Search

The aim of this study was to evaluate regeneration of a chronic large anal sphincter defect in a pig model after treatment with a plasmid encoding Stromal Cell Derived Factor-1(SDF-1). METHODS: Under ethics approved protocol 19 age/weight matched Sinclair mini-pigs were subjected to excision of the posterior 50% of anal sphincter muscle and left to recover for 6 weeks. They were randomly allocated to receive either saline treatment (Saline 1 ml, n = 5), 1 injection of SDF-1 plasmid 2 mg/ml (1 SDF-1, n = 9) or 2 injections of SDF-1, 2 mg/ml each at 2 weeks intervals (2 SDF-1, n = 5). Euthanasia occurred 8 weeks after the last treatment. In vivo outcomes included anal resting pressures done under anesthesia pre-injury, pre-injection and before euthanasia (8 weeks after treatment). Anal ultrasound was done pre injury and pre-euthanasia. Tissues were saved for histology and analyzed quantitatively. Two way ANOVA followed by Holm-Sidak test and one way ANOVA followed by the Tukey test were used for data analysis, p < 0.05 was regarded as significant. RESULTS: Posterior anal pressures at the 3 time points were not significantly different in the saline group. In contrast, post-treatment pressures in the 1 SDF-1 group pressures were significantly higher than both pre-injury (p = 0.001) and pre-treatment time points (p = 0.003). At the post-treatment time point, both 1 SDF-1 (p = 0.01) and 2 SDF-1 (p = 0.01) groups had significantly higher mean pressures compared to the saline group. Histology showed distortion of normal anatomy with patchy regeneration in the control group while muscle was more organized in both treatment groups. CONCLUSIONS: Eight weeks after a single or two doses of SDF-1injected into a chronic anal sphincter injury improved resting anal pressures and regenerated muscle in the entire defect. SDF-1 plasmid is effective in treating chronic defects of the anal sphincter in a large animal and could be clinically translated.

Benign anorectal disorders of structure and function are common in clinical practice. These guidelines summarize the preferred approach to the evaluation and management of defecation disorders, proctalgia syndromes, hemorrhoids, anal fissures, and fecal incontinence in adults and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations Assessment, Development and Evaluation process. When the evidence was not appropriate for Grading of Recommendations Assessment, Development and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.

Levator ani syndrome (LAS) is a functional disorder that can be a challenge to treat. LAS that is refractory to medical management may be treated with electrogalvanic stimulation (EGS) or Botulinum toxin A (BTX) injection. The aim of the present study was to evaluate the outcomes associated with both EGS and BTX in patients with medically refectory LAS to determine if either demonstrate a long-term benefit or whether one treatment is better than the other. A retrospective study was performed on consecutive patients with LAS treated with BTX or EGS at our institute. Patients were identified from a prospectively maintained database. The study time frame was 6 years. One hundred and twenty patients [80 females, mean age 52 years (range 21–84, SD 15.8)] were treated for medically refractory LAS: 102 with BTX and 18 with EGS. With EGS, 28.6% of patients reported a complete response, 14.3% reported a partial response and 57.1% reported no response to treatment. With BTX, 35.5% of patients reported a complete response, 19.7% reported a partial response and 44.7% reported no response to treatment. There was no difference between BTX and EGS with regard to treatment response. Patients who had BTX were more likely to report a short-term benefit in treatment when compared to those patients who had EGS (p = 0.002). This difference between reported outcome to BTX and EGS treatments did not sustain in the long term (p = 0.2). Both BTX and EGS are to some extent effective at resolving symptoms of LAS. In the short term, BTX appears to be more effective. Neither treatment sustains its benefit in the long term.

