[Defecography study of outpouchings of the external wall of the rectum: posterior rectocele and ischio-rectal hernia]

PURPOSE

To report the clinical and defecographic features of posterior rectal wall outpouchings, i.e., posterior rectocele and ischiorectal hernia.

MATERIALS AND METHODS

Sixty-six patients with posterior rectal wall outpouching (61 with posterior rectocele and 5 with ischiorectal hernia) were selected among the patients examined in the last two years for defecation disturbance. All patients underwent physical examination, rectoscopy and videodefecography.

RESULTS

Posterior rectal wall outpouchings were detected at physical examination in 28 patients and at rectoscopy in 9 patients. Posterior rectocele, more frequent and bigger in men, was usually demonstrated at videodefecography as an outpouching of the lower portion of posterior rectal wall: this finding was visible only in the dynamic phases in 51 patients while it was seen also at rest in 10 patients. In 52 patients, posterior rectocele was associated with other abnormalities--i.e., anterior rectocele (64%), puborectal muscle syndrome (38%), descending perineum (33%), mucosal prolapse (33%) and intussusception (20%). An ischiorectal hernia, defined as a posterolateral ampullar outpouching deeper than 4 cm and already visible at rest, was identified in 5 patients. Descending perineum and anterior rectocele were the most common associated disorders.

CONCLUSIONS

We report the clinical and defecographic features of these rectal abnormalities and stress the importance of videodefecography in the real-time study of these morphofunctional disorders.

Microradiographic anatomy of the explanted rat colon

The colon of 32 healthy Sprague-Dawley rats was studied microradiographically. The colonic arterial distribution of 18 rats was examined after injecting barium sulfate into the isolated aorta. The mucosal surface in 9 rats was studied using double-contrast technique after colon explantation. In 5 animals arterial and mucosal studies were carried out simultaneously. The radiographic thickness of the colonic wall was measured using a comparative microscope. The specimens were observed, photographed and examined histologically. Unlike the cecum and distal colon which, when insufflated, do not have mucosal folds, the proximal colon exhibits folds in an oblique direction corresponding to that of the arteries, and the colonic wall in this region is thicker. Comparison between arterial and mucosal microradiographic anatomy and wall thickness enables the proposition of a simple nontopographic division of the rat colon into cecum, proximal colon and distal colon.

[The National Workshop on Defecography: anorectal deformities with a functional origin (prolapse, intussusception, rectocele)]

The nonoperative treatment--i.e., rubber band ligation and sclerotherapy--of mucous rectal prolapse, rectocele and intussusception is much less expensive than conventional surgery (Lit. 325,000 vs. 6,500,000, p < 0.0001 on the average). Symptom relief, however, has been reported in 0 to 57% of cases only, according to current literature. A possible cause is represented by improper management from misdiagnosis, relying on clinical findings only, overestimating mucous prolapse in 36.37% of cases and underestimating intussusception in 14.22% of cases (with respect to defecography). Defecography is a cost-effective method (average cost: Lit. 37,000) potentially reducing failure rate after the surgical repair of rectal prolapse.

[The kidney xenograft. An echographic assessment of the tissue parameters of the normal pig kidney]

The prospect of xenogeneic transplantation emphasizes the usefulness of codifying the US patterns of normal pig kidney. Nineteen pigs underwent 35 US studies. Pig kidney is similar to the human one in size and US patterns. However, the average human and pig medullary pyramid indexes (MPI) differ, since the latter is half the former (2.10 vs 4.17). This is a valuable finding, since MPI is a tissular index used in the US evaluation of acute renal allograft rejection. Our results demonstrate that US is a reliable method for the morphological assessment of pig kidney and, therefore in our opinion, it should be used as a major diagnostic tool in the study of xenogeneic renal transplantation.

[National working team report on defecography]

A questionnaire concerning defecography was submitted to 5 national experts in order to: 1) quantify the demand and 2) develop a consensus report. The demand is currently 2-8 exams week and the most frequent indication (70%) is obstructed defection, with/without constipation. The highest discriminatory capabilities was exhibited by the following variables: a) the anorectal angle (ARA) on straining and b) the distance from the pubococcygeal line (PCL) on squeezing (101.2 degrees +/- 15 vs. 120.6 degrees +/- 13, p < 0.05 and 27.4 mm +/- 15 vs. 2.4 mm +/- 7, p = 0.005, respectively) in chronically constipated patients (mean age: 60 years) when compared to the control group; and c) PCL on squeezing and at rest (35.5 mm +/- 20 vs. 2.4 mm +/- 7, p = 0.005 and 38.9 mm +/- 18 vs 18.4 mm +/- 17, p < 0.05, respectively) in patients with severe incontinence with respect to healthy subjects. While sensitivity and positive predictive values of the test were highest (97 and 98% respectively) for rectocele, specificity ranked first (92%) in anal gaping.

