Although immediate results are good to excellent in great majority of patients who undergo biofeedback treatment (BFT) for chronic constipation and fecal incontinence, they tend to loose the benefit over a period of time. The purpose of this study was to evaluate the long-term sustainability of results after successful biofeedback treatment. Two groups of patients who successfully completed BFT at our institution from 1995 to 1997 were created based on the date of completion. The first had a mean follow-up of 35 months and the second group was followed for an average of 12 months. Both groups were questioned as to the presence of constipation and incontinence. The questioning was focused depending on the patient's diagnosis. This information was then compared with the initial BFT results. Overall, all patients were satisfied by the initial BFT results. All patients initially had an excellent or good response to BFT. However, after a mean of 35 months, in the first group, 19 of 22 patients had a near complete regression back to their pre-biofeedback status. In the 14 patients in the second group with mean follow-up of 12 months, 11 had a significant decay in benefits. Only time was a significant factor in the decay of BFT benefits. In conclusion, BFT is highly effective in the treatment of selected patients with complex defecation disorders. Although there is a high initial success rate, there is a clear loss of the immediate benefits over time. Other factors such as dietary habits, pelvic floor exercises, manometry, invasive EMG, and rectal sensation did not correlate with long-term outcomes. The comparison between the two groups reveals a linear model describing the time decay of the benefits of BFT. Based on the linear model, patients may need reevaluation after one year and may benefit from additional BFT.

Fecal incontinence occurs frequently in both men and women. Yet, few studies on fecal incontinence have separated the evaluation and interpretation of data by gender. This study was designed to identify differences in the clinical, anorectal manometry, and electromyography (EMG) characteristics between male and female patients with fecal incontinence. We compared 53 incontinent males (mean age, 64 years) with 72 incontinent females (mean age, 61 years). Each patient underwent computerized anorectal manometry, and invasive (pudendal nerve conduction studies and concentric needle EMG) and noninvasive EMG (anal sensor surface electrode). An anal incontinence score (AIS) ranging from 0 to 6 was used to categorize patients. Male patients had higher incontinence scores at presentation (AIS greater than 4, 70% vs. 54%). Female patiens had significantly lower resting pressure (40 vs. 53 mmHg, p < 0.05) and more women had sphincter asymmetry (36% vs. 25%, p < 0.05). Both groups had similar PNTMLs (2.41 vs. 2.47 ms). Difference was seen in the net strength of the sphincter (women 4.0 μV vs. men 8.0 μV, p < 0.05), as measured by noninvasive EMG. In conclusion, it is well known that there are differences in anorectal physiologic function between male and female patients with normal continence. Comparing male and female patients with fecal incontinence suggests that female patients tend to have worse sphincter function that men. Both groups had similar EMG alterations, suggesting a common neurogenic injury as etiology. Future studies are needed to address the sexes separately.

Since laparoscopy was first introduced as a diagnostic tool for pelvic pathology 15 years ago, the technique has been successfully adapted by general and specialty surgeons as a therapeutic tool for a variety of diseases. Laparoscopic surgery has been used to treat colon and rectal pathology since 1991. The introduction and acceptance of this new access technique also brought the realization of specific complications associated with a laparoscopic approach. Advanced laparoscopic skills are required for laparoscopic pelvic and, to minimize laparoscopic-associated complications, specialized training is required. We will review the specific complications of the laparoscopic approach in pelvic surgery with a view to their recognition, prevention, and treatment.

Small-cell carcinoma of the rectum is an infrequent pathologic finding, and its precise incidence is unknown. Its incidence is less than 0.2 percent among all colorectal cancers. This tumor manifests highly aggressive behavior. The treatment of choice is combination chemotherapy similar to that used for small-cell carcinoma of the lung, but in small localized tumors surgery plus chemotherapy is an alternative. We present two cases of small-cell carcinoma of the lower rectum and a review of the literature.

