Anorectal manometry in the assessment of anorectal function in Parkinson's disease: a comparison with chronic idiopathic constipation

We investigated the role of anorectal manometry in evaluating constipation and anorectal function in 15 patients with Parkinson's disease (PD) and compared results with those of 9 patients with idiopathic constipation (IC) and 8 control (C) subjects. Anal sphincter pressures on voluntary squeeze were lower in the PD patients. Sustained squeeze pressures (mm Hg C versus IC versus PD: 46.8 +/- 5.2 versus 31.2 +/- 3.6 versus 26.6 +/- 3.9; p < 0.05 PD versus C), squeeze duration (seconds: 53.6 +/- 2.5 versus 48.5 +/- 4.1 versus 33.6 +/- 9; p < 0.05 PD versus C) and squeeze index (area under the squeeze curve: 44.0 +/- 2.9 versus 34.5 +/- 3.3 versus 21.4 +/- 2.9; p < 0.001 PD versus C) were significantly lower in the PD group in comparison to the control group. In contrast, none of the parameters of anorectal manometry differed between controls and patients with idiopathic constipation. Some Parkinson's disease patients demonstrated an abnormal, hypercontractile response on testing of the rectoanal inhibitory reflex. Anal sphincter length, basal sphincter pressures, maximal squeeze pressures, extent of relaxation on rectoanal inhibitory reflex and threshold volume for rectal sensation were similar in the three groups. We conclude that an impaired squeeze response is a specific feature of anorectal function in Parkinson's disease. This may indicate direct involvement of the pelvic floor musculature by the parkinsonian disease process.     

Anorectal malformations

The posterior sagittal approach was used to treat 792 patients with anorectal malformations. From these, 387 cases were evaluated 6 months to 13 years later. Voluntary bowel movements were present in 74.3% of the entire series. When distributed by diagnosis, the percentages varied: 100% in patients with rectal atresia and perineal fistula; 93.2% in those with vestibular fistula; 80.9% in those with bulbar fistula; 71.1% in those with cloacas; 66.7% in those with prostatic fistula, and 15.8% in those with bladder-neck fistula. Soiling was present in 57% of all cases. Patients with voluntary bowel movements and no soiling were classified as totally continent; 40.8% of the series belong to this group. Distributed by diagnosis, it varied from 100% in cases with rectal atresia or perineal fistula, 65.9% in those with vestibular fistula, 34% in those with bulbar fistula, 31.6% in those with cloacas, 26.3% in those with prostatic fistula; none of the patients with vaginal fistula or bladder-neck fistula was totally continent. Constipation was detected in 43.1% of all patients, and was more frequent in those with simple defects. Urinary incontinence was found in 19% of patients with cloacas who had a common channel shorter than 3 cm, and in 68.8% of the patients who had longer common channels. Other patients suffered from urinary incontinence only when they had an absent sacrum or other severe bladder or urethral congenital defects. An accurate diagnosis and evaluation of the sacrum allows us to establish, with reasonable accuracy, functional prognosis in most children. Those with functional disorders must be treated properly medically, to improve their quality of life.     

Staged pull-through for rectosigmoid Hirschsprung's disease is not safer than primary pull-through

Conventional treatment of Hirschsprung's disease consists of initial colostomy followed by pull-through (staged PT). During the past decade immediate definitive operation (primary PT) has been reported by several investigators with a complication rate ranging from 0% to 20%. In the authors' institution primary PT has been performed since 1992 in patients with rectosigmoid aganglionosis responsive to rectal irrigations. The authors reviewed the records of all patients (n = 124) with Hirschsprung's disease diagnosed and treated between 1989 and 1995. One hundred sixteen patients underwent a definitive operation. This study analysed the complications observed in 87 of these patients with aganglionosis limited to the rectosigmoid colon. Patients were divided into groups according to the type of surgical treatment (staged versus primary), the year of operation (1989 through 1992 versus 1992 through 1995), and the age at primary PT (15 infants age < or = 4 months versus 10 children age > 4 months). There were no deaths. There was no significant difference in complication rates between staged PT and primary PT. Similar complication rates were encountered in infants and children who underwent primary PT. The rate of postoperative complications did not change according to the year of the operation. Major complications were observed in all 3 patients who had a primary Swenson PT compared with 20% who had a primary Duhamel PT. Staged Swenson and Duhamel PT had similar complication rates. The authors conclude that (1) staged PT for rectosigmoid Hirschsprung's disease is not any safer than primary PT; (2) primary PT can be performed safely in young infants; and (3) primary Swenson PT is less satisfactory than primary Duhamel PT.     

