Journal/Magazine Articles
Permanent URI for this collectionhttp://repository.kln.ac.lk/handle/123456789/13
This collection contains original research articles, review articles and case reports published in local and international peer reviewed journals by the staff members of the Faculty of Medicine
Browse
8 results
Search Results
Item Faecal incontinence after vaginal delivery(Sri Lanka Medical Association, 2003) Deen, K.I.No Abstract AvailableItem Neosphincters in the management of faecal incontinence(2000) Niriella, D.A.; Deen, K.I.BACKGROUND: Surgical treatment of end-stage faecal incontinence has its origin in the early 1950s. Interest has been revived as a result of technical advances achieved in the recent past. The purpose of this article is to review the principles that underlie the use of skeletal muscle transposition around the anal canal and of electrical stimulation in the treatment of incontinence, and to explore new methods of treatment of this condition. METHODS: A literature search was performed using Pubmed and Medline, employing keywords related to treatment of faecal incontinence by neosphincter reconstruction. Basic science and clinical aspects of neosphincter reconstruction were gathered from relevant texts, original articles and recently published abstracts. RESULTS: The electrically stimulated gracilis neoanal sphincter seems to be the popular choice of biological neosphincter. It is more likely to produce higher resting anal canal pressures than the unstimulated neosphincter, and hence improved continence. However, electrostimulator failure may result in explantation in a proportion of patients. Impairment of evacuation is a functional setback in approximately one-third of patients with the gracilis neosphincter. Overall, improvement of continence may be expected in up to 90 per cent of patients according to some reports. By contrast, experience with the artificial neosphincter, which is less expensive, has been limited to a few tertiary centres across the world. Reported continence of stool is 100 per cent, and that of gas and stool 50 per cent, following implantation of the artificial sphincter. Both of the above operations have been associated with implant-related infection and impaired evacuation. CONCLUSION: Neoanal sphincter operations are technically demanding, require a considerable learning experience and should be confined to specialist colorectal centres. Patients are likely to benefit from a plan that incorporates preoperative counselling and a selective approach.Item Longterm results of total pelvic floor repair for postobstetric fecal incontinence(Lippincott Williams and Wilkins, 1997) Korsgen, S.; Deen, K.I.; Keighley, M.R.B.PURPOSE:This study was designed to assess the long-term results of total pelvic floor repair for postobstetric neuropathic fecal incontinence. METHOD: Sixty-three of 75 women who had undergone total pelvic floor repair for postobstetric neuropathic fecal incontinence were traced and interviewed a median of 36 (18-78) months after surgery. Thirty-nine patients agreed to repeat anorectal physiology. RESULTS: Six patients required further surgery for persistent incontinence (colostomy, 4; graciloplasty, 2). For the remaining 57 patients, incontinence improved greatly in 28 (49 percent) patients, mildly in 13 (23 percent), and not at all in 16 (28 percent); daily incontinence was present in 41 patients (73 percent) before the operation but persisted in 13 (23 percent). Only eight (14 percent) patients were rendered completely continent; those with marked improvement were socially more active than those with little or no improvement. Resting and maximum squeeze pressures, anal canal sensation, rectal sensation, and pudendal nerve terminal motor latency did not predict outcome. Perineal descent, obesity, and a history of straining before the operation were all associated with a poor outcome. CONCLUSION: Total pelvic floor repair rarely renders patients with postobstetric neuropathic fecal incontinence completely continent but substantially improves continence and lifestyle in approximately one-half of them. The operation is less successful in obese patients and in those with a history of straining or perineal descent.Item Management of faecal incontinence(State Pharmaceuticals Corporation, 1997) Deen, K.I.; Ravindran, S.Item Rectal prolapse: impact on pelvic floor physiology and current management(Elsevier-W.B. Saunders, 1996) Deen, K.I.; Madoff, R.D.Rectal prolapse may be associated with fecal incontinence or constipation. Incontinence results from reduced internal sphincter tone and may be worsened by direct or neurogenic damage to the external sphincter and puborectalis muscles. Impaired anal sensation and previous anal sphincter injury may also contribute to incontinence. Constipation results from either difficulty in evacuation, delayed transit, or both. Management should aim to identify the extent of prolapse and degree of