Summary Background Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo. Methods In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565. Findings Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change −1·5 points, 95% CI −3·4 to 0·4, p=0·12), biofeedback versus education (−0·7 points, −2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (−1·9 points, −4·1 to 0·3, p=0·092) or versus loperamide plus education (−1·1 points, −3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group). Interpretation In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation. Funding Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health

For patients with rectal prolapse undergoing Ventral Rectopexy (VR), the impact of prior prolapse surgery on prolapse recurrence is not well described. The purpose of this study was to compare recurrence rates after VR in patients undergoing primary and repeat rectal prolapse repairs. This study is a prospective cohort study. IRB-approved prospective data registry of consecutive patients undergoing VR for full-thickness external rectal prolapse between 2009 and 2015. Rectal prolapse recurrence was defined as either external prolapse through the anal sphincters or symptomatic rectal mucosa prolapse warranting additional surgery. Preoperative and postoperative morbidity and functional outcomes were analyzed. Actuarial recurrence rates were calculated using the Kaplan-Meier method. A total of 108 VRs were performed during the study period. Seventy-two were primary and 36 repeat repairs. Seven cases were open, 23 laparoscopic, and 78 robotic. Six cases were converted from laparoscopic/robotic to open. In 63 patients, VR was combined with gynecological procedures. There were no statistical differences between primary or recurrent prolapse for the following: demographics, operative time, concomitant gynecologic procedures, complications, blood loss, and graft material type. Length of stay was longer in patients with a history of prior prolapse surgery (p = 0.01). Prolapse recurrence rates for primary repairs were reported at 1.4, 6.9, and 9.7% and for recurrent prolapse procedures 13.9, 25, and 25% at 1, 3, and 5 years (p = 0.13). Mean length of follow-up was similar between groups. Time to recurrence was significantly shorter in patients undergoing repeat prolapse surgery 8.8 vs 30.7 months (p = 0.03). VR is a better option for patients undergoing primary rectal prolapse repair.

Patient selection is a crucial step when considering total abdominal colectomy and ileorectal anastomosis (TAC/IRA) for refractory constipation. This study aimed to evaluate the results of short- and long-term outcomes for patients with pure slow transit constipation (STC) compared to those with slow transit and features of obstructive defecation (STC + OD). This study included all patients who underwent TAC/IRA for constipation from 1999–2010. Patients were divided into two groups: group A (STC) and group B (STC + OD) based on abnormal physiology or motility testing in addition to the surgeon's clinical impression of symptomatic obstructive defecation. Demographics, operative variables, and short-term outcomes were collected by retrospective chart review and were compared between groups. Long-term functional outcomes were assessed by telephone survey. This included: number of bowel movements, use of laxatives, antidiarrheal medications, and surgery satisfaction. Validated questionnaires were collected postoperatively. One hundred forty-four patients (143 females; mean age, 40 (18–68) years old) underwent TAC/IRA by either laparoscopic (63 (44 %)) or open (81 (56 %)) techniques. One hundred three patients had pure STC and 41 had STC + OD. Four patients underwent TAC with end ileostomy at first procedure. Seven patients underwent surgery after a trial of diverting ileostomy. One patient died unexpectedly, 2 days after uneventful surgery. Median follow-up was 43 (IQR, 16–75) months. Five (5 %) patients in group A and two (5 %) in group B underwent subsequent ileostomy for poor functional outcomes. Eighty-eight (68 %) patients were available by telephone. Short- and long-term outcomes were equivalent in both groups as well as patient satisfaction (89 vs. 85 %, p = 0.7). Total abdominal colectomy can be offered to selective patients with slow transit constipation and obstructive defecation with equivalent long-term results.