: The number of patients who undergo ambulatory surgery for haemorrhoids has been increasing over the past few years. The aim of present study was to evaluate our experience with ambulatory treatment of haemorrhoids in a dedicated colorectal surgical unit from January 1995 to April 1997. We performed 225 ambulatory haemorrhoidectomies in this period. Mean age of the patients was 49.5 years, 52% of the patients were male, and 48% female. Thirty-two percent of our patients were classified as ASA level II or III. The most frequent procedure was the threequadrant haemorrhoidectomy (87% of patients). Only 20 patients (8.9%) presented with postoperative complications, of these, only five (2.2%) were considered major and required hospital admission. The mean time until the first postoperative visit was 8.2 days, and to the final visit 37.2 days. The mean number of postoperative visits was 2. Patients with complications had a longer postoperative follow-up. Patient satisfaction was high. We thus conclude that outpatient haemorrhoidectomy is safe and cost effective.

American Society of Colon and Rectal Surgeons 95th Annual Convention Podium and Poster Abstracts June 9-14, 1996 Seattle, Washington: PDF Only

With the increasing frequency of minimally invasive surgical procedures, we have begun to see descriptions of new and unforseen complications. One such complication is the formation of a ventral hernia through an unclosed or poorly closed fascial defect created by trocar insertion. The necessity to perform fascial closure of trocar insertion sites, particularly those greater than 5 mm, has been established and is routinely practiced by the majority of laparoscopists. Standard suture techniques can be difficult and frustrating, and often involve blind closure of the fascial defect. A number of instruments have been developed to facilitate this fascial closure. We are currently using a self-contained disposable fascial closure device (Endo-JudgeTM--Synergistic Medical Technologies, Inc., Orlando, Florida), which is quick and relatively simple to use. It enables secure fascial closure under direct vision with the pneumoperitoneum intact. Initial results reveal consistent fascial and peritoneal closure and no postoperative hernia formation.

Laparoscopic resection for carcinoma of the colon and rectum is currently under intense scrutiny. PURPOSE: The purpose of this study is to review our three-year experience of laparoscopic surgery for colon and rectal carcinoma. METHODS: From October 1991 to September 1994, 76 laparoscopic procedures were performed for colorectal neoplasia (32 males and 44 females; mean age, 69 years). Fifty-five procedures were done for carcinoma, 16 for large polyps, and five for diversion in patients with unresectable cancer. For resectable tumors, the average size was 4 cm; staging was as follows. Dukes A, 10 patients; Dukes B1, 11; Dukes B2, 18; Dukes C1, 1; Dukes C2, 9; and Dukes D, 8. Fourteen cases (25 percent) that were converted to open procedures were compared with the 41 cases that were completed laparoscopically for differences in tumor size, surgical margins, number of lymph nodes harvested, length of hospital stay, and evidence of recurrence. Procedures completed laparoscopically were then compared with a group of open controls completed during the same time period. RESULTS: During the first six months, the conversion rate was 32 percent but dropped to 8 percent in the fast six months. There were a total of 19 complications (25 percent), of which 8 (14 percent) were directly related to the laparoscopic technique. The mean number of lymph nodes harvested in laparoscopic resection for carcinoma was 8.5, and the average closest tumor margin was 4.5 cm. When laparoscopic resections were compared with converted and standard open colectomies, there was no significant difference in tumor margins or numbers of nodes resected. Length of stay was significantly shorter for anterior resections completed laparoscopically than for converted or conventional colectomies. Although this was also the trend for right hemicolectomies, it did not reach statistical significance. Mean follow-up of the group completed laparoscopically was 16.7 months, during which there was one recurrence. There were no trocar site recurrences. CONCLUSIONS: This early experience seems to indicate that laparoscopic surgery for colorectal carcinoma does not per se compromise surgical oncologic principles and encourages us to continue out critical appraisal of this technique.

