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Background: Disordered continence is frequently reported after operations for anal fistulae and preoperative anorectal physiology may be carried out prior to surgery to improve functional outcome. Elderly patients and multiparous females are at higher risk for incontinence, whereas males under 60 have stronger sphincters. The aim of this study was to investigate the predictive role of anal manometry and the causes of postoperative soiling and its effect on the quality of life in males with intact sphincters undergoing excision of either trans or supra sphincteric fistulae. Methods: Thirty-eight patients (median age 47 years) were analysed retrospectively. None had previous anal surgery and all were fully continent. Five had Crohn's disease. Anal pressures and rectal sensation were evaluated prior to fistulectomy by means of anal manometry in all cases and after surgery in those who had postoperative incontinence. A cutting seton was used in 17 patients, a rectal advancement flap in 15 and a double rectalcutaneous flap in six. None had a lay-open. The intersphincteric plane was explored and drained in all cases. A previously described incontinence grading and score was used to assess postoperative soiling. The median follow-up was 22 (range 5-89) months. The patients with postoperative anal incontinence were evaluated with the Gastrointestinal quality of Life Index Questionnaire (0:poor, 4:good) at a median follow-up of 49 months. Results: Twenty-nine (76%) patients were continent after surgery, whereas 9 (24%) complained of some degree of anal incontinence (minor in 4, severe in 1, the 1-6 incontinence score being 3.7 ± 1.3 (mean ± s.d.m.). Their Quality of life score was 3.8 ± 0.5 (mean ± sdm). None of them had Crohn's disease, five had frequent diarrhoea, four had a reintervention for either anal fissure or recurrent fistula (two), three had a postseton anal deformity. No difference was found between continent and incontinent patients as far as pre-operative anal pressures were concerned, but the maximum rectal volume threshold was significantly higher in incontinent patients, 165 ± 67 vs. 123 ± 49 ml of air (P = 0.04). Conclusions: Sphincter division, diarrhoea and anal deformity may cause soiling after fistulectomy in males and it does not severely affect quality of life. Surgery rather than manometry may predict it and rectal sensation may play a role which needs further investigation. [ABSTRACT FROM AUTHOR]

Aim Some benign anorectal diseases may have psychosomatic aetiology, but patients often refuse direct psychological counselling. The Draw-the-Family Test (DFT) is a simple indirect investigation. The aim of this study was to evaluate the DFT in patients with psychological problems undergoing surgery for benign anorectal disease and to correlate the results with surgical outcome. Method DFT was administered prior to surgery to 62 patients with benign anorectal disease who admitted psychological problems at the time of the outpatient visit. Of these 18 (29%) had functional disease, mainly obstructed defecation (OD) while 44 (71%) had organic disease (haemorrhoids, fissures, pilonidal sinus or fistula). DFT was also administered to 40 healthy control subjects. Each DFT was judged as normal or pathological according to 10 parameters. Patients were followed up for a median of 12 months (range 3–64) and divided into two outcome groups, success ( n = 58) and failure ( n = 12) according to the results of a questionnaire. The DFT of all patients was then correlated with the outcome. Results None of the patients refused DFT. All DFT parameters but one (animal/things instead of human beings) were more frequent in patients compared with controls ( P < 0.05). When comparing separately organic or functional disease patients with controls, one parameter (absence of patient in the drawing) was only pathological in the organic disease group ( P < 0.05). Another parameter (schematic figures) was more frequently altered in the organic disease group compared with the functional disease group ( P = 0.01). Eight out of 10 parameters were more frequently pathological in patients who failed after treatment, but none reached statistical significance. Conclusion Results of DFT in patients with anorectal disease admitting to psychological problems are markedly different from healthy controls. Patients with organic disease and those with functional bowel disease have different DFT profiles. In our study group, DFT had an excellent compliance but could not predict the outcome of surgery. [ABSTRACT FROM AUTHOR]

This review addresses the range of operations suggested to be of contemporary value in the treatment of constipation with critical evaluation of efficacy data, complications, patient selection, controversies and areas for future research. [ABSTRACT FROM AUTHOR]

