Radiobiological advantages of an immediate interstitial boost dose in conservative treatment of breast cancer

Minimum surgery with irradiation is emerging as one of the main modalities of therapy for operable early breast cancer. Between June 1982 and June 1986, 110 breasts with Tis, T1 to T3 lesions have been treated at our institution with lumpectomy and interstitial irradiation to the tumor bed with Iridium-192 perioperatively followed by external beam irradiation. There have been two local recurrences at or near the vicinity of the primary, at a median follow-up of 60 months. To analyze the parameters that might have contributed to the local control, we have examined the treatment volumes, prescribed dose to the tumor bed, dose at the core of the tumor bed, and dose to the surrounding normal tissue. Immediate interstitial implant has the radiobiological advantage of delivering continuous low dose irradiation, immediately upon removal of gross tumor to residual foci. Implantation of the afterloading catheters intraoperatively facilitates accurate dose delivery and avoidance of geographical misses. By precise treatment of any residual foci, immediately upon removal of the gross mass, perioperative interstitial irradiation improves local control and by facilitating less radical surgical excision, leads to better cosmetic results.

Effect of dietary linolenic acid on endotoxin-induced thromboxane and prostacyclin production by equine peritoneal macrophages

In laboratory animals, the incorporation of alpha linolenic acid or other n-3 series fatty acids into the diet results in marked changes in cell membrane composition as well as arachidonic acid metabolism. The purpose of the present study was to determine whether endotoxin-induced thromboxane A2 (TxA2) and/or prostacyclin (PGI2) production by equine peritoneal macrophages was altered by feeding horses a diet containing 8% linseed oil as a source of alpha linolenic acid for 8 weeks. Peritoneal macrophages were cultured in vitro in the presence of endotoxin (LPS) (0.5-500 ng/ml) or calcium ionophore for 6 and 24 hours. After horses were fed the alpha linolenic acid-enriched diet, their peritoneal macrophage production of TxA2 was reduced in response to 0.5 ng/ml and 5 ng/ml LPS. compared to that before the diet (P less than .05). The production of PGI2 during 6 hour incubation with 5 ng/ml and 50 ng/ml LPS and during 24 hour incubation with 5 ng/ml LPS were reduced, compared to that before the diet (P less than .05). Peritoneal macrophage production of PGI2 during 24 hour incubation with nothing, LPS (0.5 ng/ml, 5 ng/ml and 500 ng/ml), and calcium ionophore was greater than during 6 hour incubation, after horses were fed the ALA-rich diet (P less than .05). Results suggest that linseed oil supplementation may be an aid in prophylaxis of endotoxemia in horses.

Anorectal physiology validated: a repeatability study of the motor and sensory tests of anorectal function

Sixteen subjects (mean (s.d.) age 50.7 (12.8) years, three men) were studied on two separate occasions by two experienced investigators in random order. A standard protocol of anatomical, manometric and electrophysiological assessments of anorectal motor and sensory function was followed. No significant differences were found between the results obtained by the two investigators in the measurements of perineal descent, anal canal length, and canal resting pressure and squeeze pressure, pudendal nerve terminal motor latency, single-fibre electromyography fibre density of the external anal sphincter, and thresholds of mucosal electrosensitivity. This study shows that the standard tests of anorectal sensorimotor function are repeatable by different investigators. In addition, it suggests that comparison of data obtained in different centres using these techniques is valid.

Increased segmental activity and intraluminal pressures in the sigmoid colon of patients with the irritable bowel syndrome

