Ambulatory manometric examination in patients with a colonic J pouch and in normal controls

Anorectal function after anterior resection may be impaired as a result of reduced luminal capacity in the pelvis. The aim of this study was to evaluate the colonic J pouch neorectum by means of ambulatory manometry. Twelve patients with a colonic pouch following anterior resection and seven healthy controls were studied for a median of 6 (range 6-24) h using a probe with two pouch-rectal and two anal canal transducers. Records were interpreted by visual inspection. Pressure values and wave frequencies were determined by software analysis. Pouches had been functioning for a median of 32 (range 11-55) months. All patients with a pouch had an acceptable stool frequency. Seven of 12 patients complained of incomplete evacuation. Resting anal canal pressure (73 versus 100 cmH2O), pouch-rectal pressure (29 versus 15 cmH2O) and anal canal pouch-rectal pressure gradients (60 versus 85 cmH2O) were similar in patients and controls. The frequency of slow-wave activity in patients with a pouch was significantly lower than that in controls (7 versus 16 cycles per min, P = 0.001). Coordination between the colonic J pouch and the anal canal, in the form of sampling episodes, was observed in more than half of the patients with a functioning pouch. Large isolated contractions (pressure greater than 30 cmH2O and lasting longer than 20 s) and rhythmic contractions were the most frequent pattern of pouch motility.     

The continent sigmoid urinary reservoir--an experimental study in pigs

OBJECTIVE: To evaluate the function of a continence mechanism in combination with a colonic urinary reservoir in a pig model. MATERIALS AND METHODS: A colonic urinary reservoir was constructed as a bladder augmentation in six domestic pigs. The pouch was connected to a narrowed and tunnelled ileal tube as a continence mechanism. The closure pressure was measured intra-operatively and 3 months post-operatively. RESULTS: The mean difference between the pressure in the continence mechanism and in the reservoir was 74 cmH2O (range 50-100). Continence was complete both intra-operatively and 3 months post-operatively. CONCLUSION: The modified narrowed and tunnelled ileal tube is a safe continence mechanism when combined with a colonic urinary pouch.     

Combining the strength-duration curve of the external anal sphincter with manometry for the assessment of faecal incontinence

BACKGROUND: The strength-duration curve of a muscle is thought to be a measure of its innervation. This study was designed to evaluate the ability of the strength-duration curve of the external anal sphincter to discriminate between controls and patients with faecal incontinence. METHODS: Forty-three women with faecal incontinence due to sphincter weakness were studied together with 45 age-matched women with no disorders of defaecation. Strength-duration curves of the external anal sphincter and anorectal manometry were recorded for all subjects with the additional measurement of pudendal nerve terminal motor latency in the incontinent group. RESULTS: Logistic regression was performed using resting and voluntary squeeze pressures and current strengths at 28 different pulse durations to develop a predictive equation for incontinence. Only currents at 1 and 6 ms were significant predictors. When anorectal manometry data were included, only the current required to elicit contraction at 1 ms was necessary. The following regression equation can be applied to predict continence in this population with a sensitivity of 95 per cent and a specificity of 100 per cent: logit(P)=4.1605-(0.0559 x squeeze pressure)-(0.1755 x resting pressure)+0.8622I(1 ms). A negative value indicates continence. CONCLUSION: The strength-duration curve, when used in conjunction with anorectal manometry, may have a role in the investigation of faecal incontinence.     

Physiology of ileal pouch-anal anastomosis. Current concepts

PURPOSE: Increasing experience with ileal pouch-anal anastomosis (IPAA) associated with increasing knowledge about anorectal physiology has lead to a large number of publications. The purpose of this review is to evaluate the current understanding of fecal continence as revealed by the evolution of the ileoanal procedure. METHODS: Review of the literature covering the most important physiologic parameters involved in fecal continence was undertaken. RESULTS: Rectoanal inhibitory reflex is probably absent after IPAA but is preserved when distal anorectal mucosa is spared. Anal resting pressure decreases but is less affected when the internal anal sphincter is less traumatized. Squeeze pressure is not importantly affected, and the importance of reservoir function as a determinant of stool frequency is emphasized. IPAA does not affect the coordination between pouch and anal canal motility in the majority of cases. Normal continence is preserved, even during the night, by preserving a gradient of pressure between the pouch and anal canal. CONCLUSIONS: Physiologic concepts are well established, but controversies about the continence mechanism related to IPAA remain. The IPAA procedure has allowed discrimination of details about the function of multiple structures involved in fecal continence.     

