Constipation Score Research Articles

Randomized clinical trial of transcutaneous electrical posterior tibial nerve stimulation versus lateral internal sphincterotomy for treatment of chronic anal fissure

ObjectivesThe objective of this study was to evaluate the efficacy of transcutaneous electrical posterior tibial nerve stimulation in treatment of patients with chronic anal fissure and to compare it with the conventional lateral internal sphincterotomy. Patients and methodsConsecutive patients with chronic anal fissure were randomly allocated into two treatment groups: transcutaneous electrical posterior tibial nerve stimulation group and lateral internal sphincterotomy group. The primary outcome measures were number of patients with clinical improvement and healed fissure. Secondary outcome measures were complications, VAS pain scores, Wexner's constipation and Peascatori anal incontinence scores, anorectal manometry, and quality of life index. ResultsSeventy-three patients were randomized into two groups of 36 patients who were subjected to transcutaneous electrical nerve stimulation and 37 patients who underwent lateral internal sphincterotomy. All (100%) patients in lateral internal sphincterotomy group had clinical improvement at one month following the procedure in contrast to 27 (75%) patients in transcutaneous electrical nerve stimulation group. Recurrence of anal fissure after one year was reported in one (2.7%) and 11 (40.7%) patients in lateral internal sphincterotomy and transcutaneous electrical nerve stimulation groups respectively. Resting anal pressure and functional anal canal length were significantly reduced after lateral internal sphincterotomy. ConclusionTranscutaneous electrical posterior tibial nerve stimulation for treatment of chronic anal fissure is a novel, non-invasive procedure and has no complications. However, given the higher rate of clinical improvement and fissure healing and the lower rate of fissure recurrence, lateral internal sphincterotomy remains the gold standard for treating chronic anal fissure.

PTU-181 An exploratory qualitative study investigating patients’ experiences of constipation and how their self-reported symptoms and quality of life compare with currently available validated measures

<h3>Introduction</h3> The most widely-used validated questionnaires for assessing constipation are the Patient Assessment of Constipation Symptoms (PAC-SYM) and the Cleveland Clinic Constipation Score (CCCS). We aimed to assess patients’ reported symptoms of constipation, preferred terminology, and quality of life (QoL) issues, and whether these are reflected in currently available validated questionnaires. <h3>Method</h3> Nineteen semi-structured interviews were conducted with patients presenting with constipation to assess their symptoms, the terminology they preferred, suitability of existing assessment tools, and to explore participants’ constipation-related QoL issues. An inductive thematic framework was adopted to identify subthemes. Eleven clinicians rated the clinical importance of the symptoms and QoL issues reported by patients. <h3>Results</h3> Three main themes were identified: a) language used to describe bowel issues, b) symptoms and toilet behaviours and c) issues regarding QoL. <i>“Stool”</i>and <i>“motions”</i>were the most acceptable words to describe stool, and <i>“going to the toilet”</i>for describing the act of defecation. The words <i>“digital assistance”, “evacuation”</i>and <i>“defecation”</i>were poorly understood. Of the 12 most troublesome symptoms patients reported, only four are included in the PAC-SYM and five in the CCCS. Six of the symptoms reported as most troublesome are not included in either the PAC-SYM or the CCCS. Although all clinicians reported uncontrolled leakage of stool as a clinically important symptom, this was not included in either assessment tool. Of the symptoms that clinicians thought to be the most clinically relevant, two were not reported to be bothersome by patients (use of laxatives, straining). Only a small number of clinicians perceived some of the most bothersome symptoms reported by patients as clinically relevant. <h3>Conclusion</h3> Patients presenting with constipation report a range of individual symptoms and QoL issues, most of which are not included in validated questionnaires. The terminology used in these questionnaires for describing bowel issues is poorly understood by patients. Furthermore, there is a discrepancy between patients and clinicians on what symptoms and QoL issues are perceived to be important. The development of a new assessment tool evaluating the wide range of constipation-related symptoms and QoL issues is needed. <h3>Disclosure of interest</h3> E. Dimidi: None Declared, L. Dibley: None Declared, N. Cotterill Consultant for: Astellas Pharma Europe B. V. and Procter and Gamble, C. Knowles: None Declared, S. Scott: None Declared, K. Whelan: None Declared, C. Norton: None Declared.

