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PubMed1993

Predicting the functional result of anastomoses to the anus: the paradox of preoperative anal resting pressure.

UNLABELLED: This article examines the effect of ileal pouch-anal (n = 134) and coloanal (n = 16) anastomoses on resting anal canal pressures in 150 patients. METHODS: Patients underwent anal manometry before ileal pouch-anal anastomosis (IPAA) and coloanal anastomosis (CAA) and again six weeks after ileostomy closure following these procedures. A water-perfused catheter system with four radial ports was used for manometry, pressures being recorded during both station and continuous pull through. RESULTS: Patients with IPAA were younger than those with CAA (34 years vs. 50 years) and had a different ratio of hand-to-stapled anastomosis (1:2.6 vs. 1.3:1). All CAA patients had had rectal cancer while IPAA patients suffered mainly from ulcerative colitis (n = 114) or familial polyposis (n = 10). The mean preoperative resting pressure for all patients was 79 mmHg (75-87, 95 percent confidence limit) and the mean fall in this pressure after surgery was 25 mmHg (-21 to -29, 95 percent confidence limit). There was no difference in preoperative pressure or fall between handsewn and stapled anastomoses, or between IPAA and CAA. CONCLUSION: There was a significant relationship between preoperative pressure and change in pressure that held true for all subgroups (change = -0.7 x preoperative pressure + 31, r = 0.69). Analysis of the functional results confirmed that patients with high preoperative pressure are at risk for severe falls after surgery and are not guaranteed a good result. Conversely, patients with low preoperative pressures may actually have an increase with surgery and are not always incontinent. Patients with low preoperative anal resting pressures should not be denied anastomosis to the anus if they are continent.

Adolescent↗
PubMed1994

Simplified solid sphere test to investigate anal sphincter strength in patients with anorectal diseases.

PURPOSE: The solid sphere test has not gained general acceptance to investigate anal sphincters, despite its simplicity and low cost. We studied continent and incontinent patients to evaluate whether the solid sphere test is suitable in assessment of anal sphincter function. METHODS: Seventy colorectal patients with anal incontinence of varying severity were studied by means of incontinence grading, solid sphere test, and anal manometry. RESULTS: Anal sphincter strength, studied using the solid sphere test, declined gradually with increasing severity of anal incontinence from 1,186 (+/- 334, SD) g in 28 continent patients to 619 (+/- 256, SD) g in 13 patients with daily soiling (P < 0.001). The test also correlated with anal manometry; there was positive correlation with maximum basal pressure (r = 0.643, P < 0.001) and maximum voluntary contraction pressure (r = 0.393, P < 0.01). CONCLUSION: The solid sphere test is useful in the primary assessment of patients with anal incontinence as a screening test, but alone it is too inaccurate for clinical decision making.

Adult↗
PubMed1991

Recovery of anal sphincter function following transabdominal repair of rectal prolapse: cause of improved continence?

Twenty-eight patients with complete rectal prolapse underwent anorectal manometry before and 6 months and 1-2 years after abdominal rectopexy and sigmoid resection in a study of the mechanisms responsible for postoperatively improved anal continence. Preoperatively, 22 patients reported defective and control. Seven patients (all with minor incontinence) regained normal control and eight other patients achieved improved continence after surgery. Anal resting, squeeze, and voluntary contraction pressures were significantly lower for defective than for normal control, with a significant rise in these pressures at 6 months after the operation, except for those incontinent patients in whom continence was not improved. No further pressure rise was seen later. Improvement of continence was not accompanied by changes in rectal sensation or reflexive functions of the internal anal sphincter. These results suggest that recovery of the resting and voluntary contraction functions of the sphincter muscles was the cause of continence improvement observed after surgery. Anal manometry was unable to predict outcome of function. Therefore, supplementary procedures for restoration of continence are not advisable, although patients with only minor incontinence are likely to regain full continence after rectopexy alone.

Adult↗
PubMed1990

Physiologic evaluation of the anorectum. A new ultrasound technique.