Functional results following the antegrade continence enema procedure

BACKGROUND: Forty children who underwent the antegrade continence enema (ACE) procedure for faecal soiling were studied to determine factors predictive of outcome. METHODS: There were four patient groups: (1) ambulant with spinal dysraphism (n = 13), (2) wheelchair bound with spinal dysraphism (n = 14), (3) ambulant with miscellaneous disorders (n = 11) and (4) wheelchair bound with miscellaneous disorders (n = 2). Effectiveness of the procedure was assessed using technical evaluation and quality-of-life improvement (QOLI) scores (0-5). Objective assessment included colonic transit time (CTT) and anorectal manometry. Median follow-up was 21 (range 5-37) months. RESULTS: Some 28 of 40 children achieved continence. The procedure was reversed in four of 40 children. Of the other 36 children with a functioning ACE stoma, all reported improvement in quality of life (mean QOLI score 3.5). There were no significant differences in technical evaluation score, QOLI score, CTT, manometry findings or continence between ambulant groups and the wheelchair-bound group with miscellaneous disorders. QOLI score, anorectal squeeze pressure and continence were significantly poorer in those who were wheelchair bound with spinal dysraphism. Absent squeeze pressure was associated with poor outcome. CONCLUSION: Wheelchair-bound children with spinal neuropathy have a poorer outcome following the ACE procedure. Although ACE is an effective method of promoting faecal continence, it is essential to determine the aetiology of incontinence and sphincter function before operation.     

A new transrectal pull-through operation for high anorectal anomalies

Twenty-five cases of high anorectal anomalies were treated by a modified transrectal pull-through operation. All patients underwent diverting colostomy before definitive surgery, through which a balloon was passed into the blind rectal pouch. EMG studies were done at the site of the external sphincter in response to gradual inflation of the balloon. There was typical behavior both before and after surgery, except in two cases with sacral anomalies. These findings indicate the importance of a sensitive mucosa in the rectal pouch and of a functioning external sphincter. A modification of the pull-through technique in which a window of intact mucosa is left in situ to preserve sensation was employed in five cases and is expected to provide improved continence.     

Pseudoexstrophy associated with congenital pouch colon

Pseudoexstrophy or covered exstrophy is a rare exstrophy variant. The authors report a case of covered exstrophy that presented as a newborn with widely separated pubic bones and rectus muscles, a low-set umbilicus, and a subcutaneous bladder. The anal opening was absent, and there was a complex malformation of the external genitalia consisting of a small, laterally displaced penis and a right-sided ectopic hemiscrotum. Micturition and urinary continence were normal. The child also had a high anorectal malformation with a coexistent type IV congenital pouch colon (CPC) malformation. Both kidneys were normal. Preliminary surgery consisted of a divided sigmoid colostomy proximal to the colonic pouch. The literature is reviewed and the embryogenesis of pseudoexstrophy and its associated malformations are discussed.     