Objective Many procedures are used to treat internal (IRP) and external rectal prolapse (ERP). We report the outcome of surgery tailored in accordance with an evolving Unit algorithm over a 21-year period. Method Two hundred and sixty-eight patients (151 IRP and 117 ERP) are reported. Perineal procedures (Delorme’s mucosectomy, Altemeier’s perineal rectosigmoidectomy) were used in frail elderly patients with ERP with abdominal sacrorectopexy or the Frykman-Goldberg procedure in fit patients. In IRP, prolapsectomy was most common with anterior hemi-Delorme’s procedures for rectocele and levatorplasty for coincident faecal incontinence. Clinical and functional outcome was assessed over a median of 61 months (range 4–184 months). Results Postoperative mortality was 0.4%. For ERP, a perineal procedure was carried out in 75 (61.4%) cases with a 7.2% complication rate, postoperative incontinence in 20 (26.7%), constipation in four (5.3%) and recurrence in 12 (16%). For 42 abdominal procedures, the complication rate was 5% with incontinence in 7.1%, constipation in eight (19%) and recurrence in five (11.9%). A perineal operation was used in 89.4% of patients with IRP with incontinence in 10.6%, persistent constipation in 48 (52.7%) and recurrence in 25 (27.5%). The overall incontinence rate was 11% following abdominal and 24% following perineal procedures ( P < 0.05). Recurrence of ERP was significantly higher following a perineal operation ( P < 0.05). Conclusion Tailored surgery for ERP achieves satisfactory results in terms of recurrence and functional outcome. For patients with IRP, perineal procedures are associated with a high incidence of recurrence and residual evacuatory difficulty. [ABSTRACT FROM AUTHOR]

Objective Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an ‘iceberg syndrome’ characterized by ‘underwater rocks’ or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders, in order to alert the clinician of these and minimize failures. Method One hundred consecutive constipated patients with OD symptoms, 81 women, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry and anal/vaginal ultrasound (US). Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultations. Symptoms were graded using a modified 1–20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel ‘iceberg diagram’. The type of treatment, whether conservative or surgical, was also recorded. Results Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three of them: anxiety–depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33%, respectively). The median constipation score was 11 (range 2–20), the median number of ‘occult disorders’ was 5 (range 2–8). Conservative treatment was carried out in most cases. Surgery was carried out in 14 (14%) patients. Conclusion The novel ‘iceberg diagram’ allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery. [ABSTRACT FROM AUTHOR]

Objective Surgical treatment of constipation and obstructed defecation (OD) carries frequent recurrences, as OD is an ‘iceberg syndrome’ characterized by ‘underwater rocks’ or occult diseases which may affect the outcome of surgery. The aim of this study was to evaluate occult disorders in order to alert the clinician of these and minimize failures. Method One hundred consecutive constipated patients with OD symptoms, 81 female patients, median age 52 years, underwent perineal examination, proctoscopy, anorectal manometry, and anal/vaginal ultrasound. Anorectal physiology and imaging tests were also carried out when indicated, as well as psychological and urogynaecological consultation. Symptoms were graded using a modified 1–20 constipation score. Both evident (e.g. rectocele) and occult (e.g. anismus) diseases were prospectively evaluated using a novel ‘iceberg diagram’. The type of treatment, whether conservative or surgical, was also recorded. Results Fifty-four (54%) patients had both mucosal prolapse and rectocele. All patients had at least two occult OD-related diseases, 66 patients had at least three: anxiety-depression, anismus and rectal hyposensation were the most frequent (66%, 44% and 33% respectively). The median constipation score was 11 (range 2–20), the median number of ‘occult disorders’ was 5 (range 2–8). Conservative treatment was carried out in most patients. Surgery was carried out in 14 (14%) patients. Conclusion The novel ‘iceberg diagram’ allowed the adequate evaluation of OD-related occult diseases and better selection of patients for treatment. Most were managed conservatively, and only a minority were treated by surgery. [ABSTRACT FROM AUTHOR]

