Video laparoscopic surgery and rectal prolapse. Our experience in rectopexy

BACKGROUND: Laparoscopy is gaining an important role in the treatment of benign colorectal disorders. The aim of this study is the evaluation of clinical and functional results in 4 patients submitted to a laparoscopy rectopexy according to Wells. METHODS: Four females (22-76, mean 53.7 years) affected from a total rectal prolapse with fecal incontinence underwent this procedure from 1993 through 1995. Six months after surgery, at the end of a rehabilitation program consisting of kinesitherapy, bio-feedback and electrostimulations, all patients have been re-evaluated by means of a clinical exam, anorectal manometry, defecography. RESULTS AND CONCLUSIONS: Preliminary results seem satisfactory and may allow to prefer this approach instead of the traditional open one.     

Globoside expression within the human placenta

PURPOSE: To validate a computer-based area calculation method of quantification of rectal evacuation by using defecography videotapes and to use that method to compare evacuation in constipated patients with that in control subjects. MATERIALS AND METHODS: For validation of the method, simultaneous defecography and weight measurements were compared in 36 patients with constipation or incontinence. Evacuation was calculated as the rate of change of the contrast medium-covered rectal area (percentage per second) or of the evacuated amount of contrast medium (percentage per second [relative] and grams per second [absolute]). After method validation, from a series of 215 consecutive constipated patients, individuals with an isolated radiologic diagnosis of intussusception greater than 0.6 cm (n = 27), rectocele greater than 2 cm (n = 19), enterocele (n = 12), or paradoxic puborectal muscle contraction (n = 12) were selected. Rectal evacuation in these groups was compared with that in 30 control subjects. RESULTS: Rectal evacuation rates measured at defecography correlated well with weighed amounts of evacuated contrast medium during the initial and total evacuation periods in 21 patients without contrast medium leak (r = 0.92, P < .001). Constipation overall, a rectocele greater than 2 cm, or paradoxic puborectal muscle contraction were associated with impaired evacuation (P < .001). CONCLUSION: Area calculations of rectal evacuation reflect rectal emptying. A rectocele greater than 2 cm or a paradoxic puborectal muscle contraction may be associated with obstructed defecation.     

Fecal incontinence and rectal prolapse. Clinico-functional assessment

Rectal Prolapse is a rare and distressing condition, with a multifactorial etiopathogenesis. Often, this pathology is associated with fecal incontinence. The recommended approach to the patient with rectal prolapse and fecal incontinence is to repair the prolapse first, then deal particularly with fecal incontinence at a second operation. A retrospective, clinical and manometric study has varying degrees of fecal incontinence. Clinically five of their operation, and a further three patients improved, in two patients the degree of fecal incontinence remained invariable. One patient was worsened after surgery. Manometrically resting and pressure (RAP) was significantly higher in continent patients than in voluntary contraction pressure (MVCP) (p < 0.05) in preoperative testing. Postoperatively, there was a significant increase in the resting anal pressure as well as in maximum voluntary contraction pressure. Patients who remained incontinent had a significantly lower RAP and MVCP than patients who improved our regained continence. In conclusion this study shows an alteration of internal and external sphincteric function in patients with rectal prolapse. The surgical treatment of this disease improves sphincteric function. Incontinent patients with RAP < 10 mmHg and MCVP < 20 mmHg, probably they would be better treated simultaneously either for rectal prolapsus and incontinence. In this kind of patients the perianal proctectomy with total sphincteroplasty could be the elective treatment.     

