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PubMed1996

Long-term results of total abdominal colectomy for chronic idiopathic constipation. Value of preoperative assessment.

PURPOSE: A small proportion of patients with chronic idiopathic constipation are incapacitated by the problem. We have assessed 1) the efficacy of total abdominal colectomy, and 2) the predictive value of preoperative testing. METHODS: Preoperative testing included complete history and physical examination, appropriate biochemical and hematologic assessment, psychiatric interview, colon transit studies using ingested radiopaque pellets, anorectal manometry, colonic intraluminal manometry, and measurement of colon diameters and length on barium enema examination. All patients were followed for 65 +/- 40 months. RESULTS: Seventy-one percent had excellent or very good results. Twenty-one percent were satisfied, had improved the quality of their life, and felt the operation was worthwhile despite frequent residual or new symptoms. Two (8 percent) patients did not improve. Patients with a psychiatric history or physiologic evidence of an afferent nerve defect had poorer results (P < 0.05). CONCLUSIONS: Total abdominal colectomy with ileorectal anastomosis is highly effective in alleviating symptoms in patients with chronic idiopathic constipation.

Adult↗
PubMed1996

Functional results after transanal endoscopic microsurgery.

PURPOSE: Compared with traditional operations, superior results after transanal endoscopic microsurgery (TEM) for rectal tumors have been demonstrated in terms of morbidity and mortality. However, no data were available on functional outcome after TEM. We, therefore, studied 42 patients who were undergoing TEM. METHODS: Patients were examined by anorectal manometry and participated in a standardized interview preoperatively and three months and one year after surgery. RESULTS: Anorectal function as assessed by manometry was impaired three months after surgery but improved again during the first postoperative year. In parallel, some patients complained of impaired continence or defecation disorders in the interview three months postoperatively. These functions improved during the first year after surgery, too. CONCLUSIONS: Correct comparison of our results with functional outcome after anterior rectal resection is impossible. We feel, however, that functional results after TEM are likely to be superior to those after anterior resection for rectal tumors.

Adenoma, Villous↗
PubMed1994

Severe late radiation enteropathy is characterized by impaired motility of proximal small intestine.

Late radiation enteropathy (LRE) is a serious disorder, and therapeutic progress has thus far been hampered by insufficient understanding of the pathogenesis. This prospective study addresses whether alterations in proximal intestinal motility can predict the clinical severity of this disorder. Forty-one consecutive patients with chronic abdominal complaints after radiotherapy for gynecological cancer were examined by prolonged ambulatory manometry. Twenty-seven healthy adults served as controls. Impaired fasting motility was found in 12 of 41 patients (29%), and attenuated postprandial motor response after a liquid-solid meal was seen in 10 of 41 patients (24%). Postprandial delay of the migrating motor complex (MMC) was a good predictor of the degree of malnutrition (Cox regression, P < 0.01), and intensity of the MMC and postprandial motility index explained 69% (P < 0.001, multiple regression) of the variability in degree of malnutrition, assessed by weight loss and serum albumin level. The typical presentation of severe LRE was clinical symptoms suggesting intestinal pseudoobstruction, malnutrition, failure of a liquid-solid meal to induce postprandial motility, and delayed initiation and reduced intensity of MMC during nocturnal fasting. Prolonged ambulatory manometry was useful for detection of dysmotility in patients with symptoms of LRE and impaired motility of proximal small intestine seems to be a key factor in the pathogenesis of severe LRE.

Adult↗
PubMed1994

Intestinal dysmotility in patients with sphincter of Oddi dysfunction. A reason for failed response to sphincterotomy.

Sphincter of Oddi dysfunction (SOD) is associated with abdominal pain and is treated by sphincterotomy. Of 215 patients who underwent biliary sphincterotomy for SOD in our institution, 26 reported no improvement and 25 of those were found to have pancreatic sphincter dysfunction and subsequently underwent pancreatic septotomy. Nine patients remained symptomatic after the second intervention. Six of those nine patients, and seven of the 16 patients who improved after the septotomy, agreed to undergo an ambulatory duodenojejunal (DJ) manometry. DJ manometry was abnormal in four of the six symptomatic patients but only in one of seven patients who became asymptomatic after endoscopic treatment. We conclude that the persistence of symptoms after endoscopic ablation of the biliary and pancreatic sphincters is associated with abnormal intestinal motility, which may explain in part the lack of response to the endoscopic treatment.

