摘要:

BACKGROUND:A prospective, three‐armed, randomized, controlled trial was performed to assess whether pelvic floor exercises with biofeedback using anal manometry or transanal ultrasound are superior to pelvic floor exercises with feedback from digital examination alone in terms of continence, quality of life, physiologic sphincter strength, and compliance. Its secondary objectives were to assess whether there are any differences in these outcomes between biofeedback with transanal ultrasoundvs.anal manometry and to correlate the physiologic measures with clinical outcome.METHODS:One hundred twenty patients with mild to moderate fecal incontinence were randomized into one of three treatment groups: biofeedback with anal manometry, biofeedback with transanal ultrasound, or pelvic floor exercises with feedback from digital examination alone. Commencing one week after an initial 45‐minute assessment session, patients attended monthly treatments for a total of five sessions. Each session lasted 30 minutes and involved sphincter exercises with biofeedback that involved instrumentation or digital examination alone, and patients were encouraged to perform identical exercises twice per day between outpatient visits.RESULTS:One hundred two patients (85 percent) completed the four‐month treatment program. Across all treatment allocations, patients experienced modest but highly significant improvements in all nine outcome measures during treatment, with 70 percent of all patients perceiving improvement in symptom severity and 69 percent of patients reporting improved quality of life. With the possible exception of isotonic fatigue time, there were no significant differences between the three treatment groups in compliance, physiologic sphincter strength, and clinical or quality‐of‐life measures. Correlations between physiologic measures and clinical outcomes were much stronger with ultrasound‐based measures than with manometry.CONCLUSIONS:Although patients in this study who completed pelvic floor exercises with feedback from digital examination achieved no additional benefit from biofeedback and measurement with transanal ultrasound or manometry, it may be that the guidance received through digital examination alone offered patients in the pelvic floor exercise group an effective biofeedback mechanism. Contrary to our hypothesis, the use of transanal ultrasound offered no benefit over manometry, but the use of ultrasound for isotonic fatigue time and isometric fatigue contractions provided potentially important physiologic measures that require further study. This study has confirmed, through a large sample of patients, that pelvic floor retraining programs are an effective treatment for improving physiologic, clinical, and quality‐of‐life parameters in the short term.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study evaluated the durability and long‐term safety of radio‐frequency energy delivery for fecal incontinence (Secca procedure).METHODS:This was an extended follow‐up of a prospective study in which patients with fecal incontinence of various causes underwent radio‐frequency energy delivery to the anal canal muscle. The Cleveland Clinic Florida Fecal Incontinence Scale (0‐20), fecal incontinence‐related quality‐of‐life score, and Medical Outcomes Study Short Form 36 were administered at baseline and at 1, 2, 3, 6, 12, and 24 months after the procedure. Differences between baseline and follow‐up were analyzed with the Wilcoxon signed‐rank test.RESULTS:Ten females (aged 55.9 ± 9.2 (range, 44‐74) years) were treated. At two‐year follow‐up, the mean Cleveland Clinic Florida Fecal Incontinence Scale score was improved from 13.8 to 7.3 (P= 0.002), with eight patients having scores of ≤10. All fecal incontinence‐related quality‐of‐life score parameters were improved, including lifestyle (from 2.3 to 3.3;P= 0.002), coping (from 1.7 to 2.7;P= 0.002), depression (from 2.4 to 3.4;P= 0.004), and embarrassment (from 1.5 to 2.4;P= 0.008). There was no decrement in effect noted in any parameter between 12 and 24 months (P> 0.2). The social function component of the Short Form 36 improved from 50 to 82.5 (P= 0.04), whereas there was an improvement trend for the mental component summary of the Short Form 36 from 38.3 to 48.1 (P= 0.11). Protective pad use was eliminated in four of the seven baseline users. There were no long‐term complications, such as stricture, pain, or constipation.CONCLUSIONS:A significant improvement in symptoms of fecal incontinence and quality of life persists two years after radio‐frequency delivery to the anal canal, which demonstrates durability of this intervention.