The effects of postnatal repair on internal and external sphincter function has been assessed by comparing preoperative and postoperative manometric results in 39 patients with neurogenic fecal incontinence. Postanal repair was effective in 70 percent. The urge to defecate was restored in 70 percent, the ability to retain feces in 45 percent. The procedure caused an increase in squeeze pressure (P = .001), but clinical results were not related absolutely to improvement of external sphincter function, which remained within limits of fecal incontinence in most cases. The procedure restores anatomy rather than function. The influence of the procedure on resting pressure was not statistically significant (P = .4).
The records of 72 consecutive patients with unresectable pancreatic cancer treated between 1974 and 1986 were evaluated to determine whether gastroenterostomy should be performed on a routine basis at initial intervention or on a therapeutic basis. Fourteen patients underwent an explorative laparotomy, 41 patients underwent biliary bypass, and 17 patients required biliary bypass and therapeutic gastroenterostomy at initial laparotomy. The mortality and morbidity rates in this last group were 18 and 59%, respectively. The most common complication was delayed gastric emptying (29%). Of the 37% of patients who required gastroenterostomy after initial biliary bypass, the mortality rate was 50% and delayed gastric emptying occurred in 57%. The mean survival after biliary bypass was 9.4 months while survival after therapeutic gastroenterostomy averaged 4.2 months. These findings suggest that gastroenterostomy should be performed on a prophylactic basis at initial intervention, unless a limited survival is expected.
During the last five years, 37 patients with fecal incontinence because of childbirth have been investigated. Ages varied from 22 to 62 years and duration of symptoms from 0.3 to 26 years. Anal manometry was performed in all patients and electromyography was performed in 24 patients. Thirty patients underwent delayed sphincter repair. In all patients, a dehiscence was found anteriorly, bridged by scar tissue. Continence was restored in 25 patients (83 percent). Electromyography was performed postoperatively in patients who remained incontinent and who demonstrated severe denervation. All these patients had undergone previous sphincter repair. In seven patients, there were no signs of obstetric injury. Electromyography demonstrated severe denervation, but sphincter mapping did not demonstrate muscle discontinuity. Continence improved in four patients within one year as a result of reinnervation demonstrated by electromyography. The authors conclude that fecal incontinence after childbirth may be due to either obstetric rupture or denervation. Both disorders may coexist. Delayed sphincter repair gives excellent results provided that denervation is not present. Preoperative assessment with electromyography is mandatory.
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