Role of anal cushions in maintaining continence

Long-term Outcomes of Botulinum Toxin Injection Into the External Anal Sphincters: An Effective New Treatment of Chronic Functional Constipation in Children

BACKGROUND

Botulinum toxin (BT) is a well-recognised treatment of chronic functional constipation (FC) and soiling refractory to medical treatment. The aims of this study were to assess the short and long-term outcomes of BT injection into the external anal sphincter muscles (EAS) for chronic FC treatment.

METHODS

We studied 196 children unresponsive to medical management of chronic FC, soiling, painful defecation and withholding behaviour (Rome III criteria) from April 2011 to January 2023. All patients underwent anorectal manometry (ARM) and endosonography-guided BT injection (Dysport® or Botox®) 10 units/kg body weight (maximum 200 units) into the EAS muscles at 3 and 9 o'clock positions and colonic transit study. Outcomes were measured using a validated symptom severity (SS) score questionnaire pre-operatively, at 3-6 months and 12-24 months follow up including: defecation frequency and pain, soiling, laxative(s), general health, behaviour, symptom improvement and faecaloma. Sum of scores ranged from 0 (best) to 65 (worst). We used Wilcoxon signed-rank test for matched-pairs related analysis and data presented as median (range) and p value < 0.05 was considered significant.

RESULTS

196 patients (104 male) with a median age of 7 (1-16) years underwent anorectal investigations and BT injection into the external anal sphincters during 12 year study period. The median short and long term follow-up was 4 (1-27) months and 16 (5-60) months, respectively. 26 (13 %) patients had autism and 14 (7.1 %) had attention deficit hyperactivity disorder (ADHD). Median anal sphincter resting pressure was of 55 (20.5-113) mmHg. The pre-operative total SS score improved from median 31/65 (4-57) before BT treatment to median 15/65 (0-49) at 4-month after BT injection and median 16/65 (0-56) at 16-month follow-up, p < 0.001. 80 % (104/130) of patients showed significant short-term and 79 % (71/90) showed long-term improvement of their chronic FC symptoms following BT injections. 9 % (18/196) children required second BT injection for symptom recurrence and 18.3 % (36/196) required formation of an antegrade colonic enema (ACE) stoma.

CONCLUSION

BT injection is an effective and safe new treatment of chronic FC unresponsive to conventional medical treatments. In our experience, 80 % of children have significant improvement of their symptoms and 9 % require repeat BT injection during a long term follow-up.

Blastopore gating mechanism to regulate extracellular fluid excretion

Fluid uptake and efflux play roles in early embryogenesis as well as in adult homeostasis. Multicellular organisms have two main pathways for fluid movement: cellular-level, such as transcellular and paracellular pathways, and tissue-level, involving muscle contraction. Interestingly, early Xenopus embryos with immature functional muscles excrete archenteron fluid via a tissue-level mechanism that opens the blastopore through a gating mechanism that is unclear. Using microelectrodes, we show that the archenteron has a constant fluid pressure and as development progress the blastopore pressure resistance decreases. Combining physical perturbations and imaging analyses, we found that the pushing force exerted by the circumblastoporal collars (CBCs) at the slit periphery regulates pressure resistance. We show that apical constriction at the blastopore dorsoventral ends contributes to this pushing force, and relaxation of ventral constriction causes fluid excretion. These results indicate that actomyosin contraction mediates temporal control of tissue-level blastopore opening and fluid excretion in early Xenopus embryos.

Faecal incontinence in adults

Faecal incontinence, which is defined by the unintentional loss of solid or liquid stool, has a worldwide prevalence of ≤7% in community-dwelling adults and can markedly impair quality of life. Nonetheless, many patients might not volunteer the symptom owing to embarrassment. Bowel disturbances, particularly diarrhoea, anal sphincter trauma (obstetrical injury or previous surgery), rectal urgency and burden of chronic illness are the main risk factors for faecal incontinence; others include neurological disorders, inflammatory bowel disease and pelvic floor anatomical disturbances. Faecal incontinence is classified by its type (urge, passive or combined), aetiology (anorectal disturbance, bowel symptoms or both) and severity, which is derived from the frequency, volume, consistency and nature (urge or passive) of stool leakage. Guided by the clinical features, diagnostic tests and therapies are implemented stepwise. When simple measures (for example, bowel modifiers such as fibre supplements, laxatives and anti-diarrhoeal agents) fail, anorectal manometry and other tests (endoanal imaging, defecography, rectal compliance and sensation, and anal neurophysiological tests) are performed as necessary. Non-surgical options (diet and lifestyle modification, behavioural measures, including biofeedback therapy, pharmacotherapy for constipation or diarrhoea, and anal or vaginal barrier devices) are often effective, especially in patients with mild faecal incontinence. Thereafter, perianal bulking agents, sacral neuromodulation and other surgeries may be considered when necessary.

Anorectal Transplantation: The First Long-term Success in a Canine Model

OBJECTIVE

Anorectal transplantation is a challenging procedure but a promising option for patients with weakened or completely absent anorectal function.

SUMMARY BACKGROUND DATA

We constructed a canine model of anorectal transplantation, evaluated the long-term outcomes, and controlled rejection and infection in allotransplantation.

METHODS

In the pudendal nerve function study, 6 dogs were randomly divided into 2 groups, transection and anastomosis, and were compared with a control using anorectal manometry, electromyography, and histological examination. In the anorectal transplantation model, 4 dogs were assigned to 4 groups: autotransplant, allotransplant with immunosuppression, allotransplant without immunosuppression, and normal control. Long-term function was evaluated by defecography, videography, and histological examination.

RESULTS

In the pudendal nerve function study, anorectal manometry indicated that the anastomosis group recovered partial function 6 months postoperatively. Microscopically, the pudendal nerve and the sphincter muscle regenerated in the anastomosis group. Anorectal transplantation was technically successful with a 3-stage operation: colostomy preparation, anorectal transplantation, and stoma closure. The dog who underwent allotransplantation and immunosuppression had 2 episodes of mild rejection, which were reversed with methylprednisolone and tacrolimus. The dog who underwent allotransplantation without immunosuppression had a severe acute rejection that resulted in graft necrosis. Successful dogs had full defecation control at the end of the study.

CONCLUSIONS

We describe the critical role of the pudendal nerve in anorectal function and the first long-term success with anorectal transplantation in a canine model. This report is a proof-of-concept study for anorectal transplantation as a treatment for patients with an ostomy because of anorectal dysfunction.

Understanding the physiology of human defaecation and disorders of continence and evacuation

The act of defaecation, although a ubiquitous human experience, requires the coordinated actions of the anorectum and colon, pelvic floor musculature, and the enteric, peripheral and central nervous systems. Defaecation is best appreciated through the description of four phases, which are, temporally and physiologically, reasonably discrete. However, given the complexity of this process, it is unsurprising that disorders of defaecation are both common and problematic; almost everyone will experience constipation at some time in their life and many will develop faecal incontinence. A detailed understanding of the normal physiology of defaecation and continence is critical to inform management of disorders of defaecation. During the past decade, there have been major advances in the investigative tools used to assess colonic and anorectal function. This Review details the current understanding of defaecation and continence. This includes an overview of the relevant anatomy and physiology, a description of the four phases of defaecation, and factors influencing defaecation (demographics, stool frequency/consistency, psychobehavioural factors, posture, circadian rhythm, dietary intake and medications). A summary of the known pathophysiology of defaecation disorders including constipation, faecal incontinence and irritable bowel syndrome is also included, as well as considerations for further research in this field.