Sympathetic nervous control of cat ileocecal sphincter

A perfusion method was designed in order to investigate that effects of stimulation of the splanchnic and lumbar colonic nerves on the ileocecal sphincter (ICS) of the cat. Splanchnic and lumbar colonic nerve stimulation at physiological frequencies, i.e., below 10-12 impulses/s, elicited a contraction of the sphincter concomitant with an inhibition of the motility of the adjacent parts of the small and large intestines. It is concluded that the splanchinc and lumbar colonic nerves contract the ICS by a direct effect on the sphincter and not via a contraction of the intestine surrounding the sphincter. Guanethidine and phenoxybenzamine but not propranolol blocked the contraction of the ICS. It is suggested that the splanchnic and lumbar colonic nerves control the sphincter via an alpha-adrenergic mechanism. Inhibitory fibers within the splanchnic or lumbar colonic nerves to the ICS were not found. The excitatory in the ICS elicited by adrenaline, nor-adrenaline, or phyenylephrine infusion was completely blocked by phenoxybenzamine. Propranolol did not block the effect on ICS of these drugs. On the contrary, an augmented response could be shown, indicating unmasking of an excitatory alpha-receptor response by blockade of inhibitory beta-receptors. Further support for these inhibitory beta-receptors was provided by the finding that isoprenaline had a relaxing effect on the sphincteric muscle, an effect that was blocked by propranolol. In order to block the inhibitory effect on the small and large intestine elicited by splanchnic and lumbar colonic nerve stimulation, both phenoxybenzamine and propranolol had to be administered.     

The role of pubococcygeus muscle in urinary continence in the male rat

The role of the male rat pubococcygeus muscle (Pcm) in the micturition reflex was analyzed. Anatomical features of Pcm, electrical stimulation of its nerve, electrical recording and stimulation of the muscle and cystometrograms were carried out. Results showed that Pcm has fibers attached to the ventrolateral part of the external urethral sphincter, and that its activity contributes to hold the tail in the midline. Pcm shows activity during fluid expulsion in cystometrograms and spontaneous micturitions. This activity produced reflex inhibition of detrusor contraction and was not the cause of intravesical high frequency oscillations. Thus, it is proposed that Pcm activity produces the discharge of its afferents which in turn activates a spinal reflex to promote continence.     

Clinical effects of childbirth with median episiotomy and anal sphincter injury on fecal incontinence of primiparous women

Obstetric damage of the anorectal continence organ can lead to impaired anal continence. To assess the effect of birth, either with or without direct injury of the anal sphincter, 123 primiparae were studied. 41 patients with a midline episiotomy and 82 patients with an additional injury of the anal sphincter were assessed at a median of 21 weeks postpartum and compared with 18 healthy volunteers. Anorectal manometry as well as a standardized questionnaire were employed. Patients with an additional injury of the anal sphincter reported persistent flatus incontinence significantly more often (p = 0.0069) than patients with a midline episiotomy only. Incontinence of solid or liquid stool occurred only transiently. Compared to nulliparae in all primiparae a significant shortening of anal canal and a decreased squeeze pressure were observed. In addition, a significantly reduced resting pressure was seen in patients with an anal sphincter injury. The rectoanal inhibitory reflex was absent significantly more often following anal sphincter tear (p = 0.0023). Vaginal delivery, both with and without anal sphincter injury, leads to early detectable changes in anorectal sphincter function.     

Electrical stimulation of the lingual musculature in obstructive sleep apnea

The influence of lingual muscle activity on airflow dynamics in the upper airway was examined in nine patients with obstructive sleep apnea. Muscles that retract the tongue (hyoglossus and styloglossus) and protrude the tongue (genioglossus) were selectively stimulated electrically during sleep with fine wire electrodes placed intramuscularly transorally. We confirmed that stimulation with 50 Hz and 40-microseconds pulse duration did not elicit changes in electroencephalographic patterns or heart rate or alter airflow after the stimulation burst had ceased. The highest stimulus intensity that did not arouse patients from sleep was then utilized to examine the effect of lingual muscle recruitment on airflow dynamics during steady-state periods of inspiratory airflow limitation. When applying a stimulus burst during single inspirations, maximal inspiratory airflow decreased by 239 +/- 177 ml/s (P < 0.05) during retractor stimulation, whereas maximal inspiratory airflow increased by 217 +/- 93 ml/s during protrusor stimulation (P < 0.001) compared with breaths immediately before and after the stimulated breath. When consecutive inspirations were stimulated repeatedly, protrusor stimulation decreased the frequency of obstructive breathing episodes in four patients breathing at 3.9 +/- 3.4 (SD) cmH2O nasal pressure. The findings suggest that stimulation of the lingual muscles can increase or decrease airflow depending on the specific muscles stimulated without arousing patients from sleep.     

