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Biomedical subjects

D C Bartolo

Publications and source records attributed to D C Bartolo.

At least 37 records · Page 2Linked to original sources
PubMed1995

Island advancement flaps in the management of anal fissures.

The classic high-pressure fissure responds well to lateral internal sphincterotomy. The management of recurrent fissures and those that occur in patients with weak sphincters is open to debate. An island advancement flap technique used in 21 patients is described with the above criteria. Preoperative median resting anal pressure was 66 (range 43-90) cmH2O and median maximal squeeze pressure was 132 (range 76-193) cmH2O, values that were significantly lower than in controls and those with classic fissure. Endoanal ultrasonography in 15 of these patients showed defects in the anal sphincters. All flaps healed primarily with preservation of sensation. Perfect continence was maintained in all patients. Follow-up was for a median of 18 (range 2-28) months. There were no serious complications. All fissures healed with minimal postoperative discomfort. This procedure provides a useful alternative for symptomatic anal fissures, in which a sphincter-weakening procedure might jeopardize continence.

Adult↗
PubMed1994

Abnormal transient internal sphincter relaxation in idiopathic pruritus ani: physiological evidence from ambulatory monitoring.

Patients with idiopathic pruritus ani have an abnormal rectoanal inhibitory reflex and a lower threshold for internal sphincter relaxation during the saline continence test. This led to the hypothesis that these patients may exhibit abnormalities of the transient internal anal sphincter relaxation reflex. To study this, 23 men of median age 41 (range 27-64) years with idiopathic pruritus ani and 16 male controls of median age 39 (range 26-68) years were assessed using computerized ambulatory anorectal electromyography and manometry. Resting anal pressure, maximum anal squeeze pressure, internal sphincter electromyogram frequency, the number of internal sphincter relaxations and pudendal nerve terminal motor latency were similar for the two groups. The rise in rectal pressure during internal sphincter relaxation was higher in patients with pruritus than in controls (median (range) 29 (18-60) versus 18 (11-37) cmH2O, P < 0.01). Furthermore, the fall in anal pressure was greater in patients with pruritus than in controls (median (range) 39 (15-52) versus 29 (21-43) cmH2O, P < 0.01). The duration of internal sphincter relaxation was prolonged in patients compared with controls (median (range) 29 (18-55) versus 8 (5-12) s, P < 0.001). Fourteen patients reported staining of underclothes and 17 complained of perianal itch within 1 h of these episodes of abnormal internal sphincter relaxation. Pruritus ani may result from occult faecal leakage as a result of abnormal transient internal sphincter relaxation.

Adult↗
PubMed1994

Rectoanal inhibition and incontinence in patients with rectal prolapse.

Thirty-five patients with complete rectal prolapse, 32 with neurogenic faecal incontinence and 33 controls underwent ambulatory recording using a computerized anal electromyographic and anorectal manometry system. Median resting anal pressures were 34 cmH2O in patients with prolapse, 51 cmH2O in those with neurogenic faecal incontinence and 94 cmH2O in controls. Median basal rectal pressures were 18, 21 and 21 cmH2O respectively. High-pressure rectal waves of median amplitude 71 cmH2O lasting 30-150 s and associated with inhibition of the electromyographic activity of the internal and sphincter and a fall in anal pressures were seen in all patients with prolapse but not in controls or those with neurogenic incontinence. These waves were abolished following successful resection rectopexy. Recovery of continence occurs by abolition of high-pressure rectal waves, which produce maximal inhibition of sphincter activity before operation.

Adult↗
PubMed1994

Recovery of the internal anal sphincter and continence after restorative proctocolectomy.