Modified procedure for prolapse and hemorrhoids: Lower recurrence, higher satisfaction

BACKGROUND

Hemorrhoidal prolapse is a common benign disease with a high incidence. The treatment procedure for prolapse and hemorrhoids (PPH) remains an operative method used for internal hemorrhoid prolapse. Although it is related to less pos-operative pain, faster recovery and shorter hospital stays, the postoperative recurrence rate is higher than that of the Milligan-Morgan hemorrhoidectomy (MMH). We have considered that recurrence could be due to shortage of the pulling-up effect. This issue may be overcome by using lower purse-string sutures [modified-PPH (M-PPH)].

AIM

To compare the therapeutic effects and the patients’ satisfaction after M-PPH, PPH and MMH.

METHODS

This retrospective cohort study included 1163 patients (M-PPH, 461; original PPH, 321; MMH, 381) with severe hemorrhoids (stage III/IV) who were admitted to The 2^nd Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University from 2012 to 2014. Early postoperative complications, efficacy, postoperative anal dysfunction and patient satisfaction were compared among the three groups. Established criteria were used to assess short- and long-term postoperative complications. A visual analog scale was used to evaluate postoperative pain. Follow-up was conducted 5 years postoperatively.

RESULT

Length of hospital stay and operating time were significantly longer in the MMH group (8.05 ± 2.50 d, 19.98 ± 4.21 min; P < 0.0001) than in other groups. The incidence of postoperative anastomotic bleeding was significantly lower after M-PPH than after PPH or MMH (1.9%, 5.1% and 3.7%; n = 9, 16 and 14; respectively). There was a significantly higher rate of sensation of rectal tenesmus after M-PPH than after MMH or PPH (15%, 8% and 10%; n = 69, 30 and 32; respectively). There was a significantly lower rate of recurrence after M-PPH than after PPH (8.7% and 18.8%, n = 40 and 61; P < 0.0001). The incidence of postoperative anal incontinence differed significantly only between the MMH and M-PPH groups (1.3% and 4.3%, n = 5 and 20; P = 0.04). Patient satisfaction was significantly greater after M-PPH than after other surgeries.

CONCLUSION

M-PPH has many advantages for severe hemorrhoids (Goligher stage III/IV), with a low rate of anastomotic bleeding and recurrence and a very high rate of patient satisfaction.

M-PPH

Transanal minimally invasive surgery for rectal polyps and selected malignant tumors: caution concerning intermediate-term functional results

PURPOSE

Transanal minimally invasive surgery (TAMIS) is gaining worldwide popularity as an alternative for the transanal endoscopic microsurgery (TEMS) method for the local excision of rectal polyps and selected neoplasms. Data on patient reported outcomes regarding short-term follow-up are scarce; data on functional outcomes for long-term follow-up is non-existent.

METHODS

We used the fecal incontinence severity index (FISI) to prospectively assess the fecal continence on the intermediate-term follow-up after TAMIS. The primary outcome measure is postoperative fecal continence. Secondary outcome measures are as follows: perioperative and intermediate-term morbidity.

RESULTS

Forty-two patients (m = 21:f = 21), median age 68.5 (range 34-94) years, were included in the analysis. In four patients (9.5%), postoperative complications occurred. The median follow-up was 36 months (range 24-48). Preoperative mean FISI score was 8.3 points. One year after TAMIS, mean FISI score was 5.4 points (p = 0.501). After 3 years of follow-up, mean FISI score was 10.1 points (p = 0.01). Fecal continence improved in 11 patients (26%). Continence decreased in 20 patients (47.6%) (mean FISI score 15.2 points, [range 3-31]).

CONCLUSIONS

This study found that the incidence of impaired fecal continence after TAMIS is substantial; however, the clinical significance of this deterioration seems minor. The present data is helpful in acquiring informed consent and emphasizes the need of proper patient information. Functional results seem to be comparable to results after TEMS. Furthermore, we confirmed TAMIS is safe and associated with low morbidity.

Sonographic appearance of anal cushions of hemorrhoids

AIM

To evaluate the diagnostic value of different sonographic methods in hemorrhoids.

METHODS

Forty-two healthy volunteers and sixty-two patients with grades I-IV hemorrhoids received two different sonographic examinations from January 2013 to January 2016 at the First and Second Hospitals of Xinjiang Medical University in a prospective way. We analyzed the ultrasonographic findings of these participants and evaluated the outcomes. Resected grades III and IV hemorrhoid tissues were pathologically examined. The concordance of ultrasonographic results with pathology results was assessed with the Cohen’s kappa coefficient.

RESULTS

All healthy volunteers and all patients had no particular complications related to sonography. There were no statistically significant differences between the participants regarding age (P = 0.5919), gender (P = 0.4183), and persistent symptoms (P > 0.8692). All healthy control participants had no special findings. However, 30 patients with hemorrhoids showed blood signals around the dentate line on ultrasonography. When grades I and II hemorrhoids were analyzed, there were no significant differences between transrectal ultrasound (TRUS), transperianal ultrasound (TPUS), and transvaginal ultrasound (TVUS) (P > 0.05). Grades III and IV hemorrhoids revealed blood flow with different directions which could be observed as a “mosaic pattern”. In patients with grades III and IV hemorrhoids, the number of patients with “mosaic pattern” as revealed by TRUS, TPUS and TVUS was 22, 12, and 4, respectively. Patients with grades III and IV disease presented with a pathologically abnormal cushion which usually appeared as a “mosaic pattern” in TPUS and an arteriovenous fistula in pathology. Subepithelial vessels of resected grades III and IV hemorrhoid tissues were manifested by obvious structural impairment and retrograde and ruptured changes of internal elastic lamina. Some parts of the Trietz’s muscle showed hypertrophy and distortion. Arteriovenous fistulas and venous dilatation were obvious in the anal cushion of hemorhoidal tissues. After pathological results with arteriovenous fistulas were taken as the standard reference, we evaluated the compatibility between the two methods according to the Cohen’s kappa co-efficiency calculation. The compatibility (Cohein kappa co-efficiency value) between “mosaic pattern” in the TPUS and arteriovenous fistula in pathology was very good (ĸ = 0.8939). When compared between different groups, TRUS presented the advantage that the mosaic pattern could be confirmed in more patients, especially for group A. There was a statistical difference when comparing group A with group B or C (P < 0.05 for both). There were obvious statistical differences between group A and group B with regard to the vessel diameter and blood flow velocity measured by TRUS (P < 0.05).

CONCLUSION

Patients with grades III and IV hemorrhoids present with a pathologically abnormal cushion which usually appears as a “mosaic pattern” in sonography, which is in accord with an arteriovenous fistula in pathology. There are clearly different hemorrhoid structures shown by sonography. “Mosaic pattern” may be a parameter for surgical indication of grades III and IV hemorrhoids.

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Zusammenfassung. Der auf Höhe der Linea dentata gelegene Corpus cavernosum recti spielt eine tragende Rolle bei der Regulierung der Feinkontinenz. Kommt es zu einer pathologischen Vergrösserung des Corpus cavernosum verbunden mit Symptomen, spricht man von einem Hämorrhoidalleiden. Das Hämorrhoidalleiden ist eine Volkskrankheit mit einer Inzidenz von ca. 40 %, wobei die Rate an Selbsttherapien hoch ist. Im klinischen Alltag fällt der stadienadaptierten Therapie eine wichtige Rolle zu: Hämorrhoiden Grad I sind die Domäne der konservativen Therapie, Hämorrhoiden Grad II können in Abhängigkeit der Schwere der Symptome konservativ oder operativ angegangen werden. Hämorrhoiden Grad III und Grad IV sollten einer Operation zugeführt werden.