During childbirth, a combinatorial injury occurs and can result in stress urinary incontinence (SUI). Simulated childbirth injury, consisting of vaginal distension (VD) and pudendal nerve crush (PNC), results in slowed recovery of continence, as well as decreased expression of brain-derived neurotrophic factor (BDNF), a regenerative cytokine. Electrical stimulation has been shown to upregulate BDNF in motor neurons and facilitate axon regrowth through the increase of βII-tubulin expression after injury. In this study, female rats underwent selective pudendal nerve motor branch (PNMB) stimulation after simulated childbirth injury or sham injury to determine whether such stimulation affects bladder and anal function after injury and whether the stimulation increases BDNF expression in Onuf's nucleus after injury. Rats received 4 h of VD followed by bilateral PNC and 1 h of subthreshold electrical stimulation of the left PNMB and sham stimulation of the right PNMB. Rats underwent filling cystometry and anal pressure recording before, during, and after the stimulation. Bladder and anal contractile function were partially disrupted after injury. PNMB stimulation temporarily inhibited bladder contraction after injury. Two days and 1 wk after injury, BDNF expression in Onuf's nucleus of the stimulated side was significantly increased compared with the sham-stimulated side, whereas βII-tubulin expression in Onuf's nucleus of the stimulated side was significantly increased only 1 wk after injury. Acute electrical stimulation of the pudendal nerve proximal to the crush site upregulates BDNF and βII-tubulin in Onuf's nucleus after simulated childbirth injury, which could be a potential preventive option for SUI after childbirth injury.

Objective. Fecal incontinence reduces the quality of life of many women but has no long-term cure. Research on mesenchymal stem cell (MSC)-based therapies has shown promising results. The primary aim of this study was to evaluate functional recovery after treatment with MSCs in two animal models of anal sphincter injury. Methods. Seventy virgin female rats received a sphincterotomy (SP) to model episiotomy, a pudendal nerve crush (PNC) to model the nerve injuries of childbirth, a sham SP, or a sham PNC. Anal sphincter pressures and electromyography (EMG) were recorded after injury but before treatment and 10 days after injury. Twenty-four hours after injury, each animal received either 0.2 ml saline or 2 million MSCs labelled with green fluorescing protein (GFP) suspended in 0.2 ml saline, either intravenously (IV) into the tail vein or intramuscularly (IM) into the anal sphincter. Results. MSCs delivered IV after SP resulted in a significant increase in resting anal sphincter pressure and peak pressure, as well as anal sphincter EMG amplitude and frequency 10 days after injury. MSCs delivered IM after SP resulted in a significant increase in resting anal sphincter pressure and anal sphincter EMG frequency but not amplitude. There was no improvement in anal sphincter pressure or EMG with in animals receiving MSCs after PNC. GFP-labelled cells were not found near the external anal sphincter in MSC-treated animals after SP. Conclusion. MSC treatment resulted in significant improvement in anal pressures after SP but not after PNC, suggesting that MSCs could be utilized to facilitate recovery after anal sphincter injury.

Stromal derived factor-1 (SDF-1) and monocyte chemotactic protein-3 (MCP-3) are signals forcing the migration of bone marrow-derived stem cells to ischemic tissue. This study investigates SDF-1 and MCP-3 expression following direct injury to the anal sphincter and pudendal nerve and to determine if these same mechanisms have any role. Chemokine expression was studied after anal sphincter injury in female rats after either a sphincterotomy (n = 15), pudendal nerve crush (PNC; n = 15), sham pudendal nerve crush (n = 15), or acted as unmanipulated controls (n = 5). Analysis was done at 1 h and 10 and 21 days after injury. After injury, SDF-1 expression increased 40.2 ± 6.42 (P = 0.01) at 1 h and 28.2 ± 2.37 (P = 0.01) at 10 days, respectively, compared to controls. Likewise, MCP-3 expression increased 40.8 ± 8.17 (P = 0.02) at the same intervals compared to controls. After PNC, SDF-1 expression increased 46.4 ± 6.01 (P = 0.02) and 50.6 ± 10.11 (P = 0.01), and MCP-3 expression increased 46.3 ± 7.76 (P = 0.03) and 190.8 ± 22.15 (P = 0.01), respectively, at the same time intervals compared to controls. However, when PNC was compared to sham injured, a significant increase was seen in SDF-1 and MCP-3 at 10 days. At 21 days, PNC compared to sham injured was significantly low in expression for both SDF-1 and MCP-3 (P

