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Conservative anal surgery, with maximum preservation of the anal sphincters and continence, is becoming increasingly possible with the emergence of new sphincter-sparing treatments. Many surgeons remain skeptical, however, of the nature and impact of incontinence after anal surgery. We aimed to characterize the patterns of anal sphincter injury in patients with fecal incontinence after anal surgery. We reviewed our fecal incontinence database and studied a subset developing incontinence after anal surgery. Maximum resting and squeeze pressures and the distal high-pressure zone to mid–anal canal resting pressure gradient were evaluated. Anal ultrasounds were evaluated and specific postoperative lesions were characterized. Patterns of sphincter injury in 93 patients with fecal incontinence after manual dilation, internal sphincterotomy, fistulotomy, and hemorrhoidectomy were studied. The internal sphincter was almost universally injured, in a pattern specific to the underlying procedure. One-third of patients had a related surgical external sphincter injury. Two-thirds of women had an unrelated obstetric external sphincter injury. The distal resting pressure was typically reduced, with reversal of the normal resting pressure gradient of the anal canal in 89 percent of patients. Maximum squeeze pressure was normal in 52 percent. Incontinence after anal surgery is characterized by the virtually universal presence of an internal sphincter injury, which is distal in the high-pressure zone, resulting in a reversal of the normal resting pressure gradient in the anal canal. These data support concerns that non–sphincter-sparing anal surgery leads to fecal incontinence and is increasingly difficult to justify given the availability of modern sphincter-sparing approaches.

A consecutive series of 23 patients with colonic J pouch-anal anastomosis for low rectal cancer (17 men; mean age 64.4 (range 44–76) years) was studied prospectively. The mean distance from the pouch-anal anastomosis to the anal verge was 3.5 (range 2.0–4.5) cm. During follow-up one patient died from an unrelated cause and four developed metastases, two local and two hepatic. In 19 surviving patients a mean of 7 months after ileostomy closure mean bowel frequency was 2.1 (range 1–4) per day, five patients had urgency and four had mild faecal seepage up to three times per week, and seven patients had some degree of incomplete evacuation. In 13 patients there were no manometric differences before and after surgery with respect to maximum tolerated volume or maximum resting pressure, but maximum squeeze pressure was significantly lower after surgery (mean 189 versus 132 cmH2O before and after surgery respectively, P < 0.05). Colonic pouch reconstruction should be considered as an alternative to straight coloanal anastomosis in patients undergoing very low anterior resection.

PURPOSE: Fibrin glue is a novel treatment for anal fistulas and possesses many advantages in the treatment of difficult high fistulas. Fibrin glue treatment is simple and repeatable; failure does not compromise further treatment options; and sphincter function is preserved. We aimed to compare the outcomes of patients with low and high anal fistulas randomly assigned to either fibrin glue or conventional treatment. METHODS: Patients with simple fistulas (low fistulas) and complex fistulas (high, Crohn’s, and low fistulas with compromised sphincters) were randomly assigned to either fibrin glue or conventional treatment (fistulotomy or loose seton insertion with or without subsequent advancement flap). Patients with rectovaginal fistulas and anal fistulas associated with chronic cavities, acute sepsis, and side branches were excluded. The primary end point was fistula healing. Secondary end points were complications, changes in preoperative continence score, changes in maximum resting and squeeze pressure, satisfaction scores, and pain scores and time off work (simple fistulas only). RESULTS: Patients in the fibrin glue and conventional treatment arms were well matched for gender, median age, duration of fistula symptoms, and follow-up. Fibrin glue healed three (50 percent) of six and fistulotomy seven (100 percent) of seven simple fistulas (difference, 50 percent; confidence interval, 10 to 90 percent; P = 0.06, Fisher’s exact probability test). There was no change in baseline incontinence score, maximum resting pressures, or squeeze pressures between the study arms. Return to work was quicker in the glue arm, but pain scores were similar and satisfaction scores higher in the fistulotomy group. Fibrin glue healed 9 (69 percent) of 13 and conventional treatment 2 (13 percent) of 16 complex fistulas (difference, 56 percent; 95 percent confidence interval, 25.9 to 86.1 percent; P = 0.003, Fisher’s exact probability test). There was no change in baseline incontinence score, maximum resting pressures, or squeeze pressures in either study arm. Satisfaction scores were higher in the fibrin glue group. CONCLUSIONS: No advantage was found for fibrin glue over fistulotomy for simple fistulas, but fibrin glue healed more complex fistulas than conventional treatment and with higher patient satisfaction.