Intraluminal pressure activity has been recorded in the unprepared true sigmoid colon of seven normal controls (mean age 37 years, range 22-55, three men) and seven patients with irritable bowel syndrome (IBS) (45 years, 24-75, four men) for 30 minutes before and 100 minutes after a standard 1000 kcal meal. Results differ from previously published data by showing much higher indices of pressure activity with amplitudes up to 490 mmHg in IBS, and 450 mmHg in controls. Study segment activity index and mean pressure wave amplitudes were significantly (p less than 0.015 and p less than 0.01) higher in IBS than controls, but per cent duration of activity was similar for the whole period of study. During the basal period in controls mean amplitudes recorded from the proximal sigmoid (40 cm from anus) were significantly (p less than 0.01) higher than those in the descending colon (50 cm), distal sigmoid (30 cm) and rectum (15 cm). This study shows that the increased colonic activity in IBS is characterised by increased amplitude, but not duration of pressure waves. In the basal state there is a high pressure zone in the proximal sigmoid colon of controls. Pressures in the unprepared colon of controls and IBS were higher than those measured under other experimental conditions.

Anorectal physiology measurement: report of a working party

A 2-day meeting was held in Bristol on 5 and 6 July 1988 immediately before the Tripartite meeting of the Surgical Research Society in order to discuss methods and identify areas of agreement with regard to measurement of indices of anorectal physiology. The following report highlights our findings.

Fecal incontinence and rectal prolapse

The majority of patients who suffer from full-thickness prolapse can be treated successfully and safely. The small proportion who remain incontinent of feces after correction of prolapse may at a later date be helped by postanal repair. If dietary indiscretion and abnormal patterns of defecation are major etiologic factors in this condition, then measures to improve dietary and defectory habits must be instituted mainly to prevent further problems after the deformity has been cured surgically. There seems no doubt that following rectopexy there is an increased tendency to constipation.

Increase in pudendal nerve terminal motor latency with defaecation straining

The relationship between perineal descent and pudendal nerve damage was tested in 57 consecutive patients by measuring the left and right pudendal nerve terminal motor latency (PNTML) before and after a maximal defaecation straining effort. In 13 patients the PNTML was also measured 1 and 4 min later. The difference between the mean PNTML before and after straining (delta PNTML) was correlated with the amount of descent (r = 0.40, P less than 0.005), and with the perineal position during straining (r = -0.46, P less than 0.001). Four minutes after the straining effort the PNTML again approached the resting value in each subject. These findings support the concept that perineal descent causes pudendal nerve damage.

Temperature gradient between the rectum and the anal canal: evidence against the role of temperature sensation as a sensory modality in the anal canal of normal subjects

Temperature difference between the rectum and anal canal is a fundamental requirement for the hypothesis that temperature sensation is of physiological importance in discrimination of anorectal contents occurring during the 'sampling reflex'. The temperature gradient between the rectum and the anal canal was measured in 47 normal subjects (mean age 51.6 years +/- 16.8 s.d., 24 men). The maximum mean difference in temperature between the rectum and the anal canal was 0.13 degrees C (0.06-0.19, 95 per cent confidence intervals) and occurred 4 cm from the anal verge. This difference is too small to be detected by the anal canal mucosa. Under normal physiological circumstances the conscious appreciation of temperature of faeces passing from the rectum to the anal canal is impossible during the anorectal sampling reflex.

Endotoxin-induced procoagulant activity in equine peripheral blood monocytes

Increasing evidence has demonstrated the importance of monocyte procoagulant activity (PCA) in the pathogenesis of coagulopathies in a variety of diseases. Because endotoxin precipitated coagulopathies are common sequelae to intestinal ischemia/endotoxemia in the equine species, we investigated the ability of equine peripheral blood monocytes to express PCA. Monocytes isolated from five healthy adult horses were incubated in vitro with Escherichia coli endotoxin (10 micrograms), and the PCA was measured by the ability of cellular lysates to accelerate the clotting times of equine plasma in a modified one-stage recalcification assay. Equine monocyte PCA was identified as thromboplastin based on lack of clot formation in factor VII-deficient plasma. The induction of PCA occurred as early as 2 hr after endotoxin exposure, peaked at 6 hr (396% increase), and then gradually declined. The amount of PCA was proportional to the dose of endotoxin (0.01 to 100 micrograms) and the number of monocytes. Neither platelets nor neutrophils produced PCA, either in the absence or presence of endotoxin (1 microgram). Lymphocytes at a concentration of 4 x 10(6)/ml RPMI did produce a significant amount of PCA, compared to the time-matched controls. Co-incubation of neutrophils or lymphocytes with monocytes did not alter the PCA, whereas coincubation of platelets and monocytes significantly enhanced the expression of PCA. This effect was further augmented by the addition of endotoxin (1 microgram).