Anorectal diseases

Fracture of the tibia is a well-known, often occult cause of limping and leg pain in young children. This fracture is typically a hairline, oblique fracture of the shaft of the tibia, and in some cases the fracture can be so subtle that bone scintigraphy or follow-up radiography may be required for its detection. In addition, a variety of other fractures that are less well known and just as difficult to detect can occur in the tibia and the foot in young children. These fractures include plastic bowing and buckle-type fractures, especially of the fibula; impaction, compression, or stress (fatigue) fractures of the tibia and fibula; and fractures of the metatarsal and tarsal bones. All of these fractures can be remarkably similar to the non-displaced spiral tibial fracture in their clinical appearance and should be included under the rubric of "toddler's fracture."     

Repeat pull-through for Hirschsprung's disease

BACKGROUND: A repeat pull-through for Hirschsprung's disease is undertaken when the original procedure has failed. The reasons for failure include a retained aganglionic segment, stricture, fistula, or persisting incontinence. METHODS: All patients who underwent a redo pull-through from 1982 through 1996 were included. Twenty-two patients were underwent surgery; 20 notes were reviewed. The mean age at operation was 6 years (range, 1 to 13). Mean time between operations was 5.1 years (range, 0.5 to 13). RESULTS: Postoperative complications occurred in five patients. These included wound infection, recurrent rectal septum, division of a vas, compartment syndrome, and an anastomotic stricture. Follow-up was for 6.5 years (range, 0.2 to 12). The mean number of bowel movements was 2.2 per day (range, 1 to 6). Fourteen (of 19) patients were continent or soiling less than once per week. Soiling occurred more than once a week in four, but two of these were incontinent after the first operation. One has a colostomy. CONCLUSION: A repeat pull-through is a worthwhile procedure when dealing with an anatomic problem such as retained Hirschsprung's disease, stenosis, or fistula.     

Laparoscopic pull-through procedure for Hirschsprung''s disease

BACKGROUND: We investigated the suitability of two commercially available in-vitro bleeding tests (IVBT), the PFA-100 and the Hepcon HMS, to predict blood loss following operations with extracorporeal circulation (ECC) and compared them with conventional coagulation studies. METHODS: In 40 patients subjected to elective open heart surgery with ECC a blood sample was taken before and after ECC to measure platelet count, prothrombin time, aPTT, D-dimers, fibrinogen, and PFA-100 and Hepcon HMS data. The postoperative blood loss was recorded hourly until removal of drains. RESULTS: A significant correlation was found between total blood loss (250-1750 ml) and the preoperative PFA-100 (r = 0.41, p = 0.022), the preoperative platelet count (r = -0.42, p = 0.007), the preoperative D-dimer concentration in the plasma (r = 0.41, p = 0.01), and duration of ECC (r = 0.35, p = 0.044). There was no significant correlation between blood loss and the Hepcon HMS system. CONCLUSIONS: Although a significant correlation was found between blood loss and the PFA-100 IVBT, the practical value of these tests in the clinical situation is limited due to a great variability in individual results.     

Reflux esophagitis: manometry and Ph measurement

Manometry and pH-metry are essential in the examination of functional disturbances of the esophagus. Proven indications for manometry are dysphagia of unknown origin and noncardiac chest pain; in reflux esophagitis manometry is used for measuring pressure of the lower esophageal sphincter and detecting motility disorders of the esophageal body, pH-metry is used as long-term pH-metry to quantify gastroesophageal reflux during day and night; furthermore long-term pH-metry is important in the classification of atypical esophagitis. Recording gastroesophageal reflux and esophageal motility may influence planning of therapy and predict prognosis. Before antireflux surgery manometry and pH-metry are useful in judging the clearance mechanisms of the esophagus. Used critically, manometry and pH-metry can be very helpful as cost-effective diagnostic tools in the long-term therapy of reflux esophagitis.     

Anorectal dysfunction in systemic sclerosis

Melioidosis varies from subclinical infection to fulminating disease with multiple organ involvement. Although endemic in South-East Asia and northern Australia, it may be imported into temperate zones. It is the wide spectrum of manifestation that makes it 'the great imitator'. The purpose of this pictorial essay is to familiarize the radiologist with the range of radiological manifestations of this disease. Intrathoracic findings include pulmonary nodules, consolidation, necrotizing lesions, pleural effusion, pleural thickening and mediastinal abscess. Abscess in almost all organ systems can be seen in the septicaemic and suppurative infections. Both clinical and radiological findings are non-specific. A high index of suspicion is required to focus the search for bacteriological confirmation. A prompt diagnosis is essential, as melioidosis is often rapidly fatal.     

