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PURPOSE The aim of this study was to evaluate the clinical significance of perineal descent (PD) in pelvic outlet obstruction patients diagnosed by using defecography. METHODS One hundred thirty-six patients with pelvic outlet obstruction (POO; median age 49 years) had more than one biofeedback session after defecography. Demographic finding, clinical bowel symptoms and anorectal physiological studies were compared for PD at rest and PD with dynamic changes. RESULTS Age (r = 0.33; P < 0.001), rectocele diameter (r = 0.31; P < 0.01), symptoms of incontinence (P < 0.05) and number of vaginal deliveries (r = 0.46; P < 0.001) were correlated with increased fixed PD. However, the female gender (P < 0.005), rectal intussusceptions (P < 0.05), negative non-relaxing puborectalis syndrome (P < 0.00005) and rectocele (P < 0.0005) were correlated with increased dynamic PD. Duration of symptoms, number of bowel movements, history of pelvic surgery and difficult defecation were not related with PD. There was no significant correlation between fixed and dynamic PD and success of biofeedback therapy. CONCLUSION Age, vaginal delivery and diameter of the rectocele are associated with increased fixed PD. Female gender, rectal intussusceptions and a rectocele are correlated with increased dynamic PD. Biofeedback is an effective option for POO regardless of severity of PD.

Purpose The aim of this study was to evaluate the clinical characteristics and treatment outcomes, including surgical safety, in patients over 80 years of age who underwent an appendectomy. Methods This study involved 160 elderly patients who underwent an appendectomy for acute appendicitis: 28 patients over 80 years old and 132 patients between 65 and 79 years old. Results The rate of positive rebound tenderness was significantly higher in the over 80 group (P = 0.002). Comparisons of comorbidity, diagnostic tool and delay in surgical treatment between the two groups were not statistically different. American Society of Anesthesiologists score was significantly higher in the over 80 group than in the 65 to 79 group (2.4 ± 0.5 vs. 1.6 ± 0.5; P < 0.00005). Comparisons of operative times and use of drainage between the two groups were not statistically different. In the pathologic findings, periappendiceal abscess was more frequent in the over 80 group (P = 0.011). No significant differences existed between the two groups when comparing the results of gas out and the time to liquid diet, but the postoperative hospital stay was significantly longer in the over 80 group (P = 0.001). Among the postoperative complications, pulmonary complication was significantly higher in the over 80 group (P = 0.005). However, operative mortality was zero in each group. Conclusion In case of suspicious appendicitis in elderly patients, efforts should be made to use aggressive diagnostic intervention, do appropriate surgery and prevent pulmonary complications especially in patients over 80 years of age.

Purpose The appendectomy is the most common emergent surgical procedure in elderly patients. The increasing number of elderly persons has been accompanied by an increase in the number of cases of acute appendicitis in the elderly. In order to understand the clinical significance of a laparoscopic appendectomy for elderly patients with appendicitis, we investigated the results of a laparoscopic appendectomy for treating patients over 60 years of age with appendicitis and compared them with the results for an open technique. Methods We studied retrospectively patients over 60 years of age who underwent an appendectomy with either a laparoscopic (LA) or open (OA) technique for appendicitis between July 2007 and December 2009. There were 30 patients in the LA group and 47 patients in the OA group. The demographic data, operative time, length of the hospital stay, bowel movement, pain control, cost, complications and pre-existing disease were assessed. Results There were no significant differences between the LA and the OA groups with respect to pre-existing diseases, gender, age, American Society of Anesthesiologists (ASA) score and the number of cases of complicated appendicitis, operative time, length of hospital stay, and times of analgesics use. However, the proportion of early gas out (within POD #2) was significantly greater in the LA group (80% vs. 57%, P < 0.05), and postoperative complications were significantly lower in the LA group (7% vs. 32%, P < 0.01). The costs for the two groups were not significantly different. Conclusion A laparoscopic appendectomy is a safe and effective procedure in elderly patients and is not associated with any increase in morbidity. It can be recommended for routine use in treating elderly patients with appendicitis.