Objective Stapled rectal mucosectomy (SM) is less painful than manual haemorrhoidectomy but may be followed by unusual complications which may require reinterventions. The aim of the present study was to report on a particular postoperative complication, the rectal pocket syndrome (RPS). Methods Six patients, four females and two males, five with severe proctalgia and signs of intermittent sepsis and one with faecal soiling following SM, underwent clinical examination, proctoscopy ( n = 5) anal manometry and ultrasound ( n = 4) revealing a painful rectal intramucosal pocket with an endoluminal orifice at the level of the suture line. Four of them underwent a reintervention. Results At surgery, a faecolyth was found to be entrapped in the rectal pocket with an underlying chronic abscess in four patients. The cavity was laid open and curetted in all cases. One of the females needed a fistulotomy of a low intersphincteric track after one year. In none of the others did endorectal pocketing and abscess or prostatitis recur after a mean follow up of 25 months (range 2–60 months). The male patient still had moderate postevacuation pain and prostatitis possibly via a bacterial translocation after two months. Overall, the incidence of the post mucosectomy RPS at our Units was 2.5%. Conclusions The RPS can occur after SM, is likely to be due to a failure of either the purse-string or of the staples causing a suture defect leading to an intramural sinus, and may be successfully treated by a transanal lay-open in most cases. [ABSTRACT FROM AUTHOR]

Background Marsupialization of anal fistulotomy/fistulectomy wound leaves less raw unepithelialized tissue. The suture results in a more rapid healing and is likely to reduce the risk of bleeding but at the cost of an increased pain and infection. The aim of this prospective study was to compare the outcomes of marsupialization and open wound. Methods Forty-six consecutive patients with anal fistulae were recruited in a randomized controlled trial. Fistula tracks were treated by fistulotomy and/or fistulectomy. The resulting wounds were marsupialized to the skin edges with locking continuous absorbable sutures (M group) or left open (O group). The clinical outcome was then evaluated. The intra-operative effect of the suture on wound size was recorded as well as the postoperative pain using a 0-10 visual analogue scale (VAS) and the occurrence of both wound bleeding and infection. Results Twenty-two patients were randomized to the M group and 24 to the O group. There were no differences in the age, sex and fistula type between the groups. Mean follow-up times were 10.5 and 13.8 months, respectively. No significant difference was observed in postoperative pain, the VAS being 3.5 ± 1.5 in the M group and 3.4 ± 1.6 in the O group at 12 h (mean ± s.e.m.; n.s). The marsupialization nearly halved the size of the wound intra-operatively from an area of 1749 ± 66 mm² to 819 ± 38 mm² (P < 0.001), which subsequently decreased to 217 ± 15 mm² after 4 weeks (P < 0.01). No significant reduction of wound size was observed in the O group (from 1171 ± 31 mm² to 543 ± 19; n.s). Bleeding occurred less frequently in M group than in O group (36% vs 46%, P < 0.05), whereas the difference in the postoperative sepsis rate was not significant, being 14% in M vs 21% in the O group. Three reinterventions were needed in both groups due to wound sepsis. Conclusion Marsupialization after fistulotomy/fistulectomy significantly reduces the size of the wound and the risk of bleeding, without increasing postoperative pain and sepsis. [ABSTRACT FROM AUTHOR]

