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Anorectal function is often impaired after low anterior resection of the rectum. Many factors affect the functional outcome and not all are known.This trial aimed to assess whether a temporary defunctioning stoma affected anorectal function after the patients had been stoma-free for a year.Multicenter randomized controlled trial.Twenty-one Swedish hospitals performing surgery for rectal cancer participated.Patients who had undergone low anterior resection for adenocarcinoma of the rectum were eligible.Patients were randomly assigned to receive a defunctioning stoma or no stoma.Anorectal function was evaluated with a questionnaire after patients had been without a stoma for 12 months. Questions pertained to stool frequency, urgency, fragmentation of bowel movements, evacuation difficulties, incontinence, lifestyle alterations, and whether patients would prefer a permanent stoma.After exclusion of patients in whom stomas became permanent, a total of 181 (90%) of 201 patients answered the questionnaire (90 in the stoma group and 91 in the no-stoma group). The median number of stools was 3 during the day and 0 at night in both groups. Inability to defer defecation for 15 minutes was reported in 35% of patients in the stoma group and 25% in the no stoma group (P = .15). Median scores were the same in each group regarding need for medication, evacuation difficulties, fragmentation of bowel movements, incontinence, and effects on well-being. Two patients (2.2%) in the stoma group and 3 patients (3.3%) in the no-stoma group would have preferred a permanent stoma.Because this study was an analysis of secondary end points of a randomized trial, no prestudy power calculation was performed.A defunctioning stoma after low anterior resection did not affect anorectal function evaluated after 1 year. Many patients experienced impaired anorectal function, but nearly all preferred having impaired anorectal function to a permanent stoma.

PURPOSE: Thiopurines are important as maintenance therapy in Crohn's disease, but there have been concerns whether thiopurines increase the risk for anastomotic complications. The present study was performed to assess whether thiopurines alone, or together with other possible risk factors, are associated with postoperative intra-abdominal septic complications after abdominal surgery for Crohn's disease. METHODS: Prospectively registered data regarding perioperative factors were collected at a single tertiary referral center from 1989 to 2002. Data from 343 consecutive abdominal operations on patients with Crohn's disease were entered into a multivariate analysis to evaluate risk factors for intra-abdominal septic complications. All operations involved either anastomoses, strictureplasties, or both; no operations, however, involved proximal diversion. RESULTS: Intra-abdominal septic complications occurred in 26 of 343 operations (8%). Thiopurine therapy was associated with an increased risk of intra-abdominal septic complications (16% with therapy; 6% without therapy; P = 0.044). Together with established risk factors such as preoperative intra-abdominal sepsis (18% with sepsis; 6% without sepsis; P = 0.024) and colo-colonic anastomosis (16% with such anastomosis; 6% with other types of anastomosis; P = 0.031), thiopurine therapy was associated with intra-abdominal septic complications in 24% if any 2 or all 3 risk factors were present compared with 13% if any 1 factor was present, and only 4% in patients if none of these factors were present (P < 0.0001). CONCLUSIONS: Thiopurine therapy is associated with postoperative intra-abdominal septic complications. The risk for intra-abdominal septic complications was related to the number of identified risk factors. This increased risk should be taken into consideration when planning surgery for Crohn's disease.

Anal pathology occurs in 20 to 80 percent of patients with Crohn’s disease in which abscesses, fistulas, and fissures account for considerable morbidity. The etiology is not clearly defined, but altered anorectal pressures may play a role. This study was designed to investigate anorectal physiologic conditions in patients with Crohn’s disease compared with healthy controls. METHODS: Twenty patients with Crohn’s disease located in the ileum (n = 9) or the colon (n = 11) without macroscopic proctitis or perianal disease were included. All were subjected to rectal examination, anorectal manometry, manovolumetry, and rectoscopy. Comparison was made with a reference group of 173 healthy controls of whom 128 underwent anorectal manometry, 29 manovolumetry, and 16 both examinations. RESULTS: Maximum resting pressure and resting pressure area were higher in patients than in controls (P = 0.017 and P = 0.011, respectively), whereas maximum squeeze pressure and squeeze pressure area were similar. Rectal sensitivity was increased in patients expressed as lower values both for volume and pressure for urge (P = 0.013 and P = 0.014, respectively) as well as maximum tolerable pressure (P = 0.025). CONCLUSIONS: This study demonstrates how patients with Crohn’s disease without macroscopic proctitis have increased anal pressures in conjunction with increased rectal sensitivity. This may contribute to later development of anal pathology, because increased intra-anal pressures may compromise anal circulation, causing fissures, and also discharging of fecal matter into the perirectal tracts, which may have a role in infection and fistula development.