Anorectal manometry with and without ketamine for evaluation of defecation disorders in children

INTRODUCTION

Anorectal manometry (ARCM) provides valuable information in children with chronic constipation and fecal incontinence but may not be tolerated in the awake child. This study aimed to evaluate the effect of ketamine anesthesia on the assessment of anorectal function by manometry and to evaluate defecation dynamics and anal sphincter resting pressure in the context of pathophysiology of chronic functional (idiopathic) constipation and soiling in children.

METHODS

This was a prospective study of children who were investigated for symptoms of chronic constipation and soiling between April 2001 and April 2004. We studied 52 consecutive children who had awake ARCM, biofeedback training and endosonography (awake group) and 64 children who had ketamine anesthesia for ARCM and endosonography (ketamine group). We age matched 31 children who had awake anorectal studies with 27 who had ketamine anesthesia.

RESULTS

The children in awake and ketamine groups were comparable for age, duration of bowel symptoms and duration of laxative treatments. ARCM profile was comparable between the awake and the ketamine groups with regard to anal sphincter resting pressure, rectal capacity, amplitude of rectal contractions, frequency of rectal and IAS contractions and functional length of anal canal. Of 52 children who had awake ARCM, dyssynergia of the EAS muscles was observed in 22 (42%) and median squeeze pressure was 87mm Hg (range 25-134). The anal sphincter resting pressure was non-obstructive and comparable to healthy normal children. Rectoanal inhibitory reflex was seen in all children excluding diagnosis of Hirschsprung disease.

CONCLUSIONS

Ketamine anesthesia does not affect quantitative or qualitative measurements of autonomic anorectal function and can be used reliably in children who will not tolerate the manometry while awake. Paradoxical contraction of the EAS can only be evaluated in the awake children and should be investigated further as the underlying cause of obstructive defecation in patients with chronic functional constipation and soiling.

Functional outcome of autologous anorectal transplantation in an experimental model

BACKGROUND

Although anorectal transplantation is a challenging procedure, it is a promising option for patients who have completely lost anorectal function or in whom it failed to develop, as in congenital malformations. The paucity of animal models with which to test functional outcomes was addressed in this study of anorectal manometry in rats.

METHODS

Wistar rats were assigned randomly to four groups: orthotopic anorectal transplantation, heterotopic transplantation, sham operation, or normal control. Bodyweight and anal pressure were measured immediately before and after operation, and on postoperative days 7 and 14. ANOVA and Tukey's test were used to compare results for bodyweight, anal manometry and length of procedure.

RESULTS

Immediately after the procedure, mean(s.d.) anal pressure in the orthotopic group (n = 13) dropped from 31·4(13·1) to 1·6(13·1) cmH2 O (P < 0·001 versus both sham operation (n = 13) and normal control (n = 15)), with partial recovery on postoperative day 7 (14·9(13·9) cmH2 O) (P = 0·009 versus normal control) and complete recovery on day 14 (23·7(12·2) cmH2 O). Heterotopic rats (n = 14) demonstrated partial functional recovery: mean(s.d.) anal pressure was 26·9(10·9) cmH2 O before operation and 8·6(6·8) cmH2 O on postoperative day 14 (P < 0·001 versus both sham and normal control).

CONCLUSION

Orthotopic anorectal transplantation may result in better functional outcomes than heterotopic procedures. Surgical relevance Patients with a permanent colostomy have limited continence. Treatment options are available, but anorectal transplantation may offer hope. Some experimental studies have been conducted, but available data are currently insufficient to translate into a clinical option. This paper details functional outcomes in a rat model of anorectal autotransplantation. It represents a step in the translational research that may lead to restoration of anorectal function in patients who have lost or have failed to develop it.

Identifying the variables associated with pain during transrectal ultrasonography of the prostate

OBJECTIVE

The purpose of this study was to prospectively investigate the degree of pain experienced by the patients receiving transrectal ultrasonography (TRUS) of the prostate by applying a visual analog scale. We also identified the clinical parameters influencing pain during the TRUS examination.

MATERIALS AND METHODS

Records were obtained from a prospective database for male patients who received TRUS of prostate in the outpatient department of Chang Gung Memorial Hospital, Taiwan, from January 2014 to June 2014. The patients underwent a detailed physical examination and medical history review. Immediately after the TRUS examination, the patients completed questionnaires based on a ten-point visual analog pain scale. The variables of interest were age, body mass index, prostate volume, prostate sagittal length, prostate-specific antigen, previous TRUS experience, external hemorrhoids, anal surgical history, prostate calcification, and image artifact caused by stool in the rectum. All variables were correlated to the visual analog scale by applying multivariate regression analysis.

RESULTS

By using linear regression analysis, we identified the independent factors that affected the pain score during the TRUS examination. The patients who received the examination for the first time or had longer prostate sagittal lengths, external hemorrhoids, anal surgical history, or stool stored in the rectum experienced more pain during the TRUS examination. Furthermore, the pain was reduced when we provided the patients with a detailed explanation before the procedure and allowed them to observe the real-time images during the examination.

CONCLUSION

Although a TRUS examination is uncomfortable for patients, after having identified the factors affecting pain, physicians can assist patients in reducing pain during the procedure, thus providing higher quality examinations.

Hemorrhoids and fistulas: new solutions to old problems

Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.

Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection for circumferential mixed hemorrhoids

AIM: To identify a more effective treatment protocol for circumferential mixed hemorrhoids.

METHODS: A total of 192 patients with circumferential mixed hemorrhoids were randomized into the treatment group, where they underwent Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection, or the control group, where traditional external dissection and internal ligation were performed. Postoperative recovery and complications were monitored.

RESULTS: The time to wound healing was 12.96 ± 2.25 d in the treatment group shorter than 19.58 ± 2.71 d in the control group. Slight pain rate was 58.3% in the treatment group higher than 22.9% in the control group; moderate pain rate was 33.3% in the treatment group lower than 56.3% in the control group severe pain rate was 8.4% in the treatment group lower than 20.8% in the control group. No edema rate was 70.8% in the treatment group higher than 43.8% in the control group; mild local edema rate was 26% in the treatment group lower than 39.6% in the control group obvious local edema was 3.03% in the treatment group lower than 16.7% in the control group. No stenosis rate was 85.4% in the treatment group higher than 63.5% in the control group; moderate stenosis rate was 14.6% in the treatment group Lower than 27.1% in the control group severe anal stenosis rate was 0% in the treatment group lower than 9.4% in the control group.

CONCLUSION: Milligan-Morgan hemorrhoidectomy with anal cushion suspension and partial internal sphincter resection is the optimal treatment for circumferential mixed hemorrhoids and can be widely applied in clinical settings.

Anorectal functional outcome after repeated transanal endoscopic microsurgery

AIM: To evaluate the status of anorectal function after repeated transanal endoscopic microsurgery (TEM).