Rectal adaptation to distension in patients with overt rectal prolapse

BACKGROUND: High recovery rates of continence are observed after surgical procedures for rectal prolapse. Increases in rectal compliance but no obvious rise in anal pressures have been reported. The authors' hypothesis was that decreased rectal adaptation to distension may contribute to incontinence in patients suffering from overt rectal prolapse. METHODS: This was a prospective study conducted in 20 consecutive incontinent patients suffering from overt rectal prolapse with no mucosal change (two men and 18 women; mean(s.e.m.) age 50(3) years). They were compared with 20 age- and sex-matched patients with incontinence without rectal prolapse and ten age- and sex-matched healthy volunteers observed during the same period. The subjects were submitted to phasic isobaric distension of the rectum with an electronic barostat. Anal pressures, perception scores and rectal volumes were recorded at six different preselected pressures. RESULTS: Compared with healthy subjects, maximum rectal volumes (mean(s.e.m) 98(6) versus 167(11) ml; P= 0.005), volumes related to compliance (56(5) versus 100(9) ml; P= 0.004) and tone (41(3) versus 67(4) ml; P = 0.003) were decreased significantly in the rectal prolapse group. Prolapse and incontinence groups did not differ significantly with respect to rectal adaptation for all three parameters and steps of distension considered. CONCLUSION: Patients suffering from overt rectal prolapse had markedly impaired rectal adaptation to distension which may contribute to incontinence.     

Delorme operation for rectal prolapse

A consecutive series of 49 elderly patients of mean age 73 years with full-thickness rectal prolapse underwent the Delorme operation between 1986 and 1990. A standard technique was used, or supervised, by one surgeon. In this prospective series, 43 patients were reviewed clinically. The Delorme operation abolished rectal prolapse in 32 patients. Half of the 40 with faecal incontinence were rendered continent. Failure was related to previous anorectal surgery and/or psychiatric illness. Of the 11 patients in whom the first procedure failed, four were improved by a second Delorme operation. The Delorme operation is a suitable procedure for elderly and/or medically unfit patients with rectal prolapse. Good results have also been demonstrated for younger patients, suggesting that the operation may have wider application.     

FECOM: a new artificial stool for evaluating defecation

OBJECTIVE: Traditionally, barium paste has been used for performing defecography. Because this substance is not stool-like, barium defecography may not accurately represent defecatory function. Our aim was to prospectively compare the utility of a new artificial stool, "FECOM"--a silicon-filled and barium-coated, deformable device the shape and consistency of which mimicked a normal formed stool with that of barium paste. METHODS: Defecography was performed after placing FECOM or barium paste in a random order in 12 healthy subjects (two men and 10 women). We evaluated the changes in anorectal angle, rectal morphology, rectal sensation, and the subjects' preference for a "stool-like" device. RESULTS: Anorectal angle at rest, during squeeze, cough, and straining were each greater with the FECOM when compared with the barium paste (p < 0.006). Anterior rectocele (nine), mucosal intussusception (four), and incontinence (three) were identified only with barium defecography. Nine (75%) subjects preferred FECOM to barium paste (p < 0.001) and reported that expulsion of this device mimicked more closely their stools at home (p < 0.05). CONCLUSION: The anorectal angle is influenced by the form and consistency of stool material and is lower with barium paste. The detection of rectocele, mucosal intussusception, and barium leakage in normal subjects during barium defecography questions the significance of these findings. FECOM appears to be a realistic alternative to barium paste for performing defecography.     

Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse

PURPOSE: This study was undertaken to document the effect of pudendal nerve function on anal incontinence after repair of rectal prolapse. METHODS: Patients with full rectal prolapse (n = 24) were prospectively evaluated by anal manometry and pudendal nerve terminal motor latency (PNTML) before and after surgical correction of rectal prolapse (low anterior resection (LAR; n = 13) and retrorectal sacral fixation (RSF; n = 11)). RESULTS: Prolapse was corrected in all patients; there were no recurrences during a mean 25-month follow-up. Postoperative PNTML was prolonged bilaterally (> 2.2 ms) in six patients (3 LAR; 3 RSF); five patients were incontinent (83 percent). PNTML was prolonged unilaterally in eight patients (4 LAR; 4 RSF); three patients were incontinent (38 percent). PNTML was normal in five patients (3 LAR; 2 RSF); one was incontinent (20 percent). Postoperative squeeze pressures were significantly higher for patients with normal PNTML than for those with bilateral abnormal PNTML (145 vs. 66.5 mmHg; P = 0.0151). Patients with unilateral abnormal PNTML had higher postoperative squeeze pressures than those with bilateral abnormal PNTML, but the difference was not significant (94.8 vs. 66.5 mmHg; P = 0.3182). The surgical procedure did not affect postoperative sphincter function or PNTML. CONCLUSION: Injury to the pudendal nerve contributes to postoperative incontinence after repair of rectal prolapse. Status of anal continence after surgical correction of rectal prolapse can be predicted by postoperative measurement of PNTML.     