functional impairment. Almost all patients with occult prolapse should be treated conservatively. However, rare, markedly symptomatic patients with convincing evidence of occult prolapse may benefit from surgery. Abdominal fixation techniques are the abdominal operations of choice for fit patients with complete rectal prolapse. There is no evidence that addition of foreign material slings enhance the outcome of surgery. Considerable recent data support the use of a sigmoid resection in conjunction with rectal fixation, although this remains a contentious issue. Resection is not advised for patients with poor sphincter function associated with significant neuropathy. Patients with severe preoperative constipation require complete evaluation before surgery; those with documented slow-transit constipation may benefit from subtotal, rather than sigmoid colectomy, performed in conjunction with rectopexy. The Delorme operation and perineal rectosigmoidectomy are both acceptable choices for high-risk patients and patients who wish to avoid abdominopelvic dissection. Our preference is for the perineal rectosigmoidectomy, and we advocate associated levator plication at the time of surgery, particularly in incontinent patients. The Thiersch operation is associated with a high complication rate and should be avoided. The chief advantages of perineal over abdominal repair are avoidance of laparotomy and related complications, preservation of autonomic nerve function, avoidance of ureteric injury, and the ability to perform a concomitant sphincter or pelvic floor repair through the same incision. Laparoscopic prolapse repair is in its infancy with no data on long-term follow-up, making it impossible to evaluate its impact on the treatment of rectal prolapse.Item Randomized trial comparing three forms of pelvic floor repair for neuropathic faecal incontinence(1993) Deen, K.I.; Oya, M.; Ortiz, J.; Keighley, M.R.A randomized controlled trial in women with neuropathic faecal incontinence compared total pelvic floor repair (n = 12) with anterior levatorplasty and sphincter plication alone (n = 12) and postanal repair alone (n = 12). Review at 6 and 24 months indicated that results were significantly better for total pelvic floor repair than either of the other procedures. Comlete continence was achieved in eight of the 12 patients 2 years after total pelvic floor repair. Only total repair significantly elongated the anal canal. Both total pelvic floor repair and anterior levatorplasty improved sensation in the upper anal canal.Item The Prevalence of anal sphincter defects in faecal incontinence: a prospective endosonic study(British Medical Assosiation, 1993) Deen, K.I.; Kumar, D.; Williams, J.G.; Olliff, J.; Keighley, M.R.Forty six patients (median age 61 years; 42 women) with faecal incontinence and 16 age and sex matched controls undergoing a restorative proctocolectomy were assessed by clinical examination, anorectal physiology, and anal endosonography. Forty patients (87%) with faecal incontinence had a sphincter defect demonstrated on anal endosonography (31 external and 21 internal anal sphincter defects). The commonest cause of faecal incontinence was obstetric trauma. This occurred in 35 women, 30 of whom exhibited a morphological defect in the anorectal sphincter complex. In 22 of these patients with a history of a perineal tear or episiotomy, 21 (95%) had a sphincter defect. Sphincter defects were commonly located at the level of the midanal canal.Item Scintigraphic defecography: quantitative and dynamic assessment of anorectal function(Lippincott Williams and Wilkins, 1993) Hutchinson, R.; Mostafa, A.B.; Grant, E.A.; Smith, N.B.; Deen, K.I.; Harding, L.K.; Kumar, D.PURPOSE: Conventional assessment of anorectal function with defecating videoproctography is semiquantitative and the high radiation exposure precludes prolonged or repeated testing. The aim of this study was to develop a dynamic scintigraphic method of assessing anorectal function. METHODS: Fourteen patients with fecal incontinence, 18 patients with chronic constipation, and 8 control subjects were assessed by scintigraphicdefecography. This involves introduction of a technetium-99m-radiolabeled artificial stool into the rectum of the subject and acquisition of gamma camera images during evacuation. RESULTS: Mean evacuation rate was 2.8 percent/second in incontinent patients and 0.9 percent/second in constipated patients (P < 0.001). The mean anorectal angles were 136 degrees and 133 degrees, respectively. There were 18 cases of pelvic floor descent and 6 rectoceles. Scintigraphicdefecography provides quantitative information on rectal evacuation. Anorectal angle and pelvic floor movement can be examined. The radiation dose to pelvic organs is significantly less than with videoproctography. CONCLUSION: We believe that scintigraphic defecography is the investigation of choice for objective and dynamic assessment of anorectal function