METHODS: Twenty-one patients undergoing subtotal colectomy with ileorectal anastomosis were included. There were more than 5 large (> 1 cm) polyps in the remaining rectum (range: 6-20 cm from the anal edge). All patients, 19 with villous adenomas and 2 with low-grade adenocarcinomas, underwent TEM with submucosal endoscopic excision at least twice between 2005 and 2011. Anorectal manometry and a questionnaire about incontinence were carried out at week 1 before operation, and at weeks 2 and 3 and 6 mo after the last operation. Anal resting pressure, maximum squeeze pressure, maximum tolerable volume (MTV) and rectoanal inhibitory reflexes (RAIR) were recorded. The integrity and thickness of the internal anal sphincter (IAS) and external anal sphincter (EAS) were also evaluated by endoanal ultrasonography. We determined the physical and mental health status with SF-36 score to assess the effect of multiple TEM on patient quality of life (QoL).

RESULTS: All patients answered the questionnaire. Apart from negative RAIR in 4 patients, all of the anorectal manometric values in the 21 patients were normal before operation. Mean anal resting pressure decreased from 38 ± 5 mmHg to 19 ± 3 mmHg (38 ± 5 mmHg vs 19 ± 3 mmHg, P = 0.000) and MTV from 165 ± 19 mL to 60 ± 11 mL (165 ± 19 mL vs 60 ± 11 mL, P = 0.000) at month 3 after surgery. Anal resting pressure and MTV were 37 ± 5 mmHg (38 ± 5 mmHg vs 37 ± 5 mmHg, P = 0.057) and 159 ± 19 mL (165 ± 19 mL vs 159 ± 19 mL, P = 0.071), respectively, at month 6 after TEM. Maximal squeeze pressure decreased from 171 ± 19 mmHg to 62 ± 12 mmHg (171 ± 19 mmHg vs 62 ± 12 mmHg, P = 0.000) at week 2 after operation, and returned to normal values by postoperative month 3 (171 ± 19 vs 166 ± 18, P = 0.051). RAIR were absent in 4 patients preoperatively and in 12 (χ² = 4.947, P = 0.026) patients at month 3 after surgery. RAIR was absent only in 5 patients at postoperative month 6 (χ² = 0.141, P = 0.707). Endosonography demonstrated that IAS disruption occurred in 8 patients, and 6 patients had temporary incontinence to flatus that was normalized by postoperative month 3. IAS thickness decreased from 1.9 ± 0.6 mm preoperatively to 1.3 ± 0.4 mm (1.9 ± 0.6 mm vs 1.3 ± 0.4 mm, P = 0.000) at postoperative month 3 and increased to 1.8 ± 0.5 mm (1.9 ± 0.6 mm vs 1.8 ± 0.5 mm, P = 0.239) at postoperative month 6. EAS thickness decreased from 3.7 ± 0.6 mm preoperatively to 3.5 ± 0.3 mm (3.7 ± 0.6 mm vs 3.5 ± 0.3 mm, P = 0.510) at month 3 and then increased to 3.6 ± 0.4 mm (3.7 ± 0.6 mm vs 3.6 ± 0.4 mm, P = 0.123) at month 6 after operation. Most patients had frequent stools per day and relatively high Wexner scores in a short time period. While actual fecal incontinence was exceptional, episodes of soiling were reported by 3 patients. With regard to the QoL, the physical and mental health status scores (SF-36) were 56.1 and 46.2 (50 in the general population), respectively.

CONCLUSION: The anorectal function after repeated TEM is preserved. Multiple TEM procedures are useful for resection of multi-polyps in the remaining rectum.

Transanal Suture Rectopexy for Haemorrhoids: Chivate's Painless Cure for Piles

The aim of the study was to evaluate Chivate's new procedure of transanal suture rectopexy for haemorroids for pain, bleeding, hospital stay, recurrence and complications. During the period between January 2006 and December 2008, the procedure was used for 166 cases symptomatic of grade II, III and IV haemorrhoids, at six different institutes by five different colorectal surgeons. In the series, 92 cases were males and 74 cases were females; average age was 49.5 years; youngest patient was 23 years of age and eldest was of 82 years of age. According to the gradation, II-52 cases, III-86 cases and IV-28 cases were enrolled for the procedure. The piles mass was reduced by head low and manually. The mucosa and submucosa were transfixed to muscle of the rectum by 0.5-1.0 cm long stitches. Similar stitching was continued all along the complete circumference of the rectum, 2 and 4 cm distal to the dentate line. In all cases, antibiotics and anti-inflammatory medicines were prescribed for 5 days. No pain was noticed in 162 cases; in 4 cases a pain dull in nature was described by the patients. All the 166 cases were discharged after 24 h. Intraoperative bleeding from the suture line was observed in 15 cases, which required temporary compression. On proctoscopy, in 3 cases intra-anal grade I, protrusion of piles cushion without bleeding was noticed. No incontinence, no recurrent bleeding, no frequency of stool, or no tenusmus was observed. In 2 cases, 6 months after operation, residual external piles were observed, which required excision. The procedure requires no special costly instruments or any disposables. Patients require short stay for 24 h. The procedure is a painless cure for haemorrhoids.

Excisional hemorrhoidal surgery and its effect on anal continence

AIM: To investigate the role of anal cushions in hemorrhoidectomy and its effect on anal continence of the patients.

METHODS: Seventy-six consecutive patients (33 men and 43 women) with a mean age of 44 years were included. They underwent Milligan-Morgan hemorrhoidectomy because of symptomatic third- and fourth-degree hemorrhoids and failure in conservative treatment for years. Wexner score was recorded and liquid continence test was performed for each patient before and two months after operation using the techniques described in our previous work. The speed-constant rectal lavage apparatus was prepared in our laboratory. The device could output a pulsed and speed-constant saline stream with a high pressure, which is capable of overcoming any rectal resistance change. The patients were divided into three groups, group A (< 900 mL), group B (900-1200 mL) and group C (> 1200 mL) according to the results of the preoperative liquid continence test.

RESULTS: All the patients completed the study. The average number of hemorrhoidal masses excised was 2.4. Most patients presented with hemorrhoidal symptoms for more than one year, including a mean duration of incontinence of 5.2 years. The most common symptoms before surgery were anal bleeding (n = 55), prolapsed lesion (n = 34), anal pain (n = 12) and constipation (n = 17). There were grade III hemorrhoids in 39 (51.3%) patients, and grade IV in 37 (48.7%) patients according to Goligher classification. Five patients had experienced hemorrhoid surgery at least once. Compared with postoperative results, the retained volume in the preoperative liquid continence test was higher in 40 patients, lower in 27 patients, and similar in the other 9 patients. The overall preoperative retained volume in the liquid continence test was 1130.61 ± 78.35 mL, and postoperative volume was slightly decreased (991.27 ± 42.77 mL), but there was no significant difference (P = 0.057). Difference was significant in the test value before and after hemorrhoidectomy in group A (858.24 ± 32.01 mL vs 574.18 ± 60.28 mL, P = 0.011), but no obvious difference was noted in group B or group C. There was no significant difference in Wexner score before and after operation (1.68 ± 0.13 vs 2.10 ± 0.17, P = 0.064). By further stratified analysis, there was significant difference before and 2 months after operation in group A (2.71 ± 0.30 vs 3.58 ± 0.40, P = 0.003). In contrast, there were no significant differences in group B or group C (1.89 ± 0.15 vs 2.11 ± 0.19, P = 0.179; 0.98 ± 0.11 vs 1.34 ± 0.19, P = 0.123).

CONCLUSION: There is no difference in the continence status of patients before and after Milligan-Morgan hemorrhoidectomy. However, patients with preoperative compromised continence may have further deterioration of their continence, hence Milligan-Morgan hemorrhoidectomy should be avoided in such patients.