Role of radiologic diagnosis in rectal mucosal prolapse

Defecography (DG) is a useful method to detect many morpho-functional deformities of anus and rectum and pelvic floor. We report on a clinical and radiologic study of 165 patients (36 men and 129 women) suffering from defecation disorders and rectal muscosal prolapse (RMP). All the patients had been submitted to clinical examination, endoscopy and double contrast enema to rule out organic colorectal conditions. DG was performed with a dedicated conmode and high-density barium and videorecorded on VHS cassettes to assess the dynamics of evacuation phases and to reduce exposure doses. DG showed single RMP in 28% of cases and multiple RMP in 72% of cases; the condition was isolated in 22% of cases, while in 88% of cases it was associated with other anorectal dysfunctions, such as rectocele (65%), perineal descent syndrome (PDS) (15%), puborectal muscle syndrome (14%) and intussusception (8%). RMP appeared at DG as a wall defect bulging into rectal lumen, which was more evident under straining and during barium evacuation. In 12 patients with multiple RMP, dynamic CT of the pelvis was carried out to study the whole pelvic floor and in 5 cases it showed levator ani diastasis. Fifty-eight patients were submitted to surgery by elastic binding of RMP; DG follow-up showed RMP remission in 47 patients, single RMP relapse in 3 patients and multiple RMP relapse in 3 patients. One patient with PDS and intussusception was submitted to rectopexy and mucosectom.     

Anorectal function in patients with complete rectal prolapse. Differences between continent and incontinent individuals

AIMS: A study is made of the alterations in anorectal physiology among rectal prolapse patients, evaluating the differences between fecal continent and incontinent individuals. PATIENTS AND METHODS: Eighteen patients with complete rectal prolapse were divided into two groups: Group A (8 continent individuals) and Group B (10 incontinent women), while 22 healthy women were used as controls (Group C). Clinical exploration and perineal level measurements were performed, along with anorectal manometry, electrophysiology, and anorectal sensitivity to electrical stimuli. RESULTS: The main antecedents of the continent subjects were excess straining efforts, while the incontinent women presented excess straining and complex deliveries. Pathological perineal descent was a frequent finding in both groups, with a hypotonic anal canal at rest (p < 0.001 vs controls) and at voluntary squeezing (p < 0.001 vs controls). In turn, the incontinent patients exhibited a significantly lower anal canal pressure at rest than the continent women (p < 0.05). There were no significant differences between Groups A and C in terms of pudendal motor latency, though latency was significantly longer in Group B than in the controls (p < 0.01). Moreover, pudendal neuropathy was more common, severe and often bilateral in Group B. There were no differences in rectal sensation to distention or in terms of the volumes required to relax the internal anal sphincter. In turn, both prolapse groups exhibited diminished anal canal and rectal sensitivity to electrical stimuli. CONCLUSIONS: Patients with rectal prolapse exhibit a hypotonic anal canal at rest, regardless of whether they are continent to feces or not. Continent patients have less pudendal neuropathy and therefore less pressure alterations at voluntary sphincter squeeze than incontinent individuals.     