The emphasis of surgery for low rectal cancers has undergone a distinct change from the oncologic importance of complete excision, adding a focus on a good functional result and the importance of maintaining quality of life (QOL). Since the late 1960s,1,2 when the colonal anastomosis were first described, surgeons have strived to balance a good oncological outcome with QOL. These efforts are exemplified by use of the circular stapler,3 definition of minimal safe margins,4–6 total mesorectal excision,7 and neoadjuvant therapy. Lazorthes et al8 and Parc et al9 described the colonic J-pouch (JP) as an addition to the technique of coloanal anastomosis aimed at providing the reservoir function that is lacking in a straight coloanal anastomosis (SA). The pouch works by providing a segment of bowel with no functional peristalsis. Although functional outcome improved after a JP there existed evacuation difficulty10,11 that was resolved to some extent by defining the optimal length of a JP12 and level of anastomosis where a reservoir function has an advantage.13 Studies of patients with a colonic JP compared with an SA have shown that the antiperistaltic or reservoir capability of the colonic JP gave a better functional outcome in the short term.10,14,15 However urgency of defecation with the JP has not shown to be decreased by any study.3,12,14,16 Not all patients can have a JP incorporated into a coloanal anastomosis. Limitations to the construction of a JP include a narrow pelvis, a bulky mesentery or large appendices epiploicae, mucosectomy, insufficient colonic length, or extensive diverticular disease.17 In such patients, coloplasty has been suggested as an alternative. Z'Graggen18 and his group first described the coloplasty pouch in a porcine model. This followed its introduction in clinical practice.19,20 The coloplasty pouch is a way of providing a reservoir without the bulk or the loss of length of a JP. Thus, it could potentially fit in a narrow pelvis or when the mesocolon was fat laden and bulky. The exit conduit from the coloplasty reservoir could fit/traverse the anal sphincters as far as an SA can. When the coloplasty pouch was compared with the JP in some randomized, controlled trials (RCT), and limited RCT, it showed results comparable to the JP21,22 and superior to the SA.23 However, no randomized trial has prospectively compared the functional outcome of all 3 procedures. Other procedures described in the quest for achieving a good functional outcome have been the side to end coloanal anastomosis,24,25 which has been shown to have a similar outcome to the JP. The purpose of this prospective RCT was to compare the functional outcome and QOL of patients who undergo a coloanal anastomosis with or without a reservoir for low rectal cancer and to study the complications that occur.

Long-term outcome after surgery for slow transit constipation is conflicting. The aim of this study was to assess long-term quality of life after surgery. The medical records of all patients undergoing colectomy with ileorectal anastomosis between 1983 and 1998 were evaluated. Preoperative, operative, and postoperative details were recorded. A survey was conducted to evaluate current symptoms and health. Quality of life was assessed using the short-form (SF)-36 survey. Sixty-nine (2 male) patients were identified. Five were deceased. Mean age at surgery was 38.6 years (range, 19.7–78.8 years). Median follow-up after surgery was 10.8 years (range, 5.1–18.6 years). Forty-one percent had a family history of constipation. Eleven (16%) had an ileus postoperatively, which responded to medical therapy. One patient had a leak that required temporary diversion. Long-term complications occurred in 32 (46%) patients, which included hernias (3 patients; 4%), pelvic abscess (1 patient; 1.5%), rectal pain (1 patient; 1.5%), small-bowel obstruction (14 patients; 20%, with eight requiring surgery), diarrhea (5 patients; 7%), incontinence (1 patient, 1.5%), and persistent constipation (6 patients; 9%). Fifty-five percent (35/64) responded to a questionnaire. Overall, 25 of 35 (77% of the respondents) stated that surgery was beneficial. Sixty-four percent of patients have semisolid stools, 35% have liquid stools, and 4% reported hard stool. Results of the SF-36 showed the physical component score was comparable with healthy individuals. However, the mental component score was low especially in the areas of vitality (median, 45) and social functioning (median, 37). Surgery for constipation is not perfect, and preoperative symptoms may persist after surgery. When assessing long-term quality of life, the mental component of the SF-36 was low compared with the general population, and the physical component was similar. Moreover, because 77% report long-term improvement, surgery is beneficial for appropriate patients.