PTH-263 Analysing short-term outcomes and patient satisfaction with laparoscopic ventral mesh rectopexy

Introduction Laparoscopic ventral mesh rectopexy (LVMR) has been used to treat rectal prolapse and obstructive defaecation syndrome (ODS). However, limited outcome data have been reported. The purpose of this study was to evaluate the indications and outcomes of LVMR by comparing pre-and postoperative function and quality of life. Method A Prospective database identified all patients undergoing from November 2011 to July 2014. Cleveland clinic constipation score (CCCS), St Mark’s incontinence score (SMIS), Quality of life SF12 (QOL) and Cleveland surgery satisfaction questionnaire were used to evaluate surgical outcomes and patient satisfaction retrospectively. Results 28 LVMRs (26 women, mean age +/− SD, 69 +/− 29 years, median 65 years), were performed during the study period. 25 patients were followed up (median 71 days, range 39 to 197 days). 78% of patients responded to the questionnaire with 15 patients suffered from rectal prolapse and 7 patients ODS). Eight patients underwent LVMR following perineal repair, of these 1 reported recurrence of prolapse and faecal leakage. The mean score for CCCS and SMIS were compared pre and post-operatively. Both showed a reduction in symptoms, scoring 11.0 vs. 7.0 (P Changes in physical component and mental component summary were observed using QOL SF-12 with no statistically significance and a mean difference of 4.02 and 5.68. 82% of patients completing the Cleveland surgery satisfaction questionnaire would recommend LVMR with a mean score of 4.3 out of 5. Conclusion LVMR is associated with low recurrence and a significant improvement in symptoms of pelvic floor dysfunction. Improvement in QOL was observed with the majority of patients recommending this procedure. Disclosure of interest None Declared.

Constipation is not associated with diverticular disease – Analysis of 976 patients

BackgroundIn the light of controversial data in the literature, the present study was designed to evaluate potential associations between colonic diverticular disease, constipation and quality of life. DesignWe prospectively enrolled 976 consecutive patients, who participated in the nationwide colorectal cancer screening program in four medical centers between 2008 and 2009. All patients underwent full colonoscopy and completed a standardized questionnaire. The severity of constipation was assessed by the validated Wexner constipation score. Quality of Life (QOL) was evaluated by the SF-12 health score. ResultsThe median age was 62 years (range 22–90) and the male to female ratio was 1:1. Colonic diverticular disease was found in 290 participants (30%). Age, body mass index and diabetes mellitus were significantly associated with the presence of diverticular disease (p < 0.0001, p = 0.0007 and p = 0.0178).The median constipation score in patients with diverticular disease was 3 (range 0–18), and comparable to patients without diverticula (p = 0.1073). The physical component summary of the SF-12 was significantly reduced in patients with diverticular disease (p = 0.0038). ConclusionThis large population based study revealed no association between colonic diverticular disease and constipation. Notably, the presence of diverticular disease significantly impacts quality of life.

The translation and validation of the Japanese version of the patient assessment of constipation quality of life scale.

The aim of the present study was to conduct a psychometric evaluation of the patient assessment of constipation quality of life scale (PAC-QOL) in the Japanese language. The PAC-QOL was translated into Japanese. After being linguistically validated, the Japanese version of the PAC-QOL was administered to a sample of 121 patients. Validation studies were conducted to evaluate the internal consistency reliability (Cronbach's alpha), reproducibility [intraclass correlation coefficients (ICCs)], the convergent validity (correlated with the Short-Forum 36 Health Survey), the discriminant validity [correlated with the constipation scoring system (CSS)], the cross-sectional validity (analysis of variance models), and responsiveness (effect size) of the PAC-QOL scales. The internal consistency was good for all of the scales (Cronbach's alpha coefficient >0.7) and reproducible (ICCs >0.7). The four scales of the PAC-QOL were significantly correlated with the Short-Forum 36 Health Survey (P<0.01 except for the satisfaction subscale) and the CSS scores (P<0.01 except for the satisfaction subscale). The PAC-QOL scale scores were significantly associated with constipation severity (P<0.05). The effect size in patients reporting improvements in constipation over the treatment period was moderate to large, with a subscale effect size ranging from 0.69 to 1.18 and an overall scale effect size of 1.12. Similar findings were observed in the original validation study. The linguistic and psychometric evaluation demonstrated the validity of the Japanese version of the PAC-QOL.