Significance of rectal contractions during multichannel urodynamic study

BACKGROUND: The influence of rectal contractions on urination was examined using multichannel urodynamic study. METHODS: We reviewed a total of 246 consecutive urodynamic studies. Each study consisted of a uroflow measurement and multi-channel urodynamic study, evaluating total vesical pressure, abdominal (rectal) pressure, subtracted detrusor pressure and perianal electromyography. Rectal contractions were defined as periodic fluctuations over 5 cmH2O in abdominal pressure detected by a rectal balloon catheter. No relationship of these contractions with cough and breathing was observed. RESULTS: Of the 246 patients, 17 (6.9%) had a positive study for rectal contractions. The patients, who had positive rectal contractions, averaged 70-year-old were older than negative subjects averaged 62-year-old. In multichannel urodynamics, the flow rate was significantly decreased, and electromyographic activity was increased at the moment of each rectal contractions. CONCLUSIONS: The rectal contractions are not artifactual and may be regarded as one of causes responsible for urinary difficulty in the elderly.     

A constipation scoring system to simplify evaluation and management of constipated patients

PURPOSE: Constipation is a common complaint; however, clinical presentation varies with each individual. The aim of this study was to assess a standard scoring system for evaluation of constipated patients. MATERIALS AND METHODS: All consecutive patients with idiopathic constipation who were referred for anorectal physiologic testing were assessed. A subjective constipation score was calculated based on a detailed questionnaire that included over 100 constipation-related symptoms. Based on the questionnaire, scores ranged from 0 to 30, with 0 indicating normal and 30 indicating severe constipation. The constipation score was then compared with the objective findings of the physiology tests, which include colonic transit time (CTT), anal manometry (AM), cinedefecography (CD), and electromyography (EMG). Colonic inertia was defined as diffuse marker delay on CTT without evidence of paradoxical contraction on AM, CD, or EMG. Pelvic outlet obstruction was defined as paradoxical puborectalis contraction, rectal prolapse or rectoanal intussusception, rectocele, or sigmoidocele. RESULTS: A total of 232 patients (185 females and 47 males) of a mean age of 64.9 (range, 14-92) years were evaluated. All patients had a score of more than 15; on evaluation of the significance of different symptoms in the constipation score with the Pearson's linear correlation test, 8 of 18 factors were identified as significant (P < 0.05). These factors included frequency of bowel movements, painful evacuation, incomplete evacuation, abdominal pain, length of time per attempt, assistance for evacuation, unsuccessful attempts for evacuation per 24 hours, and duration of constipation. All 232 patients had objective obstruction attributable to one or more of the following causes: paradoxical puborectalis contraction (81), significant rectocele or sigmoidocele (48), rectoanal intussusception (64), and rectal prolapse (9). CONCLUSION: The proposed constipation scoring system correlated well with objective physiologic findings in constipated patients to allow uniformity in assessment of the severity of constipation.     

Paradoxical sphincter reaction is influenced by rectal filling volume

PURPOSE: Paradoxical sphincter reaction is frequently found in constipated patients but sometimes also in incontinent patients and in asymptomatic subjects. Its significance in defecation disorders has, therefore, been debated. The aim of the present study was to investigate whether paradoxical sphincter reaction is influenced by rectal filling volume. PATIENTS AND METHODS: Eighteen patients with defecation disorders and paradoxical sphincter reaction shown by electromyography were reinvestigated with an extended electromyographic investigation while in the lying position and while in the sitting position, with 50-ml, 100-ml, and 150-ml water-filled rectal balloons. RESULTS: All 18 patients showing paradoxical sphincter reaction in the first investigation also showed the reaction at the second investigation in the lying position with a 0-ml volume of rectal contents. In the sitting position, with a volume of 150 ml of rectal contents, the increase in electromyographic activity disappeared in seven patients (39 percent) and no longer showed paradoxical sphincter reaction. Electromyography showed decreased activity in one patient and unchanged activity in six patients during straining. A closing reflex was seen after completed straining in all of these seven patients. CONCLUSIONS: The present study demonstrates that paradoxical sphincter reaction diagnosed by electromyography is influenced by the rectal filling volume and might diminish when the rectum is filled with contents. The conventional electrophysiologic technique in the diagnosis of paradoxical sphincter reaction might, therefore, overdiagnose this condition.     