Abdominal Pain↗
PubMed1994

Ambulatory esophageal pressure and pH monitoring in patients with high-grade reflux esophagitis.

Using conventional manometry and 24-hr ambulatory pressure and pH monitoring, we investigated esophageal motility and the esophageal motor response to reflux in 11 patients with reflux esophagitis Savary-Miller grade III and IV, and an age- and sex-matched group of 11 healthy controls. The patients had a significantly increased esophageal acid exposure. Conventional manometry showed a significantly decreased LES pressure and distal peristaltic amplitude in patients. The 24-hr monitoring yielded a significant decrease in peristaltic contraction duration and peristaltic propagation velocity in the patient group. Distal peristaltic amplitude was not decreased. Analysis of the contractions occurring in the 2-min period after each reflux episode showed a reduced number of contractions during the upright period, caused by a significantly decreased number of peristaltic contractions. During the supine period, there was a trend towards an increased number of contractions. It is concluded that esophageal motor activity and the response to reflux are impaired in patients with high-grade reflux esophagitis. However, the abnormalities found are only minor and are unlikely to play an important role in the pathogenesis of reflux esophagitis.

Aged↗
PubMed1996

Esophageal motor function in patients with myotonic dystrophy.

To investigate pharyngeal and esophageal motor function in myotonic dystrophy (MD), and its relationship to esophageal symptoms, we used low-compliance, high-fidelity esophageal manometry and videofluorography to evaluate 14 consecutive MD patients. Patients exhibited a consistent, typical motor pattern, involving a marked reduction in resting tone of both the upper and lower esophageal sphincters, and a reduction in contraction pressure in the pharynx and throughout the esophagus. Radiology showed hypotonic pharynx with stasis and a hypo- or amotile, often dilated, esophagus. These findings were nonspecific, however, being present in patients both with and without dysphagia, which suggests that MD patients have valid compensatory mechanisms. Dysphagia only correlated to the pharyngeal impairment at manometry. Furthermore, the results of our study suggest that not only the proximal, striated part of the gullet, but also the distal part (in which smooth muscle dominates) is involved in the disease. The latter leads to the impairment of the LES resting tone and competence, highlighting the risk of gastroesophageal reflux disease in these patients.

Adult↗
PubMed1996

Three-dimensional imaging of the lower esophageal sphincter in healthy subjects and gastroesophageal reflux.

The resting pressure and intraabdominal length are the most important factors which determine competence of the lower esophageal sphincter (LES). The intraabdominal sphincter vector volume (ISVV) is a single value which takes into account both of these measurements. Normal values of ISVV and of the total sphincter vector volume (TSVV) were established in 20 normal subjects. The sensitivity and the specificity of ISVV and TSVV were then evaluated in 81 patients with gastroesophageal reflux disease (GERD) and in 19 normal subjects and were compared with the usual stepwise pullback manometry (SPM) measuring the resting pressure of the LES at the respiratory inversion point. The motorized pullthrough technique was used to perform the vector volume procedure. Normal values of ISVV were 1870-10740 mm Hg2 x mm, and of TSVV 2200-13110 mm Hg2 x mm. The sensitivity of ISVV was 93.8% (p < 0.05), of TSVV 80.2%, and of SPM 81.5%. The specificity of ISVV and TSVV was 89.5% and of SPM 78.9% (not significant). Analysis of the intraabdominal sphincter vector volume is more sensitive than the total sphincter vector volume or standard stationary manometry in establishing a defective LES in patients with GERD. Intraabdominal sphincter vector volume analysis will allow surgeons better to identify patients with a defective LES who may be suitable for antireflux surgery.

Diagnosis, Computer-Assisted↗
PubMed1990

Role of proctography in severe constipation.