The longitudinal muscle of the anal canal

The longitudinal muscle (LM) represents a strong muscular structure of the anal canal situated between the internal (IAS) and the external anal sphincter (EAS). Terminal fibres of this muscle insert at the submucosa of the anal canal, representing the m. canalis ani. Others cross the subcutaneous part of the EAS to become the m. corrugator ani. Thus, the LM connects the visceral and somatic parts of the anal sphincter complex. Histologically ganglionic cells and as Vater-Pacinian corpuscles can be identified inside the LM. Morphology, topography and histology of the LM suggest that this muscle participates in maintaining anorectal continence. It is mandatory that the exact functions of this muscular structure be to elaborated upon, if we are to understand the mechanism of anorectal continence.     

Treatment of colo-vesical fistulas in one-stage operation

BACKGROUND: Botulinum toxin A is a potent inhibitor of the release of acetylcholine from nerve endings. Local injection of botulinum toxin has recently been suggested to be helpful in sphincter of Oddi dyskinesia by decreasing sphincter of Oddi pressure. AIMS: To explore the mechanism of action of botulinum toxin A on sphincter of Oddi (SO) muscle. METHODS: Four piglets underwent duodenoscopy and SO manometry was performed. After obtaining a baseline pressure, the SO was injected with normal saline and the experiment repeated after one week. The SO was then injected endoscopically with botulinum toxin (40 U) with follow up manometry one week later. The sphincter of Oddi was removed from 10 pigs, cut into three rings, and placed in an organ bath. The force of contraction was measured and registered on a polygraph. Rings were stimulated by 70 V (10 Hz, 0.5 ms) electrical field stimulation for 20 seconds, exogenous acetylcholine (100 microM), and KCl (125 mM). Botulinum toxin (0.1 U/ml) or atropine (1 microM) was added to the incubation medium and the stimulation was repeated. RESULTS: Mean basal SO pressure in the pigs remained unchanged after saline injection but decreased to about 50% of baseline value following botulinum toxin injection (p = 0.04). The contractions induced by direct stimulation of SO smooth muscle with KCl were not significantly affected by either atropine or botulinum toxin. In all rings exogenous acetylcholine induced contractions, which were totally blocked by atropine, but not by botulinum toxin. Electrical field stimulation induced contractions that were inhibited by both atropine and botulinum toxin. CONCLUSION: Botulinum toxin inhibits pig sphincter of Oddi smooth muscle contractions by a presynaptic cholinergic mechanism, similar to that described in skeletal muscle.     

Role of the intramural ganglion cells played in the motility of the large intestine of the tortoise, Geoclemys reevesii]

The development of the intramural plexuses in the tortoise, Geoclemys reevesii was inferior to that observed in the fowl: the meshes of both Auerbach's and Meissner's plexuses were coarser, and consisted of less number of nerve fibers. Occasionally, a small ganglion was seen at the crossing points of the meshes. The average number of nerve cells contained in the ganglion was estimated to be 1500/cm2, being about half as much as that estimated in the fowl. When the mucosa of a colon in vitro was stimulated mechanically by stroking or chemically with 1/10 N HCl, the excitability of the colonic muscle was raised at the region oral to the stimulated spot, but lowered at the region anal to it. These effects were abolished by applying a ganglion-blocking agent, hexamethonium (10(-6) g/ml), to the mucosa. When the intraluminal pressure of a colon in vitro was raised from 0 to 3-12 cm H2O, the colon was distended at first but soon contracted powerfully. The contraction became extremely reduced or was abolished when hexamethonium (3.5X10(-7) approximately 1X10(-5) g/ml) was added to the saline solution in which the colon was immersed. The results indicate that the intramural ganglion cells serve as the center of the intrinsic mucosal reflex.     