Pelvic floor physiology is a complex area of clinical study. Continence and voiding functions are not completely understood. Incontinence is an especially underrated problem. With the use of manometry and ultrasound, anorectal physiology is evaluated and correlated with clinical dysfunction. A description of a previously undescribed ultrasound technique to evaluate anorectal angles and puborectalis function is presented. The results in 10 controls and 53 symptomatic patients with different degrees of continence dysfunction are discussed. The controls showed anal pressures and anorectal angles of 29 cm H2O and 114 degrees at rest and 67 cm H2O and 95 degrees with contraction. Six of the symptomatic patients had complete incontinence to solid stools. The results of their pressures and angles were 14 cm H2O and 151 degrees at rest and 32 cm H2O and 124 degrees with contraction. The values of this group compared with controls is significantly different (P less than 0.05). Ultrasound is helpful in assessing the pelvic floor, both subjectively and objectively. It has the advantages of avoiding radiation and allowing a longer viewing time. It is less expensive compared with radiographic proctography and the data are complementary. Ultrasound and manometry may be useful for long-term follow-up of anorectal physiology.

Aged↗
PubMed1990

Anorectal function investigations in incontinent and continent patients. Differences and discriminatory value.

Anal manometry, rectal capacity measurement, and the saline-infusion test were performed in 350 patients, 178 of whom had fecal incontinence and 172 of whom were continent. Anal manometry was also performed in 80 control subjects, whose results were compared with the patients. Women and older patients exhibited lower pressures. Compared with continent patients, incontinent patients had lower anal sphincter pressures at rest and during squeeze, a smaller rectal capacity, and leaked earlier and more with the saline infusion test. Differentiation between incontinent and continent patients was not possible with a single test because there was complete overlap. The maximum squeeze pressure showed the best discrimination. Combining the three tests did not show better discrimination than any individual test. Anal pressure and rectal capacity below the normal range only were found in very few incontinent patients. The authors' study demonstrates that no prediction can be made about continence with anorectal function tests. Therefore, in the individual patient, an abnormal result in one test must be interpreted with caution and only in relationship with other tests, especially when therapeutic surgery is considered.

Adult↗
PubMed1994

Study protocols and functional results in 86 electrostimulated graciloplasties.

PURPOSE: This study analyzes different protocols adopted in 86 electrostimulated graciloplasties performed during the last eight years, comparing functional and manometry results in 63 patients. METHODS: Electrostimulated graciloplasties were performed to construct a neosphincter after surgical removal of the anorectum for cancer in 75 patients and to substitute the anal sphincter in 11 fully incontinent patients. An intermittent stimulation protocol, using external devices, was applied in the first 68 patients, while long-term stimulation was carried out with implantable stimulators and intramuscular electrodes in the last 18 patients. Sixty-three patients remaining under study were evaluated by questionnaires, continence scores, and manometry. RESULTS: In patients submitted to intermittent stimulation, continence was achieved in 71 percent of 42 "neosphincters" after rectal resection and in 33 percent of 3 incontinent patients. Adopting chronic stimulation, implantable stimulators and intramuscular electrodes, continence reached 100 percent and 83 percent, respectively. Significant differences were also observed in resting and voluntary pressure values between the intermittently and chronically stimulated patients. Incontinent patients showed after chronic stimulation significant increases in mean resting and maximum voluntary pressures: from 13.3 to 60.5 mmHg and from 32 to 103 mmHg, respectively (P < 0.01). CONCLUSIONS: This study confirms the efficacy of chronic stimulation and the validity of a bilateral, "one-time" graciloplasty to reconstruct or substitute the anal sphincter.

Adolescent↗
PubMed1994

Chronic effects of pelvic radiation therapy on anorectal function.