Development of the maternal anal canal during pregnancy and the postpartum period: a longitudinal and functional ultrasound study

OBJECTIVES

Normal anatomical and physiological development of the maternal anal canal during and after pregnancy has been documented scarcely. We aimed to study the position and volume of the anal canal, during and after pregnancy, in women without previous delivery.

METHODS

This was a longitudinal study in which transvaginal three-dimensional ultrasound was used to measure anatomical structures in the anal canal during rest and squeeze in 23 nulliparous women. The total anal canal volume (ACV), anorectal curvature (ARC), anovaginal angle (AVA) and anal canal length were determined at 18, 28 and 36 weeks of pregnancy and at 3 months postpartum.

RESULTS

Total ACV at rest increased from a mean of 10.17 cm(3) at 18 weeks to 12.37 cm(3) and 12.21 cm(3) at 28 and 36 weeks, respectively (P = 0.001 and P = 0.010 vs. first measurement). For anal canal length, the corresponding mean measurements were 3.91 cm, 4.07 cm (P = 0.13) and 4.21 cm (P = 0.017). Postpartum, the mean total ACV was 10.86 cm(3) and length was 3.90 cm (P = 0.10 and P = 0.70 vs. first measurement). No significant changes were observed in ARC and AVA during or after pregnancy. Compared to at-rest status, the anal length significantly increased on voluntary squeeze (P = 0.007, 0.007, 0.022 and 0.004 at the four time points), while no differences in total ACV were observed. In mid-pregnancy AVA significantly increased during squeeze (P = 0.006 and 0.002 at weeks 18 and 28, respectively).

CONCLUSION

Anal canal length and total ACV increase during pregnancy in women without previous delivery. Voluntary squeezing elongates the anal canal and increases the angle formed with respect to the direction of the vagina. During postpartum involution, the characteristics of the anal canal revert to those observed at 18 weeks of pregnancy.

Measurement of anal cushions in continent women

AIM

Anal cushions are connective tissue complexes thought to be involved in anal continence. This study aimed to assess them in continent subjects.

METHOD

Continent women undergoing a transvaginal ultrasound scan for gynaecological reasons were included. The anal cushions were visualized at the mid-canal level. The cross-sectional area within the internal anal sphincter (Area 1) and the area enclosed within the anal cushions (Area 2) were measured and a Cushion:Canal (C:C) ratio was derived for each patient. The measurements were repeated in the semi-erect position.

RESULTS

One hundred and two patients with a median age of 41 (IQR 32-49) years were included. The median C:C ratio was 0.68 (IQR 0.61-0.73). Inter-observer error was 0.98 and intra-observer error was 0.99. There was no significant correlation between age and C:C ratio. The C:C ratio was significantly higher in parous than in nulliparous women (P = 0.04). A history of obstetric trauma or minimal haemorrhoidal symptoms did not influence C:C ratio. There was a significant increase in C:C ratio in the erect position. (P = 0.04).

CONCLUSION

There was a wide range of variability in the measurement of anal cushions in normal continent women. These were not influenced by age.

Transperineal ultrasound in the assessment of haemorrhoids and haemorrhoidectomy: a pilot study

BACKGROUND

The purpose of the study was the measurement of the anal cushion area using static transperineal ultrasound in a group of patients with symptomatic grade III and IV haemorrhoids about to undergo haemorrhoidectomy and compare them with a group of age-matched normals and the measured area following haemorrhoidectomy.

METHODS

Transperineal sonography was performed using a linear transducer measuring the anal cushion area by subtracting the measured luminal diameter of the undisturbed anal canal from the inner border of the internal anal sphincter. Measures were made 6 weeks following haemorrhoidectomy.

RESULTS

Comparisons were made between 22 normals and 36 patients with haemorrhoids (31 evaluable post-operatively). The median area of normals was 0.78 cm², that of pre-operative patients 2.25 cm² and that of post-operative cases 1.20 cm². There was a significant difference between pre- and post-operative cases with cushion areas of normal patients being significantly lower than post-operative cases. Variance of measurement in all 3 groups was negligible.

CONCLUSION

Static transperineal sonography measuring the anal cushion area is reproducible and shows marked differences between normals and patients with symptomatic haemorrhoids. There is a marked effect on measured area resultant from haemorrhoidectomy.

Anorectal functional results after transanal endoscopic microsurgery in benign and early malignant tumors

BACKGROUND

Transanal endoscopic microsurgery (TEM) has been suggested as a minimally invasive procedure of low morbidity for rectal villous adenomas and early anorectal adenocarcinomas. It has been used clinically in many areas outside of China for more than 20 years, but it began in mainland China only about 2 years ago. Some articles have reported excellent results with regard to morbidity and relapse rate with TEM, but there are no studies addressing its functional results in China until now. The aim of the present study was to analyze the effect of TEM on the manometric results.

METHODS

Thirty-seven patients (16 females, 21 males) underwent TEM and were followed for more than 6 months. Anorectal manometry and an incontinence questionnaire were administered 1 week preoperatively, 2 weeks postoperatively, 3 and 6 months postoperatively.

RESULTS

Of the 37 patients, 24 had villous adenomas and 13 had adenocarcinomas (11 uT1 and 2 uT2). Anorectal manometric values showed the mean anal resting pressure (ARP) decrease from 45 +/- 6 mmHg to 29 +/- 4 mmHg (p < 0.05) and the maximum tolerable volume (MTV) decrease from 175 +/- 21 ml to 90 +/- 15 ml (p < 0.05) at the third month after TEM. Maximal squeeze pressure (MSP) decreased from 181 +/- 20 mmHg to 92 +/- 14 mmHg (p < 0.05) at second week after operation and returned to normal value by the third postoperative month. The ARP and MTV were 45 +/- 5 mmHg and 177 +/- 21 ml, respectively, at 6 months after TEM, near the normal value (p > 0.05). Rectoanal inhibitory reflex (RAIR) was absent preoperatively in two patients; it was also absent in 10 patients 3 months postoperatively and in three patients 6 months postoperatively. Endosonography demonstrated internal anal sphincter (IAS) rupture in five patients, and full integrity of the external anal sphincter (EAS) in all patients. Of the five patients with IAS rupture, four had temporary incontinence to flatus normalized up to three postoperative months. Most patients had more times of stools per day and relative higher Wexner scores in a short period after TEM. All these patients were followed for 6-20 months with no incidence of relapse.

CONCLUSIONS

Anorectal function was preserved well after TEM, although some anorectal manometric parameters changed over time. Thus TEM is safe, in terms of anorectal function, for the cure of benign and early malignant tumors of the rectum.

Transcutaneous needle-free injection of botulinum toxin: a novel treatment of childhood constipation and anal fissure

PURPOSE

Constipation is a common problem in children, and when it becomes chronic fecal impaction, overflow soiling and megarectum may develop. Children with chronic idiopathic constipation (IC) may not respond to conventional treatments of laxatives, enemas, and toilet training. The aims of the study were to evaluate the long-term outcome of transcutaneous needle-free injection of botulinum toxin (TNFBT) into the external anal sphincter (EAS) and to assess the extent of the toxin penetration into the sphincter.

