth and velocity of inundation flow. It is found that if the inundation flow invades the studied underground space, the inundation area expands rapidly and the water depth rises very quickly. The studied space also becomes very dangerous by the difficulty of evacuation.

Functional results after the Orr-Loygue transabdominal rectopexy for complete rectal prolapse.

The aim of this study was to assess functional results after Orr-Loygue transabdominal rectopexy for complete rectal prolapse. Thirty-one consecutive patients operated on for complete rectal prolapse between 1995 and 1998 were evaluated preoperatively and postoperatively with regard to anal incontinence, constipation, evacuation difficulties, and overall satisfaction with a standardized questionnaire. Anal continence assessment was based on a clinical scoring system. After a mean follow-up of 28 +/- 13 (range, 12-57) months, no prolapse recurred. Preoperative and postoperative rates of incontinence were 81 percent (25/31) and 55 percent (17/31), respectively (P < 0.03). Continence improved in 24 (96 percent) of the 25 patients who were incontinent before surgery. The mean incontinence score decreased from 11.7 +/- 7.8 preoperatively to 3.2 +/- 4.2 postoperatively (P < 0.001). The self-reported constipation rate was 61 percent (19/31) before surgery and 71 percent (22/31) after surgery (P = nonsignificant). Constipation appeared or worsened in 16 patients (52 percent), whereas it disappeared or improved in 8 (26 percent; P = nonsignificant). Evacuation difficulties increased significantly after surgery from 23 percent (7/31) to 61 percent (19/31; P < 0.003). Ninety-seven percent of patients reported good or very good satisfaction. Transabdominal Orr-Loygue rectopexy resulted in improved continence and a high satisfaction level. Despite a significant postoperative increase in evacuation difficulties, only a 10 percent (nonsignificant) increase in the self-reported constipation rate was observed.

Pouch reconstruction in the pelvis.

ILEAL POUCH RECONSTRUCTION: Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the procedure of choice in mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). Because the disease is cured by surgical resection, functional results, pouch survival prognosis, and disease or dysplasia control are the major determinants of success. There is controversy as to whether the IPAA should be handsewn with mucosectomy or stapled, preserving the mucosa of the anal transitional zone. Crohn's disease is a contraindication for IPAA, but long-term outcome after IPAA is similar to that for MUC in patients with indeterminate colitis who do not develop Crohn's disease. As development of dysplasia and cancer in the ileal pouch have been reported, a standardized surveillance program is mandatory in cases of MUC, FAP, and chronic pouchitis. COLONIC POUCH RECONSTRUCTION: Construction of a colonic pouch is a widely accepted technique to improve functional outcome after low or intersphincteric resection for rectal cancer. Several randomized studies comparing colo-pouch-anal anastomosis (CPA) with straight coloanal anastomosis (CAA) have found the pouch functionally superior. Most controlled studies cover only 1-year follow-up, but randomized studies with 2-year follow-up show similar functional results of CPA and CAA. Evacuation difficulty as initially observed was related to pouch size, and the results with smaller pouches (5-6 cm) are more favorable, showing adequate reservoir function without compromising neorectal evacuation. The transverse coloplasty pouch may offer several advantages to J-pouch reconstruction. Current series question whether the neorectal reservoir is the physiological key of the pouch, but rather the decreased motility. The major advantage reported with colonic pouch reconstruction is the lower incidence of anastomotic complications.

Evaluation of the fascial technique for surgical repair of isolated posterior vaginal wall prolapse

Objective To study the anatomic and functional efficacy and assess long-term success of the fascial technique in the repair of rectocele. Methods Forty-two women with symptomatic posterior vaginal wall prolapse of at least stage II underwent a surgical repair using the technique of reconstruction of the rectovaginal septum. These women were evaluated at 6 weeks and 18 months postoperatively for anatomic improvement in the grade of their rectocele and a functional improvement in their vaginal, bowel, and sexual symptoms. Results Ninety-five percent (40 of 42) were assessed at 6 weeks and 78.5% (33 of 42) attended follow-up at 18 months. Preoperative symptoms included 1) vaginal protrusion (78%); 2) defecation symptoms (76%), which included fecal incontinence alone in 9.5%, evacuation difficulties in 57%, and both fecal incontinence and evacuation difficulties in 9.5%; and 3) sexual dysfunction (33%). At 6-week follow-up there was resolution of vaginal protrusion in 87.5%, and bowel symptoms in 87%. At 18 months there was anatomic cure in 92%, improvement in defecation in 81%, and improvement of sexual dysfunction in 35%. No major complications were seen. Conclusion This technique is effective in providing relatively long anatomic cure of the rectocele and resolution of its symptoms.