Investigation of quality of life in rectal cancer patients after anterior resection and expression of 5-hydroxytryptamine in rectal mucosa before and after operation

To investigate the quality of life of rectal cancer patients after anterior resection and the role of 5-hydroxytryptamine(5-HT) in the pathogenesis of anterior resection syndrome (ARS). Between November 2012 and October 2014, 90 rectal cancer patients who underwent Dixon procedure in the Institute of Surgery Research, Daping Hospital, Third Military Medical University, and developed ARS postoperatively were enrolled in the study. By clinic interview and telephone follow-up, they were investigated according to the 4 questionnaires, including gastrointestinal quality of life index(GIQLI), Wexner constipation and incontinence score(WCS, WIS), and 36-item short form health survey(SF-36). Associated clinical data and above parameters were compared between postoperative 0-6 months and 7-24 months. Expression of 5-HT in rectal mucosa was determined by immunohistochemistry preoperatively and postoperatively. The GIQLI, WCS and WIS were significantly improved in 7-24 months group compared with those in 0-6 months group(all P<0.05). Furthermore, the SF-36 test result also showed significant improvement in the terms of physical function, physical role, vitality, social function, emotional role and health changes spheres in 7-24 months group(P<0.05). 5-HT expression in rectal mucosa(upper anastomosis 3402.95±1876.24, lower anastomosis 3045.35±1373.59 of ARS patients was significantly down-regulated compared with the preoperative expression(rectal margin mucosa 7176.60±3927.61)(P<0.05). Patients with ARS experience a significant trend toward recovery in their whole long-term quality of life. The down-regulation of 5-HT expression in rectal mucosa after surgery may be related with the pathogenesis of ARS.

Laparoscopic ventral rectopexy for rectoanal intussusception: postoperative evaluation with proctography.

Laparoscopic ventral rectopexy can relieve symptoms of obstructed defecation and fecal incontinence in patients with rectoanal intussusception. However, pelvic floor imaging after surgery has not been reported. This study was designed to assess the outcome of patients who underwent laparoscopic ventral rectopexy for rectoanal intussusception, with special reference to the postoperative findings on evacuation proctography. This study was a retrospective analysis of prospectively collected data. The study was conducted from 2012 to 2013 at the Department of Surgery, Kameda Medical Center, Japan. We included 26 patients with symptomatic rectoanal intussusception. Laparoscopic ventral rectopexy was performed. Evacuation proctography was performed before and 6 months after the procedure. Defecatory function was evaluated using the Constipation Scoring System and Fecal Incontinence Severity Index. Of 26 patients with rectoanal intussusception preoperatively, 22 had symptoms of obstructed defecation and 21 complained of fecal incontinence. Postoperatively, rectoanal intussusception was eliminated in all patients, though 8 developed recto rectal intussusception. There was an overall reduction in both grade 2 rectocele size (median preop 26 mm vs. postop 11 mm; p < 0.0001) and pelvic floor descent (median preop 26 mm vs. postop 20 mm; p < 0.0001). 6 months after surgery, a reduction of at least 50% was observed in the Constipation Scoring System score for 9 patients (41%) with obstructive defecation and in the Fecal Incontinence Severity Index score for 14 incontinent patients (67%). This was a preliminary study with a small sample size, no control group, and short follow-up time. Evacuation proctography showed anatomical correction in patients with rectoanal intussusception who underwent laparoscopic ventral rectopexy. However, the data also indicate that such correction does not necessarily result in meaningful symptomatic relief.

Long-term results following sacral nerve stimulation for chronic constipation.

The long-term outcome of sacral nerve stimulation (SNS) for chronic functional constipation was assessed. Patients who received a definitive SNS implant for chronic functional constipation only (according to the Rome III criteria) and were followed up for at least 3years were included in this study. Slow transit constipation (STC) was distinguished from obstructed defaecation (OD) and mixed/undetermined constipation (MU). Constipation features, Cleveland Clinic Constipation score (CCCS) and SF-36 questionnaire data were collected; physiological tests were performed. Forty-two out of 61 patients suitable for SNS received a definitive implant (14 for STC, 15 for OD, 13 for MU). Following SNS device implantation (mean follow-up 51±15months), the baseline CCCS (17±6) dropped to 9±6 (P<0.001) and 47% of patients had an improvement in the CCCS of more than 50%. Such improvement was more significant in patients with OD. Anal pressures did not change, while threshold and urgency rectal sensation significantly decreased, in particular in patients with OD. All aspects of patients' health status (SF-36) improved significantly following SNS; this was more marked in patients with OD. Data from this study suggest that the clinical efficacy of SNS can be prolonged in constipated patients, but in both the preliminary diagnostic assessment and pathophysiological interpretation every effort should be made to select patients for SNS. Although SNS showed efficacy in a low percentage of patients with STC, patients with OD were more responsive.

Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease?

Constipation and incontinence are significant problems following pull-through surgery for Hirschsprung disease (HD). There is evidence that these problems improve with time. However, there is also evidence showing no improvements and furthermore, significant long-term data are lacking for the newer endorectal pull-through. We aim to determine if there is clinical evidence that show improvements in functional outcomes with time after an endorectal pull-through surgery for HD. We utilized the validated pediatric incontinence and constipation scoring system (PICSS) to score 51 consecutive children 3 months to 15 years posttransabdominal or transanal endorectal pull-through for HD. Cases of total colonic aganglionosis and Down syndrome were excluded. PICSS scores below the age-specific lower limit 95% confidence interval scores represent incomplete continence or constipation, respectively. We performed linear regression to analyze the relationship between PICSS scores and the follow-up duration and then compared the demographics of children with and without incomplete continence and constipation, respectively. Significance was set at p < 0.05. The median age at PICSS interview was 71 months (range, 6-191 months). Incontinence scores obtained from 42 children older than 35 months showed a positive relationship with the follow-up duration (p = 0.03). Constipation scores obtained from 51 children were unrelated to follow-up duration (p = 0.486). When demographics were compared, the continent children had longer follow-up than those with incomplete continence (mean, 111.64 vs. 69.19 months; p = 0.051), however follow-up duration did not differ in the group of constipated children compared with the nonconstipated group (mean, 61.88 vs. 71.80 months; p = 0.321). These findings suggest that after an endorectal pull-through, improved continence should be expected with time but constipation often continues to be an ongoing problem.

Manometric analysis of the influence of rectal content on anal pressures in chronically constipated patients

ObjectiveThe aim of our study was to analyze whether the presence of content in the rectum influences the anorectal manometry examination results in chronically constipated patients. MethodsWe evaluated 38 chronically constipated patients, 36 women and 2 men, with an average age of 53.55 years of age, all with a score above 10 on the Agachan Constipation Scoring System. All the patients underwent rectal preparation and then had the anorectal manometry examination without rectal content and after 5min had it with a rectal balloon inflated with 200ml of air in the rectum. Statistical analysisThe statistical parametric paired-t test was applied in order to verify the difference in response between the groups after an intervention, adopting a significant level of 5% (p<0.05). ResultsThe anal pressure was analyzed from the standard anal manometry examination and we found a statistically significant influence on the manometric results for the patients’ average resting pressures, absolute average contractions, average contractions, evacuations, and sustained contractions in the functional anal canals. ConclusionThe presence of rectal content influences the manometric values of average resting pressure, average absolute contraction, average contraction, evacuation, and average sustained contractions in the functional anal canal in the group of chronically constipated patients.

Impact of diabetes mellitus on quality of life in patients with breast cancer

Objective To investigate the impact of diabetes on quality of life in breast cancer patients. Methods A cross-sectional study was conducted among 3 344 community patients suffering from breast cancer during April to July 2013, in Shanghai. Data were collected using a questionnaire, which included socio-demographic situation, diagnosis, and treatment of cancer, as well as diabetes mellitus. European Organization for Research and Treatment of Cancer QOL Questionnaire-C30(EORTC QLQ-C30)Simplified Chinese Version and Functional Assessment of Cancer Therapy(FACT-G)Simplified Chinese Version were used to investigate the quality of life in the patients. The quality of life scores in breast cancer patients with and without diabetes were compared. Results The prevalence of diabetes was 14.38% in the patients with breast cancer. Breast cancer patients without diabetes reported significantly higher EORTC QLQ-C30 scores in physical functioning, role functioning, cognitive functioning, emotional functioning, social functioning, global health, lower EORTC QLQ-C30 scores in fatigue, pain, dyspnoea, insomnia, appetite loss, constipation, diarrhoea, and higher FACT-G scores in physical well-being, social/family well-being, emotional well-being, functional well-being, compared with the patients with diabetes(P<0.05). Conclusions Diabetes mellitus affects the quality of life in patients with breast cancer. Integrated measures for chronic disease management should be taken to improve the quality of life in patients with breast cancer as well as diabetes mellitus. (Chin J Endocrinol Metab, 2015, 31: 43-46) Key words: Diabetes; Breast cancer; Quality of life

Sacral anterior root stimulation improves bowel function in subjects with spinal cord injury.