Neurologic cause of idiopathic incontinence

The relationship between the pudendal and perineal nerve terminal motor latencies and descent (weakness) of the perineum on straining was investigated in 31 patients with idiopathic fecal incontinence, and in 30 patients with double incontinence. Pelvic floor descent was correlated with increased pudendal nerve terminal motor latency in both groups of patients. In the patients with double incontinence, there was a less significant correlation between perineal descent and increased perineal nerve terminal motor latency. In the patients with fecal incontinence, but without urinary incontinence, there was no correlation between perineal descent and perineal nerve terminal motor latency. These data support the concept that pelvic floor weakness can result in damage to the pudendal and perineal nerves, leading to fecal and urinary incontinence. In patients with isolated fecal incontinence the perineal nerves are relatively spared. Thus these common types of incontinence probably have a neurologic cause, and neurophysiologic methods can be used in their assessment.

Combined sphincter repair and postanal repair for the treatment of complicated injuries to the anal sphincters

The management of seven patients with multiple injuries to the anal sphincter musculature and its nerve supply, from major pelvic trauma, anal fistula surgery, or obstetric trauma, was reviewed. All were either incontinent of solid stools or had defunctioning colostomies. Anal manometry was abnormal in all patients. Concentric needle electromyography (EMG) showed anterior division of the external sphincter in all the patients; five also had posterior division of both the external sphincter and puborectalis. EMG abnormalities were found in the lateral quadrants of these muscles, particularly the external sphincter. Single fibre needle EMG showed evidence of reinnervation in the external sphincter in six patients, and in the puborectalis in two, indicating partial denervation of the muscles. Treatment was by anterior sphincter repair using an overlapping technique, combined with postanal repair; the repairs were protected by a defunctioning colostomy. When assessed 4-60 months (mean 17 months) after colostomy closure all seven patients were continent of solid and semi-formed stools, but had urgency of defaecation. None could control liquid stool or flatus. After complicated sphincter injuries planned surgical reconstruction, based on EMG assessment of the sphincter muscles, can restore acceptable continence.

Asymmetrical pudendal nerve damage in pelvic floor disorders

Differences in the left and right pudendal nerve terminal motor latencies have been observed in patients with pelvic floor disorders. Until now the mean value of the left and right pudendal latencies has been used as the index of pudendal neuropathy. In 22 patients of a group of 156 patients studied the pudendal nerve terminal motor latency was abnormally raised on one side only. These patients are thought to have pudendal neuropathy whether or not the mean value of the left and right pudendal latencies is also raised. This observation may have therapeutic implications.

Delayed external sphincter repair for obstetric tear

In some patients with faecal incontinence due to an obstetric tear of the external and sphincter there is additional weakness of the anal sphincter muscles from damage to the innervation of these muscles during delivery. Of 19 patients who required surgical repair of an obstetric sphincter tear some months or years after injury, 9 (47 per cent) had evidence of pudendal nerve damage at pre-operative anorectal physiological investigation. The result of surgical repair was excellent or good in eight of the ten patients in whom there was no evidence of nerve damage, while this was the case in only one of the nine patients with nerve damage. These results are significantly different (P = 0.018). Thus the functional result of delayed anal sphincter repair after obstetric lesions is partly dependent upon whether the nerve supply is intact. Pre-operative physiological evaluation can give information on the probability of a successful surgical result.

Disposable pudendal nerve stimulator: evaluation of the standard instrument and new device

A disposable version of the pudendal nerve stimulator using flexible printed circuit (FPC) technology has been developed and manufactured in our department. Evaluation of this instrument against the standard is reported.

