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Two patients, a woman aged 75 and a man aged 63 years, developed faecal incontinence after low anterior resection. Their external sphincter function was intact. They were advised to irrigate their bowel with normal tap water and reached complete pseudocontinence. Faecal incontinence is not always due to sphincter dysfunction. One of the other causes of incontinence is the lack of compliance of the rectum, as seen in patients with a low anterior resection. The part of the colon that has replaced the original rectum is not able to distend in the same manner as the rectum. Irrigation of the colon is a simple means of allowing the patient to achieve pseudocontinence. When the colon is cleaned it will take one or two days before new faeces arrive and a risk for incontinence occurs. It is important to irrigate with safe tap water at a temperature of around 37 degrees C. Most patients treated in this way feel safe to go out again. The irrigation can be performed in patients without the need for extensive diagnostics. This method of irrigation can be used in other forms of faecal incontinence as well.

Objective: To evaluate the therapeutic effect of sacral neuromodulation on faecal incontinence in patients with structurally intact sphincters., Design: Prospective., Method: In the period April 1st, 2000 to November 30th, 2001, patients with faecal incontinence and structurally intact sphincters were included, with or without previous surgery, in whom medicinal treatment and biofeedback therapy gave no improvement. Incontinence was defined as involuntary loss of stool at least once a week, which was objectified by completion of a 3-week bowel habit diary. Patients underwent 3 weeks of trial stimulation during which they also kept a diary. The trial stimulation was considered successful if the diary showed a > or = 50% improvement in continence., Results: 38 patients (31 women) with an average age of 54 years (range: 26-73) underwent trial stimulation. Trail stimulation was carried out using a permanent electrode in 6 patients and using peripheral neural evaluation in the remaining 32 patients. Two patients did not respond to peripheral neural evaluation. Upon assessment after the trial stimulation period. continence was found to have improved by > or = 50% in 31 (82%) patients. The number of incontinence episodes decreased by an average of 86% (range: 50-100). In 27 patients an implantable pulse generator was implanted for continuous stimulation. During the average follow-up of 6 months the effect remained satisfactory. Anal manometry during stimulation showed no increase of sphincter pressures., Conclusion: Sacral neuromodulation was of therapeutic value in most of the patients treated for faecal incontinence without sphincter damage.

Objective: To assess the short and middle-long term results of outpatient treatment of internal haemorrhoids by rubber band ligation., Design: Prospective., Methods: The results and the complications of rubber band ligation were assessed in a group of consecutive patients treated for internal haemorrhoids by one surgeon in March 1995-September 1997 in the Laurentius Hospital Roermond, the Netherlands. Middle-long term results were assessed by an independent examiner who questioned the patients by phone., Results: Ninety-four patients were treated: 43 women and 51 men, with a mean age of 51 years (range: 23-80). After 6-18 weeks 80 out of 90 accessible patients (89%) were symptom-free, 71 (79%) of them after one treatment. Serious complications were not reported. However, the days after treatment mild complaints of anal urgency and pain were present in 16 patients (20%). Twenty-three patients underwent sigmoidoscopy. In 10 patients (43%) adenomatous polyps (in 9 patients) or diverticulosis (in 1 patient) were found. After a mean of 18 months (range: 6-31) 32 patients (41%) (still) had anal complaints compatible with haemorrhoids., Conclusion: Rubber band ligation is an easy and safe outpatient treatment of internal haemorrhoids. Most patients become symptom-free, often after one treatment. However, about 40% of the patients have recurrent symptoms within a few years after initial treatment.

Objective: To assess the safety and effectiveness of transanal resection of large rectal adenomas., Design: Retrospective., Setting: Department of Surgery, University Hospital Maastricht, the Netherlands., Method: 35 patients underwent transanal resection of large rectal polyps. These cases were analysed as to the accuracy of preoperative biopsies, complication rate, recurrence rate and value of endoscopic follow-up., Results: Preoperative biopsies proved to be unreliable: in 49% of the cases histology of the whole specimen matched with the result of the biopsy. Five patients showed adenocarcinoma in the definite specimen, they were treated successfully by low anterior resection or rectum extirpation following the transanal resection. Six patients developed complications. In 1 patient this resulted in a colostomy. The average follow-up was 45 months. Sixty per cent of the patients in whom an adenoma or a carcinoma in situ was removed developed a recurrent adenoma. Recurrent adenomas were all treated by endoscopic polypectomy., Conclusion: Transanal resection of large rectal adenomas is a safe and effective method of treatment. However, the high recurrence requires frequent endoscopy.

Objective: To study the clinical outcome of anal dynamic graciloplasty (gracilis muscle transposition and implantation of electric stimulation device) in a consecutive series of 12 patients., Design: Prospective study., Setting: Maastricht University Hospital., Patients and Methods: Twelve patients with incapacitating faecal incontinence were treated using anal dynamic graciloplasty because they were not amenable to other medical management. The data were analysed with emphasis on the clinical outcome, anal manometry, and gracilis muscle composition before and after electric stimulation. Results were considered significant if p < or = 0.05, using the paired Student's t-test., Results: Eight patients achieved complete faecal continence, one patient still has a previously constructed colostomy and in three patients no faecal incontinence could be achieved, due to infections. Median follow-up is now over 18 months (range 16 weeks-5 years). Anal manometry demonstrated an anal pressure increased from 39 mmHg (without stimulation) to 66 mmHg with electric stimulation (mean increase 27 mmHg (CI: 19-35; n = 12, p < 0.01). Gracilis muscle composition showed an increase of type I relatively fatigue-resistant fibres, capable of prolonged contractions, from 45% before stimulation to 64% afterwards (mean increase 19% (CI: 14-21; n = 8, p < 0.01)., Conclusion: Dynamic graciloplasty is capable of replacing the function of damaged or absent anal sphincters. The construction of a colostomy in patients with incapacitating faecal incontinence can be avoided.

In the literature recurrence after operation for a recurrent inguinal hernia varies from 3 to 36%. For bilateral recurrent hernia the risk of recurrence is even higher. The results of a preperitoneal Marlex prosthesis in these patients are excellent. After this procedure we saw no new recurrences in 35 patients with 70 recurrent hernias. There was no surgical mortality; in 2 patients superficial infection occurred and there were 4 inguinal haematomas. The preperitoneal Marlex prosthesis appears to be the ideal solution for bilateral recurrent inguinal hernias.