Cross-sectional study. To evaluate the long-term effect of the sacral anterior root stimulator (SARS) on neurogenic bowel dysfunction in a large, well defined spinal cord injury (SCI) cohort. Department of Neuro-Urology, Bad Wildungen, Germany. Subjects undergone surgery at for SARS-SDAF (sacral deafferentation) between September 1986 and July 2011 (n=587) answered a questionnaire. In total, 277 SARS subjects were available for the baseline (recall) and follow-up comparison. Median age was 49 years (range: 19-80), time from SCI to surgery was 10 years (range: 0-49) and from surgery to follow-up 13 (range: 1-25). Of the responders 73% used SARS for bowel emptying. On visual analog scale (VAS) ranging from 0-10 (best), satisfaction with SARS was 10. Baseline and follow-up comparison showed a decline in the median VAS score 0-10 (worst) for bowel symptoms from 6 (range: 4-8) to 4 (range: 2-6), P<0.0001; median neurogenic bowel dysfunction score from 17 (range: 11-2) to 11 (range: 9-15), P<0.0001; median St Marks score from 4 (range: 0-7) to 4 (range: 0-5), P=0.01; and median Cleveland constipation score from 7 (range: 6-10) to 6 (range: 4-8), P<0.0001. Use of suppositories, digital evacuation and mini enema and subjects totally dependent on assistance during defecation were significantly lower after SARS. The SARS has the potential to be one of the few treatment methods targeting multiple organ dysfunctions following SCI.

Laparoscopic ventral rectopexy using biologic mesh for the treatment of obstructed defaecation syndrome and/or faecal incontinence in patients with internal rectal prolapse: a critical appraisal of the first 100 cases

Laparoscopic ventral mesh rectopexy (LVR) is gaining wider acceptance as the preferred procedure to correct internal as well as external rectal prolapse associated with obstructed defaecation syndrome and/or faecal incontinence. Very few reports exist on the use of biologic mesh for LVR. The aim of our study was to report the complication and recurrence rate of our first 100 cases of LVR for symptomatic internal rectal prolapse and/or rectocele using a porcine dermal collagen mesh. Prospectively collected data on LVR for internal rectal prolapse were analysed. Surgical complications and functional results in terms of faecal incontinence (measured with the Faecal Incontinence Severity Index=FISI) and constipation (measured with the Wexner Constipation Score=WCS) at 3, 6 and 12months were analysed. It was considered an improvement if FISI or WCS scores were reduced by at least 25% and a cure if the FISI score decreased to <10 and the WCS decreased to <5. Between April 2009 and April 2013, 100 consecutive female patients (mean age 63years, range 24-88years) underwent LVR. All patients had internal rectal prolapse (grade III [n=25] and grade IV [n=75] according to the Oxford classification) and rectocele. Mean operative time was 85±40min. Conversion rate to open technique was 1%. There was no post-operative mortality. Overall 16 patients (16%) experienced 18 complications, including rectal perforation (n=1), small bowel obstruction (n=2), urinary tract infection (n=8), subcutaneous emphysema (n=3), wound haematoma (n=2), long lasting sacral pain (n=1) and incisional hernia (1). Median post-operative length of stay was 2days. Ninety-eight out of 100 patients completed follow-up. At the end of follow-up, the mean FISI score improved from 8.4 (±4.0 standard deviation (SD) p=0.003) to 3.3±2.3 SD (p=0.04). Incontinence improved in 37 out of 43 patients (86%), and 31 patients (72%) were cured. Similarly, the mean WCS score improved from 18.4±11.6 SD to 5.4±4.1 SD (p=0.04). Constipation improved in 82 out of 89 patients (92%), and 70 patients (79%) were cured. No worsening of continence status, constipation or sexual function was observed. Fourteen patients (14%) experienced persistence or recurrence of prolapse. LVR using biologic mesh is a safe and effective procedure for improving symptoms of obstructed defaecation and faecal incontinence in patients with internal rectal prolapse associated with rectocele.

Diagnostic value of plain abdominal radiography in stroke patients with bowel dysfunction.