PURPOSE: The long-term effect of 4,500 cGy of preoperative radiation on anorectal function has not been prospectively evaluated. METHODS: Anal manometry was performed on 20 patients with rectal carcinoma before and four weeks after receiving 4,500 cGy of external radiotherapy. Four patients underwent proctectomies, three died, and three refused follow-up. Ten patients were available for long-term follow-up and underwent anal manometry at 14 to 42 (average, 35.5) months after initial radiotherapy. RESULTS: No significant difference in mean maximum squeeze or resting pressures was found after radiation therapy. The sphincter profile and minimum sensory threshold were unchanged. The rectoanal inhibitory reflex was present in all patients. Nine patients reported normal anal function. One patient who was incontinent before treatment remained incontinent. CONCLUSION: Preoperative radiation therapy has a minimal chronic effect on anorectal function. Incontinence after sphincter-saving operations for rectal cancer should not be attributed to preoperative radiation therapy.

Aged↗
PubMed1991

Comparative intrinsic and extrinsic compliance characteristics of S, J, and W ileoanal pouches.

Although compliance of the ileoanal reservoir pouch has been shown to affect function, previous compliance studies may have been influenced by the compliance of the small bowel proximal to the pouch and by supporting pelvic structures. The following study was designed to isolate the pouch and to compare intrinsic and extrinsic factors influencing pouch compliance. Thirty-three mongrel dogs underwent rectal mucosectomy and proctocolectomy with S-pouch (S) in nine, stapled J-pouch (SJ) in nine, handsewn J-pouch (HJ) in nine and handsewn W-pouch (SW) in six. At 2 weeks, each dog underwent laparotomy, the small bowel 2 cm proximal to the pouch was clamped, and in vivo pouch compliance was measured using anal balloon occlusion and continuous saline infusion manometry. The pouch was then removed and ex vivo measurements were repeated. Mean compliance slopes between 0 and 40 cm H2O were compared by ANOVA and paired t-tests. In vivo and ex vivo compliance in ml/cm H2O was 3.1 +/- 1.2 and 3.8 +/- 1.6 (P = 0.25) for the S-pouch, 3.1 +/- 0.6 and 5.2 +/- 1.7 (P less than 0.01) for the SJ-pouch, 2.3 +/- 0.5 and 4.8 +/- 0.7 (P less than 0.001) for the HJ-pouch, 3.6 +/- 0.6 and 6.0 +/- 0.7 (P less than 0.001) for the W-pouch. Pearson's correlation coefficient for in vivo and ex vivo measurements of the S, SJ, HJ, and W pouches were r2 = 0.066, 0.001, 0.039, and 0.379, respectively. It is concluded that: 1) Isolated pouch compliance can be accurately measured in experimental animals with proximal and distal occlusion and inflow manometry. 2) In vivo compliance is significantly less in the HJ compared with S, SJ, and W pouches. 3) Differences between in vivo and ex vivo compliance of SJ, HJ, and SW pouches are significant. 4) In vivo and ex vivo compliance determinations correlate poorly. 5) Extrinsic factors contribute significantly to pouch compliance.

Anal Canal↗
PubMed1995

Computer-generated profiles of the anal canal in patients with anal fissure.

PURPOSE: The pathophysiology of anal fissure remains poorly understood. This study examines manometric findings in patients with anal fissure with use of a computer-assisted system, which helps to standardize manometric performance as well as generating longitudinal and cross-sectional profiles of the anal canal. METHODS: Water-perfused, eight-channel, computer-assisted manometry was performed on 12 patients with chronic anal fissure and compared with 12 age-matched and sex-matched controls. RESULTS: Mean maximum average resting pressure (MARP) was 120.5 mmHg in patients and 82.6 mmHg in controls (P = 0.0005). Pain was felt during manometry in six patients. In these patients, MARP was 123.2 mmHg, and, in the other six patients, MARP was 117.8 mmHg. Sphincter length was 4.72 cm, and the high pressure zone or that part of the sphincter with pressure more than 50 percent of MARP) was 2.78 cm in length. The high pressure zone/sphincter length ratio was 58 percent compared with 48 percent in controls. Longitudinal profile was bell shaped. Elevated pressures were not confined to the site of the fissure. Cross-sectional analysis showed higher anterior pressures in the distal sphincter. Ultraslow waves were seen in as many as 91 percent of patients and 73 percent of controls. However, ultraslow wave amplitude was 31 mmHg in patients and 15 mmHg in controls (P = 0.03). The rectoanal reflex was normal; overshoot was not seen. CONCLUSIONS: The primary abnormality in fissure is persistent hypertonia affecting the entire internal sphincter, unrelated to pain. Cross-sectional pressure profiles may explain the predilection of fissures to occur in the posterior midline; other factors must prevent chronic fissures from healing.