Constipation assessed on the basis of colorectal physiology

BACKGROUND: Constipation is a collective term for symptoms of different aetiologies and pathophysiologies. Our aim was to determine the prevalence of colorectal pathophysiology findings in a prospective series of patients with chronic constipation. METHODS: A total of 155 consecutive patients with chronic constipation underwent anorectal manometry, electromyography (EMG), the balloon expulsion test, colonic transit-time study, and defecography. RESULTS: All investigations were completed by 134 patients (112 females) with a median age 52 (range, 17-79) years. Patients were categorized on the basis of transit time and pelvic-floor function as belonging to 1 of 4 groups: slow-transit constipation (STC) (delayed transit time but normal pelvic-floor function, n = 28), pelvic-floor dysfunction (PFD) (pelvic-floor dysfunction and normal transit time, n = 32), combined slow transit and pelvic-floor dysfunction (STC + PFD) (n = 27), and normal-transit constipation (NTC) (normal transit time and normal pelvic-floor function, n = 47). There was no difference between diagnostic groups in anal sphincter pressures. However, rectal sensitivity to balloon distension was lower (P < 0.05) in patients with delayed transit. Paradoxical puborectalis contraction (PPC) was found on EMG in 42 patients (31%). The prevalence of PPC was higher (P < 0.001) in patients with pelvic-floor dysfunction. Inability to evacuate the rectal balloon was reported by 37% of patients with pelvic-floor dysfunction and 12% of patients with normal pelvic-floor function (P < 0.001). Rectocele was the only anatomic abnormality at defecography which was associated with poor rectal emptying. CONCLUSIONS: About two-thirds of our patients with constipation had objective evidence of delayed transit or pelvic-floor dysfunction. No single test could reliably identify any of the pathophysiologic subgroups of constipation.     

Lymphoid hyperplasia causing recurrent rectal prolapse

An 8-year-old girl had a 5-month history of recurrent rectal prolapse. On colonoscopy, two submucosal masses were noted in the distal rectum and diagnosed by biopsy as benign lymphoid hyperplasia. These were excised by limited dissection superficial to the submucosa, and the histologic diagnosis was confirmed. The child has done well after removal of the nodules, with no subsequent prolapse for more than 2 years.     

Effect of indomethacin suppositories on rectal polyposis in patients with familial adenomatous polyposis

BACKGROUND: Oral sulindac is known to reduce polyps in patients with familial adenomatous polyposis (FAP). The authors speculated that rectal administration of indomethacin would be effective therapy for adenomas in the rectal remnant of FAP. METHODS: Eight patients with FAP who had been treated by total colectomy with ileorectal anastomosis were administered an indomethacin suppository (50 mg) once or twice daily during a period of 4 or 8 weeks. The number of polyps at the same site within the rectum was counted under proctoscopy prior to, at the end of, and after the treatment. In four patients, proliferative activity of the rectal mucosa was assessed by immunohistochemical staining for MIB-1. RESULTS: In six of the eight patients who initially had ten or more polyps, the number of polyps decreased to fewer than five, whereas such a decrease could not be observed in the remaining two patients. In the six patients, the number of polyps increased after indomethacin was discontinued. The proliferative activity of the rectal mucosa was higher at the end of treatment than it was prior to indomethacin administration. CONCLUSIONS: Indomethacin suppositories may be effective in the management of rectal adenomatosis in patients with FAP.     