Background Topical preparations have been used in the treatment of anal fissure. However, they are not universally successful and there is confusion over the site and dose of application. This study assessed the effectiveness of oral nifedipine in reducing resting anal pressure and on fissure healing. Methods Anal manometry was performed on eight healthy volunteers and 15 patients with chronic anal fissure before and after oral administration of nifedipine 20 mg. Nifedipine was taken twice daily. Fissure healing was assessed over an 8-week period and pain scores were monitored. Results Oral nifedipine produced an initial reduction in maximum resting anal pressure (MRP) of 35 per cent (P < 0·001) and of 28 per cent after 5 days (P < 0·001) in healthy volunteers. A reduction in MRP of 36 per cent (P < 0·001) was observed in patients with fissure. Pain scores were significantly reduced during the treatment period. Healing was complete in nine patients after 8 weeks and a further three were asymptomatic. Ten patients experience flushing and four had mild headaches. There were no episodes of postural hypotension or incontinence. Conclusion Oral nifedipine reduces resting anal pressure. It is well tolerated and offers an alternative treatment for chronic anal fissure.

Objective To assess the etiology, treatment, and utility of anal ultrasound in men with fecal incontinence and to review the outcomes of conservative (nonoperative) treatment. Background Data The etiology of fecal incontinence in women is almost exclusively from obstetric or iatrogenic surgical injuries resulting in damage to the anal sphincters and/or pudendal nerves. Corresponding data on men with fecal incontinence are sparse. Methods Between January 1995 and January 1998, 37 men with fecal incontinence were evaluated in the John Radcliffe Hospital anorectal ultrasound unit. Their clinical histories, anal ultrasound results, anorectal physiology studies, and responses to conservative therapy were reviewed. Results Median age was 57 years. Major incontinence was present in 27% of the patients. Anal ultrasound localized anal sphincter damage in nine patients, and the characteristics of these nine patients with sphincter damage were then compared with the remaining 28 without sphincter damage. Prior anal surgery was more common in patients with sphincter damage. Hemorrhoids were more common in patients without sphincter damage. Anorectal physiology studies revealed significantly lower mean maximum resting and squeeze pressures in patients with sphincter damage, confirming poor sphincter function. With 92% follow-up, patients without sphincter damage were more likely to improve with nonoperative therapy. Conclusions Anal ultrasound is extremely useful in the evaluation of fecal incontinence in men. Unlike women, the majority of men do not have a sphincter defect by anal ultrasound, and conservative management is usually successful in these patients. In contrast, in men with anal sphincter damage, almost all of these defects resulted from previous anal surgery. Conservative management rarely is successful in these cases, and surgical repair of the anal sphincter may be indicated. Therefore, because the presence or absence of sphincter damage on anal ultrasound usually predicts the response to nonoperative treatment, anal ultrasound should be used to guide the initial management of men with fecal incontinence.

Anorectal function after anterior resection may be impaired as a result of reduced luminal capacity in the pelvis. The aim of this study was to evaluate the colonic J pouch neorectum by means of ambulatory manometry. Twelve patients with a colonic pouch following anterior resection and seven healthy controls were studied for a median of 6 (range 6–24) h using a probe with two pouch-rectal and two anal canal transducers. Records were interpreted by visual inspection. Pressure values and wave frequencies were determined by software analysis. Pouches had been functioning for a median of 32 (range 11–55) months. All patients with a pouch had an acceptable stool frequency. Seven of 12 patients complained of incomplete evacuation. Resting anal canal pressure (73 versus 100 cmH2O), pouch-rectal pressure (29 versus 15cmH2O) and anal canal pouch-rectal pressure gradients (60 versus 85 cmH2O) were similar in patients and controls. The frequency of slow-wave activity in patients with a pouch was significantly lower than that in controls (7 versus 16 cycles per min, P =0.001). Coordination between the colonic J pouch and the anal canal, in the form of sampling episodes, was observed in more than half of the patients with a functioning pouch. Large isolated contractions (pressure greater than 30cmH2O and lasting longer than 20 s) and rhythmic contractions were the most frequent pattern of pouch motility.