Gluteus maximus augmentation for the treatment of fecal incontinence

Fecal incontinence is a devastating problem for school-aged children and adults. Medical and biofeedback therapies are unsuccessful in most patients who have severely defective internal and external sphincters. Continued fecal incontinence frequently leads to social isolation and withdrawal. Gluteus maximus augmentation of the sphincter mechanism is one surgical method for treating fecal incontinence. The authors present their results with gluteus maximus augmentation of the anal sphincter and describe patient selection criteria. From 1992 through 1996, seven patients underwent gluteus maximus augmentation of the anal sphincter for fecal incontinence. Six of these patients were children 5 to 6 years of age who had major deficiencies of their anorectal sphincter demonstrated by manometry. One patient was a 56-year-old adult woman who had acquired idiopathic fecal incontinence. Four of the six children (67%) had imperforate anus and two had cloacal anomalies (33%). The augmentation was performed in three stages. A sigmoid-end colostomy with a Hartman's pouch was followed 1 month later by rotation of a portion of the gluteus maximus for anorectal sphincter augmentation. A colostomy take down was performed 2 to 4 months later. All patients underwent dilatation after sphincter augmentation and were taught muscle exercises for using their neosphincter during the period before colostomy take down. Four of six children and the adult are continent postoperatively (71%). Both patients who remain incontinent are unable to sense rectal distention clinically or on anal manometric analysis but have excellent voluntary sphincter tone. Fecal incontinence can be successfully treated with gluteus maximus augmentation in carefully selected patients. Patients unable to sense rectal distension are unlikely to benefit from this procedure. The presence of a rectal reservoir and a skin-lined anal canal also appear to be important in attaining fecal continence.     

Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection

Constipation and incontinence are frequent complications of rectal prolapse. Surgery should not only aim to correct prolapse but also improve bowel and sphincter function. From 1986-1991 42 patients with procidentia were treated by rectopexy and sigmoid resection. The mean age was 61.1 years. Thirty-nine patients were available for follow-up examination. Mean follow-up was 54 months. Functional data were collected prospectively before the operation and at follow-up and included clinical parameters, a constipation score, an incontinence score, anal manometry [mean resting pressure (MRP), mean maximum pressure (MMP)], proctography [anorectal angle (ARA)] and colonic transit studies [mean transit time (MTT), rectosigmoid transit time (RSTT)]. The postoperative complication rate was 7.1% (n = 3), mortality was 0%. No recurrence was seen. Constipation complaints improved from 43.6% to 25.6% (p < 0.001) and incontinence from 66.6% to 23.1% (p < 0.001). MRP increased from 36.5 mmHg to 46.0 mmHg and MMP from 90.5 mmHg to 103.0 mmHg (p < 0.001). ARA changed from 102 to 98 degrees (p < 0.001) and correlated with sphincter tone and continence. MTT decreased from 47.8 to 38.5 hours, segmental transit (RSTT) from 21.1 to 12.7 hours (p < 0.001). Our results indicate that rectopexy with sigmoid resection is a safe and effective procedure for rectal prolapse and improves functional disorders of bowel and sphincter.     

Management of neurogenic fecal incontinence in myelodysplastic children by a modified continent appendiceal stoma and antegrade colonic enema