Association of compartment defects in pelvic floor dysfunction

OBJECTIVE: Dynamic cystoproctography was used to determine the frequency of associated urinary, genital, and anorectal abnormalities in women with pelvic floor dysfunction. SUBJECTS AND METHODS: We categorized, by pelvic floor compartments, the symptoms at presentation of 100 consecutive female patients who had been referred for dynamic cystoproctography. We then analyzed the compartment defects seen on dynamic cystoproctography relative to those detected on clinical presentation. RESULTS: Of the 20 patients with symptoms of anterior compartment (urinary) defect, dynamic cystoproctography revealed that 45% had vaginal vault prolapse of more than 50% and that 90% had rectoceles. Of the 45 patients with symptoms of middle compartment (genital) defect, dynamic cystoproctography revealed that 91% had cystoceles, 56% had a hypermobile bladder neck, 82% had rectoceles, 58% had enteroceles, 11% had sigmoidoceles, 20% had rectoanal intussusception, and 16% had anal incontinence. Of the 17 patients with symptoms of posterior compartment (anorectal) defect, dynamic cystoproctography showed that 71% had cystoceles, 65% had a hypermobile bladder neck, and 35% had vaginal vault prolapse of more than 50%. Of the 18 patients with symptoms of defects from a combination of compartments, dynamic cystoproctography revealed that 89% had cystoceles, 56% had a hypermobile bladder neck, 39% had vaginal vault prolapse exceeding 50%, 100% had rectoceles (of which 45% were large), 6% had enteroceles, 6% had sigmoidoceles, 22% had rectoanal intussusception, and 6% had anal incontinence. CONCLUSION: Although patients may present with symptoms that involve only one compartment, a multicompartment prolapse is usually revealed on dynamic cystoproctography. Of the patients with pelvic floor dysfunction, 95% had abnormalities in all three compartments.     

Prediction of genital prolapse after Burch colposuspension

OBJECTIVE: The aim of this prospective observational study was to investigate the gynecological and defecographic features in women with stress urinary incontinence operated with Burch colposuspension in order to analyze if the findings could predict subsequent development of genital prolapse. SUBJECT: Twenty-one women with urodynamically proven genuine stress urinary incontinence were consecutively operated with the Burch colposuspension during 1991-1992. No concomitant prolapse repair surgery was performed. METHODS: All were carefully examined in the lithotomy position at rest and with the Valsalva maneuver. The pelvic floor laxity was graded semiquantitatively. The defecography and the clinical examination were done preoperatively and repeated one year postoperatively. RESULTS: The clinical examination revealed a significant progression of rectoceles (p = 0.003) after the colposuspension. The colposuspension cured a significant number of cystoceles (p = 0.035). Six women (29%) had subsequent corrective prolapse surgery median 2 years after the colposuspension. The defecographic measurements showed a significant increase of the recto-vaginal distance (RVD) following the operation (p = 0.020). At the postoperative measurement the group with subsequent prolapse surgery had a significantly larger RVD as compared to the group without further surgery (p = 0.004). The kappa reliability test showed poor agreement between the defecographic and clinical assessment of the rectoceles. CONCLUSION: We failed to find any clinical or defecographic characteristic which could predict the development of surgery-demanding genital prolapse following colposuspension. The colposuspension seemed to accelerate the deterioration of the pelvic floor. However, only a minority of the patients developed symptomatic genital prolapse demanding corrective surgery. We suggest that only women with symptomatic prolapse should be considered for concomitant corrective surgery at the time of the colposuspension.     

Long-term clinical outcome of surgery for solitary rectal ulcer syndrome

BACKGROUND: When severe symptoms of solitary rectal ulcer syndrome persist despite medical management, surgery may be necessary. METHODS: A retrospective review was carried out of 81 patients undergoing surgery for solitary rectal ulcer syndrome in the 10-year period from 1984 to 1993 to determine the long-term outcome at a minimum follow-up of 12 months. Of the 81 patients, 15 were excluded from further analysis (11 were followed up for less than 12 months, two died and two were lost to follow-up). Sixty-six patients were studied (median age 38 (range 15-77) years; 53 female). Of these, 49 underwent rectopexy, nine Delorme's operation, two anterior resection and four creation of a stoma as the initial operation. RESULTS: At a median follow-up of 90 (range 12-177) months, the rectopexy had failed in 22 of 49 patients; 19 of these patients underwent further surgery, including rectal resection with coloanal anastomosis (four with three failures), colostomy (11) and other procedures (four). Ultimately, 14 required a stoma. Constipation was the indication for a stoma in nine of the 11 patients who had colostomy as the first procedure after failure of rectopexy. Nine patients had Delorme's operation as the first procedure. At median follow-up of 38 (range 19-107) months, there were four failures. Two of these ultimately required a stoma. Of the seven patients who underwent anterior resection as the initial or subsequent procedure, a stoma was finally necessary in four. Anterior resection used as a salvage procedure was not successful. The overall stoma rate was 30 per cent (20 patients). Of 11 symptoms assessed before operation only incontinence and incomplete evacuation were related to a poor outcome following surgery. CONCLUSION: Antiprolapse operations result in a satisfactory long-term outcome in about 55-60 per cent of patients having surgery for solitary rectal ulcer syndrome. Results of anterior resection are disappointing.     