Anal achalasia after pull-through operations for Hirschsprung's disease -- preliminary experience with topical nitric oxide.

Following definitive pull-through for Hirschsprung's disease (HD), a minority of patients develop constipation, incontinence and enterocolitis. The cause for these symptoms in some of the patients is believed to be "internal sphincter achalasia" related to abnormal innervation of the sphincter, with an absent anorectal relaxation reflex. Transanal myectomy, posterior sagittal rectal myectomy, anal dilatation and even intrasphincter injection of botulinum toxin have been used to solve this problem. Nitric oxide (NO) has been identified as the chemical messenger of the intrinsic non-adrenergic, non-cholinergic pathway mediating relaxation of the normal internal anal sphincter when applied topically. To evaluate the effect of topical isosorbide dinitrate (DTN) applied to the anus and its role in the management of patients with HD after pull-through who have ongoing difficulties in stool evacuation. Four children, aged 2, 5, 7 and 13 years, who all underwent the Soave operation for Hirschsprung's disease, were assessed. Three patients had recurrent episodes of enterocolitis, and all had symptoms of difficulty in rectal/colonic evacuation. Conservative treatment of repeated anal dilatation under anaesthesia had failed to improve symptoms. A rectal myectomy and conversion of Soave to Duhamel procedure had been done in 2 without significant improvement in symptoms. In all patients, ano-rectal manometry was performed before and after application of DTN paste (1 mg/kg/day in two separate doses) which was continued for a minimum period of 3 weeks. Results. Marked symptom improvement was noted in all 4 children. On manometric assessment the median maximum pressure (pre-DTN application) was 165 mm Hg (range 96 - 250), the median sphincter length 2.7 cm (range 2.3 - 3.1) and the high-pressure zone (HPZ) median length 1.6 cm (range 1.2 - 2.1). After application of DTN paste, the maximum pressure dropped by a median of 88 mm Hg (range 46 - 90), total sphincter length shortened to a median of 2.1 cm and the HPZ by a median total length of 1.4 cm (range 0.01 - 0.9). In addition, vector volume was reduced by a median of 59 % (range 40.5 - 77). From these results, it is evident that DTN paste is not only an adjunct in the investigation, but can also be used as a temporary form of treatment of obstructive symptoms in Hirschsprung's disease patients.

Management of hemorrhoidal disease in patients with chronic spinal cord injury.

Hemorrhoidal disease is a common pathology in patients with chronic spinal cord injury (SCI). We describe our experience with the primary approach to this problem at the Proctology Division of the Sheba Medical Center. We treated 29 patients (26 men) with paraplegia due to SCI between 1995 and 1999. The mean age was 49 years (range, 22-74 years). All patients had hemorrhoids in stages ranging between II and IV. Main complaints were rectal bleeding (83%), difficulties in evacuation (38%) and discomfort or pain (28%). Eleven patients (38%) were treated conservatively (e. g. diet, hygiene and laxatives), while 18 patients (62%) underwent either banding or sclerotherapy of hemorrhoids or both. No major complication were observed. In 28 of 29 patients (96%), there was a significant reduction or cessation of bleeding and/or relief of symptoms; one patient (3%) required hemorrhoidectomy. Of the 28 successful treatments, 16 (57%) had partial reduction of bleeding or relief of symptoms, while in 12 (43%) response was complete. Of those who were treated conservatively, 9 (82%) had partial and 2 (18%) had complete relief of symptoms. Of those who had banding/sclerotherapy, 7 (41%) had partial and 10 (59%) had complete relief. We also examined the effect of perianal sensation on the treatment outcome. Of 16 patients with complete anesthesia, 11 (69%) had partial and 5 (31%) had complete relief, whereas of the 12 patients with preserved sensation, 5 (42%) had partial and 7 (58%) had complete relief. In conclusion, the approach of banding or sclerotherapy of hemorrhoids in SCI patients is safe and effective. When sensation of the perianal region is preserved, the outcome seems to be better. The cause of SCI has no impact on the treatment results. There was no difference in the outcome of treatment between patients with stage II and stage III hemorrhoids; patients with stage IV hemorrhoids seem to do worse than those with stages II and III.