This research demonstrates the regenerative effects of mesenchymal stem cells (MSCs) on the injured anal sphincter by comparing anal sphincter pressures following intramuscular and serial intravascular MSC infusion in a rat model of anal sphincter injury. Fifty rats were divided into injury (n = 35) and no injury (NI; n = 15) groups. Each group was further divided into i.m., serial i.v., or no-treatment (n = 5) groups and followed for 5 weeks. The injury consisted of an excision of 25% of the anal sphincter complex. Twenty-four hours after injury, 5 × 105 green fluorescent protein-labeled MSCs in 0.2 ml of phosphate-buffered saline (PBS) or PBS alone (sham) were injected into the anal sphincter for i.m. treatment; i.v. and sham i.v. treatments were delivered daily for 6 consecutive days via the tail vein. Anal pressures were recorded before injury and 10 days and 5 weeks after treatment. Ten days after i.m. MSC treatment, resting and peak pressures were significantly increased compared with those in sham i.m. treatment (p < .001). When compared with the NI group, the injury groups had anal pressures that were not significantly different 5 weeks after i.m./i.v. treatment. Both resting and peak pressures were also significantly increased after i.m./i.v. MSC treatment compared with treatment with PBS (p < .001), suggesting recovery. Statistical analysis was done using paired t test with Bonferroni correction. Marked decrease in fibrosis and scar tissue was seen in both MSC-treated groups. Both i.m. and i.v. MSC treatment after injury caused an increase in anal pressures sustained at 5 weeks, although fewer cells were injected i.m. The MSC-treated groups showed less scarring than the PBS-treated groups, with the i.v. infusion group showing the least scarring.

Stem cells are an emerging treatment for regeneration of damaged anal sphincter tissues. Homing to the site of injury can be potentiated by stromal derived factor 1 (SDF-1) and monocyte chemotactic protein 3 (MCP-3) expression. The effects of electrical stimulation (ES) on upregulation of these cytokines were investigated. The anal sphincter complex of Sprague Dawley rats was stimulated with current of 0.25 mA, pulse duration of 40 pulses/s, pulse width of 100 μs, and frequency of 100 Hz for 1 or 4 h. Sham was created using the same needle which was inserted into the anal sphincter without electrical stimulation in different groups of animals. The rats were euthanized immediately or 24 h after stimulation. Cytokine analysis was performed using real-time polymerase chain reaction. Statistical analysis was performed. Results are presented as a fold increase compared to sham that was normalized to 1. SDF-1 and MCP-3 immediately after 1 h were 2.5 ± 0.77 and 3.1 ± 0.93 vs. sham, respectively, showing significant increase. After 1-h stimulation and euthanasia 24 h after, SDF-1 and MCP-3 were 1.49 ± 0.16 and 1.51 ± 0.14 vs. sham, respectively, showing significant increase. Immediately and 24 h after 4-h stimulation, SDF-1 was 1.21 ± 0.16 and 0.54 ± 0.16 vs. sham, respectively, and was not significantly different. Immediately and 24 h after 4-h stimulation, MCP-3 was 1.29 ± 0.41 and 0.35 ± 1.0 vs. sham, respectively, and was not significantly different. SDF-1 and MCP-3 after 1 h were significantly higher than after 4 h of stimulation at both time points. Electrical stimulation for 1 h significantly upregulates SDF-1 and MCP-3 expression that persists for 24 h. Prolonged stimulation reduced chemokine expression, suggesting electrolysis of cells.