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Graciloplasty has been used as a treatment for end‐stage fecal incontinence since 1946. Electric stimulation with an implantable pulse generator has existed for 15 years. The gracilis muscle is wrapped around the anal canal and stimulated by intramuscular electrodes connected with an implantable pulse generator. Initial reports have been promising, but long‐term results have not been presented to date.METHODS:Data of 200 consecutive patients with a follow‐up of at least two years were analyzed in a prospective manner from 1986 until 1999.RESULTS:The overall success rate was 72 percent. In patients with fecal incontinence caused by trauma, the rate was 82 percent. Once continent, patients remained continent after a median follow‐up of 261 (standard deviation, 132) weeks. Median survival of the implantable pulse generator until battery expiration was 405 weeks. Disturbed evacuation remained a problem in 16 percent of all patients. Complications were frequent but treatable.CONCLUSION:Dynamic graciloplasty is a good, cost‐effective treatment for fecal incontinence with results lasting for a median of more than five years.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study was undertaken to evaluate a single‐institution experience with the Acticon® artificial bowel sphincter for the treatment of intractable fecal incontinence.METHODS:At the University of Minnesota, 45 consecutive patients underwent artificial bowel sphincter placement (Group I, 1989‐1992, n = 10; Group II, 1997‐2001, n = 35). Group I was reviewed retrospectively and Group II prospectively.RESULTS:The outcome for Group I patients was initially reported in 1995 (mean age, 32; range, 15‐52 years; 7 males). Of these 10 patients, 4 required explantation (2 required stomas), and 6 have a functional artificial bowel sphincter; 2 patients had devices successfully replaced for fluid leaks (at 6 and 10 years). In Group II, artificial bowel sphincter placement was attempted in 37 patients and was successful in 35 (mean age, 47; range, 18‐72 years; 11 males). A total of 14 patients required explantation, 12 (34 percent) for infection and 2 (6 percent) for pain. In total, 13 patients have required 21 revisions, including 7 complete device replacements. The infection rate for revisions was 19 percent; four patients required explantation after revisions. Of 18 patients whose artificial bowel sphincter failed, 9 required a stoma. In all, 17 (49 percent) patients have a functional artificial bowel sphincter. In Group II fecal incontinence severity scores decreased from a mean of 103 preimplant to 59 at one year and to 23 at two or more years (P <0.001) in patients who retained their devices. Quality of life scores improved in all patients at six months and at one year (P <0.01).CONCLUSION:Artificial bowel sphincter therapy leads to long‐term improved continence and quality of life in patients whose implantation is successful. Success rates have not improved in the two patient groups, with infection remaining a major challenge. However, once successfully established, artificial bowel sphincter function remains stable for many years.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The artificial bowel sphincter has been proposed to treat patients with fecal incontinence. The good results achieved with this procedure encouraged us to use this device for reconversion of patients who previously underwent an abdominoperineal resection.METHODS:Between 1999 and 2001, we selected eight patients for the total anorectal reconstruction, five for a synchronous reconstruction, and three cases for a delayed procedure. One patient was male and seven were female. The mean age was 52.6 years. All the patients underwent a postoperative manometry and defecography. Continence and quality of life scores were also evaluated in the follow‐up.RESULTS:The follow‐up length ranged from 6 to 28 months. Manometry assessed a basal pressure with the ABS cuff inflated between 58 and 62.2 mmHg. All but one patient achieved a good grade of continence with a Wexner score range between 3 and 9. A certain degree of impaired evacuation occurred in three patients, but with adequate training this improved and did not affect patient's satisfaction. The administered questionnaires demonstrated a significant improvement in quality of life scores for stoma patients and an elevated quality of life in patients synchronously treated with artificial bowel sphincter implant.CONCLUSION:The artificial bowel sphincter is a good option for reconstruction of patients previously treated with an abdominoperineal resection. The procedure is feasible and safe, without serious postoperative complications. The quality of life is improved when the procedure is performed in stabilized stoma patients and is acceptable for motivated patients synchronously implanted. As compared with electrostimulated graciloplasty, the artificial bowel sphincter technique seems to be easier to perform and more acceptable for the patients, although the cost of the device is still high.