PURPOSE: The aim of this study was to determine whether a colonic J-pouch has similar properties to that of a normal rectum, including recovery of rectoanal coordination. METHODS: Ten patients with colonic J-pouch-anal anastomosis (anastomotic distance from anal verge, 3–5 (range, 2.0–4.5) cm for low rectal cancer (7 men; mean age, 64.7 (range, 44–76) years) were studied clinically and in the anorectal physiology laboratory at least one year after operation. Results were compared with a series of ten matched patients who underwent high anterior resection for upper rectal carcinoma (anastomotic height, 12.7 (range, 9.5–16) cm). RESULTS: Although results seemed to be slightly better in the group with the rectum preserved, no statistical differences could be found either in functional outcome or anorectal physiology. One-half of the patients with colonic J-pouch (neorectum) had a positive rectoanal inhibitory reflex. CONCLUSION: Addition of a colon pouch neorectum would appear to improve function to the level of those patients with a high anastomosis and “normal” rectum.

Classically, clinical assessment of faecal incontinence is supported by anal manometry and electromyography. Recently, anal endosonography has appeared to be the ideal method evaluating anatomically both the internal and external anal sphincter. In this paper, our experience in evaluating faecal incontinence by anal endosonography is presented.34 patients (26 female, 4 male; mean age, 40) complaining of faecal incontinence were analysed by traditional anorectal physiologic tests as well as by anal endosonography. Previously, patients were clinically grouped in: group 1, post-delivery, 18 cases; group 2, post-surgery, 6 cases; group 3, "idiopathic", 10 cases.Results of anal physiologic test showed significant differences between group 1 and the rest of patients. All patients complaining of post-surgery incontinence were found to have sphincter disruptions. 2 out of 10 patients from group 3 presented unsuspected lesions. Nearly 40% of women with post-delivery incontinence had normal anal muscles.Anal endosonography is a imaging technique that permits fully vision of the sphincters. It showed to be a great help in cases of faecal incontinence particularly in the decision-making of surgical approach.

One principal aim in follow-up after curative surgery for colorectal cancer is to identify recurrent disease at an early and possibly treatable stage. The major problem for patients with rectal carcinoma is local recurrence, which occurs in 3–30 per cent of cases and carries a 5-year survival rate of less than 5 per cent. Since 1989, in addition to digital and sigmoidoscopic examination, endorectal ultrasonography has routinely been used in the follow-up of patients with rectal cancer. Sixty-six patients (40 men) who had undergone attempted radical surgery for mid- and lower-third rectal cancer were included in the study. The mean age was 68 (range 43–87) years. A total of 190 scans were performed, with a mean of 3 (range 1–9) for each patient. Thirteen (20 per cent) of the 66 patients developed local recurrence; in all cases this was suggested by rectal ultrasonography. Digital examination and rigid sigmoidoscopy failed to detect recurrence in three patients. Four detected recurrences were treated radically; the remaining patients received radiotherapy, palliative transanal resection or laser management because of advanced age or refusal to undergo surgery. Six patients were alive a mean of 21 (range 4–50) months after recurrence. Of these six patients, four were free from disease (three had undergone salvage surgery and one radiotherapy). Postoperative rectal ultrasonography can detect some local recurrences at an early treatable stage. The method is more accurate than digital examination and sigmoidoscopy, and should be used as part of a regular follow-up programme.

The aim of this study was to evaluate the health state of a random group of subjects occupationally exposed to polyvinyl chloride. The emphasis was put on the hepatic functional tests in comparison with acetaminophen pharmacokinetics. Forty two males were assigned to two groups: the control group free from occupational exposure and the group exposed to polyvinyl chloride. The latter one was divided into two subgroups according to the length of exposure. The following examinations were carried out in all subjects: subjective and physical examinations, basic laboratory and functional hepatic tests, radioisotope examinations of the liver and spleen, and acetaminophen pharmacokinetics was analysed as well. Acetaminophen was administered intragastrically in a single dose of 1.0 g. Blood was collected within 24 hrs after drug administration. The method of Routh et al. was used for determination of paracetamol concentration. A two-compartment open model for extravascular administration was used for calculation of pharmacokinetic parameters. The results suggest that polyvinyl chloride leads to an accelerated acetaminophen biotransformation, regardless of the length of occupational exposure. There was no correlation between changes in paracetamol metabolism and standard functional hepatic tests. The acetaminophen test can be useful in detecting alterations in the activity of hepatic microsomal enzymes, a symptom of early occupational exposure to chemical compounds with potential hepatoxic properties.