Adult↗
PubMed1996

Factors influencing bowel function following total abdominal colectomy.

PURPOSE: The purpose of this study was to determine which factors influenced bowel function following total abdominal colectomy. METHODS: Thirty-two patients who had undergone total abdominal colectomy were studied with regard to factors that are classically thought to influence bowel function, namely, residual stump length, transit time, and rectal stump manometry. In a limited subset of patients, anal manometry was done also. RESULTS: Transit time was the best predictor of bowel function following total abdominal colectomy. This was followed by stump length. If transit time was short, then stump length became important in predicting the occurrence of diarrhea following total abdominal colectomy. CONCLUSIONS: Two factors have an important influence on bowel function following total abdominal colectomy: transit time and rectal stump length. Rectal stump length is an anatomic factor that can be controlled by the surgeon. In total abdominal colectomy, rectal stump length of at least 20 cm is necessary if the patient is to have satisfactory postoperative bowel function. This may not always be possible. In these patients, modification of diet to influence transit time and methods to increase rectal compliance will be necessary.

Colectomy↗
PubMed1997

Prospective trial of pelvic floor retraining in patients with fecal incontinence.

PURPOSE: Our aim was to prospectively evaluate pelvic floor retraining (PFR) in improving symptomatic fecal incontinence. METHODS: PFR was used to treat 30 patients with fecal incontinence (28 women; age range, 29-85 (median, 68) years). PFR was performed by a physiotherapist in the outpatient department according to a strict protocol and included biofeedback using an anal plug electromyometer. Manometry (24 patients), pudendal nerve terminal motor latency (PNTML, 16 patients), and anal ultrasound (14 patients) were done before commencing therapy. Independent assessment of symptoms was done at the commencement of therapy, at 6 weeks, and at 6 and 12 months posttherapy. RESULTS: Twenty patients (67 percent) had improved incontinence scores, with eight patients (27 percent) being completely or nearly free of symptoms. Of 28 patients followed up longer than six months, 14 achieved a 25 percent or greater improvement at six weeks, which was sustained in all cases. Fourteen had an initial improvement of less than 25 percent, with only four (29 percent) showing later improvement (P < 0.0001). There was no relationship between results of the therapy and patient age, initial severity of symptoms, etiology of incontinence, and results of anal manometry, PNTML, and anal ultrasound. CONCLUSIONS: PFR is a physical therapy that should be considered as the initial treatment in patients with fecal incontinence. An improvement can be expected in up to 67 percent of patients. Initial good results can predict overall outcome.

Adult↗
PubMed1990

Defecography in patients with anorectal disorders. Which findings are clinically relevant?

To evaluate the results and clinical impact of defecography in patients with anorectal disorders, 100 results of defecographic examinations from 92 patients were reviewed. The defecographic results were screened for the anorectal angle, defined both at rest and during straining, perineal descent, and abnormalities of the rectal configuration during straining. Anal manometry, saline infusion test, rectal capacity measurement, and anal electromyography (EMG) were also performed. There was a significant difference (P less than 0.001) both at rest (22 degrees) and during straining (12 degrees) between the two anorectal angle measurements. Incontinent patients had a larger anorectal angle, both at rest and during straining, than continent patients (P less than 0.04), but with a large overlap. The anorectal angle was not influenced by gender or age. An abnormal rectal configuration was found in 62 defecographic examinations. From the 8 patients with rectopexy performed for a large rectocele or intussusception, incontinent patients with an intussusception had the best results. In four patients, anal EMG showed an increased activity of the external sphincter during straining. Two of these four patients had abnormal defecograhic results. No correlations were found between anorectal angle and the other function tests. In conclusion, the anorectal angle lacks clinical relevance. In patients with defecation problems, defecography may be indicated whenever other investigations (physical examination, anal manometry, anal EMG) have excluded local pathology or a spastic pelvic floor syndrome. In these situations, defecography could detect an intussusception, which could easily be treated with rectopexy.