The prognostic value of postoperative manometry in fecal incontinence is still controversial. The aims of this study were to establish if Fecal Incontinence Severity Index (FISI) and Fecal Incontinence Quality of Life Scale (FIQL) scores correlate with anal manometry and endoanal ultrasound findings and to define if there is any prognostic value in performing anal manometry after patients are surgically treated for fecal incontinence. Fifty-three patients, all women, were identified. All patients underwent a surgical procedure and were analyzed pre- and postoperatively. Fecal incontinence was assessed using the FISI and FIQL. Patients who did not have these score were excluded. Manometry and ultrasound findings before treatment and manometry findings after treatment were compared with surgical patient’s incontinence scores. Anal canal length was noted, and its association with the pre- and postoperative manometry finding and incontinence scores were compared. No correlation of pre- and postoperative resting and squeeze pressures with incontinence scores was found. Ultrasound findings had no correlation with manometry results and incontinence scores. Anal canal length correlated with both pre- and postoperative manometry findings but not with incontinence scores. Preoperative anal manometry and endoanal ultrasound help in guiding treatment options in patients with fecal incontinence. A decrease in FISI and increase in FIQL scores after a sphincter repair quantifies improvement after incontinence surgery, while changes in anal manometry pressures readings do not.

Endorectal ultrasound (ERUS) has become an integral part of the assessment of rectal tumors. It provides information about the depth of invasion and lymph node status which in turn is used in devising a management plan. It is important therefore that accurate interpretation of these studies is achieved. The aim of this study was to assess how accurately we interpret ERUS. A collection of 26 ERUS images were compiled and confirmed by two experienced colorectal sonographers. The survey was sent to 100 ASCRS members practicing at institutions with residency programs in colorectal surgery in USA and Canada. Two separate mailings were sent. Participants were asked to allocate a T and N stage to each of the images. Their responses were compared with pathology results. Twenty five surveys were returned, 23 were completed. Thirteen respondents reported performing ERUS themselves, on average performing three examinations per month (range, 1–8). The mean duration of practice was 11.2 years (range, 0–26). The mean number of rectal cancer cases managed over a 12-month period was 25 (range, 10–75). T stage was accurately reported in 38–69%. If we continue to rely on ERUS as an important step in staging rectal cancer further education may be needed to improve overall interpretation.

The purpose of this study was to evaluate improvement in symptoms of fecal incontinence (FI) in a group of women who also had urinary incontinence (UI) and were successfully implanted with the sacral neuromodulation (SNM) device primarily for urinary incontinence in one US institution.Twenty-four patients with FI and UI who failed to improve with conservative or standard surgical treatment underwent permanent SNM after a successful peripheral nerve stimulation test during 2003-2007. Wexner incontinence score, fecal incontinence quality of life (FIQL), and Bristol stool scales were recorded before and after treatment. Follow-up was done by questionnaires contact.Twenty-four patients (mean age 56.5 +/- 5.3 years) were studied. The median follow-up was 28 months (range 3-49). Twenty-two patients (92%) were contacted. Seven patients (31.8%) experienced improvement in both urinary and fecal incontinence symptoms. Twelve patients (54.5%) experienced no improvement in FI symptoms after SNM. Four patients required a colostomy or ileostomy; four had the system explanted (two, due to a faded clinical response and two, due to infection); and four other patients experienced no improvement after SNM. The outcomes of ten patients (45.5%) with functioning SNM were reviewed. There were significant improvement of FI symptoms with a significantly lower Wexner score from 12.0 +/- 2.0 before SNM to 4.7 +/- 3.6 (p = 0.009). The mean FIQL scores improved significantly from the baseline score 7.8 +/- 0.8 before SNM to 13.5 +/- 2.6 (p = 0.009). Bristol stool form scale was reduced significantly from 4.5 to 3.5 after SNM (p = 0.02).SNM may be beneficial in selected female patients with UI associated with FI. Prospective trials may help delineate which patients will show FI improvement in this combined group.