Anorectal disease in HIV-infected patients

Alpha-1-antiproteinase E, the fourth isoform of rabbit alpha-1-antiproteinase (alpha-1-antitrypsin) having a glutamic acid at the reactive center, has been purified from the plasma by sequential chromatography on hydroxyapatite and anion-exchange columns. The E form of alpha-1-antiproteinase formed a complex with trypsin, chymotrypsin, elastase, plasmin and pancreatic kallikrein as judged by SDS-PAGE. The E form inhibited elastase in a stoichiometric manner and chymotrypsin moderately, but the inhibition of trypsin was gradual. The F form inhibited trypsin most effectively followed by chymotrypsin and elastase. N-chlorosuccinimide reduced the elastase inhibitory activity of the E form, while the F form was more effectively inactivated by the oxidant.     

Esophageal manometry in the opossum

The opossum esophagus is commonly used as an animal model of the human esophagus. We used esophageal manometry in normal animals to provide basal data about normal esophageal motor functions in vivo in this species. At rest, separate and distinct high pressure zones can be recorded at the level of the lower esophageal sphincter, diaphragmatic hiatus, aortic arch, and upper esophageal sphincter. Each zone demonstrates a characteristic pattern of pressures in the radii of the coronal section and a characteristic response to swallowing. The hiatal and aortic zones can be mistaken for the esophageal sphincters. Pressures in the sphincters fall with swallowing. Peristalsis is not bolus-dependent and occurs with 98% of swallows. Pressures generated by peristalsis are greater in the middle of the esophagus than at the ends. Values for resting lower esophageal sphincter pressure and the characteristics of peristalsis were reproducible between different studies in the same animals.     

Endoscopic manometry of Oddi's sphincter

BACKGROUND: Endoscopic manometry is the gold standard for the diagnosis of sphincter of Oddi dysfunction. AIM: To report the results of the first 30 endoscopic manometries of sphincter of Oddi performed in a Gastroenterology Service. PATIENTS AND METHODS: Thirty manometries were performed in 28 patients aged 30 to 70 years old (14 females). The papilla was cannulated with a perfused catheter, measuring pressure with external transducers. RESULTS: Deep cannulation of the papilla was achieved in 88%. Procedure-related complications were not observed in these cases. Normal values were registered in 11 cases with a basal sphincter pressure 15.6 +/- 10.7 mm Hg, contractions with an amplitude of 92.3 +/- 35.7 mm Hg and 6.0 +/- 2.4/min frequency. The clinical suspicion of hypertonic dyskinesis was confirmed in 5 cases with an elevated basal pressure of 43.69 +/- 13.3 mm Hg, an increased frequency of contractions ("tachyoddia") in one, and large spastic contractions of high pressure in other case. In 3 of 5 cases with common bile duct stones, a predominance of retrograde propagation of the contractions was observed with normal pressure. Variable manometric results were observed after endoscopic papillotomy observing a scale from the complete absence of motor activity to normal sphincter function. CONCLUSIONS: Endoscopic manometry is a reasonably safe method, of great importance in the diagnosis of functional disorders of the sphincter of Oddi.     

基于最小二乘支持向量机的交通流量预测模型

城市交通流具有复杂性、时变性和随机性,实时准确的交通流量预测是实现智能交通诱导及控制的前提.综合分析交通流量影响因素的基础上,进行多路段的交通流量预测研究,提出了基于最小二乘支持向量机的交通流量预测改进模型,并应用平安大街的流量数据进行实例验证.结果表明,该模型具有学习速度快、跟踪性能好及泛化能力强等优点,在交通流预测中更具有实用性和推广性.     

Anorectal melanoma--an incurable disease?