Adjustable silicone gastric banding for obesity

Adjustable gastric banding is the least invasive operation for morbid obesity. Forty-eight patients underwent surgical adjustable gastric banding between March 1990 and August 1991. In 15 of these patients, radiological examination was performed in the early postoperative period because of dysphagia and vomiting, revealing stenosis of the stoma in all cases (caliber less than 0.3 cm); in all patients we easily punched, with fluoroscopically guided observation, the inflatable portion and obtained a true calibration of the gastric banding. In seven patients radiological examination was performed 2 months after surgical treatment because of a lack of weight loss. Radiological findings explain surgical failure, revealing a too wide stoma in four patients, the absence of a gastric pouch due to a too high position of the band in two, and the caudal sliding of the banding in one patient.

[Measurement of gastric emptying with Tc 99m. Technique and reliability of the test]

Among the various methods used to measure gastric emptying time, scintigraphy is nowadays the technique of choice. Since only few data are available on the operative characteristics of the method, the authors investigated reproducibility, sensitivity, and specificity of a modified scintigraphic technique for the measurement of gastric emptying time. Three groups of subjects--healthy volunteers, patients with functional dyspepsia, and patients with upper gastrointestinal conditions--were administered liquid meals having various standard consistencies (349 tests on the whole). In both healthy volunteers and dyspeptic patients the method had high sensitivity (72%), good specificity (69%), and low intra-subject variation (25%). In all cases, the increase in meal density produced a delay in gastric emptying. Dyspeptic patients had slow gastric emptying of high-fiber meals, while in duodenal ulcer and in atrophic gastritis emptying was significantly faster. The radionuclide method proved valuable in measuring gastric emptying and was useful to confirm the pathogenesis of the various conditions. As for functional and organic pathologic conditions, it allowed treatment efficacy to be evaluated.

[Functional evaluation of the anorectal region]

Defecography is a method allowing the morphodynamic evaluation of the anorectal region. The technique we employed needs two complementary times: "phase" defecography and dynamic defecography. In our series of patients affected with severe constipation, 2 groups could be identified. Group A included those patients (mean age: 38.7 years) in whom no significant changes were observed in anorectal angle and in the distance of anorectal angle from pubococcygeal line in comparison with normal subjects (Student's t-test). Group B included those patients (mean age: 63.3 years) in whom significant reduction was observed in anorectal angle on straining, together with increased distance of anorectal angle from pubococcygeal line on squeezing in comparison with normal subjects (Student's t-test). In constipated patients narrowed anal canal was observed (60%), together with rectocele (42.6%), mucosal prolapse (27.8%), rectal prolapse (18%) and solitary ulcer (14.7%). In idiopathic incontinence patients (mean age: 63.3 years), increased distance was observed of anorectal angle from pubococcygeal line on squeezing and, in the most severe cases, even at rest, with the patient sitting (Student's t-test). In incontinent patients larger anal canal was observed (67.6%), together with rectocele (36.7%), mucosal prolapse (14.7%), and rectal prolapse (11.7%).

[Echography, computerized tomography and retrograde cholangiopancreatography for the diagnosis of focal pathology of the exocrine pancreas]

In spite of the improved imaging techniques currently available, mortality for pancreatic cancer is still high, and pancreatitis is often diagnosed only in its advanced stages. The authors investigated the value of different imaging techniques--i.e., US, CT, and ERCP--for an early diagnosis, when a more effective (curative?) treatment can be suggested. Fifty-six cases of pancreatic cancer and 36 cases of chronic pancreatitis were evaluated. The results indicate that ERCP, with the help of statistical methods, is superior to US and CT not only in evaluating early neoplastic or inflammatory lesions, but also for their differential diagnosis. In the latter case, ERCP can sometimes be used as a valid alternative to fine-needle aspiration biopsy.

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.

Crohn's disease of the esophagus

Esophageal involvement in patients with Crohn's disease is uncommon. Histologic proof is rarely obtained by means of endoscopic biopsies. Moreover, the natural history of this condition and its response to therapy are largely unknown. We report a case of biopsy-proven esophageal Crohn's disease, which presented with a stricture of the distal third of the esophagus and was successfully treated by progressive endoscopic dilatation.