Comparison of the Moskowitz criteria and the pouchitis disease activity index (PDAI) for diagnosis of ileoanal pouch inflammation.

To prospectively compare two indices for diagnosis of pouchitis: Moskowitz criteria and pouchitis disease activity index (PDAI). Fifty-six consecutive patients with an ileoanal pouch for ulcerative colitis were recruited. A clinical questionnaire was composed and the Oresland functional score calculated. Pouchoscopy and biopsy were performed after cleansing of the pouch. Seven patients had pouchitis according to both Moskowitz and PDAI ('positive' group). Five patients had PDAI > or = 7, but did not fulfil the Moskowitz criteria ('negative' group). The pouchoscopy and Oresland functional scores were similar between the two groups. The biopsy neutrophilia and ulceration were more prominent in the 'positive' group (chi2=5.18, P < 0.05), whereas urgency (chi2=8.4, P < 0.001), evacuation difficulties (chi2=5.18, P < 0.05) and history of bleeding per pouch (chi2=4.18, P < 0.05) were more pronounced in the 'negative' group. Moskowitz criteria may be broadly in agreement with the PDAI; these, however, cannot be regarded as interchangeable.

Management of bowel dysfunction: evacuation difficulties.

Bowel dysfunction affects many people and encompasses a variety of problems. This article examines the different forms of bowel dysfunction and considers the nurse's role in caring for patients with this disorder, including manual evacuation.

Clinical evaluation and management of neurogenic bowel after spinal cord injury.

To assess the state of the neurological bowel in spinal cord injured (SCI) patients, design and apply a program for the comprehensive management of neurogenic bowel and evaluate outcome. Out-patient in a Rehabilitation Service. Thirty-eight SCI patients, 12 (32%) with complete lesions of more than 5 years duration. Observational, longitudinal and prospective. Pre and post intervention. Pre and post SCI intestinal function was evaluated clinically prior to beginning program. The presence of GI symptoms were studied. Laboratory work-up included colonic transit time (CTT), anorectal manometry and recto-colonoscopy. An intestinal program was designed, in order to achieve an effective and efficient evacuation in a predictable and socially acceptable time, to avoid short and long term complications and eliminate inadequate intestinal evacuation habits. Pre and post SCI difficulty in intestinal evacuation (DIE) was increased (from 2.6% to 26.3%). The most frequent GI symptom was abdominal distention (53%). Colonic inertia was present in 49% of CTT, internal anal sphincter pressure was normal or increased in 77% and rectoanal inhibitory reflex was present in 88%. With the intestinal program, the incidence of DIE was reduced to 8.8%, manual extraction (ME) was reduced from 53% to 37%. Excellent and good results were obtained in 56% of the patients. The proposed intestinal program is effective in the rehabilitation of SCI patients with neurogenic bowel. It is essential to initiate these physiological and safe procedures as soon as possible after sustaining the injury; this will lead to better results and to the elimination of inadequate intestinal maneuvering in the future Spinal Cord (2000) 38, 301 - 308.

Detection of a Rectocele-Like Prolapse in the Colonic J-Pouch Using Pouchography: Cause or Effect of Evacuation Difficulties?

Detection of a Rectocele-Like Prolapse in the Colonic J-Pouch Using Pouchography: Cause or Effect of Evacuation Difficulties?

Horizontal inclination of the longitudinal axis of the colonic J-pouch: defining causes of evacuation difficulty.

