Studies on the rectoanal reflex in children and in experimental animals: an evaluation of neuronal control of the rectoanal reflex

A single-chamber pressure probe for rectal electromanometry was developed which seems to be superior to the complicated multichamber systems not only for clinical but also for experimental purposes. Measurements of rectoanal reflex were carried out in 268 cases with abnormal bowel function, in 103 cases following operation for Hirschsprung's disease, and in 61 cases of imperforate anus to assess postoperative continence. Experimental studies were performed in 36 dogs, 27 of which were used for short-term and 9 for long-term studies. The results of clinical and experimental studies are described and discussed, with accompanying literature. From clinical and experimental studies, the neuronal pathways of the rectoanal reflex are schematized. The normal rectoanal reflex is mediated by both the sacral cord and the myenteric neurons. It is concluded that measurements of the anal resting pressure and the rectoanal reflex constitute a valuable method to distinguish between normal and pathological sacral and myenteric innervation.

The electromyographic examination to evaluate the external sphincter muscle in anorectal malformations

Preoperative electromyographic examination is very useful in locating the external sphincter muscles and determining their degree of development. Electromyographic examinations showed the relatively abundant distribution of the external sphincter muscles in the perineum even in high-type anomalies. The results obtained by these examinations lead to the conclusion that preserving both the puborectal and external sphincter muscles should be the main consideration in surgery for anorectal malformations.

Problems in diagnosis of Hirschsprung's disease by anorectal manometry

The purpose of this study is to analyze the results of anorectal manometry and to evaluate the merits and disadvantages of this technique for the diagnosis of Hirschsprung's disease. Studies were performed in 268 patients with constipation, including 95 cases of Hirschsprung's disease. It is concluded from the results that Hirschsprung's disease can be confidently diagnosed by manometric studies. If the studies are performed carefully with a suitable probe, reliability is over 95%. Manometry is the most useful method to differentiate Hirschsprung's disease from other conditions, such as extremely short segment aganglionosis, colonic stenosis, and idiopathic megacolon.

Motility of the anorectum after the Soave-Denda operation

A total of 82 patients were assessed by rectal manometry after operation for Hirschsprung's disease according to the Soave-Denda technique. A positive rectoanal reflex was obtained in 32 cases (39%), whereas the remaining 50 cases (61%) did not exhibit a rectoanal reflex. Among the children examined, 72% showed normal rhythmic activity of the anorectum. Anorectal function tended to increase over the years, 90% having good continence 10 years or more after operation. Patients who encountered postoperative complications had poor continence since such complications may have damaged the levator and sphincter muscles.

Nucleotide sequence of the ribostamycin phosphotransferase gene and of its control region in Streptomyces ribosidificus

The nucleotide sequence of an aminoglycoside phosphotransferase gene (rph) from Streptomyces ribosidificus (a ribostamycin producer) was determined. Molecular size, amino acid composition and N-terminal amino acid sequence of the purified rph product confirmed the position of the coding region deduced from the nucleotide sequence. The 5' region of rph has been tested for its transcriptional controls; high-resolution mung-bean nuclease mapping of in vivo transcripts revealed one major start point, rphS1, controlled by the rphP1 promoter. This transcript was also observed in vitro in run-off experiments using purified Streptomyces RNA polymerase. This transcriptional start point coincided with the translational start site, with the mRNA 5' terminus being pppATG. The results of promoter-probing tests and insertion of a transcriptional termination fragment into the rph promoter region have shown that the rphP1 transcript was sufficient and essential for rph expression.

Molecular cloning and characterization of the Streptomyces hygroscopicus alpha-amylase gene

We have isolated and sequenced a gene (amy) coding for alpha-amylase (EC 3.2.1.1.) from the Streptomyces hygroscopicus genome (H. Hidaka, Y. Koaze, K. Yoshida, T. Niwa, T. Shomura, and T. Niida, Die Stärke 26:413-416, 1974). Amylase was purified to obtain amino acid sequence information which was used to synthesize oligonucleotide probes. amy-containing Escherichia coli cosmids identified by hybridization did not express amylase activity. Subcloning experiments indicated that amy could be expressed from the lac promoter in E. coli or from its own promoter in S. lividans. The amy nucleotide sequence indicated that it coded for a protein of 52 kilodaltons (478 amino acids). Secreted alpha-amylase contained amino- and carboxy-terminal as well as internal amino acid sequences which were consistent with the nucleotide sequence. The 30-residue leader sequence showed similarities to those found in other procaryotes. The DNA sequence 5' to the amy structural gene contained a sequence complementary to the 3'-terminal sequence of 16S rRNA of S. lividans (M. J. Bibb and S. N. Cohen, Mol. Gen. Genet. 187:265-277, 1982). The transcriptional start points of amy were determined by mung bean nuclease mapping, but the promoter of amy was not similar to the consensus sequence found in other procaryotes.

