http://nova.newcastle.edu.au/vital/access/services/Feed ${session.getAttribute("locale")} 5 http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:7638 A letter commenting on the ethical imperatives of new technologies within coloproctology. Coloproctologists' duty is with the introduction of new technologies but applying them to old situations. Here, the lessons learned from the institution of laparoscopic techniques should inform the practice. 2011-05-02T22:50:40.793Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:7251 Background/aims: The stapled transanal rectal resection (STARR) procedure has been suggested as a simple surgical option for patients presenting with evacuatory difficulty in the clinical presence of a rectocele. Most of these patients have a multiplicity of pelvic floor pathology unaddressed by the performance of one procedure. The aim of the study was to assess an unselected group of patients referred to a tertiary coloproctological unit following performance of the STARR procedure for obstructed defecation (OD) where the procedure was complicated or had failed. Materials and methods: Anorectal, urogynecological, and psychological examination with objective constipation/incontinence scoring, anal–vaginal-perineal ultrasound, manometry, and defecography were selectively performed utilizing the Iceberg Diagram to detect occult pelvic floor pathology. Results: Twenty patients were referred with 13 cases (female, 10; median age, 65 years; range, 40–72) operated upon. Post-STARR surgery was performed for three complications and ten failures including recurrent OD, severe proctalgia, and fecal incontinence. Overall, 11 patients underwent biofeedback therapy and psychotherapy. Of the operated group, 11 patients had a median of four associated disorders. Seven patients had a significant psychological overlay with severe depression or anxiety and four heterogeneous anal sphincter defects. Operative procedures were tailored to the clinical findings using enterocele repair, staple removal, fistulectomy, rectosigmoid resection, and levatorplasty where appropriate. Twelve patients were evaluated after a median follow-up of 18 months. Of these, six (all with psychoneurosis remained unchanged. Three patients with no psychological overlay were asymptomatic with a further two improved. Conclusion: The STARR procedure, when complicated or failed, has a poor outcome following surgical reintervention. It requires careful patient selection to determine the associated pelvic floor pathology and pre-existent psychopathology. 2011-02-21T04:30:09.625Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:7236 With reference to the article on anal cushion measurement in incontinence by Thekkinkattil and colleagues, the argument has previously been made by Gibbons and co-workers that sphincteric closure alone is insufficient to maintain continence at rest, and that additional mechanisms of hermetic anal occlusion are provided by the haemorrhoid-bearing anal mucosa and submucosa. They showed a linear relationship between sphincter tension and anal canal diameter in accordance with Laplace's law. 2011-02-21T04:00:09.489Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:6823 A case is reported of a subphrenic abscess 12 months post-aparoscopic cholecystectomy in a 72-year-old male with identification of Actinomyces meyeri and the oropharyngeal commensal Klebsiella ozaenae. The first organism is exceptionally rare following laparoscopic cholecystectomy and is presumed to be a result of inadvertent gallstone spillage. The second organism has not previously been reported in a subphrenic abscess. The etiopathogenesis and management of this condition are presented. 2010-11-23T04:50:08.179Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:6688 Endoanal probe technology provides high-resolution soft-tissue imaging for periluminal anal and rectal disease, most notably in complex perirectal sepsis and in patients presenting with fecal incontinence and sphincter damage. The trend is a movement away from direct sphincter repair toward sacral neuromodulation in external anal sphincter (EAS) injury. However, endoanal magnetic resonance imaging (EAMRI) has shown clear accuracy in the delineation of both EAS defects suitable for surgical treatment and in the definition of internal anal sphincter (IAS) damage potentially suitable for bioimplant deployment. Moreover, endoanal MR images have shown a correlation with histopathologically defined sphincter atrophy, which in turn has been predictive of relatively poor postsphincteroplasty outcomes. The role of EAMRI in the hierarchy of imaging modalities for use in an incontinence algorithm is somewhat unclear in the absence of comparative randomized clinical trials. However, it has a definitive place in defining sphincter atrophy in equivocal cases that are perhaps best treated nonoperatively or initially by temporary neuromodulatory stimulation. 