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Introduction and Objectives: The minimally invasive infrapubic inflatable penile implant procedure was developed by Dr Perito with the aim of minimising operative time and post-operative morbidity. Dr Eid has also demonstrated a significant reduction in postoperative infections with his No-Touch technique. We have developed a new technique that combines key aspects of these 2 approaches to create a minimally invasive, no-touch (“MINT”) technique for penile prosthesis insertion. We theorised that the MINT technique would take advantage of the benefits that each of these established approaches offered and therefore our primary aims were to assess feasibility, safety, post-operative infection rate and revision rate. Methods: The principles of the MINT technique involve an infrapubic approach combined with a no-touch technique facilitated by using 2 standard surgical drapes (19 clear non-adhesive drape and 19 Ioban drape) and an Alexis wound retractor (figure 1). We present results for our first 258 consecutive patients undergoing primary prosthesis implantation from May 2012 to July 2017, and followed-up for at least 3 months. Patients with complex surgery necessitating >1 incision were excluded. Data was collected using a prospective database. This is the largest penile implant series with the longest follow up to be published in Australia. Results: Average age ( SD) was 60.8 ( 10.3) years. Patients had one or more of the following aetiologies for erectile dysfunction: vascular disease (n = 121), post-radical prostatectomy (n = 142), diabetes (n = 80), Peyronie’s disease (n = 60), venous leak (n = 17) and priapism fibrosis (n = 4). Implant used: Coloplast Titan (n = 246), Genesis (n = 6), American Medical Systems (LGX; n = 5), (CX; n = 1). The average ( SD) cylinder and rear tip extender length was 19.45 ( 1.8) and 1.0 ( 0.8) cms respectively. Median (IQR) follow-up was 30.6 (16.8, 45.7) months. There has been 3 (1.2%) complications: one patient had prosthetic infection after prolonged post-op catheter, which was salvaged. 2 patients had urethral perforation which was repaired intra-operatively, but had a post-operative infection. One of these 2 patients had a prosthesis explant and the other patient management is ongoing. There were also 18 (7%) non-infection related ancillary procedures: 11 pump revisions, 2 corporoplasties, 2 prosthesis revisions, 1 revision of reservoir, 1 glanspexy, and 1 prosthesis explant due to pain with no clinical or laboratory signs of infection. Conclusions: The MINT technique for penile implant surgery is a safe and feasible procedure with a 1.2% infection rate and 7% revision rate in our first consecutive 258 patients with 30.6 months median follow-up. Notably, there were no infections unrelated to procedure complication, that is, no infections the standardised MINT technique.