METHOD

Children were recruited if symptomatic with chronic constipation, soiling, painful defecation, and withholding behavior requiring disimpaction of stool and rectal biopsy under general anesthesia. A total dose of 200 U of botulinum toxin (BT) (Dysport; Ipsen Limited, Slough, United Kingdom) was injected transcutaneously into the EAS at 3 and 9-o'clock positions using J-tip needle-free syringes (National Medical Products Inc, Irvine, Calif). The depth and width of toxin penetration was assessed by endosonography. Outcome was measured by a validated symptom severity (SS) score questionnaire. The total SS score ranged between 0 (best) and 65 (worst). The outcome was compared with 31 children in a comparable historical control group at 3 and 12-month follow-up.

RESULTS

Sixteen children were recruited with median age of 6.11 (range, 3-14.85) years and median duration of symptoms of 3.9 years (1.6-11.5). On endosonography, the median depth and width of BT penetration was 8 (7-10) mm and 8 (6-10) mm, respectively. At 3-month follow-up, the median SS score improved in all children after TNFBT from 32.50 (5-57) to 7.50 (0-26) (Wilcoxon's P < .0001). There were significant improvements in symptoms of constipation, soiling, painful defecation, general health and behavior, and fecal impaction of rectum (P < .05). Anal fissures healed in all 4 children. The SS score in the control group improved from 33 (12-49) to 15 (0-40) (P < .0001). At 12-month follow-up, the improvement of SS score in TNFBT group was significantly more than the control group as follows: 4 (0-25) vs 15 (0-51), respectively (Mann-Whitney U P < .002). Three patients had a second TNFBT injection for relapsed symptoms. There were no complications. The transcutaneous needle-free injection of botulinum toxin eliminates the risk of intravascular injection or needlestick injury. The transcutaneous needle-free injection of botulinum toxin also has other therapeutic applications including an alternative therapy to biofeedback training for dyssynergia of the EAS, treatment of muscle limb spasticity in cerebral palsy, and cosmetic treatment of overactive facial muscles and wrinkles and hyperhydrosis.

CONCLUSION

Transcutaneous needle-free injection of botulinum toxin into the external anal sphincter is a novel and safe new treatment of chronic idiopathic constipation and anal fissure in children. A second injection may be required in 20% of patients.

Anorectal and pelvic floor anatomy

The anorectum and pelvic floor are crucial in maintaining continence, facilitating evacuation, providing pelvic organ support while in females the pelvic floor is part of the birth canal. The anal sphincter is a multilayered cylindrical structure, including the smooth muscle internal sphincter and the outer striated muscle layer. The latter comprises the external sphincter as lower outer half and puborectalis as upper outer half of the sphincter. The external sphincter is continuous with the rectum at the anorectal junction. The pelvic floor constitutes four principal layers: endopelvic fascia, the muscular pelvic diaphragm (commonly referred to as levator plate), the perineal membrane (urogenital diaphragm) and the superficial transverse perineii. Anorectum and pelvic floor have multiple interconnections by fascia and ligaments as well as multiple indirect connections to the bony pelvis. Other structures as perineal body and a fibro-elastic network add to this support.

Evaluation of outcome of anorectal anomaly in childhood: the role of anorectal manometry and endosonography

The aim of this study was to evaluate role of anorectal manometry (ARM) and anal endosonography (ES) in assessment of the internal anal sphincter (IAS) quality on continence outcome following repair of anorectal anomalies (ARA). We devised a scoring system to evaluate the quality of the IAS based on ARM and ES and correlated the scores with clinical outcome, using a modified Wingfield score (MWS) for faecal continence. We also assessed the implication of megarectum and neuropathy on faecal continence. Of 54 children studied, 34 had high ARA and 20 had low ARA. Children with high ARA had poor sphincters on ES and ARM, and also poor faecal continence compared to those with low ARA. The presence of megarectum and neuropathy was associated with uniformly poor outcome irrespective of the IAS quality. The correlations between MWS on one hand, and ES and ARM scores for IAS on the other hand were weak in the whole study group, ES r = 0.27, P < 0.04, and ARM r = 0.39, P < 0.004. However, the correlations were strong in those who had isolated ARA without megarectum or neuropathy, ES r = 0.51, P < 0.02 and ARM r = 0.55, P < 0.01, respectively. In conclusion, the ARM and ES are valuable in evaluation of continence outcome in children after surgery for ARA and those with good quality IAS had better faecal continence. The IAS is a vital component in functional outcome in absence of neuropathy and megarectum.

Evaluation of the use of PTQ implants for the treatment of incontinent patients due to internal anal sphincter dysfunction

OBJECTIVE

This study reports the results of injectable silicone PTQ implants for faecal incontinence due to internal anal sphincter (IAS) dysfunction.

METHOD

Twenty patients (12 women) with partial faecal incontinence aged from 55 to 65 years were treated by a PTQ implant. All patients completed the Cleveland Clinic Continence and Quality of Life questionnaire. Endoluminal ultrasound and anorectal physiological testing were performed in each patient. All implants were inserted into the submucosal plane without ultrasound guidance.

RESULTS

Faecal continence was significantly improved up to 1 year. The Wexner continence score fell from a median of 13.05 (range, 5-20) before treatment to 4.5 (range 2-7.7) at 1 month after (P < 0.005). This rose gradually to 6.2 (range, 0-16) at one year (P = 0.02) and 9.4 (range, 1-20) at 2 years (P = 0.127). There were no differences in resting or squeeze pressure before and at 3 months after treatment (P = 0.86 and P = 0.93). Fourteen (70%) patients experienced pruritus ani during the first few weeks after the procedure and one developed infection at the implant site.

CONCLUSION

Silicone implantation is minimally invasive and technically simple. It is effective over 1 year in the treatment of faecal incontinence due to IAS dysfunction.

Transanal haemorrhoidal dearterialisation: nonexcisional surgery for the treatment of haemorrhoidal disease

BACKGROUND

Transanal haemorrhoidal dearterialisation (THD) is a nonexcisional surgical technique for the treatment of piles, consisting in the ligation of the distal branches of the superior rectal artery, resulting in a reduction of blood flow and decongestion of the haemorrhoidal plexus. The aim of this study was to assess the long-term efficacy of this treatment.

METHODS

The procedure was carried out using a proctoscope with a Doppler probe. The terminal branches were located with Doppler and then sutured.

RESULTS

From January 2000 to May 2006, we performed THD in 330 patients (180 men; mean age, 52.4 years), including 138 second-degree, 162 third-degree and 30 fourth-degree haemorrhoids. There were 23 postoperative complications (7 cases of bleeding, 5 thrombosed piles, 4 rectal haematomas, 2 anal fissures, 2 cases of dysuria, 1 of haematuria and 2 needle ruptures). The mean postoperative pain score was 1.32 on a visual analog scale. 219 patients were followed for a mean of 46 months (range, 22-79), including 100 patients with second-degree, 104 with third-degree and 15 with fourth-degree haemorrhoids. The operation completely resolved the symptoms in 132 patients (92.5%) with preoperative bleeding and in 110 patients (92%) with preoperative prolapse.

CONCLUSIONS

The efficacy and relapse rate of this procedure appears to be similar to that of traditional surgery and stapled haemorrhoidopexy. The technique was effective and safe for all degrees of haemorrhoids because of the excellent results, low complication rate and minor postoperative pain.

Age effects on internal anal sphincter thickness and diameter in nulliparous females

PURPOSE

Age can affect the delicate physiologic balance of the internal anal sphincter diameters and pressure governed by Laplace's law. This study compares the effect of aging on the internal anal sphincter thickness and diameter in younger and older nulliparous females without symptoms of fecal incontinence undisturbed by an endoanal probe.