As referred to in the literature, patients complaining of constipation may have a spastic or, in the case of chronic staining, weak pelvic floor. Twenty-two severely constipated patients who did not improve after a high fiber diet were submitted to whole gut transit time (TT), proctographic, and anorectal manometric studies. A control group consisting of five subjects for TT, five subjects for proctogram, and ten subjects for manometry was also studied. Transit time was delayed (P less than 0.001) in all patients. Manometry in the constipated group showed a high rectal threshold (64.1 vs. 17.1 ml of air, P less than 0.01), but no other significant difference. Proctograms in 10 of 22 patients (Group A) showed no differences in the anorectal angle (ARA) and in its distance from the pubococcygeal line (DLPC) in respect to the control group; 12 of 22 patients (Group B) had a paradoxical closure of the ARA at straining in respect to resting position (101.2 degrees vs. 120.1 degrees), and a higher DLPC than Group A and the control group in all positions studied. There was no difference in TT for rectal stasis of radiopaque markers between the two pathologic groups. Patients in Group B were older than patients in Group A (55.3 vs. 42.9 years, P less than 0.05). In conclusion, proctograms showed alterations of the pelvic floor, but there was no correlation between protographic data and rectal or colonic stasis of the radiopaque markers, or clinic severity of constipation, but a correlation between ages did exist.

Adolescent↗
PubMed1995

Papillary dilation vs sphincterotomy in endoscopic removal of bile duct stones. A randomized trial with manometric function.

To circumvent the long-term effects of papillary ablation for extracting common bile duct stones (< 12 mm in diameter) in endoscopic sphincterotomy (EST), endoscopic papillary dilation (EPD) was attempted in 20 patients. To evaluate papillary function before and after the procedures, manometry of the sphincter of Oddi was carried out in 13 with EPD and 10 of 20 patients with EST. Extraction of all stones was successful (100%) in both groups at an equal rate. Repeated numbers of procedures were common in both groups. However, the mean duration of the procedure was high in EPD compared to EST (63 min vs 42 min, P < NS). Adjunctive therapies like mechanical lithotripsy (ML), nasobiliary drainage, and choledochoscopy were included in EPD, while EST required a basket catheter and ML. There was no significant difference on manometry before and after the procedures (P = NS), although papillary function was found to have decreased after the EPD. In contrast, all patients in the EST group lost papillary function after the procedure. Thirty-day morbidity and mortality rate were absent in both groups. Immediate and 2.5-year follow up complications were uncommon in both groups. As a simple method, EPD may be an effective and safe alternative to EST in the management of patients with bile duct stones who require maintenance of papillary function.

Aged↗
PubMed2001

Topical 0.2 percent glyceryl trinitrate ointment has a short-lived effect on resting anal pressure.

PURPOSE: Glyceryl trinitrate ointment applied to the anal verge lowers anal resting pressure, but its duration of action is uncertain. This study investigated the effect and duration of action of 0.2 percent glyceryl trinitrate on anal resting pressure and hemodynamic parameters. METHODS: A total of 15 volunteers, 9 male, with a median age of 30 (range, 20-71) years, underwent continuous static anal manometry using a solid state catheter for ten minutes before and two hours after applying 0.2 percent glyceryl trinitrate ointment to the anoderm with a gloved finger. Pulse and blood pressure were recorded every 15 minutes. RESULTS: A significant reduction in maximal anal resting pressure compared with preglyceryl trinitrate values was observed at 15, 30, 45, 60, and 90 minutes after application, but no significant difference thereafter. There was no significant change in pulse during the study. Systolic and diastolic blood pressures dropped significantly after application of glyceryl trinitrate, but had recovered and were not significantly different from original values after 90 minutes. A significant fall in blood pressure did not correlate with the onset or duration of side effects. CONCLUSIONS: Continuous static manometry (as opposed to interval measurements reported in previous studies) demonstrates that 0.2 percent glyceryl trinitrate ointment significantly lowers anal resting pressure, but only for 90 minutes. Twice daily application of topical 0.2 percent glyceryl trinitrate heals two-thirds of fissures after eight weeks, but its apparently short duration of action may indicate that more frequent application might heal more fissures, more rapidly.

Administration, Topical↗
PubMed2001

Botulinum toxin type-A in therapy of patients with anismus.