Pelvic floor neuropathy: a comparative study of diabetes mellitus and idiopathic faecal incontinence

Twenty one patients with diabetic peripheral neuropathy, 18 with idiopathic faecal incontinence and 11 normal controls were studied with techniques of mucosal electrosensitivity, rectal distension for the quantitative assessment of anorectal sensation, and manometric and electromyographic tests for the assessment of anorectal motor function. An asymptomatic sensorimotor deficit was found in the anal canal of patients with diabetic peripheral neuropathy. Mucosal electrosensitivity thresholds in the anal canal were significantly higher (p less than 0.01 v controls) and fibre density of the external anal sphincter significantly raised (p less than 0.0001 v controls). Anal manometry and pudendal nerve terminal motor latencies were similar to controls. In patients with idiopathic faecal incontinence the tests of sensory and motor function also showed a sensorimotor neuropathy; compared with controls, mucosal electrosensitivity thresholds were significantly higher (p less than 0.002), anal canal resting and maximum squeeze pressures were significantly lower (p less than 0.05 and p less than 0.002 respectively), and pudendal nerve terminal motor latencies and fibre density of the external anal sphincter were significantly raised (both p less than 0.05). Sensory thresholds to rectal distension were similar in all groups. Pelvic floor sensorimotor neuropathy in diabetic patients has several features in common with that of patients with idiopathic faecal incontinence but its functional significance remains uncertain.

Lower respiratory illness in early childhood and lung function and bronchial reactivity in adolescent males

We examined the relationship between lower respiratory illness (LRI) experience in early childhood and lung function and bronchial reactivity in 57 boys, 11 to 22 yr of age, whose histories of outpatient physician visits for wheezing and nonwheezing LRI had been documented prospectively during their first 6 yr of life. These boys were a subpopulation of 159 children whose early childhood LRI experience and spirometric performance had been studied an average of 4 yr previously. The majority of boys had been free of chronic respiratory symptoms in the 2 yr before evaluation. Boys with histories of 2 or more preschool wheezing illnesses had lower mean levels of performance for FEV1, FEF25-75, FEF50, FEF75, and FEV1/FVC than did boys who had zero or 1 preschool wheezing illness, replicating observations that had been made when the boys had been studied 4 yr previously. Boys with lower spirometric performance relative to the study population on initial testing continued to have lower relative levels of spirometric performance 4 yr later. Neither preschool wheezing nor nonwheezing illness experience was associated with the degree of methacholine sensitivity measured in adolescence. Increasing degrees of methacholine sensitivity were associated with lower levels of spirometric performance; however, preschool wheezing illness experience remained a significant correlate of spirometric performance after adjustment for level of methacholine sensitivity. We conclude that recurrent preschool wheezing illness in these adolescent boys was associated with persistently lower lung function, but not enhanced methacholine sensitivity, during the middle to late school years.

Combined sensory and motor deficit in primary neuropathic faecal incontinence

Eleven patients with idiopathic faecal incontinence (IFI) and nine normal controls were studied with techniques of mucosal electrosensitivity and rectal distention for the quantitative assessment of anal and rectal sensation and with manometric and electromyographic tests for the assessment of anorectal motor function. The tests of motor function showed pelvic floor motor neuropathy in the patients with IFI, compared with controls, anal canal resting and voluntary contraction pressures were significantly (p less than 0.05, p less than 0.002) lower, pudendal nerve terminal motor latency and external anal sphincter fibre density were significantly (p less than 0.05, p less than 0.05) raised. The results of mucosal electrosensitivity (MES) disclosed a sensory deficit in the anal canal in patients with IFI, compared with controls, MES threshold was significantly (p less than 0.002) higher. Sensory thresholds to rectal distension were similar in the two groups. This study shows that sensory deficit of the anal canal occurs in combination with the motor neuropathy of the anal canal musculature in primary neuropathic faecal incontinence.

Is paradoxical contraction of puborectalis muscle of functional importance?