Hirschsprung's disease: catecholamine content, alpha-adrenoceptors, and the effect of electrical stimulation in aganglionic colon

In order to assess abnormalities in the adrenergic mechanism in the intestine of Hirschsprung's disease, catecholamine concentrations, alpha-adrenoceptors, and the effect of electrical field stimulation were examined in aganglionic segments of colon or rectum. The aganglionic segment had a higher concentration of norepinephrine, assayed with high performance liquid chromatography with an electrochemical detector, whereas concentrations of epinephrine or dopamine were similar in normal and pathological segments. In four patients with extensive aganglionosis, the norepinephrine concentration in aganglionic colon segments decreased progressively in descending, transverse, and ascending colon. The tissue content of alpha-adrenoceptors and their affinity assayed from the specific binding of [3H]dihydro-alpha-ergocryptine appeared similar in normal and aganglionic segments of the rectosigmoidal colon. Electrical field stimulation of normal rectosigmoidal colon segments caused relaxation at low frequencies and contraction at a very high frequency. Relaxation was not abolished by blocking concentrations of propranolol or phentolamine. In aganglionic segments, the predominant response to electrical field stimulation was contraction, which was inhibited by either atropine or tetrodotoxin. These results indicate that an alpha-adrenergic system and cholinergic innervation apparently exist in aganglionic colon segments and that dysfunction of the colon appears to result from lack of a nonadrenergic inhibitory system.

The use of computerized tomography to evaluate anorectal anomalies

Computerized tomography (CT) was applied to various types of anorectal anomalies to directly image the anal sphincters. In normal cases and low type anomalies, CT demonstrated clear images of the puborectal muscle and external sphincters. Among high type anomalies, the distribution of sphincter muscle in patients with rectovesical fistula is totally different from that seen in patients with rectourethral fistula. In the latter, the puborectal muscle is attached not only around urethra, but also around the distal part of the blind rectum; external sphincters are present as a mass beneath the perineum. In the rectovesical fistula, however, the puborectal muscle cannot be identified and the external sphincters exist only as a string-like structure. CT done postoperatively identified two different causes for incontinence. In one type, the pull-through colon missed the sphincteric musculature, and in the other, sphincters were markedly hypoplastic. CT, therefore, provides adequate imaging to determine the type of operation needed to correct the abnormality.

[Our new operative method for high-type anorectal malformations based on the histological studies]

From 1971 onwards we have been examining the anatomy and histology of sphincter components in patients with several anorectal malformation who died of associated anomalies. These histological studies demonstrated that not only puborectal muscle but also the superficial and deep external sphincters exist, even in the high type anomalies, and that the mass of external sphincter is located above the anal dimple. Moreover, the inner circular muscle of rectum is thickened at the level of the closest part to the fistula. Based on our histological studies, we devised our new operation to use all the sphincter musculature effectively for the newly reconstructed anal canal. Our new surgical procedure is clearly different from Kiese wetter-Rehbein's method in that the puborectal muscle is penetrated from the outside of rectal wall and might be damaged, since puborectal muscle is attached to the blind pouch of rectum. Moreover, the puborectal muscle and the external sphincters can be easily identified by electrical stimulation under direct vision from extended sacroperineal approach. And the colon can be pulled exactly through the centre of the external sphincters and puborectal muscle under direct vision without causing any damage to these important sphincters, unlike Pena's operation.

[Late complications of Hirschsprung's disease and anorectal manometry]

In 84 patients treated with Soave-Denda method, informations of their bowel habits were obtained through a questionnaire. These patients were classified into 4 groups (A; less than 3 years, B; 3 to 6 years, C; 7 to 9 years and D; more than 10 years after the operation) and analyzed by comparing their bowel habits with those of normal children in corresponding age group. Some late complications were demonstrated although 80% of patients followed for more than 10 years had a normal bowel habit. Frequent incontinence (more than once a week) was found in 18.2% of group B and 5% of group C. No patients has incontinence in group D. Frequent soiling (more than once a week) was demonstrated in 58.8% of group B, 30% of group C and 23.1% of group D although the incidence of frequent soiling ranged from 0.5 to 2.1% in normal children of these age group. Manometry to detect a rectonal reflex was useful to evaluate anorectal function because patients who showed normal reflex had excellent bowel habits without incontinence. These unexpected high incidence of late complications indicate that postoperative training of defecation is extremely important to give normal bowel habit to the patients with Hirschsprung's disease.