Disordered continence is frequently reported after operations for anal fistulae and pre-operative anorectal physiology may be carried out prior to surgery to improve functional outcome. Elderly patients and multiparous females are at higher risk for incontinence, whereas males under 60 have stronger sphincters. The aim of this study was to investigate the predictive role of anal manometry and the causes of postoperative soiling and its effect on the quality of life in males with intact sphincters undergoing excision of either trans or supra sphincteric fistulae. Thirty-eight patients (median age 47 years) were analysed retrospectively. None had previous anal surgery and all were fully continent. Five had Crohn's disease. Anal pressures and rectal sensation were evaluated prior to fistulectomy by means of anal manometry in all cases and after surgery in those who had postoperative incontinence. A cutting seton was used in 17 patients, a rectal advancement flap in 15 and a double rectal-cutaneous flap in six. None had a lay–open. The intersphincteric plane was explored and drained in all cases. A previously described incontinence grading and score was used to assess postoperative soiling. The median follow-up was 22 (range 5–89) months. The patients with postoperative anal incontinence were evaluated with the Gastrointestinal quality of Life Index Questionnaire (0:poor, 4:good) at a median follow-up of 49 months. Twenty-nine (76%) patients were continent after surgery, whereas 9 (24%) complained of some degree of anal incontinence (minor in 4, severe in 1, the 1–6 incontinence score being 3.7 ± 1.3 (mean ± s.d.m.). Their Quality of life score was 3.8 ± 0.5 (mean ± sdm). None of them had Crohn's disease, five had frequent diarrhoea, four had a reintervention for either anal fissure or recurrent fistula (two), three had a postseton anal deformity. No difference was found between continent and incontinent patients as far as pre-operative anal pressures were concerned, but the maximum rectal volume threshold was significantly higher in incontinent patients, 165 ± 67 vs. 123 ± 49 ml of air ( P = 0.04). Sphincter division, diarrhoea and anal deformity may cause soiling after fistulectomy in males and it does not severely affect quality of life. Surgery rather than manometry may predict it and rectal sensation may play a role which needs further investigation. [ABSTRACT FROM AUTHOR]

Abstract An unusual case of acute intestinal obstruction following a PPH stapled haemorrhoidectomy is reported: the complication was due to an almost complete interruption of the rectal lumen tightened by a purse-string suture anchored by staples. The stricture was dilated and the suture released thus restoring intestinal continuity. Surgeons should be aware that such troublesome complication may occur and can be treated successfully by a transanal approach. [ABSTRACT FROM AUTHOR]

- The purpose of this study was to evaluate the function of the intestinal segments used to replace the bladder after cystoprostato-vesiculectomy. The series included 30 patients, 10 of whom underwent clinical, radiological, urodynamic and electromanometric investigations. Seven patients had an ileocaeco-urethrostomy (ICUS) and 3 had an ileo-urethrostomy with a reservoir (IR). The results were good in all patients and there was no sign of tumour recurrence. All were completely continent during the day but during the night only those who observed the 2-h intervals between voiding were continent. The radiological findings for 1 patient showed grade I asymptomatic vesicoureteric reflux. In all cases, periodic pressure waves were observed during electrocystomanometric tests at basal levels, with the IR patients showing waves higher in frequency and lower in amplitude. Prostigmin induced a significant variation in motor activity in IR patients only. The urodynamic tracings showed an almost physiological flow in both groups. Cystomanometry revealed good compliance in both types of new bladders. The height and width of contraction waves during filling was greater in ICUS than in IR patients. Good perineal sphincteric activity was demonstrated by electromyography. Low passive resistance was indicated by the urethral pressure profile. Preliminary analysis of data indicated good functional micturition and renal function in both ICUS and I R patients. Slight differences were found between the two intestinal segments used for bladder replacement. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article about the risk of early recurrence after stapled hemorrhoidopexy (SE) by M. L. Corman in the previous issue.

A letter to the editor is presented in response to the article about the stapled resection of external prolapse.

Presents a letter to the editor related to the article colonic hydrotherapy for obstructed defeation by N.J. Taffinder published in the January 2005 issue of the journal "Colorectal Disease."

Presents a letter to the editor of the periodical "Colorectal Disease" about poor clinical results after surgery for occult rectal prolapse.

The article comments on lateral internal anal spincterotomy for chronic anal fissure. Although chronic fissures can clearly heal following very limited internal anal sphincterotomy, the mechanism may, in part, lie outside of the sphincterotomy itself, where anal distraction by the retractor used can affect postoperative sphincter tone as can the pre-operative use of topical GTN and the change in diet imposed by the surgeon following surgery. What is still most important is the clinical functional outcome following internal anal sphincterotomy. This too would have been aided by an objective score of continence in this study before and after surgery.

Presents a letter to the editor on stapled hemorrhoidopexy.

A letter to the editor is presented in response to the article on surgery for internal rectal collapse that was published in the April 2009 issue.

Examines the influence of rectal hyposensation in the incidence of outlet obstruction. Application of anal manometry; Effects of sensory and motor biofeedback on rectal sensation and puborectalis function; Factors causing the reduction of anorectal pressure.