OBJECTIVES: Antegrade colonic enemas for neurogenic fecal incontinence via reverse reimplanted appendices (Mitrofanoff principle) have been primarily reported by Malone and coworkers in 1990. We used a modification of the described surgical technique and treated the first 10 patients with neurogenic fecal incontinence due to spina bifida. The surgical procedure and the results are reported. METHODS: Since November 1991, we have used a surgical procedure similar to the appendiceal continence mechanism in urinary diversion to establish a continent colonic cutaneous stoma for antegrade enemas in 10 myelodysplastic patients (4 females, 6 males; median age 13.2 years [range 6 to 26]) with severe neurogenic fecal incontinence. The average follow-up is now 26.4 months (range 12.5 to 50). All patients had neurogenic bladder dysfunction successfully managed by clean intermittent catheterization, anticholinergic drugs, or artificial sphincter implantation. The surgical technique for fecal incontinence included the partial orthotopic submucosal imbedding of the appendix into a cecal tenia and the fixation of the ileocecal region at the inner side of the abdominal wall after creation of an appendicocutaneous catheterizable stoma. RESULTS: All patients reached fecal continence for at least 38 hours (median 45.3) by using antegrade colonic enemas with 1.5% saline solution (n = 9) or GoLYTELY solution (n = 1), 0.5 to 1.5 L every 2 to 3 days. All other therapies (diet, oral medication, rectal purgative, or enema) to reach fecal continence had previously failed. There were only two complications seen at the follow-up. One boy with an artificial urinary sphincter presented with infection of the sphincter system, which led to explantation. Another boy presented 15 months after creation of the colonic appendiceal stoma with saline intoxication possibly due to a homemade saline solution. CONCLUSIONS: We conclude that the antegrade colonic enema via an orthotopic continent appendiceal stoma is a safe and highly effective treatment modality for fecal incontinence in patients with neurogenic bowel dysfunction if nonsurgical management has failed.     

Nitrergic modulation of cholinergic responses in the opossum lower oesophageal sphincter

1. Electrical field stimulation (EFS) of the superfused lower oesophageal sphincter from opossum (Monodelphis domestica) elicited biphasic responses. The first phase (relaxation) was strictly dependent on the duration of the EFS. The second phase (contraction) started following termination of the EFS (< or = 15 Hz). EFS at frequencies above 15 Hz led only to contraction, which started immediately upon initiation of the stimulation. 2. In the presence of NG-nitro-L-arginine (L-NOARG; 0.1-300 microM), the relaxation phase was abolished and the contractile response started with the initiation of EFS (at all frequencies) and was greater in magnitude. The contractile response to EFS was completely blocked with scopolamine (10 microM). 3. Exogenous acetylcholine (1-100 microM) elicited concentration-dependent contractions of the sphincter in the presence of botulinum toxin. These contractions were abolished when EFS was applied during administration of acetylcholine. This inhibitory effect of EFS was completely reversed when the tissue was treated with L-NOARG (100 microM). 4. These results suggest that the cholinergic response in the opossum lower oesophageal sphincter is under nitrergic control.     

Third-degree obstetric perineal tear: long-term clinical and functional results after primary repair

BACKGROUND: This study was designed to investigate the long-term clinical and anorectal functional results after primary repair of a third-degree obstetrical perineal rupture. METHODS: One hundred and fifty-six consecutive women who had a primary repair of a third-degree perineal rupture were sent a questionnaire and asked to undergo anorectal function testing (anal manometry, anorectal sensitivity, anal endosonography and pudendal nerve terminal motor latency (PNTML)) RESULTS: Some 117 women (75 per cent) responded. Anal incontinence was present in 47 women (40 per cent); however, in most cases only mild symptoms were present. In 40 women additional anorectal function tests were performed and compared with findings in normal controls. Mean(s.d.) maximum squeeze pressure (31(15) versus 63(17) mmHg, P< 0.001) was decreased and first sensation to filling of the rectum (88(47) versus 66(33) ml, P=0.03) and anal mucosal electrosensitivity (4.7(1.7) versus 2.5(0.8) mA, P=0.003) were increased compared with values in normal controls. In 35 women (88 per cent) a sphincter defect was found with anal endosonography. Factors related to anal incontinence were the presence of a combined anal sphincter defect (relative risk (RR) 1.7 (95 per cent confidence interval (c.i.) 1.1-2.8)) or subsequent vaginal delivery (RR 1.6 (95 per cent c.i. 1.1-2.5)). CONCLUSION: Anal incontinence prevails in 40 per cent of women 5 years after primary repair of a third-degree perineal rupture. The presence of a combined sphincter defect or subsequent vaginal delivery increase the risk of anal incontinence.