Sphincter preservation therapy for distal rectal carcinoma: a review

BACKGROUND: There has been increasing interest in the use of sphincter-preserving therapy for patients with distal rectal carcinomas. The outcomes of conservative treatments for early stage rectal carcinoma appear to be comparable to that achieved with abdominoperineal resection. METHODS: Retrospective and prospective clinical series of patients with distal rectal carcinoma treated by local excision alone, local excision with postoperative adjuvant therapy, preoperative radiation followed by local excision, or radical circumferential sphincter-sparing surgeries were reviewed. The local control rates, salvage rates, and treatment complications in patients treated by these various methods were examined. RESULTS: Patients with T1 distal rectal carcinoma with favorable clinical and histopathologic characteristics treated with local excision alone had a local control rate of greater than 90% in most series. Postoperative chemoradiation improved local control for those with T1 disease with unfavorable characteristics, or those with T2 disease. Most T3 patients had failure rates of greater than 30% despite adjuvant local and systemic therapy. With high dose preoperative radiation, approximately 80% of patients with locally advanced or unresectable tumors were able to undergo sphincter-preservation treatment. CONCLUSIONS: Patients with favorable T1 rectal carcinoma are likely to be adequately treated with local excision alone. Patients with T1 disease with unfavorable characteristics as well as T2 patients will benefit from postoperative chemoradiation. The use of local therapy in T3 patients needs to be carefully considered because these patients are at relatively high risk for local recurrence despite adjuvant therapy. Preoperative radiation followed by either local excision or radical circumferential sphincter-sparing resections appears promising in allowing sphincter preservation in patients with locally advanced tumors.     

Gas enema for the reduction of intussusception: relationship between clinical signs and symptoms and outcome

OBJECTIVE: The aim of this study was to establish the extent to which the clinical features of intussusception can be used to predict successful outcome of gas enema and to determine whether the nonsurgical management of intussusception in children can be improved by refining the criteria used to select patients for gas enema. SUBJECTS AND METHODS: Clinical data on 282 consecutive episodes of intussusception (255 patients) were collected prospectively from January 1987 to July 1991. Gas enema was performed in 273 episodes, in which the clinical signs and symptoms were studied by using logistic regression. Nine patients had primary surgery. RESULTS: Gas enema was successful in 216 (79%) of 273 enemas attempted. Fifty-seven patients had surgery after unsuccessful enema. Univariate analysis showed significant associations between successful enema and duration of signs and symptoms less than 12 hr, no rectal bleeding, absence of small-bowel obstruction, presence of a palpable mass, and normal hydration. Multivariate analysis showed that dehydration, small-bowel obstruction, and duration of signs and symptoms longer than 12 hr were significant predictors of unsuccessful enema; yet, in these groups the rate of success still justified attempted enema. Even in severe dehydration, the successful enema reduction rate was 31%. CONCLUSION: Our data suggest that although the factors identified had some predictive value in determining the outcome of attempted enema reduction, they could not be used to indicate patients in whom enema reduction should not be attempted. All patients with intussusception should have a gas enema if the absolute contraindications to enema (i.e., peritonitis or perforation) are absent.