METHODS

Magnetic resonance images were selected from a large database of nulliparous females to form two groups: "younger" females, aged 30 years and younger (n = 32), and "older" females, aged 50 years and older (n = 32). All patients were scanned without endoanal coils to allow undistorted measurement of the internal anal sphincter diameters. Inner and outer diameters were measured from axial magnetic resonance images and used to calculate sphincter thickness and mean radius by two independent investigators blinded to patient age.

RESULTS

The mean age in the younger group was 26 +/- 2.8 years, whereas that of the older group was 61.8 +/- 7.6 years. Older females had a 33 percent thicker internal anal sphincter (younger vs. older: 4.5 +/- 0.7 vs. 5.9 +/- 1 mm; P < 0.001), a 20 percent larger inner diameter (7.1 +/- 1.3 vs. 8.5 +/- 1.8 mm; P = 0.001), and a 27 percent larger outer diameter (16 +/- 2.1 vs. 20.3 +/- 3.3 mm; P < 0.001) than younger females. Neither sphincter thickness nor inner or outer diameter correlated with body mass index.

CONCLUSIONS

There is an increase in internal anal sphincter thickness, inner diameter, and outer diameter, which correlates with age in asymptomatic nulliparous females.

Botulinum toxin, a new treatment modality for chronic idiopathic constipation in children: long-term follow-up of a double-blind randomized trial

BACKGROUND

Myectomy of the internal anal sphincter (IAS) has been performed on some children after failure of medical treatment to treat idiopathic constipation. The aim of this study was to compare botulinum toxin injection with myectomy of the IAS in the treatment of chronic idiopathic constipation and soiling in children.

METHODS

This was a double-blind randomized trial. Patients between 4 and 16 years old were included in the study if they had failed to respond to laxative treatment and anal dilatation for chronic idiopathic constipation. All study patients had anorectal manometry and anal endosonography under ketamine anesthesia. Outcome was measured using a validated symptom severity (SS) scoring system, with scores ranging from 0 to 65.

RESULTS

Of 42 children, 21 were randomized to the botulinum group and 21 were randomized to the myectomy group. At the 3-month follow-up, the median preoperative SS score improved from 34 (range = 19-47) to 20 (range = 2-43) in the botulinum group (P < .001) and from 31 (range = 18-49) to 19 (range = 3-47) in the myectomy group (P < .002). At the 12-month follow-up, the scores were 19 (range = 0-45) and 14.5 (range = 0-41) for the botulinum group and the myectomy group, respectively (P < .0001). There was no complication in both groups.

CONCLUSION

Botulinum toxin is equally effective as and less invasive than myectomy of the IAS for chronic idiopathic constipation and fecal incontinence in children.

Sonographic investigation of the rectoanal inhibitory reflex: a qualitative pilot study in healthy females

PURPOSE

The rectoanal inhibitory reflex has been studied using various methods, e.g., anometry and electromyography. The aim of this study was to apply ultrasound for direct visualization of the rectoanal inhibitory reflex.

METHOD

The rectoanal inhibitory reflex was induced in ten healthy females (age range, 21-55 years) by injection of small amounts of water (7, 12, and 20 ml), into the rectum. The intra-anal pressure was measured with a microtransducer and the rectoanal inhibitory reflex was visualized with real-time transvaginal or transperineal sonography.

RESULTS

The rectoanal inhibitory reflex consisted of a reduction in the intra-anal pressure and relaxation of the internal anal sphincter, manifested as an increase in the inner diameter of the internal anal sphincter from the mean of 11 to 16 mm (P<0.001). Simultaneously, a wave of rectal contents entered the anal canal. The distance from the most distal border of the rectal contents to the anal verge decreased from a mean of 33 to 20 mm (P<0.001). The rectoanal inhibitory reflex ended with a retrograde transport returning anal contents into the rectum. During the retrograde transport a contraction in the internal anal sphincter was observed.

CONCLUSIONS

The rectoanal inhibitory reflex can readily be visualized with ultrasound as a wave of rectal contents entering the anal canal. The transport into the anal canal was not of voluntary origin and could be either noticed or not noticed by the subjects. The observed retrograde transportation in the anal canal was not noted by the subjects; it is related to a contraction in the internal anal sphincter and visualized for the first time using ultrasound.

Combined urinary and faecal incontinence

Combined urinary and faecal (liquid or solid) incontinence (double incontinence) is the most severe and debilitating manifestation of pelvic floor dysfunction. The community prevalence is 9-19% (urinary) and 5-10% (faecal), increasing with age. Pathophysiological factors include childbirth-associated external anal sphincter injury and pudendal nerve damage, pelvic floor descent, menopause, collagen disorders and multiple sclerosis-like conditions. The presence of crossed reflexes between the bladder, urethra, anorectum and pelvic floor in animal studies may explain the comorbidity of urinary and faecal urgency. Surgical treatment is based on aetiology and combined optimum techniques such as colposuspension or suburethral sling with overlapping sphincteroplasty. Other methods for improving sphincteric control include sacral nerve neuromodulation, bulking agents and artificial sphincters.

Thickening of the internal anal sphincter in idiopathic constipation in children

Thickening of the internal anal sphincter (IAS) is observed in chronic idiopathic constipation (IC) and solitary rectal ulcer syndrome (SRUS), where it has been correlated with the presence and severity of rectal intussusception. Alternatively, thickened IAS may be a feature of the obstructed megarectum in a similar way to the hypertrophy of bladder neck seen in dyssynergic bladders. The aim of this study was to investigate the significance of thickening of the IAS in children with chronic IC and to determine any association between the thickened IAS and anorectal manometry findings and patient's symptoms. A total of 144 children were admitted for investigations and treatment of chronic IC and evaluated prospectively between April 2001 and April 2003. IAS thickness was measured by endosonography using B&K axial endosonic probe type 1850 with a 10-MHz rotating transducer. The thickness of IAS was measured at 3, 6, and 9 o'clock, and the mean value of the three measurements was used for analysis. Functional assessment was done by anorectal manometry pressure studies under ketamine anaesthesia. A validated symptom score (SS) was used to assess the severity of symptoms. The sum of SS ranged between 0 and 65. Spearman's rho two-tailed test was used to correlate the thickness of IAS with patients' symptoms and anorectal manometry findings. Results were expressed as median and range and p-value of less than 0.05 was considered significant. Of 144 children, 84 were boys, median age 8.1 years (range 3.1-15). Soiling was present in 137 (94%) patients, delay in defecation in 132 (91%), and a palpable megarectum on abdominal examination in 117 (80%). The median duration of symptoms and duration of laxative treatment were 4 years (range 0.3-14.5) and 3.3 years (0.2-13.5), respectively. The average severity score for soiling, delay in defecation, palpable megarectum, and the total SS were 8 (range 0-10), 5 (0-10), 2 (0-12), and 33 (11-51), respectively. The median thickness of IAS was 0.9 mm (range 0.3-2.8) and the median resting anal sphincter pressure was 54 mmHg (19-107). The median amplitudes of rectal and anal sphincter contraction were 3 mmHg (1-25) and 9 mmHg (1-35), respectively. The thickness of IAS correlated significantly with total symptom severity score (r=0.31, p=0.0001), soiling score (r=0.28, p=0.001), megarectum score on abdominal palpation (r=0.29, p=0.001), size of megarectum on manometry (r=0.36, p=0.0001), amplitude of rectal contraction (r=0.23, p=0.007), and age of patient (r=0.55, p=0.0001). There was also a significant correlation between the amplitude of rectal and anal sphincter contraction (r=0.32, p=0.0001). There was no correlation between thickness of IAS and resting anal sphincter pressure and amplitude of anal sphincter contraction on anorectal manometry study. A total of 24 children had myectomy of thickened and overactive IAS in addition to the medical treatment of their chronic IC. The histology examination of myectomy specimen with eosin and haematoxylin staining and histochemical acetylcholine esterase staining showed smooth muscle fibres and ganglion cells. Thickening of IAS correlates significantly with duration and severity of symptoms, size of megarectum, and amplitude of rectal contraction. The pathogenesis is secondary to the continuous presence of faeces in the rectum, resulting in chronic abnormal stimulus to the IAS, which leads to hypertrophic changes in the rectum wall and IAS.