Paradoxical contraction of the puborectalis muscle during simulated defecation straining (anismus) has been cited as a cause of constipation. The functional specificity of this phenomenon was evaluated in 79 patients, 50 with constipation, 21 with idiopathic perineal pain, and eight with solitary rectal ulcer syndrome. Electromyogram evidence of paradoxical puborectalis contraction was observed in 38 (76 percent), ten (48 percent), and four (50 percent) of these patients, respectively. All patients with solitary rectal ulcer syndrome had difficulty defecating; defecation was normal in all patients with perineal pain. These observations suggest that paradoxical contraction of the puborectalis muscle is not a specific finding, and that it is not the sole cause of constipation in patients with anismus.

Natural history of anterior mucosal prolapse

Case notes of 250 patients (M:F, 1:2.7; age 48.7 +/- 16.5 years) in whom anterior mucosal prolapse had been diagnosed, at one hospital between 1974 and 1976, were reviewed. The commonest symptoms were bleeding (56 per cent), pain (32 per cent) and a sense of prolapse (32 per cent). The prevalence of constipation was significantly higher among women (47 per cent) than men (29 per cent). Perineal descent was present in 20 per cent of cases and was significantly more frequently associated with excessive straining at defaecation (28 per cent) compared with patients in whom there was no history of excessive straining (12 per cent). Sixty-six patients (26 per cent) experienced recurring symptoms over the 10 year period following presentation but did not deteriorate, while 28 patients (11 per cent) deteriorated. Deterioration was associated with a history of symptoms for longer than 1 year at the time of presentation, female sex, and the presence of perineal descent on clinical examination. The risk of developing perineal descent was less than 10 per cent over the 5 years after presentation while that of developing sphincter laxity among patients who had already developed perineal descent was 30 per cent over this period. Complete rectal prolapse occurred in 20 per cent (3/15) of patients with clinical perineal descent and sphincter laxity but was not seen in the absence of these signs. The results of treatment by submucosal phenol injection, mucosal rubber banding, or glycerine suppositories were the same.

Relation between perineal descent and pudendal nerve damage in idiopathic faecal incontinence

In 60 patients with idiopathic anorectal incontinence, without neurological disease, there was a significant relationship, shown by regression analysis, between the pudendal nerve terminal motor latency and the extent of perineal descent during straining (r 0.59; p less than 0.001), and the plane of the perineum on straining (r -0.61; p less than 0.001). These data are consistent with the suggestion that perineal descent can lead to stretch-induced damage to the perineal nerves in this condition.

Pathogenesis and management of fecal incontinence in the adult

In the author's opinion, post-anal repair remains the procedure of choice for patients with levator neuropathy and loss of anorectal angle. The operation is minimally invasive and relatively free of major complications. A knowledge of the anatomy of the perineum and in particular of the intersphincteric space is mandatory before undertaking such surgery. Any surgeon who is accustomed to performing internal anal sphincterotomy will already be accustomed to identifying the plane and the internal sphincter. Progression to performing post-anal repair is only a small step. On the other hand, gracilis transposition seems to be a procedure of considerable technical complexity. Also it must be difficult to gauge the tension of the repair correctly. Presumably it can be all too easy to make the repair too tight and cause a stricture or create a lax repair by leaving too long a length of tendon. However, in patients whose pelvic floor has failed to develop (e.g., in patients with rectal atresia) it is hard to imagine any procedure other than gracilis transposition which can possibly be considered. Clearly, post-anal repair in this case would be contra-indicated. Finally, it is always relevant to remember that colostomy has a creative role to play in the management of anorectal incontinence. In the elderly patient who has a severe atrophy of the pelvic floor the incontinent abdominal wall stoma may be considerably easier to manage than a perineal "stoma." Patients with fecal incontinence are depressed and embarrassed. They have often been told by friends, relatives, and their family doctor that there is little that can be done and not to complain. It is essential in the initial consultation with the patient that this defeatist attitude be countered. Much can be done to restore full function by relatively simple measures which may include surgery. For the surgeon they represent a very gratifying group of patients to treat.