Abdomino-extended sacroperineal approach in high-type anorectal malformation--and a new operative method

From 1971 onwards we have been examining the anatomy and histology of sphincter components in patients with several anorectal malformation who died of associated anomalies. These histological studies demonstrated that not only puborectal muscle but also the superficial and deep external sphincters exist, even in the high type anomalies, and that the mass of external sphincter is located above the anal dimple. Moreover, the inner circular muscle of rectum is thickened at the level of the closest part of the fistula. Based on our histological studies, we devised our new operation to use all the sphincter musculature effectively for the newly reconstructed anal canal. Our new surgical procedure is clearly different from Kiesewetter-Rehbein's method in that the puborectal muscle is penetrated from the outside of rectal wall and might be damaged, since puborectal muscle is attached to the blind pouch of rectum. Moreover, the puborectal muscle and the external sphincters can be easily identified by electrical stimulation under direct vision from extended sacroperineal approach. And the colon can be pulled exactly through the centre of the external sphincters and puborectal muscle under direct vision without causing any damage to these important sphincters, unlike Pena's operation.

Blood lactate and glycerol after 400-m and 3,000-m runs in sprint and long distance runners

Lactate, glycerol, and catecholamine in the venous blood after 400-m and 3,000-m runs were determined in eight sprint runners, eight long distance runners, and seven untrained students. In 400-m sprinting, average values of velocity, peak blood lactate, and adrenaline were significantly higher in the sprint group than in the long distance and untrained groups. The mean velocity of 400-m sprinting was significantly correlated with peak blood lactate in the untrained (r = 0.76, P less than 0.05) and long distance (r = 0.71, P less than 0.05) groups, but not in the sprint group. In the 3,000-m run, on the other hand, average values of velocity and glycerol were significantly higher in the long distance group than in the sprint and untrained groups, but there are no significant differences in lactate levels between the three groups. These results suggest that 1) performance in 400-m sprinting may depend mainly upon an energy supply from glycolysis in the long distance and untrained group, but in the sprinters is influenced not only by glycolysis, but also by other factors such as content of ATP or force per unit muscle cross-sectional area; 2) peak blood lactate obtained after 400-m sprinting may be used as a useful indication of anaerobic work capacity in the long distance and untrained groups, but not in the sprinters. 3) high speed in the 3,000-m run could be maintained in the long distance runners by means of a greater energy supply from lipid metabolism as compared with sprinters or untrained subjects.

Extended dissection of the portahepatis and creation of an intussuscepted ileocolic conduit for biliary atresia

This paper introduces a new operation for biliary atresia that establishes successful biliary drainage by extending the portahepatic dissection, and decreases ascending cholangitis by incorporating a nonrefluxing intussuscepted draining conduit. An analysis of the postoperative results is presented. The usual dissection of the portahepatis is extended to include the area between and beneath the branches of the right portal vein to incorporate all potentially usable remnants of the intrahepatic ducts. Ascending cholangitis is decreased by interposing an intussuscepted ileocolic segment between the portahepatis and the abdominal wall. This extended dissection of the portahepatis was performed since 1978 in 15 infants with noncorrectable biliary atresia, and bile drainage was achieved in all. In ten infants an intussuscepted ileocolic conduit was constructed. Ascending cholangitis in these ten infants has been either completely absent or easily controlled by antibiotics. The draining bile was highly concentrated due to the water-absorbing capacity of the interposed colonic segment; therefore, fluid and electrolyte disturbances, which develop frequently in patients having jejunal conduits, have never been encountered.

The proposed Japanese TNM classification of primary liver carcinoma in infants and children

The TNM classifications of neuroblastoma, nephroblastoma and soft tissue sarcoma were adopted at the International Conference for TNM Classification (UICC) held in May 1980. There is no TNM system under contemplation, however, for primary liver carcinoma in childhood. Accordingly, we have formulated the proposed Japanese TNM system for this carcinoma in children and examined its validity in 136 cases of hepatoblastoma seen in the listed 14 institutions. The basic policy of the Committee on the Japanese TNM Classification is not to include the resectability of the tumor and regional lymph nodes or any other status of the disease resulting from therapeutic intervention as a component of the pTNM system. This is a feature which makes our proposed system widely divergent from the accepted classification scheme for the three types of tumor cited above.