As healthcare providers for Crohn’s disease, we assume that we have a good understanding of the disease progression and its symptoms. The aim of this study was to gather information about what patients with Crohn’s disease think are relevant to their symptoms and what helps them cope with this lifelong benign disease. A questionnaire was sent to all patients with a diagnosis of Crohn’s disease seen in the Digestive Disease Center in the last 5 years. The returned forms were downloaded into a database and sent for analysis. Sixty-two percent of respondents were female. One third were between the ages of 35 and 50 years. Seventy percent were married. Thirty-eight percent had a graduate degree, 19% were unemployed. Fifty percent still smoked, half of them less than one pack a day. Sixty-eight percent said that their symptoms affected work, and one fourth changed jobs due to this. Foods worsened symptoms in 60%, with a decrease in symptoms while on low fiber foods and white meats. Lifestyle change worsened symptoms in 66%. A change in the caregiver was not a significant stressor. More than half used Remicade, with one third stating that it was helpful. Eight percent had never used steroids. Alcohol increased symptoms in 40%. Factors that did not cause a significant change were children at any age, pregnancy, menopause, and hormone replacement therapy. Surgery caused half the patients to improve for many years, although one third felt a lowered self-esteem postoperatively. Patients with Crohn’s disease should be managed in a more comprehensive manner to provide optimal care. Thus, a team approach that includes a dietician and counselor should be considered as an integral part of this team. This will allow patients to have enhanced skills to cope with changes in their symptoms, whether they are due to the disease itself or the changes in their routine.

Background and aims. Peutz-Jeghers syndrome (PJS) is a rare, autosomal-dominant disease characterized by hamartomatous polyps of the alimentary tract, hyperpigmentation of the skin, and family history of PJS. Rarely, solitary Peutz-Jeghers polyps (PJP) arise in patients without other features of PJS. Patients and methods. We reviewed eight patients since 1979 with solitary PJP, six men and two women. Results. The average age at diagnosis was higher (56±13 years) than that of PJS patients in the literature. Polyps were found in the sigmoid colon (n=4), cecum (n=1), stomach (n=1), and duodenum (n=2). The colonic polyps were diagnosed and removed endoscopically. Indications for colonoscopy included routine screening (n=4) or rectal bleeding (n=1). The duodenal and gastric polyps were diagnosed and removed during gastroduodenoscopic examinations, which were performed for nonspecific dyspepsia (n=2) or gastrointestinal bleeding (n=1). The median size was 20 mm (range 2 mm-25 mm). Patients were followed for a median of 11.5 years (range 3–22) without another PJP or cancer. Three patients died of causes unrelated to PJP. Five patients are alive and polyp free. Conclusion. Solitary PJP do not carry a risk of gastrointestinal cancer and are not an indication for specific high-risk screening.

Methods: 30 SD rats underwent placement of a tunneled catheter into the proximal colon. 22 underwent parasympathetic denervation (bilateral vagotomy and transection of pelvic nerves) while the others received a sham operation. To measure colonic transit, 51Cr was injected into the proximal colon at post op days 1, 3, and 7 and the geometric center (GC) of distribution of Cr was calculated. 10 SD rats were divided into 2 groups, sham operation and parasympathetic denervation. At post op day 3, mucosa/submucosal layers of the proximal, middle and distal colon were harvested. 5-HT4 receptor expression was evaluated by Western blot and real time PCR. Results: At post op day 1, colonic parasympathetic denervation caused a significant decrease in GC (4.4, p

Purpose Crohn’s-related rectovaginal fistulae have significant impact on quality of life including sexual function. The aim of this study was to obtain long-term follow-up of Crohn’s related rectovaginal fistulae to assess variables that influence surgical success and determine its effects on quality of life and sexual function.