INTRODUCTION: Anismus is a common cause of constipation and outlet obstruction. Standard therapy with laxatives or biofeedback has conflicting results. Surgical treatment gives poor results and has practically been abandoned. PURPOSE: This study was designed to evaluate the efficacy of botulinum toxin type-A (Botox) injection to the puborectalis muscle in patients with anismus. METHODS: Twenty-five patients (15 females; mean age, 23.2) with history of constipation and symptoms of outlet obstruction underwent anorectal perfusion manometry and video-proctography. All patients were found to have a nonrelaxing puborectalis muscle on both modalities. All have been unable to expel a rectal balloon. Each patient who participated in the study was randomly assigned to undergo local injection of Botox--10 units to each side of the puborectalis or 20 units to the posterior aspect of this muscle. Eight patients underwent further injections1-5 every 3 months in accordance with previous results. Follow-up was conducted 1, 4, 12, and 24 weeks after injection. Straining, anorectal pain, and overall satisfaction were assessed on a visual analog scale. Weekly evacuation, fecal incontinence, and complications were recorded. At the weekly meeting, each patient underwent anorectal manometry with a balloon expulsion test. RESULTS: Manometric relaxation was achieved after the first injection in 18 patients (75 percent). Once relaxation was achieved, it lasted throughout the follow-up. Nine patients (37.5 percent) expelled the rectal balloon after the first injection. Seven of 16 patients who failed the first injection had an additional one. In 2 patients it was successful (28.6 percent). Symptom improvement of 29.2 percent in straining index was recorded during follow-up. In 3 patients (12.5 percent) pain developed after injection. No other complications were observed. Overall satisfaction with Botox injection results was observed in 58.3 percent. CONCLUSIONS: Botox injection to the puborectalis muscle has been found to have a limited therapeutic effect on patients suffering from anismus. Our results justify the need for further double-blind placebo-controlled trials to determine the exact role of botulinum toxin type-A in anismus.

Adult↗
PubMed1998

Postpartum fecal incontinence is more common in women with irritable bowel syndrome.

PURPOSE: Anal sphincter damage can occur during vaginal delivery and may lead to impairment of fecal continence. The aim of this study was to determine the influence of irritable bowel syndrome on symptoms of fecal incontinence following first vaginal delivery. METHODS: A prospective, observational study was performed before delivery, six weeks, and six months following delivery in primiparous women. A bowel function questionnaire was completed, and anal vector manometry, mucosal electrosensitivity, pudendal nerve terminal motor latency, and anal endosonography were performed. A total of 208 women were assessed before and after delivery, and 104 primigravid women were studied after delivery only. A total of 34 of 312 (11 percent) had an existing diagnosis of irritable bowel syndrome. RESULTS: The prevalence of abnormal manometry or endosonography was similar in women with and without irritable bowel syndrome. However, six weeks after delivery, women with irritable bowel syndrome had a higher incidence of defecatory urgency (64 percent) and loss of control of flatus (35 percent) compared with those without (urgency, 10 percent, P < 0.001; flatus, 13 percent, P = 0.007). The incidence of frank fecal incontinence was similar in the two groups. Women with IBS had increased mucosal sensitivity to electrical stimulation of the upper anal canal both before and after delivery. CONCLUSION: Women with IBS are more likely to experience subjective alteration of fecal continence postpartum compared with the healthy primigravid population, but they are not at increased risk of anal sphincter injury.

Colonic Diseases, Functional↗
PubMed1998

Is rectal intussusception a cause of idiopathic incontinence?

PURPOSE: The cause of rectal intussusception in patients primarily dominated by symptoms of anal incontinence has not been fully elucidated, especially for patients with idiopathic incontinence. METHODS: Between 1991 and 1996, 51 patients referred with a diagnosis of idiopathic incontinence were prospectively evaluated by standard questionnaire, clinical examination, defecography, and anal manometry. Fourteen female patients were identified with rectal intussusception and were treated by transabdominal rectopexy. Postoperatively, clinical assessment and anal manometry were performed at regular intervals. RESULTS: Continence was improved after rectopexy (P < 0.01). The postoperative increases in the anal resting pressure, maximum squeeze pressure, and maximum tolerated volume were not statistically significant. CONCLUSIONS: Rectopexy improved anal incontinence in patients with rectal intussusception. The cause of rectal intussusception in anal incontinence could not be explained by functional improvement of the internal anal sphincter tone or an increase in the maximum tolerated volume. Rectal intussusception may be a cause of idiopathic incontinence in patients; however, larger prospective studies are required to support this concept.