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:This study was designed to test the hypothesis that the extent of anal sphincter muscle injury as graded at endosonography correlates with the degree of functional impairment.METHODS:Three hundred and thirty adults presenting for evaluation of fecal incontinence were recruited. Ultrasound was performed with a 7.5‐MHz radial rotating axial endoprobe in the left lateral position. Anal sphincter muscle tears were graded on the basis of the degree of circumferential involvement (< or >25 percent) and by an assessment of the superoinferior longitudinal extent of an external anal sphincter tear. Muscles that demonstrated multiple tears, poor visualization, or fragmentation were classed as fragmented. Sphincter injuries were correlated with basal and squeeze pressures at manometry, pudendal nerve terminal latencies, and the severity of symptoms using the Parks‐Browning clinical score.RESULTS:Patients with an intact external anal sphincter had a higher squeeze pressure (mean, 162.6 cm H2O) than those with a partial‐ (mean, 125.7 cm H2O) or full‐length tear (mean, 124.9 cm H2O;P< 0.0001). There was no significant difference in squeeze pressure between those with partial‐vs.full‐length external anal sphincter tears nor between circumference tears < or >25 percent. Basal pressure was significantly lower in those with a full‐length external anal sphincter tear (47.8 cm H2O)vs.an intact external anal sphincter (65.7 cm H2O;P< 0.001). The basal pressure in those with an intact internal anal sphincter was not significantly different from those with clearly defined internal anal sphincter tears, and the degree of circumferential involvement was also not important in this regard. However, those with a fragmented internal anal sphincter had a significantly lower basal pressure than other subgroups of internal anal sphincter injuries (P< 0.001). There was no association between external or internal anal sphincter status and the mean pudendal nerve terminal motor latency, suggesting the patient groups were neurologically similar. There was no significant association between external or internal anal sphincter status and the severity of reported symptoms.CONCLUSION:Correlations between the presence or absence of muscle tears and reduced manometric function have been identified. Further grading of tears was of less importance. No relationship between muscle injuries and the severity of clinical symptoms could be elicited.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to determine whether a postpartum bowel‐habit questionnaire could reliably identify females who had sustained perineal and anal sphincter trauma after vaginal delivery.METHODS:A prospective cohort design was used to recruit 156 consecutive primigravid females, of whom 134 delivered vaginally without clinical evidence of a third‐degree tear. These 134 females completed a specific anal continence questionnaire and underwent anal endosonography before and after delivery to identify those with postpartum deterioration in anal continence and to relate this to sonographic evidence of anoperineal trauma.RESULTS:Anal continence deteriorated in 37 females (27.6 percent) after delivery, 16 of whom (43.2 percent) had sonographic evidence of trauma. There was no postpartum deterioration of continence in the remaining 97 females, 17 (17.5 percent) of whom had sonographic evidence of trauma. Sensitivity, specificity, positive predictive value, and negative predictive value of the questionnaire for sonographic trauma were 48.5, 79.2, 43.2, and 82.5 percent, respectively, with corresponding values of 57.1, 75.8, 21.6, and 93.8 percent for external anal sphincter disruption.CONCLUSION:A bowel‐habit questionnaire will detect approximately 60 percent of females who sustain external sphincter tears after vaginal delivery.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Pouchitis is the most common complication of ileal pouch‐anal anastomosis for ulcerative colitis. Our previous study suggested that symptoms alone are not reliable for the diagnosis of pouchitis. The most commonly used diagnostic instrument is the 18‐point pouchitis disease activity index consisting of three principal component scores: symptom, endoscopy, and histology. Despite its popularity, the pouchitis disease activity index has mainly been a research tool because of costs of endoscopy (especially with histology), complexity in calculation, and time delay in determining histology scores. It is not known whether pouch endoscopy without biopsy can reliably diagnose pouchitis in symptomatic patients. The aim of the present study was to determine whether omitting histologic evaluation from the pouchitis disease activity index significantly affects the sensitivity and specificity of diagnostic criteria for pouchitis.METHODS:Ulcerative colitis patients with an ileal pouch‐anal anastomosis and symptoms suggestive of pouchitis were evaluated. Patients with chronic refractory pouchitis and Crohn's disease were excluded. Patients with pouchitis disease activity index scores of seven or more were diagnosed as having pouchitis. Different diagnostic criteria were compared on the basis of the pouchitis disease activity index component scores. Nonparametric receiver‐operating‐characteristic curves were used to measure proposed pouchitis scores' diagnostic accuracy compared with diagnosis from the pouchitis disease activity index. The receiver‐operating‐characteristic area under the curve measured how much these diagnostic strategies differed from each other.RESULTS:Fifty‐eight consecutive symptomatic patients were enrolled; 32 (55 percent) patients were diagnosed