ObjectiveTo evaluate the diagnostic value of plain abdominal radiography in stroke patients with bowel dysfunction.MethodsA total of 59 stroke patients were recruited and assigned into constipation or non-constipation group. Patients were interviewed to obtain clinical information, constipation score, and Bristol stool form scale. The total and segmental colon transit time (CTT) was measured using radio-opaque markers (Kolomark). The degree of stool retention was evaluated by plain abdominal radiography and scored by two different methods (Starreveld score and Leech score). The relationship between the clinical aspects, CTT, and stool retention score using plain abdominal radiography was determined.ResultsAverage constipation score was 4.59±2.16. Average Bristol stool form scale was 3.86±1.13. The total and segmental CTTs showed significant differences between the constipation and non-constipation groups. There was statistically significant (p<0.05) correlation between the total CTT and constipation score or between Starreveld score and Leech score. Each segmental CTT showed significant correlation (p<0.05) between segmental stool retention scores.ConclusionThe stool retention score showed significant correlation with constipation score as well as total and segmental CTT. Thus, plain abdominal radiography is a simple and convenient method for the evaluation of bowel dysfunction in stroke patients.

A New Acid-Resistant Seamless Capsule of Bifidobacterium Improves Chronic Constipation in Patients on Maintenance Hemodialysis

Objective: To assess the therapeutic efficacy of a new acid-resistant seamless capsule of Bifidobacterium supplements (Bs) for chronic constipation (Cc) in patients on maintenance hemodialysis (MHD). Design: This was a prospective interventional study. Setting: This study was performed in a tertiary care hospital. Subjects: Sixtheen patients on stable MHD (mean ± standard deviation age, 70.4 ± 10.1; mean ± SD duration of dialysis, 10.2 ± 7.4 years) were enrolled. Patients with physical frailty or cognitive decline were excluded. Intervention: Bs was added to the diet once daily for three months to assess whether it could achieve a beneficial effect on bowel habits in patients on MHD. Main outcome measure: We used the constipation scoring system (css) and Bristol stool form scale (Bss) for objective assessment of Cc. In this system, the constipation score (cs) ranges from 0 to 30, with 30 being the worst. Bs ranges from 1 to 7, 1 being interpreted as a hard stool and 7 being classified as a liquid one: diarrhea. Results were obtained by patient questionnaire, and scores were calculated monthly. Results: Compared with baseline, the mean cs improved significantly after the first month (from 10.7 ± 5.9 to 5.0 ± 4.0; p<0.001 by one-way analysis of variance with repeated measures). We also confirmed that the mean Bss changed significantly (from 3.4 ± 1.5 to 3.8 ± 1.0; p<0.02) after second month. Conclusion: The results of our study suggest that this new type of Bs may have merit for improving Cc in patients on stable MHD without any adverse effects and is well tolerated.

Clinical and pelvic morphologic correlation after subtotal colectomy with colorectal anastomosis for combined slow-transit constipation and obstructive defecation.

The treatment of slow-transit constipation combined with outlet obstruction is controversial. Subtotal colectomy with colorectal anastomosis is regarded as a safe and effective surgical option for refractory constipation. The clinical and morphologic outcomes of patients who underwent subtotal colectomy with colorectal anastomosis for refractory mixed constipation were prospectively evaluated. This study is a nonrandomized, prospective review of gathered data. This investigation was conducted at a tertiary-care GI surgical center in China. The study prospectively included 42 consecutive patients with refractory constipation who were diagnosed with obstructed defecation syndrome combined with slow colon transit. The primary outcomes measured were the Longo obstructive defecation syndrome score and the Wexner constipation scale. The pelvic morphologic changes were determined with defecography before surgery and at 6 and 24 months after surgery. A significant reduction in the Wexner constipation score was observed between baseline (median 24) and 6 months (median 10), which was maintained until 24 months (median 8, compared with baseline, p < 0.01). Improvement in the constipation score was matched by an overall improvement in the Longo obstructive defecation syndrome score at the 6- and 24-month follow-up times (compared with baseline, p < 0.01). In 17 of 21 patients, preexisting intussusception was no longer visible during defecography. Rectoceles were significantly reduced in depth, from 36 mm to 8 mm (p < 0.01), whereas the number of detectable rectoceles was also significantly decreased, from 29 to 7 (p < 0.01). Incomplete evacuation disappeared in 28 of 38 patients. No stenosis was observed at the colorectal posterior side-to-side anastomosis. Most complications were managed conservatively without significant events. This study was performed in selected patients with constipation and did not include a comparison group. Subtotal colectomy with colorectal anastomosis can correct pelvic anatomical disorders in patients with mixed refractory constipation. The clinical improvement of obstructed defecation syndrome after subtotal colectomy with colorectal anastomosis is highly correlated with the morphologic correction of the rectal redundancy.