Functional outcome after low anterior resection for rectal cancer is improved by the construction of a colonic J-pouch. One disadvantage of this type of reconstruction is evacuation difficulty, which has been associated with large pouches. The purpose of this study was to elucidate the causes of evacuation difficulty in large pouches using pouchography. The angle between the longitudinal axis of the pouch and the horizontal line (pouch-horizontal angle) on lateral pouchography was determined in 26 patients with 10-cm J-pouch reconstructions (10-J group) and 27 patients with 5-cm J-pouch reconstructions (5-J group). Measurement were made at three months, one year, and two years after surgery. Clinical function was evaluated using a questionnaire one year postoperatively. The pouch-horizontal angle in the 10-J group was significantly smaller than that in the 5-J group at all three time points. In both groups the pouch-horizontal angle at one year was significantly smaller than that at three months. There were no significant differences between the pouch-horizontal angles at one and two years. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. The evacuation difficulty observed in patients with large colonic J-pouch reconstructions may be attributed to the development of a horizontal inclination within one year of surgery.

Enlargement of colonic pouch after proctectomy and coloanal anastomosis: potential cause for evacuation difficulty.

Although the functional outcome after low anterior resection for rectal cancer using colonic J-pouch reconstruction is superior to that using conventional straight reconstruction, the one drawback of colonic J-pouch reconstruction is difficulty with evacuation. Recently it has been suggested that construction of a larger colonic J-pouch causes the evacuation difficulty. The purpose of this study was to elucidate the cause of evacuation difficulty with colonic J-pouch reconstruction. We compared pouchography of 26 patients with 10-cm colonic J-pouch reconstructions (10-J group) and 27 patients with 5-cm colonic J-pouch reconstructions (5-J group) at three months, one year, and two years after surgery. Functional assessments were performed one year postoperatively. Clinical function was evaluated using a questionnaire. Evacuation function was evaluated by the balloon expulsion and saline evacuation tests. The greatest width of the pouch in the 10-J group in the anteroposterior view was significantly greater than that in the 5-J group at all three measurement times (3 months, 4.9 vs. 4 cm; P = 0.0011; 1 year, 9 vs. 5.6 cm; P < 0.0001; 2 years, 9.2 vs. 5.8 cm; P < 0.0001). The value in the 10-J group at one year after surgery was 1.9 times that at three postoperative months; in the 5-J group this ratio was 1.4. There was a significant difference between these ratios (P < 0.0001). No significant difference existed between the values at two years and one year after surgery in either the 10-J or the 5-J group. An evacuation difficulty was significantly more common in the 10-J group than the 5-J group. Evacuation function in the 10-J group was significantly inferior to that in the 5-J group. The evacuation difficulty observed in patients with larger colonic J-pouch reconstructions is associated with excessive distention of the pouch occurring within one year of surgery.

Treatment of enterocele by obliteration of the pelvic inlet.

Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This hernial sac contains either sigmoid colon or small bowel. It is well known that enteroceles are associated with symptoms of pelvic discomfort. It is unclear whether enteroceles contribute to evacuation difficulties. Controversies also exist regarding their treatment of choice. The aim of the present prospective study was to evaluate the impact of obliteration of the pelvic inlet on evacuation difficulties and on symptoms of pelvic discomfort. From October 1994 to August 1996 20 females (median age, 53; range, 41-73 years) with symptomatic enterocele diagnosed on evacuation proctography underwent obliteration of the pelvic inlet with a nonabsorbable Mersilene mesh. All patients presented with pelvic discomfort, characterized by feelings of prolapse (n=20), pelvic pressure (n=16), lower abdominal pain (n=13), and false urge to defecate (n=15). Symptoms of obstructed defecation were noted in 15 patients. Six months after repair, evacuation proctography with opacification of the small bowel and the vagina was repeated. The median duration of follow-up was 25 (range, 10-34) months. A persistent or recurrent enterocele was observed in none of the patients. All symptoms of pelvic discomfort disappeared except feelings of a false urge to defecate, which persisted in 27 percent of cases. Symptoms of obstructed defecation persisted in all patients with evacuation difficulties. In patients with pelvic discomfort enterocele should be considered as a possible causative factor. It is unlikely that this abnormality contributes to the problem of obstructed defecation. In patients with a symptomatic enterocele, obliteration of the pelvic inlet with a Mersilene mesh is an adequate treatment.