Geriatric fecal incontinence

Fecal incontinence is a common problem in the elderly population,particularly in nursing homes, and is one of the common reasons for nursing home placement. In addition to the inconvenience of the incontinence for the patient and caregiver, it is associated with increased mortality. Identifiable physiologic changes in the anorectal region may contribute to the development of fecal incontinence.Fecal incontinence is a disorder of men and women, with an equal or greater prevalence in men in advancing years. All patients who have fecal incontinence warrant an initial medical evaluation,including the exclusion of fecal impaction. Cognitively impaired patients benefit most from habit training. Selected elderly patients who have fecal incontinence may benefit from biofeedback and surgical intervention.

Faecal incontinence in adults

Faecal incontinence can affect individuals of all ages and in many cases greatly impairs quality of life, but incontinent patients should not accept their debility as either inevitable or untreatable. Education of the general public and of health-care providers alike is important, because most cases are readily treatable. Many cases of mild incontinence respond to simple medical therapy, whereas patients with more advanced incontinence are best cared for after complete physiological assessment. Recent advances in therapy have led to promising results, even for patients with refractory incontinence. Health-care providers must make every effort to communicate fully with incontinent patients and to help restore their self-esteem, eliminate their self-imposed isolation, and allow them to resume an active and productive lifestyle.

Pathophysiology of adult fecal incontinence

Fecal incontinence occurs when the normal anatomy or physiology that maintains the structure and function of the anorectal unit is disrupted. Incontinence usually results from the interplay of multiple pathogenic mechanisms and is rarely attributable to a single factor. The internal anal sphincter (IAS) provides most of the resting anal pressure and is reinforced during voluntary squeeze by the external anal sphincter (EAS), the anal mucosal folds, and the anal endovascular cushions. Disruption or weakness of the EAS can cause urge-related or diarrhea-associated fecal incontinence. Damage to the endovascular cushions may produce a poor anal "seal" and an impaired anorectal sampling reflex. The ability of the rectum to perceive the presence of stool leads to the rectoanal contractile reflex response, an essential mechanism for maintaining continence. Pudendal neuropathy can diminish rectal sensation and lead to excessive accumulation of stool, causing fecal impaction, mega-rectum, and fecal overflow. The puborectalis muscle plays an integral role in maintaining the anorectal angle. Its nerve supply is independent of the sphincter, and its precise role in maintaining continence needs to be defined. Obstetric trauma, the most common cause of anal sphincter disruption, may involve the EAS, the IAS, and the pudendal nerves, singly or in combination. It remains unclear why most women who sustain obstetric injury in their 20s or 30s typically do not present with fecal incontinence until their 50s. There is a strong need for prospective, long-term studies of sphincter function in nulliparous and multiparous women.

Physiologic variables that predict the outcome of treatment for fecal incontinence

Identification of physiologic factors that predict response to fecal incontinence therapy would be helpful in choosing the optimal treatment and advising patients on the likelihood of a successful outcome. However, few physiologic parameters have been consistently identified as important in predicting response to either biofeedback or surgery. The process of isolating these factors has been hampered by heterogeneity in the definition of fecal incontinence, lack of consensus on what constitutes a successful outcome, lack of follow-up data, variations in the way "standard" treatments are implemented, and lack of properly powered randomized controlled trials. Among the physiologic variables that studies have generally found to be predictive of successful outcomes in biofeedback treatment are the threshold for external anal sphincter contraction after treatment, the inclusion of sensory training in treatment, and a reduction in volume for the first sensation after treatment. Factors that have not been found to be important in predicting outcome following biofeedback retraining include the duration of fecal incontinence, pudendal nerve damage, patient age, symptom severity, pretreatment anal canal pressures, and results of anal ultrasonography. The presence of some degree of anorectal sensation is the only preoperative assessment that has been found to be predictive of response to surgical therapy. It is recommended that outcome measures for fecal incontinence be more clearly defined, that future biofeedback studies elaborate the predictive value of pretreatment anorectal sensation and the response to sensory retraining, and that postsurgical measurements such as anal squeeze pressure and sphincter length be taken into account.

Fecal incontinence: evaluation and treatment

Fecal incontinence affects men and women of all ages, leading to personal disability and high financial costs. The evaluation of the patient should clarify the pathophysiology of the symptoms and provide guidance in choosing the appropriate treatment. A comprehensive history and physical examination including endoscopic assessment is able to identify the cause of most cases of fecal incontinence. If necessary, functional methods can be used to confirm the diagnosis. Patient selection for suitable treatment is most important and should be based on clinical and physiologic findings. Conservative dietary or medical treatment is often effective, when the symptoms are mild. Biofeedback therapy is effective in most patients. It has no side effects and is well tolerated. Structural damage to the anus may be repaired by surgery, like sphincter repair, the best treatment of selective sphincter defects. Neoanal sphincters and artificial sphincters are the last possibility after failed surgery and before colostomy. They are less attractive because of technical difficulties and low success rate. A multidisciplinary approach to treatment has the potential to improve the outcome for patients with fecal incontinence.

Fecal incontinence secondary to CAPD

A 74-year-old patient who has developed fecal incontinence following continuous ambulatory peritoneal dialysis (CAPD) is presented. Incontinence was caused by elevated intra-abdominal pressure during peritoneal dialysis, which correlated with the volume of dialysate and position of the patient. The lowest pressure was found in the recumbent position. A change of dialysis schedule to continuous cycler peritoneal dialysis (CCPD) with "dry day" resulted in a disappearance of the symptoms.

Internal sphincterotomy with hemorrhoidectomy does not relieve pain: a prospective, randomized study

PURPOSE

Pain after hemorrhoidectomy is universal. Several attempts have been made to reduce or alleviate the pain after excisional hemorrhoidectomy. The origin of pain is undetermined. Current theories propose that the pain is mediated through the internal sphincter. This prospective, randomized study was performed to assess the degree of discomfort in patients with and without a sphincterotomy when performing a closed hemorrhoidectomy.

METHODS

Between December 1999 and September 2001, 42 patients (22 males), median age 52 (range, 30-80) years, who underwent excisional hemorrhoidectomy were randomly chosen to have an internal sphincterotomy in the base of the left lateral wound.

RESULTS

Thirty-nine patients were available for the study. Parameters elicited in the study were pain, postoperative bleeding, urinary retention, impairment of continence by day and by night, and day the patient returned to work. There was no statistical difference in the postoperative pain in each of the two categories at four hours after surgery, after the first bowel movement, or four days after surgery.

CONCLUSIONS

Results showed no difference in the perception of pain after hemorrhoidectomy in patients who had an internal sphincterotomy compared with those who did not. Both groups were equally likely to have difficulty with control of gas and soiling.