Mitra, A.; Walker, S. A.; Bayer, I.; Pickovsky, B.; Cohen, S. M.; Schmitt, S. L.; Lucas, F. L.; Wexner, S. D.; Szilagy, E. J.; Ryan, J. B.; Williams, J. G.; Deen, K. I.; Grant, E.; Kumar, D.; Wiltz, O. H.; Garcia, J. E.; Feliciano, R.; Martino, J.; Solomon, M.; McLeod, R. S.; O'Connor, B.; Steinhart, H.; Greenberg, G.; Cohen, Z.; Meagher, A. P.; Adams, W. J.; Lubowski, D. Z.; Ellis, C. N.; Boggs, H. W.; Coyle, D. J.; Blakemore, W. S.; Nahas, S. C.; Ibrahim, R. El; Pinotti, H. W.; Palakanis, K.; DeNobile, J.; Sweeney, B.; Blankenship, C.; Sun, J. H.; Stiegmann, G. V.; Kim, J. G.; Pearlman, N. W.; Landes, R. V.; Hankin, R. C.; Barkel, D. C.; Beauregard, W. L.; Poulik, M. D.; Chen, J. C.; Dmuchowski, C.; Cho, E.; Lee, P. Y.; Fletcher, W. S.; Sullivan, E. S.; Vetto, J. T.; Hull, T. L.; Lavery, I. C.; Saxton, J. P.; McCue, J.; Sheffield, J.; Phillips, R.; DiPierro, J.; Milsom, J. W.; Fazio, V. W.; Strong, S. A.; Vernava, A. M. III; Longo, W. E.; Wade, T. P.; Virgo, K. S.; Coplin, M. A.; Johnson, F. E.; Cavina, E.; Menconi, C.; Ghiselli, G.; Seccia, M.; Tjandra, J. J.; Lowndes, R.; McKirdy, H.; Schroeder, T.; Hughes, L. E.; Sentovich, S. M.; Rivela, L. J.; Thorson, A. G.; Blatchford, G. J.; Christensen, M. A.; Jensen, L. L.; Lowry, A. C.; Miller, R.; Mills, A.; Durdey, P.; Hock-Saive, D.; Lombard, R.; Jehaes, C.; Markiewicz, S.; Penders, L.; Fontaine, F.; Cusumano, P.; Nelissen, G.; MacDonald, A.; Baxter, J. N.; Bessent, R. G.; Gray, H. W.; Finlay, I. G.; Duthie, G. S.; Farouk, R.; Bartolo, D. C. C.; Ramanujam, P. S.; Venkatesh, K. S.; Oliver, G. C.; Vachon, D.; Eisenstat, T. E.; Rubin, R. J.; Salvati, E. P.; Dorsey-Tyler, K. R.; Harmon, G.; Medwell, S. J.; Binderow, S. R.; Noguerás, J. J.; Jagelman, D. G.; Decanini, C.; Bohm, B.; Stolfi, V. W.; Cataldo, P. A.; Hadick, C.; Resnikov, P.; Mellinger, J. D.; Cunningham, B.; Vayer, A. J. Jr.; Larach, S. W.; Williamson, P. R.; Ferrara, A.; Salomon, M.; Nogueras, J. J.; Sullivan, J.; Staniunas, R. J.; Keck, J. O.; Counihan, T.; Marcello, P.; Barrett, R. C.; Oster, M.; Roberts, P. L.; Schoetz, D. J.; Murray, J. J.; Veidenheimer, M. C.; Coller, J. A.; Sagar, P. M.; Lewis, W.; Williamson, M.; Holdsworth, P. J.; Johnston, D.; Jorge, J. M. N.; Morgado, P. J. Jr.; James, K.; Morgado, P. Jr.; Penna, C.; Kartheuser, A.; Tiret, E.; Parc, R.; McIntyre, P. B.; Pemberton, J. H.; Wolff, B. G.; Dozois, R. R.; Beart, R. W.; Kelley, K. A.; Harrison, J. B.; Hockenberry, S. E.; Williamson, M. E. R.; Lewis, W. G.; Sagar, P.; Armstrong, D. N.; Collopy, B. C.; Ryan, P. J.; Fink, R.; Mackay, J. R.; Woods, R. J.; Nazarian, H. K.; Kong, L. B.; Fleshner, P. R.; Keighley, M. R. B.; Farmakis, N.; Tudor, R.; Wiltz, O.; Wong, W. D.; Goldberg, S. M.; Rothenberger, D. A.; Arnold, M. W.; Schneebaum, S.; Martin, E. W. Jr.; Young, D. C.; Schechter, S.; Snyder, M. L.; Orkin, B. A.; Smith, L. E.; Dean, P. A.; Ramsey, P. S.; Nelson, H.; Barker, G.; Neoptolomos, J. P.; Patel, R. T.; Pall, A.; Adu, D. Author Information

A technique is described for laparoscopic abdominoperineal resection (APR). Three of four such cases could be successfully completed laparoscopically. One major complication was directly related to the laparoscopic approach, an enterotomy caused by the Babcock clamp, which was discovered at the time of conversion to laparotomy for bleeding. A minor complication related to the laparoscopic procedure, subcutaneous emphysema, required no treatment. There was one postoperative death unrelated to the laparoscopic technique. The intraoperative advantage was enhanced visualization; the intraoperative disadvantages were increased operative time and cost. Postoperative advantages were earlier mobilization, oral intake, and discharge; decreased pain; and improved cosmesis. Laparoscopic APR is both feasible and safe and with more experience should prove to be cost effective.

We evaluated local recurrences of midrectal cancer in 33 patients treated with low anterior resection and stapled end-to-end anastomosis. All patients had follow-up for at least 2 years or until death. There were 21 men and 12 women. Data were analyzed with attention to Astler-Coller modified Dukes' stage, distal margin of resection, degree of histologic differentiation, location of the tumor, blood transfusion, and adjuvant therapy. Distal margin of resection, histologic differentiation, and location of the tumor had no prognostic significance regarding local recurrence. The use of adjuvant therapy remains controversial. The immunosuppressive effects of blood transfusion may affect local recurrence. Dukes' staging remains the standard for prognosis of recurrence in rectal cancer.