Continuous consumption of fermented milk containing Bifidobacterium bifidum YIT 10347 improves gastrointestinal and psychological symptoms in patients with functional gastrointestinal disorders.

The aim of this study was to investigate whether consumption of probiotic fermented milk containing Bifidobacterium bifidum YIT 10347 improves symptoms in patients with functional gastrointestinal disorders (FGID). Thirty-seven FGID patients (18 male, 19 female) aged 12–80 years (mean ± SD, 52.6 ± 17.5 years) whose condition had not improved despite being seen at several medical institutions consumed 100 mL/day of B. bifidum YIT 10347 fermented milk for 4 weeks. Symptoms were evaluated after the enrollment period (BL: baseline), sample consumption period (CP) and 4 weeks after the CP (FP: follow-up period). Gastrointestinal symptoms were evaluated using the Gastrointestinal Symptom Rating Scale (GSRS) and the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG); psychological symptoms were evaluated using the Profile of Mood States (POMS) short form. Concentrations of salivary stress markers and the oxidative stress marker urinary 8-hydroxy-2’-deoxyguanosine (8-OHdG) were measured. GSRS subscale scores for abdominal pain, diarrhea, and constipation significantly improved relative to BL after consumption of the fermented milk, as did FSSG subscale scores for symptoms of acid-related dyspepsia. Some subjective psychological symptoms improved. POMS scores significantly improved, and “Anger-Hostility” subscale scores significantly decreased after the consumption period, while “Vigor” subscale scores marginally increased during the consumption period. The concentrations of urinary 8-OHdG and the stress marker salivary cortisol were significantly lower at CP but returned to baseline levels at FP. Continuous consumption of B. bifidum YIT 10347 fermented milk is expected to improve gastrointestinal symptoms and reduce psychological stress in FGID patients.

Delorme's Procedure for Complete Rectal Prolapse: A Study of Recurrence Patterns in the Long Term.

Introduction. The objective of this study was to determine the recurrence rate and associated risk factors of full-thickness rectal prolapse in the long term after Delorme's procedure. Patients and Methods. The study involved adult patients with rectal prolapse treated with Delorme's surgery between 2000 and 2012 and followed up prospectively in an outpatient unit. We assessed epidemiological data, Wexner constipation and incontinence score, recurrence patterns, and risk factors. Data were analyzed by univariate and multivariate studies and follow-up was performed according to Kaplan-Meier technique. The primary outcome was recurrence. Results. A total of 42 patients, where 71.4% (n = 30) were women, with a median age of 76 years (IQR 66 to 86), underwent Delorme's surgery. The median follow-up was 85 months (IQR 28 to 132). There was no mortality, and morbidity was 9.5%. Recurrence occurred in five patients (12%) within 14 months after surgery. Actuarial recurrence at five years was 9.9%. According to the univariate analysis, constipation and concomitant pelvic floor repair were the only factors found to be associated with recurrence. Multivariate analysis showed no statistically significant differences among variables studied. Kaplan-Meier estimate revealed that constipation was associated with a higher risk of recurrence (log-rank test, p = 0.006). Conclusions. Delorme's procedure is a safe technique with an actuarial recurrence at five years of 9.9%. The outcomes obtained in this study support the performance of concomitant postanal repair and levatorplasty to reduce recurrences. Also, severe constipation is associated with a higher recurrence rate.

Frequency of REM sleep behavior disorders in patients with Parkinson's disease.