A population survey of bowel habits in urban Swiss men

The aim of this study was to determine the prevalence of symptoms related to constipation in urban Swiss men and to identify associated sociodemographic factors and health habits. A sample of 773 men aged between 35 and 74 years randomly selected from the Geneva population answered a questionnaire on bowel habits during a personal interview in a mobile epidemiological unit. ‘Constipation’ was reported by more than 6% of subjects, difficulties in stool evacuation by approximately 5% and less than three stools per week by approximately 2%. These symptoms appeared less prevalent in subjects with post-baccalaureate education (the excess prevalence of self-reported constipation, difficulty in stool evacuation and frequent daily defecation was greater than 5%). Smokers were more likely to have a frequency of 3–7 stools per week and were less affected by frequent daily defecation. Self-reported constipation was more prevalent in subjects with a higher dietary fibre intake. No statistically significant effects of age, nationality, dietary fat or physical activity were observed. These results are consistent with national surveys in US populations. Factors related to socioeconomic status or education may be a cause of constipation in men, but they still need to be elucidated.

Comparison between the colonic J pouch-anal anastomosis and healthy rectum: Clinical and physiological function

Colonic pouch anastomosis after restorative rectal excision obviates much of the early dysfunction which is commonly experienced with the traditional straight coloanal anastomosis. A disadvantage with colonic pouch reconstruction, however, appears to be impaired evacuation. Distal bowel function was investigated in 30 patients with a colonic J pouch anastomosis at 1 year after surgery and in 39 control subjects. While the degree of urgency and incontinence were similar, the patients with a pouch experienced more difficult evacuation. The maximum volume of the pouch (median 235 ml) and rectum (221 ml) was similar, but the rectum was more compliant (3.5 versus 2.6 ml per cmH2O, P < 0.01). The sensory function in terms of initial sensation of filling, urge to defaecate and maximum distension pressure was impaired in those with pouches. The amplitude of the neorectal and anal canal motility pattern was threefold that of controls. Maximum volume of the pouch was significantly associated with degree of impaired evacuation; the larger the volume the more difficult the evacuation. To reduce evacuation difficulty the pouch should not be fashioned too large. No conclusion about optimal pouch size could be drawn. In spite of fundamental physiological differences between a pouch and healthy anorectum, patients with a colonic pouch will usually experience satisfactory clinical bowel function.

The Electrically Stimulated Gracilis Neosphincter Incorporated as Part of Total Anorectal Reconstruction after Abdominoperineal Excision of the Rectum

The authors investigated the feasibility and effectiveness of combining electrically stimulated gracilis neoanal (ESGN) sphincter and a coloperineal anastomosis in selected patients after abdominoperineal excision of the rectum (APER). The ESGN is effective in the treatment of idiopathic fecal incontinence. Between March 1989 and September 1993, 12 patients (9 men, 3 women) with a median age of 59.25 years (range, 45-70) underwent the procedure. The underlying disease was adenocarcinoma in 10, anal malignant melanoma in 1, and a sweat gland tumor in the other. In all patients, a sphincter saving resection was contraindicated. The procedure was performed in stages. Stage 1 involved a conventional APER with the formation of a perineal stoma. Eleven patients underwent a vascular delay procedure. All patients were defunctioned. In stage 2, the gracilis was mobilized, transposed around the anal canal, and the electrodes and hardware needed for electrical stimulation were implanted. Once muscle conversion was complete, the defunctioning stoma was closed. Eight patients were closed successfully. In seven of the eight patients, complete physiologic measurements were taken. Median basal and maximum neosphincter pressures were 30 and 122 cm H2O, respectively, at the start of electrical stimulation and 22.5 and 76.2 cm H2O, respectively, after 1 year. Median functioning neosphincter pressure was 36 cm H2O at 1 year. All of the patients whose stomas were closed experienced episodes of incontinence to solid stool and wore pads for persistent fecal soiling. They all reported difficulty in evacuation. Despite imperfect continence, no patient wished to go back to life with a stoma. The incorporation of ESGN as part of total anorectal reconstruction is technically feasible. The majority of patients are satisfied with their function and pleased to avoid a permanent stoma.

Apical Pouch Bridge Syndrome after IIeal J Pouch-Anal Anastomosis

After ileal J pouch-anal anastomosis, a residual septum in the J reservoir occasionally causes evacuation difficulties and obstructive symptoms. In our experience, 10 of 134 ileoanal anastomosis patie