Purpose: The aim of this study was to identify the prognostic factors associated with poor outcome of biofeedback therapy. Methods: One hundred thirty-seven (137) constipated patients with pelvic outlet obstruction (median age 49 years) had more than one biofeedback session after defecography. Follow-up data (mean follow-up: 14 months; range: 2∼37 months) were obtained in 114 patients. Any differences in demographics, clinical symptoms, and parameters of an anorectal physiological study were evaluated between the success group and the failure group. Results: At follow-up, 80 (70 percent) patients felt improvement in symptoms, but 34 (30 percent) patients did not. Pre-biofeedback presence of symptoms of difficult defecation predict poor outcome (88 vs. 69 percent for failure vs. success, P＜0.05). The positive and the negative predictive values of difficult defecation for poor outcome were 35 percent and 86 percent, respectively. A negative mean pressure change on pre-biofeedback anal manometry was related to a poor outcome (65 vs. 26 percent for failure vs. success, P＜0.001). The positive and the negative predictive values of negative mean pressure change for poor outcome were 51 percent and 83 percent, respectively. A negative electrical current change on pre-biofeedback anal electromyography was related to a poor outcome (23 vs. 9 percent for failure vs. success, P＜0.05). The positive and the negative predictive values of negative electrical-current change for poor outcome were 53 percent and 74 percent, respectively. Conclusions: Difficult defecation, negative mean pressure change in pre-biofeedback anal manometry, and negative electrical current change in pre-biofeedback anal electromyography were predictors associated with poor outcome of biofeedback therapy for constipated patients with pelvic outlet obstruction.

Purpose: Biofeedback therapy is widely used for the management of constipation associated with pelvic outlet obstruction. Some patients have shown poor outcome after biofeedback alone. A subgroup of patients complains of absence of desire to defecate. The main pathophysiology of constipation may be impaired rectal sensation or compliance. This study evaluated the effect of electrical stimulation and biofeedback therapy (EST-BF) for this subgroup of constipated patients with impaired rectal sensation. Methods: Of the 37 patients diagnosed with pelvic outlet obstruction by using cinedefecography, 9 patients (M：F=2：7, age=22～77 years, median=57 years) who had impaired rectal sensation (rectal desire threshold ≥100 ml) on anorectal manometry were selected. These patients were treated with EST-BF therapy 2～6 (median: 5) sessions, Kontinece, Multichannel system, HMT, Inc, Seoul, Korea). Treatment consisted of 20 minutes of variant-mode electrical stimulation and 20 minutes of EMG biofeedback therapy per week administered by a specialized colorectal surgeon. All patients were evaluated by using a standardized questionnaire and a threshold for rectal sensation based on balloon distention before and after treatment. Results: At post EST-BF, six (67%) patients had experienced an improvement in symptoms, including five (56%) patients with complete symptom relief. Significant improvement in rectal sensation, especially the rectal defecation desire threshold (pre-EST-BF vs. post- EST-BF: 181.0±38.7 vs. 88.3±29.1) was achieved. Conclusions: EST- BF may be an effective option for use in the treatment of functional constipation with impaired rectal sensation.

Purpose: To determine the outcome and identify predictors of success of biofeedback for descending perineum syndrome (DPS). Methods: 103 patients diagnosed with DPS by defecography were evaluated by standardized questionnaire, before, immediately after treatment, and at follow-up. Clinical bowel symptoms and anorectal physiological studies were also analyzed. Results: At post- biofeedback, 81 patients felt improvement in symptoms, including 29 with complete symptom relief. At follow-up (median: 13 months, n=82), 58 patients felt improvement in symptoms, including 12 with complete symptom relief. There was a significant reduction in difficult defecation (from 78 to 34, 37%, from pre-biofeedback to post-biofeedback, and at follow-up respectively; P＜0.001), incomplete defecation (from 88 to 44, 41%; P＜0.001), hard stool (from 63 to 25, 0%; P＜0.01), small caliber stool (from 63 to 0,0%; P＜0.001, P＜0.005), fecal incontinence (from 10 to 1,1%; P＜0,01), anal pain (from 21 to 2, 6%; P＜0.001, P＜0.05), laxative use (from 30 to 11, 6%; P＜0.001), enema use (from 16 to 0, 1%; P＜0.001) and digitation (from 11 to 1%, from pre-biofeedback to at follow-up; P＜0.05). Normal spontaneous bowel movement was increased from 47% pre-biofeedback to 79% post-biofeedback (P＜0.001), 86% at follow-up (P＜0.001). Difficult defecation predict poor outcome (96 vs. 66%; failure vs. success, P＜0.01). Positive mean pressure change predict good outcome (69 vs. 35%; success vs. failure, P＜0.05). Conclusions: Biofeedback is an effective option for DPS. J Korean Soc Coloproctol