Aged↗
PubMed1999

Ambulatory manometric recording of anorectal activity.

PURPOSE: Ambulatory anorectal manometry is usually analyzed by computer analysis only. An in-depth analysis with visual assessment of the recordings combined with computer analysis is presented. METHODS: Recordings of 20 to 24 hours in length were performed on ten healthy subjects. Spontaneous anal canal relaxations were analyzed and related to changes in rectal pressure and any reported rectal sensation. Pressure variations in the anorectum, including the rectal motor complex, were studied. RESULTS: In the awake subject the frequency of anal canal relaxations was 14.5 to 18.7/hour, and the frequency was 4.3/hour while asleep. They can be divided into two different subtypes. The amplitude of the pressure fall was 26 to 29 mm Hg, but diminished during sleep to 19 mm Hg. The duration of each relaxation was 16 to 19 seconds. Passage of flatus and the sensation of flatus in the rectum occurs 1.5 and 1.2 times per hour, respectively, usually with simultaneous anal canal relaxation. The frequency of rectal motor complexes in the midrectum was 0.4/hour and in the lower rectum was 0.7/hour; the duration was 10.3 and 5.8 minutes, respectively, with no nocturnal variation. The complexes could not be related to anorectal events. CONCLUSIONS: The study provides supplementary knowledge of anorectal physiology, particularly of anal canal relaxation, and proposes a more detailed method for evaluation of data obtained by ambulatory anorectal manometry.

Adult↗
PubMed2000

Artificial anal sphincter: prospective clinical and manometric evaluation.

INTRODUCTION: Artificial anal sphincter has been proposed in severe anal incontinence when local treatment is unsuitable or has failed. The outcome after implantation of this newly developed device has not yet been determined. METHODS: Twenty-four consecutive patients (7 men; median age, 44; standard deviation, 18; range, 14-80 years) implanted since May 1996 for a minimum of six months at three centers were prospectively evaluated. Continence (scoring system, 0 (normal) to 120 (complete incontinence)), rectal emptying, and general satisfaction were assessed clinically and at anal manometry preoperatively and postoperatively at a six-month interval. The causes of incontinence included anal trauma (9 cases), neuropathy (6 cases), neurologic disorders (4 cases), congenital malformations (3 cases), and prolapse (2 cases). Median duration of incontinence was 7.5 (standard deviation, 8) years. Stomas pre-existed in two cases and was created at implantation in one. RESULTS: Median follow-up was 20 (standard deviation, 8; range, 10-35) months. Seven patients had their devices explanted, and reimplantation was successfully performed in three of these cases. At the end of follow-up, 20 (83 percent) patients had an implanted activated device. Fecal incontinence score dropped significantly from a median 106 (standard deviation, 13) preoperatively to 19 (standard deviation, 32), 25 (standard deviation, 29), and 25 (standard deviation, 25) at six months, one year, and the end of follow-up, respectively (P<0.0001). Minor and major emptying difficulties occurred in seven and two patients, respectively. A high degree of satisfaction was achieved at the end of follow-up in 18 (75 percent) of the total series. Median anal pressures at rest on manometry increased significantly from 28 (standard deviation, 17; range, 5-76) mm Hg preoperatively to 60 (standard deviation, 17; range, 38-96) mmHg with a closed cuff at the end of follow-up. These pressures dropped to 30 (standard deviation, 16; range, 9-65) mm Hg with an open cuff, and reocclusion time lasted a median of 4.6 minutes (standard deviation, 3 minutes; range, 38 seconds to 10 minutes). CONCLUSION: Artificial anal sphincter provided prolonged and reasonably good functional results in severe incontinence, reproducing an efficient sphincteric mechanism and allowing satisfactory anal occlusion and rectal emptying in approximately 75 percent of cases in this study. The definitive explantation rate was kept low by careful patient selection and appropriate surgical and perioperative management.

Adolescent↗
PubMed2000

Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects.