The internal anal sphincter (IAS) was assessed prospectively using electromyography and manometry in 66 patients (48 men) undergoing restorative proctocolectomy to determine its role in the gradual return of continence. Twenty-nine patients received a J pouch and 37 a W reservoir. Some 38 pouches (J, ten; W, 28) were hand-sewn (mucosal proctectomy with endoanal anastomosis) and 28 (J, 19; W, nine) stapled (end-to-end pouch-anal anastomosis 1 cm above the dentate line). Twelve patients underwent a one-stage procedure (all J pouches), while the remainder had a covering loop ileostomy. Each patient was reassessed immediately after restorative proctocolectomy and again at 7 days, 1 month, 4 months, 9 months and 18 months after pouch formation. Internal sphincter electromyographic activity was greatly reduced after pouch-anal anastomosis (median preoperative frequency 0.51 Hz versus immediate postoperative frequency 0.21 Hz, P < 0.003) and gradually recovered from 4 months after surgery. At 18 months, measurements of IAS function had not fully recovered to preoperative values (median frequency 0.31 Hz; P < 0.03). Resting anal pressures (median preoperative value 99 cmH2O) decreased by over 50 per cent after surgery (median immediate postoperative resting pressure 44 cmH2O) and recovered gradually but incompletely (median pressure at 18 months 63 cmH2O). Eleven patients reported leakage in the follow-up period. The median (range) resting pressure in these patients (54 (40-71) cmH2O) was not significantly different at 9 months from that of those who were continent either before or after operation (59 (46-68) cmH2O). Prolonged recordings in patients with faecal leakage revealed evidence of high-pressure pouch waves that overwhelmed anal sphincter pressures and coincided with leakage. These episodes were most common during sleep, when anal sphincter activity was reduced.

Adolescent↗
PubMed1994

Evidence of electromechanical dissociation of the internal anal sphincter in idiopathic fecal incontinence.

PURPOSE: This study was designed to evaluate the relationship between internal sphincter electromyographic frequency and ambulatory anal pressures in order to clarify the pathophysiology of internal anal sphincter dysfunction in fecal incontinence. METHODS: Seventy-two patients of median age 55 years (range, 24-75; 63 females) with neurogenic fecal incontinence and 33 normal subjects of median age 48.5 years (range, 25-74; 21 females) underwent fine-wire anal sphincter electromyography and anal manometry. RESULTS: The median internal anal sphincter electromyographic frequency was incontinent 0.25 Hz (0.2-0.34) and the control was 0.44 Hz (0.36-0.55; P < 0.03). Ambulatory resting pressures were incontinent median 54 cm of H2O (34-68 cm of H2O) and control 94 cm of H2O (72-102; P < 0.01). Internal sphincter electromyographic frequency correlated with anal resting pressures in both groups (P < 0.002). Internal sphincter electromyographic silence not attributable to electrode movement or the rectoanal inhibitory reflex, lasting 0.5 to 4 minutes occurred in all but two of the incontinent patients. The anal pressure during this period did not significantly change (P > 0.1). No recruitment of the external sphincter or puborectalis was noted during these episodes. Such electromechanical dissociation was not seen in the control group. The frequency of transient internal sphincter relaxation was 4 (ranges 2-6) per hour in controls and 8 (ranges, 6-12) per hour in incontinent patients (P < 0.01). Rectal pressures did not exceed midanal pressures in any of the controls but did in all of the incontinent patients on at least one occasion per hour in the incontinent group. CONCLUSION: Internal anal sphincter activity exhibits electromechanical dissociation and relaxes abnormally in incontinent patients.

Adult↗
PubMed1994

Sustained internal sphincter hypertonia in patients with chronic anal fissure.

PURPOSE: This study was designed to determine whether functional variations of internal sphincter activity occur in order to differentiate between patients with anal fissures from those with hemorrhoids. METHODS: Thirty patients with chronic anal fissure (median age, 28 years; 12 females), 22 patients with hemorrhoids (median age, 37 years; 7 females), and 33 control volunteers (median age, 48.5 years; 21 females) underwent ambulatory anal sphincter fine-needle electromyography and anorectal manometry. RESULTS: The median internal sphincter electromyography frequency was similar: fissure group, 0.49 Hz; hemorrhoid group, 0.46 Hz (P > 0.05), and control group, 0.44 Hz (P > 0.05). Median anal resting pressures were similar in the fissure group (132 cm. H2O) and the hemorrhoids group (116 cm of H2O) (P > 0.05), but significantly greater than those in the control group (94 cm. H2O) (P < 0.05). The median number of transient relaxations of the internal and sphincter with an associated rise in rectal pressure and fall in anal pressure was 1 (range, 0-4) per hour in the fissure group, 6 (range, 4-7) per hour in the hemorrhoid group, and 4 range, 3-6) per hour in the control group. Six patients with fissures were reassessed following lateral internal sphincterotomy. Median and pressure was 102 cm of H2O (P > 0.1 vs. controls) and the number of internal sphincter relaxations increased to 4 per hour (P < 0.01 vs. preoperative number). CONCLUSIONS: Internal anal sphincter relaxation occurs on fewer occasions in patients with chronic anal fissures that have failed to heal in comparison to patients with hemorrhoids and normal controls. This evidence further supports the hypothesis that internal sphincter hypertonia may be relevant to the pathogenesis of this disorder.