PURPOSE: This study was designed to describe recurrence and survival rates after operative treatment for anorectal melanoma and to identify predictive factors for recurrence. METHODS: Records of 50 patients with anorectal melanoma from 1939 to 1993 were reviewed. RESULTS: Overall five-year survival and disease-free survival were 22 and 16 percent, respectively. At the time of diagnosis, 26 percent of patients had metastatic disease, and all died within 12 (mean, 6.3) months. Five-year survival and recurrence rates were identical after either abdominoperineal resection (APR) or wide local excision, both with curative intent. Gender, size of tumor, presence of melanin, positive perirectal lymph nodes, or treatment were not predictive of recurrence. Anorectal melanoma was found incidentally after hemorrhoidectomy or polypectomy in five patients. Three other patients underwent an excisional biopsy of a lesion measuring less than 2 cm. Of these eight patients, five underwent APR and three underwent wide local excision with no microscopic residual tumor at pathology. All developed regional or systemic recurrence at a mean of 21 (range, 4-88) months, and all died of their disease at a mean of 29 (range, 5-98) months. CONCLUSION: Prognosis for anorectal melanoma is poor, irrespective of surgical treatment performed. No predictive factors for recurrence were identified in this series. Wide local excision with a negative margin of a least 1 cm is suggested as the treatment of choice. APR should be reserved for tumor not amenable to local excision or for palliative treatment of large obstructive lesion until effective adjuvant therapies are available.     

Laparoscopic esophagomyotomy and antireflux procedure with intraoperative manometry

We have been routinely performing laparoscopic cholecystectomy and antireflux procedures. Having this experience, we decided to assess the feasibility and safety of performing a laparoscopic esophagomyotomy and antireflux procedure. Here we present a case of a 37-year-old man with a history of progressive dysphagia and a diagnosis of achalasia, made on the basis of clinical, endoscopic, and manometric studies. Preoperative manometry reported a pressure of 52 mm Hg (normal, 15-25 mm Hg) for 4.5 cm (normal, > 3 cm). Laparoscopic esophagomyotomy and anterior fundoplication were performed. The esophagomyotomy included a 6-cm segment of distal esophagus and 2 cm of stomach; postoperative manometry was 18 mm Hg for 3 cm. Eight months postoperatively, a barium swallow demonstrated no reflux. Laparoscopic esophagomyotomy and antireflux procedure can be performed with efficacy and safety, with the advantage of a shorter hospitalization and an early recovery compared with the traditional procedure. Also, we emphasize the importance of the intraoperative manometry in the relevance of a concomitant antireflux procedure.     

Clinical applications of esophageal manometry and pH monitoring

In summary, GERD patients are usually well managed using a careful medical history, endoscopy, and empirical trials of antireflux medications. Extended esophageal pH monitoring is unnecessary in most patients but can be of considerable value in managing patients with typical or atypical symptoms who are refractory to standard therapy for GERD. Furthermore, the test can be useful in documenting abnormal reflux in an individual without esophagitis being evaluated for antireflux surgery. The test is done with compact, portable data loggers, miniature pH electrodes, and computerized data analysis. The pH electrode should be positioned 5 cm above the manometrically defined upper limit of the LES, and patients should undergo the test on an unrestricted diet. In terms of data analysis, the total percentage time of pH < 4 provides as much information as any other scheme of quantifying esophageal acid exposure, but symptom association is essential when evaluating atypical or sporadic symptoms. Enthusiasm for 24-h pH monitoring must, however, be tempered with an analysis of its proven clinical utility in patient management with its utility rightfully compared with that of an empirical trial of anti-reflux therapy. Ambulatory pH monitoring is probably most useful in examining patients without typical reflux symptoms or patients who have either partially or completely failed a trial of anti-reflux therapy. To date, there have not been any prospective, controlled clinical trials evaluating these uses. Suggested clinical indications for ambulatory pH monitoring are listed in Table 5 (53).     

Anorectal manometric examination in encopretic-constipated children

PURPOSE: We have investigated the use of anorectal manometry to distinguish encopretic-constipated children (n = 88) from sibling controls (n = 16) and nonsibling controls (n = 11). METHODS: Study variables included manometrically determined resting and maximum voluntary anal sphincter pressure, depth and speed of rectoanal inhibitory reflex, minimum rectal volume sensation, critical distending volume for fecal urgency, rectal and anal pressure responses during attempted defecation, and ability to defecate a water-filled balloon. RESULTS: Change in anal sphincter pressure during attempted defecation (P = 0.03), gradient between rectal and sphincter pressure during attempted defecation (P = 0.02), critical distending volume for fecal urgency (P = 0.02), and ability to defecate a water-filled balloon (P = 0.05) distinguished encopretic-constipated from control children. The change in rectal pressure associated with the rectoanal inhibitory reflex just escaped significance at P = 0.07. CONCLUSIONS: Anal sphincter spasm and megacolon are pathophysiologic abnormalities associated with pediatric constipation-encopresis.