[Radiologic diagnosis of anal fistulae with radio-opaque markers]

Fistulography classifies anal fistulas in low-below puborectalis muscle-, high-above puborectalis muscle-, and middle. This classification increases the scope and accuracy of radical surgery. In order to improve the diagnostic reliability of anal fistulography the authors point out the importance of radio-opaque markers for anatomical definition of the anorectal region. Thirty patients (25 males and 5 females; mean age: 47 years) were studied by anal fistulography using radiopaque markers: a Foley's 22 Fr catheter, with distal balloon filled of idrosoluble radiopaque contrast medium, was placed in the anal canal; a metal marker was fixed to the anus. In order to demonstrate the relationship between fistula and puborectalis muscle, we subdivided the anal canal in 3 equal segments: high, middle and low. The idrosoluble contrast medium for fistulography is injected through a pediatric Foley's catheter 8 Fr when external opening is large enough, and through a K7072 endovenous catheter when the opening is small. Fistulous tract was visible in all patients: internal fistulous opening in 23/90 cases, and relationship of fistulous tract to puborectalis muscle in 25/30 (83.3%). In demonstrating either secondary fistulous tracts or abscesses, fistulography with radiopaque markers was correct in 60% of cases; in 20% of patients some of the above-mentioned complications were demonstrated, and in the 20% no complications at all were detected.

[Specificity and sensitivity of ERCP in pancreatic pathology]

Fifty-three patients were examined by endoscopic retrograde cholangiopancreatography (ERCP). Operative and/or instrumental-clinical findings indicated that 38 patients had pancreatic disease, consisting of 17 cases of neoplasia, 10 of chronic pancreatitis with benign stenosis, and 11 of chronic pancreatitis without stenosis. An analysis of Wirsung's duct and of the secondary ducts was carried out employing, in the latter case, linear discriminate analysis (Nix and Schmitz method). With this method, 16 of 17 patients (94%) were correctly assigned to group A (pancreatic neoplasia), thus indicating high sensitivity; 7 of 8 patients (88%) were assigned to group B (chronic pancreatitis with benign stenosis), and finally 7 of 10 patients (70%) were placed in group C (chronic pancreatitis without stenosis). Detection of a sample sign such as sharp and/or irregular stenosis of Wirsung's duct enabled a correct diagnosis of neoplasia in the cases examined; this criterion, however, is very specific but poorly sensitive. When it is absent, analysis of the secondary ducts is determinant. If the two criteria are applied together, an exact diagnosis of all forms of neoplasia is obtained.

[Morpho-functional radiologic evaluation of ileal reservoirs]

Nine patients (4 males and 5 females) have been treated by proctocolectomy with ileal pouch "reservoir". Defecography has been performed. Five patients have been examined by defecography before and four after closure of a loop ileostomy performed to cover healing of the pouch and ileoanal anastomoses. Pouch's evacuation is often inadequate in "S" shaped reservoir (Parks), but postoperative complications are infrequent. Pouch's evacuation is often total in "J" shaped reservoir (Utsunomiya), but post-operative complications are possible.

[Radiologic methods in the evaluation of upper esophagoplasties]

Post-operative radiologic control of esophageal plastic surgical procedures in pathologic conditions of the cervical esophagus involves difficulties due to the poor collaboration of the patient, who swallows only small quantities of contrast medium. Contrast medium injection through esophageal-gastric probes, and its reflux toward the cervical region with the Trendelemburg position and/or straining, enables the demonstration of fistulas otherwise unrecognized.

[Duodenal and colonic involvement in neoplastic pathology. Anatomical and radiological considerations]

The authors present 3 cases of duodeno-colic involvement by malignant neoplasms and analyse the main radiological features. Benign and malignant duodenocolic fistulas are discussed and colic lesions caused by an extrinsic process. Guiding radioanatomical criteria are stated namely the alterations in the site of the principal lesion first and, afterwards, the morphological changes or displacement of the bowel.

[Radiological and instrumental study of the colon in idiopathic constipation]

It has been demonstrated that it is not always possible to attribute to constipation a reduced colonic transit time as being evidenced by radiological studies using radiopaque markers. In fact, in constipated patients with a normal transit time, it was more reasonable to consider a recto-anal disorder as evidenced by defecography and manometry.

[Radiological examination of esophagoplasty interventions for esophageal cancer]

The experience in the radiological study on the esophagoplasty for esophageal cancer is reported. In the various types of surgical operations: gastroplasty: 284 cases, colonplasty: 28 cases, jejunoplasty: 10 cases, substitution of the cervical esophagus: 74 cases, the radiological contribution is analysed both in the early anastomosis check: after 7 days the intrathoracic and after 10 days the cervical ones, and in the distance check. For this last aspect, particularly the functional pattern, it is also suggested the use of paraphysiologic meals.

[New radiological aspects of the intestinal mucosa in celiac sprue: injection of barium into the intestinal glands]

The radiologic findings are described of mucosal folds thickening in coeliac sprue in patients with short clinical history. Moreover attention is pointed on the flattening of the valves and the thinning of the intestinal walls which appear in dilated segments in cases with evident clinical findings. Finally in patients with long standing clinical manifestations and histologic positive controls, a thin spiculation of intestinal outlines and a dotted mucosal surface are visible, probably due to the filling of the Lieberkühn glands with contrast medium.