Adult↗
PubMed1994

Two different glycosyltransferase defects that result in GalNAc alpha-O-peptide (Tn) expression.

This study shows for the first time that different glycosyltransferase defects in the biosynthesis of O-linked oligosaccharides give rise to the same GalNAc alpha-O-Ser/Thr determinant on Tn erythrocytes and colorectal carcinoma cells. The O-linked oligosaccharides isolated from the glycophorins of Tn erythrocytes contained predominantly alpha-N-acetylgalactosamine-O-Ser/Thr (Tn antigen) and sialyl-Tn. A marked reduction in normal sialylated oligosaccharides was also observed. Monoclonal antibody BRIC 111 raised against Tn erythrocytes reacted with both Tn erythrocytes and colorectal carcinoma tissues. Weak staining was detected in the supranuclear area and at the surface membranes in normal colorectal cells, but was absent from goblet cell vesicles. An increase in supranuclear staining over controls was found in tumour tissue and in the majority of resection margin specimens. The highest levels of staining were present in transitional mucosa, adjacent to the tumours where goblet vesicles were also positive. Glycosylation defects in the same patients were further studied by determination of the activity of glycosyltransferases in mucosal tissue from control and cancer patients. The reduction in or loss of beta 1-3 N-acetylglucosaminyl transferase activity to GalNAc-peptide in asialo-ovine submaxillary gland glycoprotein was detected by direct assay and by isolation of the oligosaccharides from the incubation products. No differences in N-acetylglucosaminyl-, galactosyl- or sialyl-transfer to Gal beta 1-3GalNAc in antifreeze glycoprotein or in sialyl transferase to asialo-ovine submaxillary gland glycoprotein were detected. Our study shows that the GalNAc alpha-O-Ser/Thr determinant on Tn erythrocytes and in colorectal carcinoma results from different glycosyltransferase defects in separate biosynthetic pathways for haematopoietic and epithelial tissues.

Antigens, Tumor-Associated, Carbohydrate↗
PubMed1994

Glutamine-supplemented total parenteral nutrition enhances T-lymphocyte response in surgical patients undergoing colorectal resection.

OBJECTIVE: The authors determined the effect of glutamine-supplementation of TPN on postoperative peripheral blood T-cell response and proinflammatory cytokine production in patients undergoing colorectal resection. SUMMARY BACKGROUND DATA: Several vital tissues, including the immune system, are very dependent on glutamine; however, this amino acid, which may be essential in conditions of stress, only now is becoming formulated suitably for incorporation into TPN. The effects of such supplementation on the immune function of stressed surgical patients is unknown. METHODS: Patients (n = 20) were randomized to receive conventional TPN (0.2 g nitrogen/kg/d) or an isonitrogenous/isocaloric regimen with 0.18 g of glutamine/kg/d from days 1 to 6 postoperatively. T-cell DNA synthesis and interleukin (IL)-2 production and peripheral blood mononuclear cell IL-6 and tumor necrosis factor (TNF) production were measured in vitro preoperatively and on days 1 and 6 postoperatively. RESULTS: T-cell DNA synthesis after 5 days of TPN was increased compared with preoperative values in the glutamine-supplemented group (median preoperative tritiated thymidine uptake: 78.3 x 10(3) cpm, day 6: 95.0 x 10(3) cpm, p < 0.05). There was no such increase in the control TPN group (preoperative: 89.0 x 10(3) cpm, day 6: 69.4 x 10(3) cpm, p > 0.05). Glutamine supplementation did not influence IL-2 production or the production of TNF or IL-6. CONCLUSIONS: Glutamine supplementation may be a method of enhancing T-cell function in the surgical patient receiving TPN.

Adolescent↗
PubMed1994

The use of endoluminal ultrasound in the assessment of patients with faecal incontinence.