Aged↗
PubMed1997

Treatment of puborectalis syndrome with progressive anal dilation.

PURPOSE: The aim of this study is to assess the ability of progressive anal dilations to improve frequency of spontaneous bowel movements in patients with puborectalis syndrome (PRS). METHOD: Thirteen patients (9 females and 4 males; mean age, 37 years) with severe, chronic constipation caused by PRS were treated with daily, progressive anal dilation for a three-month period. Three dilators of 20, 23, and 27 mm in diameter were used. Dilators were inserted every day for 30 minutes (10 minutes each dilator). Patients were evaluated with anorectal manometry and defecography halfway through treatment, at the end of treatment, and six months after the end of treatment. At six months, patients also underwent physical examination. RESULTS: There was a significant improvement of weekly mean spontaneous bowel movements from zero to six (P < 0.0001), and the need for laxatives decreased from 12 patients with a weekly mean of 4.6 to 2 patients once per week (P < 0.001). Enemas used before treatment by eight patients who had a weekly mean of 2.3 were, after treatment, needed only by three patients once per week (P < 0.01). During straining, tone measured with anorectal manometry decreased from 93 to 62 mmHg after six months of the end of therapy (F = 6.97; P < 0.01), and anorectal angle measured with defecography during the strain increased from 95 degrees to 110 degrees (P = not significant). CONCLUSIONS: Daily progressive anal dilation should be considered as the first and most simple therapeutic approach in patients with PRS.

Adolescent↗
PubMed1996

Microchip implants on the anterior sacral roots in patients with spinal trauma: does it improve bowel function?

PURPOSE: This study evaluated the effect of anterior sacral roots stimulator implants on bowel function of patients with spinal cord trauma. METHOD: Eight patients with spinal cord injury and constipation had anterior sacral roots stimulator implants inserted for concomitant bladder dysfunction. Questionnaires on bowel function and anorectal manometry tests were given before and after insertion of the implants. RESULTS: Six patients achieved improvement in bowel function. Four of these patients could defecate spontaneously following stimulation. Two patients had no improvement in bowel function. Anorectal manometry studies showed a negative rectoanal pressure difference at the time of stimulation. All patients were unable to defecate during stimulation. Positive rectoanal pressure difference was recorded in the six patients who had improved bowel function. This may be attributable to the slower relaxation of the smooth rectal muscle compared with the easily fatigable striated external anal sphincter. CONCLUSION: Anterior sacral roots stimulator implants can improve bowel function in patients with spinal cord trauma.

Adult↗
PubMed1995

Effect of propofol on human sphincter of Oddi.

The effect of propofol was studied in 11 patients who had common bile duct sphincter of Oddi manometry for suspected dysfunction. Patients were initially sedated with midazolam and then further or resedated with propofol for the second set of pressure measurements. Recordings were made about 10 min after giving each drug. No patient had elevated basal pressure initially. Average basal pressure was unchanged (16.7 +/- 16.4 mm Hg), phasic contraction frequency was unchanged (3.4 +/- 3.8/min), and phasic contraction amplitude fell but did not achieve statistical significance (91.8 +/- 77.3 mm Hg, P = 0.1). There was no difference in lowest blood pressure, pulse, or oxygen saturation recorded during midazolam or propofol sedation. Subjectively, the patients were more sedated during propofol administration. It is concluded that propofol is a safe and effective agent for conscious sedation. It does not alter the sphincter of Oddi pressure profile in patients with normal basal sphincter pressures and thus could be used as an alternative and perhaps better form of sedation for ERCP with sphincter of Oddi manometry.

Adolescent↗
PubMed1995

Effect of gastric distension and duodenal fat infusion on biliary sphincter of Oddi motility in healthy volunteers.