PURPOSE: Electrical sacral root stimulation induces defecation in spinal cord injury patients and is currently under examination as a new therapy for fecal incontinence. In contrast to electrical stimulation, magnetic stimulation is noninvasive. To gain more insight into the mechanism of action of sacral root stimulation, we studied the effects of magnetic sacral root stimulation on anorectal pressure and volume in both fecal incontinence and spinal cord injury patients. METHODS: Three groups were examined: 14 healthy volunteers, 18 fecal incontinence patients, and 14 spinal cord injury patients. Repetitive magnetic sacral root stimulation was performed bilaterally using bursts of five seconds at 5 Hz. Anal and rectal pressure changes and rectal volume changes were measured. RESULTS: An increase in anal pressure was seen in 100 percent of the control subjects, in 86 percent of the spinal cord injury patients, and in 73 percent of the fecal incontinence patients (P=0.03). The overall median pressure rise after right-sided and left-sided stimulation was 12 (interquartile range, 8–18.5) and 13 (interquartile range, 6–18) mmHg at the mid anal level. A decrease in rectal volume was provoked in 72 percent of the control subjects, in 79 percent of the spinal cord injury patients, and in 50 percent of the fecal incontinence patients. Overall median volume changes after right-sided and left-sided stimulation were 10 (range, 5–22) and 9 (range, 5–21) percent from baseline volume. An increase in rectal pressure could be measured in 56 percent of the control subjects, 77 percent of the fecal incontinence patients, and 43 percent of the spinal cord injury patients. Median pressure rises after right-sided and left-sided stimulation were 5 (range, 3–12) and 5 (range, 3–5) mmHg. CONCLUSIONS: Magnetic sacral root stimulation produces an increase in anal and rectal pressure and a decrease in rectal volume in healthy subjects and patients with fecal incontinence or a spinal cord injury.

PURPOSE: The aim of this controlled study was to examine whether it was feasible to use magnetic stimulation as a new diagnostic tool to evaluate the motor function of the sacral roots and the pudendal nerves in patients with fecal incontinence. PATIENTS AND METHODS: Nineteen consecutive patients (17 females) with a median age of 67 (range, 36–78) years referred for fecal incontinence and 14 healthy volunteers (six females) with a median age of 42 (range, 23–69) years were examined. Latency times of the motor response of the external anal sphincter were measured after electric transrectal stimulation of the pudendal nerve and magnetic stimulation of the sacral roots. RESULTS: The success rates of pudendal nerve terminal motor latency and sacral root terminal motor latency measurements were 100 and 85 percent, respectively, in the control group and 94 and 81 percent, respectively, in the fecal incontinence group. Median left pudendal nerve terminal motor latency was 1.88 (range, 1.4–2.9) milliseconds in the control group and 2.3 (range, 1.8–4) milliseconds in the fecal incontinence group (P

PURPOSE: This study was designed to investigate incidence, treatment, and outcome for patients with colorectal cancer. METHODS: From 1984 to 1986 in Ostergotland, a county in Sweden with a defined population, a prospective registration using a computerized protocol was undertaken. RESULTS: In the surgical departments 596 cases were diagnosed and 31 more cases were diagnosed in other departments, bringing the incidence to 53 cases per 100,000 inhabitants per year. Of the cases, 14 percent presented as emergencies. The resectability rate was 90 percent, and the rate of curative operations was 74 percent. Postoperative mortality within 30 days was 2.9 percent. Crude five-year survival for all patients was 40 percent, and the corrected survival rate was 53 percent. After curative resection the crude five-year survival rate was 53 percent, and the corrected survival rate was 70 percent. Prognosis was better for colon than for rectal cancer, 76 percent vs.59 percent corrected five-year survival rate. For rectal cancer the local recurrence rate was 20 percent after curative resection. CONCLUSIONS: The prognosis was improved compared with a previous study from the same area because of decreased postoperative mortality, increased rate of operations for cure, and an increased five-year corrected survival rate. Local recurrence after rectal cancer was still high but may be reduced with improved surgical technique.

Retained menstrual blood, colpitis, chronic discharge from the vagina, and dyspareunia are not uncommon symptoms after proctectomy. In patients suffering from this syndrome, the vaginal drainage is impaired because of a pouch caused by adhesions formed between the coccyx and the vagina, and an angulation of the upper part of the vagina. Surgical treatment consists of extirpation of the coccyx, separation of the posterior fornix from the lower part of the sacrum, and interposition of muscle flaps from the right and left gluteus maximus muscle, which shifts the vagina to a more vertical position. The authors report the results of this procedure in nine women observed for more than two years. Wound infection occurred in two patients, and one underwent a second operation because of relapsing symptoms. Eight patients were relieved of impaired drainage of the vagina; one patients empties her menstrual blood by straining. Dyspareunia disappeared in all patients. The operation can be recommended in patients with "the horizontal vagina syndrome."