To determine the clinical value of endoanal ultrasonography in the assessment of patients with faecal incontinence, we have assessed 98 patients with neurogenic incontinence (median age 58 years, 85 women). Twenty-one patients with a history of previous anal surgery (13 men), 12 nulliparous women, and 73 women with an obstetric history (including eight with previous anal surgery) were assessed. All of the patients who had undergone surgery and 43 patients with a previous obstetric history had abnormalities identified by ultrasound. Endoanal ultrasound identified two internal sphincter injuries in patients who were suspected of having an external sphincter defect alone. In addition, in 18 patients who had an obstetric history but no documented obstetric trauma, defects were identified in the external sphincter by ultrasonography. The technique appears most useful in those patients with an obstetric history and/or a previous history of anal surgery. Symptoms of incontinence were most severe in those who had internal sphincter division.

Adult↗
PubMed1993

Internal anal sphincter dysfunction in neurogenic faecal incontinence.

Forty-eight patients of median age 57 years with neurogenic faecal incontinence and 44 normal subjects of median age 51 years underwent fine-wire anal sphincter electromyography and anal manometry. The median (interquartile range (i.q.r.)) internal anal sphincter (IAS) electromyogram frequency was 0.26 (0.21-0.32) Hz for patients with faecal incontinence and 0.44 (0.31-0.55) Hz for controls (P < 0.01). The median (i.q.r.) ambulatory resting pressure was 48 (34-68) cmH2O for patients and 86 (72-102) cmH2O for controls (P < 0.01) and median (i.q.r.) frequency of transient IAS relaxations 9 (7-12) and 4 (3-7) per h respectively (P < 0.05). Mid-anal pressure fell to a greater extent in patients with incontinence during these episodes of transient IAS relaxation. Rectal pressure during such relaxation did not exceed mid-anal canal pressure in controls; for the patient group, rectal pressure increased during relaxation and exceeded mid-anal canal pressure in 36 cases. Frequent abnormal episodes of IAS relaxation may cause occult faecal leakage in patients with neurogenic faecal incontinence.

Adult↗
PubMed1993

The clinical contribution of integrated laboratory and ambulatory anorectal physiology assessment in faecal incontinence.

To determine the clinical value of anorectal physiology testing, we have assessed 73 patients with neurogenic incontinence (median age 55 years, 60 female) and 115 controls (median age 48 years, 81 female). All the faecally incontinent patients displayed abnormal anal mucosal electrosensitivity and prolonged pudendal nerve latencies. Rectal compliance was poor in 14% of patients with neurogenic incontinence. Twenty-seven sphincter injuries were identified by endoanal ultrasonography in patients with neurogenic incontinence. Anal sphincter electromyographic abnormalities were demonstrated in all the incontinent patients. Anal pressures were lower in the incontinent group. Frequent, abnormal internal sphincter relaxations were observed in patients with incontinence during ambulatory assessment. These tests provide objective evidence of injury but do not frequently affect clinical decision making. Endoanal ultrasonography and ambulatory assessment provided clinical information of the mechanism of incontinence in 60% of patients.

Adult↗
PubMed1993

Pathology of the defunctioned rectum in ulcerative colitis.

Faecal stream diversion may induce inflammatory changes in the defunctioned segment of the large intestine. These changes are predominantly mucosal, although confusing histological features including granulomas may be present. The pathology of 15 defunctioned rectal stumps has been studied. All patients had previously undergone urgent total colectomy for ulcerative colitis and rectal stumps had been left in situ while they awaited pelvic ileal reservoir construction. All rectal stumps showed predominantly mucosal disease but there were additional features such as florid lymphoid follicular hyperplasia (12 cases), transmural inflammation (nine cases), granulomas (four cases), fissures (eight cases), and changes akin to ischaemia or to pseudomembraneous colitis (four cases). These changes may result from a combination of defunctioning and of active ulcerative proctitis. Some induce a histological appearance that may mimic Crohn's disease. Nevertheless review of all 15 colectomy specimens showed unequivocal ulcerative colitis and none of the patients has subsequently shown any clinical, radiological, or pathological evidence to support a diagnosis of Crohn's disease. Histology of the rectal stump in ulcerative colitis may lead to an erroneous diagnosis of Crohn's disease and the patient may subsequently be denied the advantage of a pelvic ileal reservoir.

Adult↗
PubMed1993

[Intermittent electromechanical dissociation of the internal anal sphincter in idiopathic fecal incontinence].