2010-09-10T04:20:05.706Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:6687 In assessing patients who present as the final common pathway with the symptom complex of evacuatory dysfunction, there is general recognition that the vast majority of them have a multiplicity of pelvic-floor and perineal soft-tissue abnormalities across compartments. A dynamic imaging modality is required to define the real-time integration of these anomalies and to highlight their significance in each case, particularly when there is clinical or radiographic evidence of a dominant pathology and where corrective surgery is contemplated. Dynamic transperineal ultrasound (DTP-US) is a simple, radiation-free, inexpensive, and learnable technique that highlights pathology in each pelvic compartment and the interplay between compartments during straining and simulated bolus defecation. Another significant advantage of the technique is its ability to demonstrate tissues that lie well beyond the focal distance of an endoanal probe. Studies on selected patient subgroups with complex evacuatory difficulty are awaited that compare DTP-US with its counterpart, dynamic magnetic resonance (MR) imaging. We suggest that using DTP-US for realtime assessment of pelvic-floor function is best performed by the clinician managing the case or in close collaboration with the radiologist for the best potential clinical outcome. Consideration should be given to its formal accreditation by coloproctologists, gastroenterologists, radiologists, gynecologists, and biofeedback therapists. 2010-09-10T04:20:02.986Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:4987 It is accepted that dorsal anal fistulas, (which are relatively uncommon), are almost always associated with an underlying anal fissure but it is not the general experience that most fissures are accompanied by a fistulous track beyond the cutaneous pocketing surrounding the exposed internal anal sphincter. On this logic, it would be expected that dorsal anal fistulas should be much more common in medically-treated fissures. The authors’ theory may explain the relatively poor cutaneous blood supply differentially affecting the fissure as opposed to the sphincterotomy site but this should also be a feature of any cryptogenic anal fistula; a finding not previously reported. It should be recognized that the causes of postsphincterotomy leakage are multifactorial and only part of this is secondary to the sphincterotomy itself even when it is intended to be limited in extent. Our group has previously shown in fissure patients that there is a variable recovery of the rectoanal inhibitory wave (an internal anal sphincter function) particularly when there is external anal sphincter atrophy; with, in some cases, preoperative evidence of a constitutively shorter subcutaneous component of the external anal sphincter overlapping the internal anal sphincter termination. This would render the distal anal canal relatively unsupported following internal anal sphincterotomy and contribute to predictable postoperative incontinence. Moreover, internal anal sphincterotomy may be accompanied by a weakened voluntary sphincter function even when there are continent postsphincterotomy outcomes, where Shafik and colleagues have shown external anal sphincter atrophy with a change in its histomorphologic structure up to 10 months following internal anal sphincter excision in a canine model. The surgical alternatives to sphincterotomy include advancement anoplasty with or without fissurectomy, tailored sphincterotomy, pressure-directed sphincterotomy, pneumatic sphincter dilatation, and now fissurotomy. 2010-04-27T04:41:20.943Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:4986 The advantage of the impedance planimetric technique is to more readily define reproducible values for dynamic rectal compliance and elasticity, where conventional proctometrographic (pressure/volume) curves have proven less accurate. The real-time ultrasonographic measurement of rectal cross-sectional areas (CSA) during distension (and deflation) is less reliant on the intrinsic compliance characteristics of the balloon assembly or on inherent rectal geometry. In this sense, impedance planimetry provides a better reflection of rectal wall stiffness and altered viscoelastic properties during inflation/deflation cycles. 2010-04-27T04:41:17.237Z ]]> http://nova.newcastle.edu.au/vital/access/manager/Repository/uon:5712 Exciting technical advances in US, CT, and MRI over the past decade have greatly enhanced the challenging task of investigating intestinal, pelvic floor, and anorectal function and dysfunction. The goal of Imaging Atlas of the Pelvic Floor and Anorectal Diseases, edited and authored by international experts in the field, is to clearly and precisely present indications, techniques, limitations, sources of errors, and pitfalls of these imaging modalities. The concise text describes the abundant, high-quality images that show the normal anorectal anatomy as well as the pathological appearance of the all-too-common large-bowel and pelvic floor functional diseases. The use of radiopaque markers in diagnosing colonic inertia; defecography, 3D US, and MRI in investigating obstructed defecation; 3D US and MRI in differentiating between benign and malignant anorectal neoplasms; CT and MRI in assessing pelviperineal anatomy and identifying pelvic tumors and inflammatory processes; and 2D and 3D US in determining appropriate treatment for fecal incontinence are discussed in depth. One of the atlas’s strongest points is illustrating the use of 3D anorectal US with automatic scan in identifying complex anal fistula tracks, staging benign and malignant tumors, and postradiotherapy follow-up. Of particular importance is the description of novel dynamic techniques, such as dynamic transperineal US, in assessing pelvic floor functional diseases. Also importantly, this atlas demonstrates the value of a "team approach" between colorectal surgeons and radiologists for solving complex clinical disorders of the anorectum and pelvic floor. 2010-04-27T04:30:26.964Z ]]>