Sleep is prompted by natural cycles of activity in the brain and consists of two basic states: rapid eye movement (REM) sleep and non-rapid eye movement (NREM) sleep. REM sleep behavior disorder (RBD) is characterized by violent motor and vocal behavior during REM sleep which represents dream enactment. The normal loss of muscle tone, with the exception of respiratory, sphincter, extra ocular and middle ear muscles, is absent in patients with RBD. The origin of RBD is frequently unknown, but can be associated with degenerative neurological disorders, such as Parkinson's disease (PD). PD patients do not necessarily express features of RBD, which is identified in approximately third to a half of them. The aim of this study was to estimate the prevalence of RBD in a cohort of PD patients, as well as to identify risk-factors for its development. In the period from December 2010 to September 2011 we recruited 97 consecutive PD outpatients, treated in the Institute of Neurology, Clinical Center of Serbia, Belgrade. After establishing the diagnosis, all the patients filled out a specially constructed questionnaire with the following items: actual age, sex, age at disease onset, disease duration, form of the disease, type of treatment, duration of treatment, the presence of constipation, lessening of smell sense, and family history of PD. At entring the study, patients disability was scored using the Unified Parkinson's Disease Rating Scale (motor part - UPDRS). Cognitive abilities were assessed by the Mini Mental Status Examination (MMSE) scale, and depression symptoms by the 21-item Hamilton Depression Rating Scale (HDRS). The patients with PD were dichotomized to those with and without RBD using the RBD Questionnaire-Hong Kong (RBDQ-HK) in the manner of an interview. Forms of PD, mode of treatment, sex, constipation and family history were investigated using the Fishers χ2 test. Symptoms and treatment duration, the presence of smell disturbances, MMSE score, UPDRS motor score and HDRS score were analyzed by implementation of the Z-test. Actual age and age at disease onset were evaluated by the unpaired t-test. The RBD-positive group contained 15 (15.5%) patients, while in the rest of them (82/97), RBD was not identified (nonRBD group). There was no difference between the two groups considering gender distribution (p = 0.847), age (p = 0.577), age at disease onset (p = 0.141 ), duration. of PD (p = 0.069), family history (p = 0.591), type of initial symptoms (p = 0.899), constipation (p = 0.353), olfaction (p = 0.32) and MMSE scores (p = 0.217). The duration of treatment in the RBD group was longer than in the non-RBD group (9.4 ± 5.3 and 6.3 ± 3.9 years, respectively; p = 0.029), and the UPDRS motor score in the RBD group was higher (19.1 ± 9.4 and 12.7 ± 8.2, respectively; p = 0.013). Also, HDRS scores were higher in patients expressing RBD (10.1 ± 6.0 and 6.4 ± 4.5, respectively; p = 0.019). We found that 15.5% of the consecutive PD patients had RBD, and that the patients with RBD differed from the non-RBD ones regarding duration of treatment, disease and depressive symptoms severity.

Comparative analysis of laparoscopic low rectal resections

Objective: to study the immediate results of laparoscopic intersphincteric resection (ISR) and ultralow anterior resection (ULAR) of the rectum. Subjects and methods. The results of surgical treatment in 42 patients operated on in the Saint Petersburg Clinical Research-Practical Center for Specialized Medical (Oncology) Cares in March 2014 to January 2015 are given. The inclusion criteria were the lower edge of cT1–3N0 adenocarcinoma 2-5 cm above the dentate line and no signs of invasion into the sphincter and levators. All the patients were divided into 2 groups: 1) 24 patients who had undergone laparoscopic ISR; 2) 18 patients who had laparoscopic ULAR. Both groups were matched for gender, age, body mass index, and CR-POSSUM predicted mortality scores. Thirty-two patients received neoadjuvant chemoradiotherapy. Results. The mean duration of operations did not differ significantly in the groups: 206 ± 46 and 216 ± 24 min (р = 0.72). The differences in the mean volume of blood loss were also insignificant: 85 and 113 ml (р = 0.93). Circular and distal resection margins were intact in all the cases. In 18 (75 %) patients in Group 1 and in 14 (77.8 %) patients in Group 2, the quality of total mesorectumectomy (TME) was rated as grade 3 according to the Quirk criteria (p = 0.83). In Group 1, complications requiring no reoperation occurred in 5 (20.8 %) cases: anastomotic incompetence in 3 (12.5 %) cases, anastomotic stricture with further bougienage in 1 (4.2 %), and urinary retention in 1 (4.2 %). In Group 2, postoperative coтplications were also observed in 5 (27.8 %) cases: necrosis of the brought-out bowel in 2 (11.1 %) patients and coloanal incompetence in 1 (5.6 %) required reoperation; 2 (11.1 %) patients underwent bougienage due to established anastomotic stricture. One month postoperatively, the Wexner constipation scoring system was used to rate the degree of encopresis: anal incontinence turned out to be significantly higher in Group 2 and amounted to 9.3 versus 6.2 in Group1. ULAR required consumables costing an average of 45 000 rubles more than did ISR. Conclusion. Both surgical procedures are comparable in the duration of a surgical intervention, the volume of intraoperative blood loss, and the quality of TME. ULAR with a reservoir is functionally more preferential.