PURPOSE: Topical glyceryl trinitrate heals anal fissures, but a majority of patients experience headache. Topical gels of the calcium channel blocker diltiazem and the cholinomimetic bethanechol significantly lower anal sphincter pressure in volunteers. This study investigated the use of these two new pharmacologic agents in the treatment of patients with chronic anal fissure. METHODS: Two studies were conducted, each involving 15 patients with chronic anal fissure. In each study patients underwent anal manometry and laser doppler flowmetry before treatment. They were treated with either 2 percent diltiazem gel or 0.1 percent bethanechol gel three times daily for eight weeks. Assessment every two weeks was by clinical examination, repeat anal manometry, and laser doppler flowmetry. Daily pain was assessed by linear analog charts. RESULTS: Fissures healed in 10 of 15 (67 percent) patients treated with 2 percent diltiazem gel and in 9 (60 percent) patients treated with 0.1 percent bethanechol gel. There was no significant difference in the pretreatment maximum resting sphincter pressure (MRP) between responders and nonresponders in either group. There was significant reduction in the pain score after treatment with diltiazem (P = 0.002) and bethanechol (P = 0.005) compared with that before treatment. MRP was significantly lower after diltiazem (P = 0.0001) and bethanechol (P = 0.02) compared with pretreatment MRP. No headaches or side effects were reported. CONCLUSIONS: Both topical diltiazem and bethanechol substantially reduce anal sphincter pressure and achieve fissure healing to a similar degree reported with topical nitrates, but without side effects.

Administration, Topical↗
PubMed1998

Transanal approach to rectocele repair may compromise anal sphincter pressures.

PURPOSE: This study prospectively assessed the functional results, particularly anal sphincter impairment, following transanal repair of rectocele for chronic intractable constipation. METHOD: Twenty-one consecutive women (mean age, 47.7 (standard error of the mean, 2.7) years) had the diagnosis of rectocele obstructing defecation made on synchronized anal manometry, electromyography, and cinedefecography. All underwent a standardized transanal repair with controlled anal stretching (maximum of 4 cm) from self-retaining anal retractors. The clinical function and anorectal manometry were assessed before surgery and were repeated six months later. RESULTS: All 21 patients were subjectively satisfied with the relief from constipation after surgery. There were significant improvements in the straining at defecation (before, n = 19; after, n = 3; P = 0.001), need to digitate per vagina (before, n = 16; after, n = 0; P = 0.001), stool frequency (before, 3.8 (0.7) times weekly; after, 8.6 (1.2); P = 0.004), and laxative requirements (before, n = 7; after, n = 0; P = 0.03). Although none were clinically incontinent, there was a mean 28 mmHg impairment in resting (P < 0.05) and 42.6 mmHg impairment in maximum squeeze anal pressures (P < 0.05) after operations. There was no other morbidity. CONCLUSION: Transanal rectocele repair effectively improves constipation problems, at the risk of impaired anal sphincter function. Although clinical incontinence was minimum, an alternative approach to rectocele repair should be considered when anal sphincters are lax.

Anal Canal↗
PubMed1998

Biofeedback training in patients with fecal incontinence.

PURPOSE: This study was undertaken to assess the functional results of biofeedback training in patients with fecal incontinence in relation to clinical presentation and anorectal manometry results. METHODS: Twenty-six consecutive patients with fecal incontinence were treated with biofeedback training using anorectal manometry pressure for visual feedback. Ten patients had passive incontinence only, six patients had urge incontinence, and ten patients had combined passive and urge incontinence. RESULTS: Patients with urge incontinence had a lower maximum voluntary contraction pressure (92+/-12 mmHg) and a lower maximum tolerable volume (78+/-13 ml) than patients with passive incontinence (140+/-43 mmHg and 166+/-73 ml). Twenty-two patients completed the treatment, five patients (23 percent) showed excellent improvement, nine patients (41 percent) had good results, and eight (36 percent) patients showed no improvement. At follow-up on average of 21 months after therapy, 41 percent of our patients reported continued improvement. The maximum tolerable volume was higher in those with excellent (140.4+/-6.8 ml) or good (156.3+/-6.64 ml) results of therapy than it was in those with poor results (88.5+/-2.5 ml). Greater asymmetry of the anal sphincter also correlated to poor results. CONCLUSION: Biofeedback therapy improved continence immediately after training and at follow-up after 21 months, but the initial results were better. The urge fecal incontinence seems to be related to function of the external anal sphincter and to the maximum tolerable volume. Low maximum tolerable volume and anal sphincter asymmetry were associated with a poor outcome of therapy.

Adult↗