with pouchitis. With the use of the pouchitis disease activity index as a criterion standard, the use of only symptom and endoscopy scores (modified pouchitis disease activity index) produced an area under the curve of 0.995. Establishing a cut‐point of five or more for diseased patients resulted in a sensitivity equal to 97 percent and specificity equal to 100 percent.CONCLUSIONS:Diagnosis based on the modified pouchitis disease activity index offers similar sensitivity and specificity when compared with the pouchitis disease activity index for patients with acute or acute relapsing pouchitis. Omission of endoscopic biopsy and histology from the standard pouchitis disease activity index would simplify pouchitis diagnostic criteria, reduce the cost of diagnosis, and avoid delay associated with determining histology score, while providing equivalent sensitivity and specificity.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:The purpose of this study was to evaluate the costs associated with the ileal pouch‐anal anastomosis procedure and identify those factors that most affected or determined such costs. Specifically evaluated were the costs, complication rates, and length of stay associated with the ileal pouch‐anal anastomosis done as a one‐stage, two‐stage, two‐stage modified, or three‐stage procedure.METHODS:Costs from the hospital accounting database and clinical data from retrospective chart review of 135 ileal pouch‐anal anastomosis patients from a ten‐year period were compiled. Overall costs and length of stay (the sum of all hospitalizations for all surgeries and any related complications) for each group were compared by analysis of variance. Linear regression was used to compute net costs and length of stay excluding contributions from other relevant factors such as number of operative stages, complications, demographics, and nonelective operations.RESULTS:The average overall cost and length of stay of the ileal pouch‐anal anastomosis ranged from a low of $12,738 and 13.5 days for the one‐stage procedure to a high of $32,758 and 23.9 days for the three‐stage pathway. Overall costs, length of stay, and incidence of complications increased with the number of operations necessary to complete the ileal pouch‐anal anastomosis. This pattern of increased costs and length of stay with the greater number of stages persisted even after demographic and preoperative characteristics were controlled for in the analyses. The occurrence of a complication added an average of $9,304 (P< 0.0001) and 7.4 days to the procedure (P= 0.0002), whereas an urgent presentation added an average of $5,258 (P= 0.15) and 6.1 days (P= 0.04).CONCLUSIONS:The two most definitive determinants of cost and length of stay after ileal pouch‐anal anastomosis are complications and number of operative stages used to complete the operation. Elective ileal pouch‐anal anastomosis operations done in the fewest stages with the least complications provide the least costly result and the shortest hospital stay. For patients with severe disease, the two‐stage modified pathway (total abdominal colectomy followed by pouch creation without a protecting ileostomy) appears to have fewer complications, lower costs, and a shorter length of stay than the traditional three‐stage pathway.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

PURPOSE:Several procedures have been described for the management of rectourethral fistula. There has been no consensus on the best method of repair. The aim of this study was to review our experience with treatment of rectourethral fistula, focusing on the outcomes of rectal advancement flap repair.METHODS:Data collected included demographics, cause, procedure type, presentation, operative details, and morbidity. Telephone follow‐up was conducted to evaluate functional outcome and quality of life.RESULTS:From 1981 to 2001, 23 male patients (age, 54 ± 15 years) were treated for rectourethral fistula. Fecal diversion alone was performed in seven patients (30 percent), and urinary diversion alone was performed in one patient (4 percent). Both fecal and urinary diversion were performed in 12 patients (52 percent), and no diversion was performed in 3 (13 percent). Four patients were managed conservatively with diversion only. Nineteen patients underwent definitive repair. Rectal advancement flap repair was used in 12 (52 percent) of the cases. Postoperative length of stay was 4.5 ± 4 days. Patients were followed up for an average of 31 ± 33.4 months. Rectal advancement flap achieved primary closure in 8 (67 percent) of 12 patients. There were four recurrences. Two patients underwent successful repeat repair, for a final success rate of 83 percent. Morbidity associated with rectal advancement flap was 8 percent (1/12 patients). Cleveland Global Quality of Life score averaged 0.82 ± 0.13.CONCLUSION:The rectal advancement flap provides an effective repair for rectourethral fistula. Successful repair can be achieved in a majority of patients with minimal morbidity, short length of stay, and a good postoperative quality of life.

ISSN:0012-3706    

出版商:OVID    

年代:2003

数据来源: OVID