Ten patients with median age of 51 years (range 24-75; 9 female) presenting idiopathic faecal incontinence and twelve normal subjects with median age of 34 years (range 25-71; 5 female) underwent fine wire anal sphincter electromyography and anal manometry. The results were analysed using non-parametric methods of statistical analysis. The median IAS EMG was 0.30 Hz (range 0.18-0.38), in incontinent and 0.48 Hz (range 0.31-0.55) in controls; p. < 0.01. Ambulatory resting pressures were a median of 66 cmH2O (range 49-83 cmH2O), for the incontinent and 82 cmH2O (range 66-120) for controls; p < 0.04. IAS EMG frequency correlated with resting anal pressures in both groups (p < 0.003). IAS EMG silence not attributable to electrode movement or to the recto-anal inhibitory reflex, lasting 0.5-4 minutes, occurred in all but two of the incontinent patients. No recruitment of the external sphincter or puborectalis muscle was noted during these episodes. Such electromechanical dissociation was not seen in the control group.

Adult↗
PubMed1992

Abdominal rectopexy for rectal prolapse: a comparison of techniques.

To compare the methods of abdominal rectopexy and to elucidate the mechanism by which rectopexy restores continence in patients with rectal prolapse, the role of sphincter recovery, rectal morphological changes and improved rectal sensation were assessed in 68 patients (eight men, 60 women) of median age 63 (range 18-83) years undergoing resection rectopexy (n = 29), anterior and posterior Marlex rectopexy (n = 20), posterior Ivalon rectopexy (n = 9) or suture rectopexy (n = 10). Preoperative and postoperative manometry, radiology and electrosensitivity measurements were made. Age and duration of follow-up were similar in all groups and the prolapse was controlled in all patients. Significantly improved continence was seen in all but the Ivalon group. There was no evidence of increasing postoperative constipation. Sphincter length and voluntary contraction were unaltered, but improved resting tone was seen in the resection and suture groups. This was not seen in the prosthetic groups. Improved continence correlated with recovery of resting pressure. Upper and sensation was improved in all groups. Radiological changes did not correlate with improved continence. We conclude that continence is improved by all rectopexy procedures but seems better without prosthetic material. Sphincter recovery seems to be the most important factor.

Adult↗
PubMed1992

Restoration of continence following rectopexy for rectal prolapse and recovery of the internal anal sphincter electromyogram.

Twenty-two patients with full-thickness rectal prolapse underwent ambulatory fine wire electromyography of the internal and sphincter (IAS), external and sphincter and puborectalis, together with anorectal manometry, using a computerized system. Examinations were performed both before and 3 to 4 months after rectopexy. The median (interquartile range (i.q.r.)) preoperative IAS electromyogram (EMG) frequency was 0.18 (0.05-0.31) Hz and the median (i.q.r.) preoperative resting anal pressure was 28 (15-64) cmH2O. An improvement in the IAS EMG frequency, median (i.q.r.) 0.29 (0.19-0.38) Hz (P less than 0.03), and resting anal pressure, median (i.q.r.) 41 (20-72) cmH2O (P less than 0.05), was recorded after operation, but these variables remained significantly lower than those found in normal controls: median (i.q.r.) IAS EMG frequency 0.44 (0.36-0.48) Hz and median (i.q.r.) resting anal pressure 92 (74-98) cmH2O. We suggest that repair of the prolapse allows the IAS to recover by removing the cause of persistent rectoanal inhibition.

Adult↗
PubMed1992

Mucin changes in ileoanal pouches monitored by metabolic labelling and histochemistry.

The pattern of mucin synthesis and secretion in mucosal biopsies from the proximal ileum, distal ileum, rectum and pouch before and after ileostomy closure was monitored in patients undergoing restorative proctocolectomy by metabolic labelling with [3H]glucosamine and [35S]sulphate and compared with the mucin histochemistry in each patient. Metabolic labelling clearly demonstrated a reduction in sulphation associated with the rectal mucosa in colitis. Significant differences in the turnover of isolated secreted mucin between proximal and distal ileum and rectum were also found, as was a metaplastic change towards a colonic-type mucosa in the pouch before and after ileostomy closure relative to the proximal and distal ileum, and rectum. This technique can be used to monitor colonic metaplasia in the pouch mucosa and is suitable for comparative studies where mucin changes are implicated.

Adult↗