Although sphincter of Oddi (SO) dysfunction has been implicated in the pathogenesis of postcholecystectomy syndrome and pancreatitis, little is known about normal physiologic stimuli, such as intraduodenal fat on human SO motility. Furthermore, gastric distension that frequently accompanies endoscopic manometry has been shown in animal studies to affect SO motility. We evaluated the effects of intraduodenal fat and gastric distension on SO basal pressure. Asymptomatic volunteers had SO manometry performed while sequentially performing gastric distension and intraduodenal fat perfusion. Five subjects (ages 29.8 +/- 4.8 years, range 22-35 years) had a mean basal sphincter of Oddi pressure of 23.4 +/- 5 mm Hg (range 17-31 mm Hg). Injection of air into the stomach caused no appreciable change in either intragastric pressure or SO pressure. Intraduodenal fat infusion resulted in a decrease in mean SO basal pressure from 23.4 +/- 5.0 to 4.4 +/- 4.4 mm Hg (P = 0.004). These results demonstrate that gastric distension does not affect SO basal pressure and that intraduodenal fat infusion reduces SO basal pressure.

Adult↗
PubMedDate not supplied

The usefulness of tests in anorectal disease.

Specialized tests of anorectal function are designed to complement but not to replace good clinical examination and sound professional judgement. The different methods of recording pressure changes have advantages and disadvantages. Poor correlation exists when data recorded using miniature balloons are compared with data from microtransducers. Prolonged ambulatory monitoring of anal sphincter and rectal pressure reveal that spontaneous transient episodes of sphincter relaxation are demonstrable in normal subjects. In the investigation of patients with possible traction injury to the pudendal nerve, electromyography and pudendal nerve terminal motor latency data are more precise than manometry data. Good correlation between noninvasive surface electromyography using an intra-anal plug electrode and anal manometry can be attained. Mapping of sphincter defects using concentric needle technology is reasonably accurate but distinctly painful. Dynamic defecography readily demonstrates abnormalities of the rectal wall. The division between what is normal and what is clinically relevant is rather imprecise. Comparative studies of sonographic and electromyographic mapping of sphincter defects give good correlation. Recent application of fine hooked electrodes have demonstrated periodic episodes of smooth muscle and sphincter relaxation. The saline infusion test and balloon expulsion test help to accurately quantify the difficulty patients experience in retention or evacuation, respectively. Perineometry is a simple, rapid, noninvasive method of measuring the extent of perineal descent on straining. Although reproducible, it tends to underestimate the degree of descent when compared with the radiological method but it avoids the use of ionized radiation.

Anus Diseases↗
PubMedDate not supplied

Fecal incontinence: indications for repairing the anal sphincter.

Incontinent patients should be comprehensively investigated by objective tests, especially manometry, continence tests, and electromyography. Manometry can be used to predict the functional outcome and to calibrate the sphincter repair. Pure anatomical defects of the anal and pelvic musculature deserve surgical correction with or without overlapping the muscle ends. If the repair is delayed it should be done after a 3 month interval. A protective colostomy has to be performed in complex cases and in cases with septic complications. Before closing the colostomy, the ano-rectal function should be assessed. Acceptable continence can be restored in the majority of the patients, the outcome depending on the extent of local defects and the severity of concomitant pelvic floor neuropathy. Skeletal muscle transposition remains an esoteric approach to be used only in selected patients; the implantation of a neuromuscular stimulator seems to be warranted. In the presence of important functional deficits, sphincter repair may create a situation where additional conservative measures become more effective. A post-anal repair may be considered 3-12 months after rectopexy or sphincter repair. Incontinence based on pure functional defects is initially treated conservatively. A post-anal repair may improve the situation in two thirds of the patients but fails to help those who need it most. Failure seems to be related to a continuing neuropathic process. A peri-anal prosthetic band implant may be a valuable alternative in such patients. A sigmoidostomy is a measure of last resort. The prevention of fecal incontinence is most important and concerns surgeons, obstetricians, and physicians.

Anus Diseases↗