Reappraisal of endorectal pull-through procedure. II. Animal experiment

Anorectal manometry and pelvic histology following endorectal pull-through and simple abdominoperineal pull-through procedures were studied experimentally in dogs. dogs that had undergone endorectal pull-through preserved normal resting pressure of the anal canal, rectoanal reflex response, and intact perirectal anatomy. Dogs that had simple abdominoperineal pull-through, on the other hand, showed low anal canal pressure, loss of rectoanal reflex, and damage of the pelvic muscles. good continence following endorectal pull-through operation was supported by these physiologic and anatomic studies.

Reappraisal of endorectal pull-through procedure. I. Anorectal malformations

Postoperative continence in anorectalmalformations was assessed by clinical score, rectoanal manometry, and electromyography. The results in low deformities operated by perineal rectoplasty showed "good" clinical scores, good preservation of the rectoanal reflex, and good electrical activity of the external sphincter. High deformities, on the other hand, showed low clinical scores, poor recordings of the rectoanal reflex, and diminished electrical activity around the anus. Analysis of high deformities treated by operative procedures, however, indicated better clinical scores and better preservation of rectoanal reflex in those who had undergone the endorectal pull-through procedure (Rehbein) than those who had had an abdominoperineal pull-through procedure. Furthermore, dissections of newborns with a rectourethral fistula revealed the presence of the puborectalis sling around the terminal rectum and fistula in a hammock fashion. This finding supports our suggestion that the colon can be safely pulled-through within the sling by the original Rehbein procedure without sacral dissection.

A quantitative study of acetylcholine in Hirschsprung's disease

This is the first report on acetylcholine (Ach) quanititaion of the aganglionic colon by a chemical assay. Ach content in the colon of Hirschsprung's disease was measured by pyrolysis gas chromatography, which was found to be a simple, accurate, and reliable method. Microwave irradiation on the surgical resected specimens was performed before extraction procedure to abolish acetylcholinesterase (Ach-E) and cholineacetyltransferase (CAT) activity in the tissue. Ach content in the ganglionic colon was 8.51 +/- 3.15 nmole/g (n 5 in contrast to 23.79 +/- 14.17 nmole/g (n = 19) in the aganglionic segment of Hirschsprung's disease. The meaning of elevated Ach level in the aganglionic segment was discussed from the pathophysiologic standpoint.

Metabolic response to postoperative parenteral nutrition in infants

Thirty-five infants who had tracheoesophageal fistula, esophageal stenosis, anal atresia, or Hirschsprung's disease were managed with various types of parenteral solution after their radical operations. The infants were divided into 6 groups and given 1) the usual low calorie infusion consisting of 5% glucose, water, and electrolytes, 2) high calorie formula consisting of 21 g/kg/day glucose, and 4 g/kg/day synthesized crystalline L-amino acids, 3) solutions without phosphate, 4) solutions of Cal/N ratio 200 providing 4 g/kg/day amino acids, 5) solutions of Cal/N ratio 400 providing 2 g/kg/day amino acids, and 6) a regimen containing fat emulsion. Nitrogen (N) and phosphorus (P) balances, blood urea nitrogen (BUN), blood glucose, plasma phosphate, immunoreactive insulin (IRI), and non-esterified fatty acid (NEFA) values were investigated. Parenteral solutions, providing 100 Cal/kg/day of Cal/N ratio 200, yielded sufficient positive N balance (120 mg/kg/day average). High calorie solutions without phosphate caused marked hypophosphatemia (0.3 mEq/1) with undetectable P in 24-hr urine. P balance correlated with N balance. Solutions of Cal/N 400 induced a lower BUN level, although there was a cumulative negative N balance. Solutions of Cal/N 200 induced higher levels of IRI and lower glucose than those of Cal/N 400. Increased IRI response and remarkedly decreased NEFA levels were seen in the group administered solutions without fat. Solutions with fat emulsion suppressed IRI response and improved the level of plasma NEFA.

Plexiform neurofibromatosis of the ileum in an infant

An infant is reported in whom severe malabsorptive symptoms developed shortly after birth associated with intermittent episodes of intestinal obstruction. Plexiform neurofibromatosis involving the terminal ileum was found at laparotomy at the age of 6 mo. The infant died from gastrointestinal functional impairment at the age of 1 yr.